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Wong's Essentials of Pediatric Nursing
TENTH EDITION
Marilyn J. Hockenberry, PhD, RN, PPCNP-BC, FAAN Bessie Baker Professor of Nursing and Professor of Pediatrics Associate Dean for Research Affairs Chair, Duke Institutional Review Board Duke University Durham, North Carolina
David Wilson, MS, RNC-NIC (deceased) Staff Children's Hospital at Saint Francis Tulsa, Oklahoma
Cheryl C. Rodgers, PhD, RN, CPNP, CPON Assistant Professor Duke University School of Nursing Durham, North Carolina
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Table of Contents
Cover image
Title Page
Copyright
Contributors
Reviewers
Dedication
Preface
Organization of the Book
Unifying Principles
Special Features
Acknowledgments
Unit 1 Children, Their Families, and the Nurse
1 Perspectives of Pediatric Nursing
Health Care for Children
The Art of Pediatric Nursing
Clinical Reasoning and the Process of Providing Nursing Care to Children and Families
NCLEX Review Questions
Correct Answers
References
2 Family, Social, Cultural, and Religious Influences on Child Health Promotion
General Concepts
Family Structure and Function
Family Roles and Relationships
Parental Roles
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Parenting
Special Parenting Situations
Sociocultural Influences upon the Child and Family
Influences in the Surrounding Environment
Broader Sociocultural Influences upon the Child and Family
Understanding Cultures in the Health Care Encounter
Health Beliefs and Practices
NCLEX Review Questions
Correct Answers
References
3 Developmental and Genetic Influences on Child Health Promotion Growth and Development
Development of Personality and Cognitive Function
Role of Play in Development
Developmental Assessment
Genetic Factors That Influence Development
Review Questions
Correct Answers
References
Unit 2 Assessment of the Child and Family
4 Communication and Physical Assessment of the Child and Family Guidelines for Communication and Interviewing
Communicating with Families
History Taking
Nutritional Assessment
General Approaches Toward Examining the Child
Physical Examination
Review Questions
Correct Answers
References
5 Pain Assessment and Management in Children
Pain Assessment
Assessment of Pain in Specific Populations
Pain Management
Common Pain States in Children
Review Questions
Correct Answers
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References
6 Childhood Communicable and Infectious Diseases
Infection Control
Communicable Diseases
Intestinal Parasitic Diseases
Infections of the Skin
Systemic Disorders Related to Skin Lesions
NCLEX Review Questions
Correct Answers
References
Unit 3 Family-Centered Care of the Newborn
7 Health Promotion of the Newborn and Family
Adjustment to Extrauterine Life
NCLEX Review Questions
Correct Answers
References
8 Health Problems of Newborns
Birth Injuries
Cranial Deformities
Common Problems in the Newborn
Nursing Care of the High-Risk Newborn and Family
High Risk Related to Dysmaturity
High Risk Related to Physiologic Factors
High Risk Related to Infectious Processes
High Risk Related to Maternal Conditions
Genetic Evaluation and Counseling
NCLEX Review Questions
Correct Answers
References
Unit 4 Family-Centered Care of the Infant
9 Health Promotion of the Infant and Family
Promoting Optimal Growth and Development
Promoting Optimal Health During Infancy
NCLEX Review Questions
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Correct Answers
References
10 Health Problems of Infants Nutritional Imbalances
Health Problems Related to Nutrition
Skin Disorders
Special Health Problems
NCLEX Review Questions
Correct Answers
References
Unit 5 Family-Centered Care of the Young Child
11 Health Promotion of the Toddler and Family
Promoting Optimal Growth and Development
Promoting Optimal Health during Toddlerhood
NCLEX Review Questions
Correct Answers
References
12 Health Promotion of the Preschooler and Family Promoting Optimal Growth and Development
NCLEX Review Questions
Correct Answers
References
13 Health Problems of Toddlers and Preschoolers Sleep Problems
Skin Disorders Related to Chemical or Physical Contacts
Skin Disorders Related to Animal Contacts
Thermal Injury
Ingestion of Injurious Agents
Child Maltreatment
NCLEX Review Questions
Correct Answers
References
Unit 6 Family-Centered Care of the School-Age Child and Adolescent
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14 Health Promotion of the School-Age Child and Family
Promoting Optimal Growth and Development
NCLEX Review Questions
Correct Answers
References
15 Health Promotion of the Adolescent and Family
Promoting Optimal Growth and Development
Promoting Optimal Health during Adolescence
NCLEX Review Questions
Correct Answers
References
16 Health Problems of School-Age Children and Adolescents
Health Problems of School-Age Children
Health Problems of Adolescents
NCLEX Review Questions
Correct Answers
References
Unit 7 Family-Centered Care of the Child with Special Needs
17 Quality of Life for Children Living with Chronic or Complex Diseases Perspectives on the Care of Children and Families Living with or Dying From Chronic or Complex Diseases
The Family of the Child with a Chronic or Complex Condition
The Child with a Chronic or Complex Condition
Nursing Care of the Family and Child with a Chronic or Complex Condition
Perspectives on the Care of Children at the End of Life
Nursing Care of the Child and Family at the End of Life
NCLEX Review Questions
Correct Answers
References
18 Impact of Cognitive or Sensory Impairment on the Child and Family
Cognitive Impairment
Sensory Impairment
Communication Impairment
NCLEX Review Questions
Correct Answers
References
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Unit 8 The Child Who Is Hospitalized
19 Family-Centered Care of the Child During Illness and Hospitalization
Stressors of Hospitalization and Children's Reactions
Stressors and Reactions of the Family of the Child Who is Hospitalized
Nursing Care of the Child Who is Hospitalized
Nursing Care of the Family
Care of the Child and Family in Special Hospital Situations
NCLEX Review Questions
Correct Answers
References
20 Pediatric Variations of Nursing Interventions
General Concepts Related to Pediatric Procedures
Skin Care and General Hygiene
Safety
Positioning for Procedures
Collection of Specimens
Administration of Medication
Maintaining Fluid Balance
Alternative Feeding Techniques
Procedures Related to Elimination
Procedures for Maintaining Respiratory Function
NCLEX Review Questions
Correct Answers
References
Unit 9 The Child with Problems Related to the Transfer of Oxygen and Nutrients
21 The Child with Respiratory Dysfunction Respiratory Infections
Upper Respiratory Tract Infections
Croup Syndromes
Infections of the Lower Airways
Other Infections of the Respiratory Tract
Pulmonary Dysfunction Caused by Noninfectious Irritants
Long-Term Respiratory Dysfunction
Respiratory Emergency
NCLEX Review Questions
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Correct Answers
References
22 The Child with Gastrointestinal Dysfunction Distribution of Body Fluids
Gastrointestinal Dysfunction
Inflammatory Disorders
Hepatic Disorders
Structural Defects
Obstructive Disorders
Malabsorption Syndromes
NCLEX Review Questions
Correct Answers
References
Unit 10 The Child with Problems Related to the Production and Circulation of Blood
23 The Child with Cardiovascular Dysfunction
Cardiovascular Dysfunction
Congenital Heart Disease
Clinical Consequences of Congenital Heart Disease
Nursing Care of the Family and Child with Congenital Heart Disease
Acquired Cardiovascular Disorders
Heart Transplantation
Vascular Dysfunction
NCLEX Review Questions
Correct Answers
References
24 The Child with Hematologic or Immunologic Dysfunction Hematologic and Immunologic Dysfunction
Red Blood Cell Disorders
Defects in Hemostasis
Immunologic Deficiency Disorders
Technologic Management of Hematologic and Immunologic Disorders
NCLEX Review Questions
Correct Answers
References
25 The Child with Cancer
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Cancer in Children
Nursing Care Management
Cancers of Blood and Lymph Systems
Nervous System Tumors
Bone Tumors
Other Solid Tumors
The Childhood Cancer Survivor
NCLEX Review Questions
Correct Answers
References
Unit 11 The Child with a Disturbance of Regulatory Mechanisms
26 The Child with Genitourinary Dysfunction Genitourinary Dysfunction
External Defects of the Genitourinary Tract
Glomerular Disease
Miscellaneous Renal Disorders
Renal Failure
Technologic Management of Renal Failure
NCLEX Review Questions
Correct Answers
References
27 The Child with Cerebral Dysfunction
Cerebral Dysfunction
Evaluation of Neurologic Status
The Child with Cerebral Compromise
Cerebral Trauma
Intracranial Infections
Seizure Disorders
Cerebral Malformations
NCLEX Review Questions
Correct Answers
References
28 The Child with Endocrine Dysfunction The Endocrine System
Disorders of Pituitary Function
Disorders of Thyroid Function
Disorders of Parathyroid Function
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Hypoparathyroidism
Disorders of Adrenal Function
Disorders of Pancreatic Hormone Secretion
NCLEX Review Questions
Correct Answers
References
Unit 12 The Child with a Problem that Interferes with Physical Mobility
29 The Child with Musculoskeletal or Articular Dysfunction
The Immobilized Child
Traumatic Injury
Sports Participation and Injury
Birth and Developmental Defects
Acquired Defects
Infections of Bones and Joints
Disorders of Joints
NCLEX Review Questions
Correct Answers
References
30 The Child with Neuromuscular or Muscular Dysfunction
Congenital Neuromuscular or Muscular Disorders
Acquired Neuromuscular Disorders
NCLEX Review Questions
Correct Answers
References
Answers to Critical Thinking Case Studies
Chapter 8
Chapter 10
Chapter 15
Chapter 16
Chapter 18
Chapter 19
Chapter 21
Chapter 22
Chapter 23
Chapter 25
Chapter 27
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Chapter 28
Index
IBC
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Copyright
3251 Riverport Lane St. Louis, Missouri 63043
HOCKENBERRY: WONG'S ESSENTIALS OF PEDIATRIC NURSING, TENTH EDITION ISBN: 978- 0-323-35316-8
Copyright © 2017 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Nursing Diagnoses—Definitions and Classification 2012-2014. Copyright © 2011, 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 by NANDA International. Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley and Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in the work.
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NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks and service marks of the National Council of State Boards of Nursing, Inc.
Previous editions copyrighted 2013, 2009, 2005, 2001, 1997, 1993, 1989, 1985, 1982.
International Standard Book Number: 978-0-323-35316-8
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Contributors
Rose U. Baker PhD, PMHCNS-BC Assistant Lecturer School of Nursing College of Health Professions Akron, Ohio
Annette L. Baker RN, BSN, MSN, CPNP Nurse Practitioner Cardiovascular Program Auburndale, Massachusetts
Raymond Barfield MD, PhD Associate Professor of Pediatrics and Christian Philosophy; Director Pediatric Quality of Life and Palliative Care Duke University Durham, North Carolina
Amy Barry RN, MSN, PNP-BC Pediatric Nurse Practitioner Leukemia and Lymphoma Service Aflac Cancer and Blood Disorders Center Atlanta, Georgia
Heather Bastardi MSN, BSN, PNP Heart Failure/Heart Transplant Coordinator Boston Children's Hospital Boston, Massachusetts
Debra Brandon PhD, RN, CNS, FAAN Associate Professor School of Nursing Duke University Durham, North Carolina
Terri L. Brown MSN, RN, CPN Assistant Director Clinical Outcomes & Data Support Texas Children's Hospital Houston, Texas
Meg Bruening PhD, MPH, RD Assistant Professor School of Nutrition and Health Promotion College of Health Solutions Arizona State University Phoenix, Arizona
Rosalind Bryant PhD, RN, PPCNP-BC Pediatric Nurse Practitioner Texas Children's Hospital;
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Instructor Baylor College of Medicine Houston, Texas
Cynthia J. Camille MSN, RN, CPNP, FNP-BC Pediatric Nurse Practitioner Pediatric Urology Duke University Health System Durham, North Carolina
Patricia M. Conlon MS, APRN, CNS, CNP Pediatric Clinical Nurse Specialist; Assistant Professor of Nursing Mayo Clinic Children's Center Rochester, Minnesota
Erin Connelly APRN, CPNP Aflac Cancer & Blood Disorders Center; Children's Healthcare of Atlanta Emory University Atlanta, Georgia
Martha R. Curry MS, RN, CPNP Instructor Immunology, Allergy, and Rheumatology Department of Pediatrics Baylor College of Medicine Texas Children's Hospital Houston, Texas
Amy Delaney RN, MSN, CPNP-AC/P Pediatric Nurse Practitioner Boston Children's Hospital Boston, Massachusetts
Sharron L. Docherty PhD, PNP-BC, FAAN Associate Professor School of Nursing; Associate Professor Department of Pediatrics; Director Center for Excellence in Cognitive/Affective Symptom Science Duke University Durham, North Carolina
Angela Drummond MS, APRN, CPNP Pediatric Nurse Practitioner-Orthopedics Gillette Children's Specialty Healthcare St. Paul, Minnesota
Jan M. Foote DNP, ARNP, CPNP, FAANP Clinical Associate Professor The University of Iowa College of Nursing Iowa City, Iowa Pediatric Nurse Practitioner Blank Children's Hospital Des Moines, Iowa
Quinn Franklin MS
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Manager Child, Adolescent, and Young Adult Life Program The University of Texas MD Anderson Children's Cancer Hospital Houston, Texas
Debbie Fraser MN, RNC-NIC Associate Professor Faculty of Health Disciplines Athabasca University Athabasca, Alberta, Canada; Advanced Practice Nurse, NICU ST Boniface General Hospital Winnipeg, Manitoba, Canada
Teri Lavenbarg MSN, APRN, PPCNP-BC, FNP-BC, CDE Nurse Practitioner Medical Center University of Kansas Kansas City, Kansas
Patricia McElfresh MN, RN, PNP-BC Pediatric Nurse Practitioner Hematology Oncology Children's Healthcare of Atlanta Atlanta, Georgia
Tara Merck CPNP Director of Advanced Practice Providers Children's Specialty Group Medical College of Wisconsin Milwaukee, Wisconsin
Mary A. Mondozzi MSN, BSN, RN Burn Center Education/Outreach Coordinator Akron Children's Hospital The Paul and Carol David Foundation Burn Institute Akron, Ohio
Rebecca A. Monroe MSN, RN, CPNP Certified Pediatric Nurse Practitioner Medical City Children's Hospital Urgent Care Dallas, Texas
Kim Mooney-Doyle PhD, RN, CPNP-AC Postdoctoral Research Fellow School of Nursing University of Pennsylvania Philadelphia, Pennsylvania
Patricia O'Brien MSN, RN, CPNP-AC Nurse Practitioner Cardiovascular Program Boston Children's Hospital Boston, Massachusetts
Cynthia A. Prows MSN, CNS, FAAN Clinical Nurse Specialist, Genetics Cincinnati Children's Hospital Medical Center
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Cincinnati, Ohio
Patricia A. Ring MSN, RN, CPNP Pediatric Nurse Practitioner Pediatric Nephrology Children's Hospital of Wisconsin Milwaukee, Wisconsin
Maureen Sheehan MS, CPNP Pediatric Nurse Practitioner Child Neurology and Epilepsy Stanford Children's Health Palo Alto, California; Clinical Faculty (Volunteer) School of Nursing University of California, San Francisco San Francisco, California
Anne Feierabend Stanton MSN, APRN, PCNS-BC Pediatric Clinical Nurse Specialist University of Kansas Medical Center Kansas City, Kansas
Barbara J. Wheeler RN, BN, MN, IBCLC Neonatal Clinical Nurse Specialist & Lactation Consultant St. Boniface General Hospital; Professional Affiliate Manitoba Centre for Nursing & Health Research; Instructor II College of Nursing University of Manitoba e-Health Services Winnipeg, Manitoba, Canada
Kristina D. Wilson PhD, CCC-SLP Senior Speech Language Pathologist and Clinical Researcher Texas Children's Hospital; Adjunct Assistant Professor Division of Plastic Surgery Baylor College of Medicine Houston, Texas
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Reviewers
Sharon Anderson MSN, NNP-BC, APNG Instructor School of Nursing Rutgers, The State University of New Jersey
Brigit M. Carter PhD, RN, CCRN Assistant Professor; Project Director Health Equity Academy Duke University School of Nursing Durham, North Carolina
Enrique Chaves-Carballo MD Clinical Professor, Departments of Pediatrics and History and Philosophy of Medicine The University of Kansas Medical Center Kansas City, Kansas
Elizabeth Conoley RN, MSNEd, CPN Assistant Professor Brenau University School of Nursing Gainesville, Georgia
Ciara Culhane MS, RN-BC, CPN Professional Development Specialist Children's Hospital Colorado Aurora, Colorado
Jacqueline Sayre Dorsey MS, RN, ANP Assistant Professor Nursing Monroe Community College Rochester, New York
Patricia A. Duclos-Miller MSN, RN, NE-BC Professor Capital Community College Hartford, Connecticut
Stephanie C. Evans PhD, APRN, PNP Assistant Professor, Nursing Harris College of Nursing and Health Sciences Texas Christian University Fort Worth, Texas
Kari Gali DNP, RN, CPN Pediatric Nurse Practitioner Distance Health/MyCare Online Cleveland Clinic Cleveland, Ohio
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Bonnie Jensen RN, BSN, MSN Faculty Provo College Provo, Utah
Christine B. Kavanagh RD, MSN, PNP-BC Instructor Nursing Programs School of Health Sciences Pennsylvania College of Technology Williamsport, Pennsylvania
Ann Marie McCarthy RN, PhD, FNASN, FAA Professor & Associate Dean for Research College of Nursing The University of Iowa Iowa City, Iowa
Carmella Mikol PhD, CPNP, CNE, RN-BC Instructor College of Lake Country Grayslake, Illinois
Deborah A. Roberts MSN, EdD Professor and Chair Department of Nursing Sonoma State University Rohnert Park, California
Nicole Shonka MS, RN-BC, CPN Professional Development Specialist Children's Hospital Colorado Aurora, Colorado
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Dedication
We dedicate the tenth edition of this book to David Wilson who passed away on March 7, 2015, after a long battle with cancer. David had been co-author of the Wong nursing
textbooks for over 15 years. He was known as an expert clinical nurse and nurse educator. His last clinical position was at St. Francis Health Services in Tulsa, Oklahoma,
where he worked in the Children's Day Hospital as the coordinator for Pediatric Advanced Life Support (PALS).
Students and faculty have recognized David's contributions to the Wong textbooks for many years. He was known as an outstanding educator and supporter of nursing
students; his attention to clinical excellence was evident in all this work. Those who contributed to the books and had the opportunity to work with David realize the
important role he played as a leader in nursing education for students and faculty. His clinical expertise provided a critical foundation for ensuring relevant and evidence-based
content was used in all the Wong textbooks. David led by example in exemplifying excellence in clinical nursing practice.
Those who knew David well will miss his humor, loyalty to friends and colleagues, and his never-ending support. He is missed greatly by those who worked closely with him on
the Wong textbook over the years. Most importantly we miss his friendship; he was always there to support and to encourage. We have lost an amazing nurse who worked effortlessly over the years to improve the care of children and families in need. David
will not be forgotten.
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Preface
Wong's Essentials of Pediatric Nursing has been a leading book in pediatric nursing since it was first published almost 40 years ago. This kind of support places immense accountability and responsibility on us to earn your future endorsement with each new edition. So, with your encouragement and constructive comments, we offer this extensive revision, the tenth edition of Wong's Essentials of Pediatric Nursing. This tenth edition continues the legacy of Donna Wong and David Wilson; our beloved colleagues. We hold dear their contributions and memories of their pursuit of excellence in all they did for the Wong textbooks.
To accomplish this, Marilyn J. Hockenberry, as editor-in-chief, along with Cheryl Rodgers, co- editor, and many expert nurses and multidisciplinary specialists, have revised, rewritten, or authored portions of the text concerning areas that are undergoing rapid and complex change. These areas include community nursing, development, immunizations, genetics, home care, pain assessment and management, high-risk newborn care, adolescent health issues, end-of-life care, and numerous pediatric diseases. We have carefully preserved aspects of the book that have met with universal acceptance—its state-of-the-art research-based information; its strong, integrated focus on the family and community; its logical and user-friendly organization; and its easy-to-read style.
We have tried to meet the increasing demands of faculty and students to teach and to learn in an environment characterized by rapid change, enormous amounts of information, fewer traditional clinical facilities, and less time.
This text encourages students to think critically. New to this edition is a change in the format and content for nursing care plans throughout the book. We have developed case studies that discuss clinical scenarios allowing the student to visualize how the care plan develops as a clinical situation evolves over time. The Critical Thinking Case Studies ask the nurse to examine the evidence, consider the assumptions, establish priorities, and evaluate alternative perspectives regarding each patient situation. The Critical Thinking Case Studies support our belief that the science of nursing and related health professions is not black and white. In many instances, it includes shades of gray, such as in the areas of genetic testing, resuscitation, cultural issues, end-of-life care, and quality of life. Revised evidence-based practice boxes include the latest knowledge crucial for nurses to practice using quality and safety competencies. Competencies included in the evidence-based practice boxes are designed specifically for prelicensed nurses and are from the Quality and Safety Education for Nurses website.
This text also serves as a reference manual for practicing nurses. The latest recommendations have been included from authoritative organizations such as the American Academy of Pediatrics, the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, the Agency for Healthcare Research and Quality, the American Pain Society, the American Nurses Association, and the National Association of Pediatric Nurse Associates and Practitioners. To expand the universe of available information, websites and e-mail addresses have been included for hundreds of organizations and other educational resources.
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Organization of the Book The same general approach to the presentation of content has been preserved from the first edition, although some content has been added, condensed, and rearranged within this framework to improve the flow; minimize duplication; and emphasize health care trends, such as home and community care. The book is divided into two broad parts. The first part of the book, Chapters 1 through 16, follow what is sometimes called the “age and stage” approach, considering infancy, childhood, and adolescence from a developmental context. It emphasizes the importance of the nurse's role in health promotion and maintenance and in considering the family as the focus of care. From a developmental perspective, the care of common health problems is presented, giving readers a sense of the normal problems expected in otherwise healthy children and demonstrating when in the course of childhood these problems are most likely to occur. The remainder of the book, Chapters 17 through 30, presents the more serious health problems of infancy, childhood, and adolescence that are not specific to any particular age group and that frequently require hospitalization, major medical and nursing intervention, and home care.
UNIT ONE (Chapters 1 through 3) provides a longitudinal view of the child as an individual on a continuum of developmental changes from birth through adolescence and as a member of a family unit maturing within a culture and a community. Chapter 1 includes the latest discussion of morbidity and mortality in infancy and childhood and examines child health care from a historical perspective. Because unintentional injury is one of the leading causes of death in children, an overview of this topic is included. The nursing process, with emphasis on nursing diagnosis and outcomes and on the importance of developing critical thinking skills, is presented. In this edition, the critical components of evidence-based practice are presented to provide the template for exploring the latest pediatric nursing research or practice guidelines throughout the book.
This book is about families with children, and the philosophy of family-centered care is emphasized. This book is also about providing atraumatic care—care that minimizes the psychologic and physical stress that health promotion and illness treatment can inflict. Features such as Evidence-Based Practice, Family-Centered Care, Community Focus, Research Focus, Drug Alert, and Atraumatic Care boxes bring these philosophies to life throughout the text. Finally, the philosophy of delivering nursing care is addressed. We believe strongly that children and families need consistent caregivers. The establishment of the therapeutic relationship with the child and family is explored as the essential foundation for providing quality nursing care.
Chapter 2 provides important information on the family, social and cultural and religious influences on child health promotion. The content clearly describes the role of the nurse, with emphasis on cultural and religious sensitivity and competent care.
Chapter 3, devoted to the developmental and genetic influences on child health continues to provide the latest information on genetics and also focuses on a theoretic approach to personality development and learning.
UNIT TWO (Chapters 4 to 6) is concerned with the principles of nursing assessment, including communication and interviewing skills, observation, physical and behavioral assessment, health guidance, and the latest information on preventive care guidelines. Chapter 4 contains guidelines for communicating with children, adolescents, and their families, as well as a detailed description of a health assessment, including discussion of family assessment, nutritional assessment, and a sexual history. Content on communication techniques is outlined to provide a concise format for reference. Chapter 4 continues by providing a comprehensive approach to physical examination and developmental assessment, with updated material on temperature measurement, body mass index– for-age guidelines, and the latest World Health Organization and CDC clinical growth charts. Chapter 5 is an important chapter, devoted to critical assessment and management of pain in children. Although the literature on pain assessment and management in children has grown considerably, this knowledge has not been widely applied in practice. Chapter 6 was added to address common infectious diseases in children. This chapter emphasizes the importance of infection control and review the various bacterial and viral infections encountered in childhood. Hospital-acquired infections, childhood communicable disease and immunizations are also discussed.
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UNIT THREE (Chapters 7 and 8) stresses the importance of the neonatal period in relation to child survival during the first few months and the impact on health in later life. In Chapter 7, several areas have been revised to reflect current issues, especially in terms of the educational needs of the family during the infant's transition to extrauterine life as well as the recognition of newborn problems in the first few weeks of life. Current issues that have been updated include proactive measures to prevent infant abduction; hospital-based, baby-friendly breastfeeding initiatives; choices for circumcision analgesia; newborn atraumatic care; car safety seats; and newborn screening, including universal newborn hearing screening. Newborn skin care guidelines have also been updated, and choices for newborn umbilical cord care are discussed. Chapter 8 stresses the nurse's role in caring for the high-risk newborn and the importance of astute observations to the survival of this vulnerable group of infants. Modern advances in neonatal care have mandated extensive revision with a greater sensitivity to the diverse needs of infants, from those with extremely low birth weights, late-preterm infants, and those of normal gestational age who have difficulty making an effective transition to extrauterine life. This chapter also includes the latest information regarding the detection and management of inborn errors of metabolism.
UNITS FOUR through SIX (Chapters 9 through 16) present the major developmental stages outlined in Unit One, which are expanded to provide a broader concept of these stages and the health problems most often associated with each age group. Special emphasis is placed on preventive aspects of care. The chapters on health promotion follow a standard approach that is used consistently for each age group. Chapter 10 has been streamlined in regard to nutritional imbalances and continues to focus on the influence of nutrition in early childhood as it impacts health status in adulthood. The sections on colic, sudden infant death syndrome, and car seat safety in infancy have been updated as well. The influence of nutrition in preschool-age and school-age children (especially decreasing fat intake) in relation to later chronic diseases such as obesity and hypertension is also discussed. The importance of safety promotion and injury prevention in relation to each age group is included as well. Chapter 14 contains updated information on bullying.
The chapters on health problems in these units primarily reflect more typical and age-related concerns. The information on many disorders has been revised to reflect recent changes. Examples include sudden infant death syndrome, lead poisoning, severe acute malnutrition, burns, attention- deficit/hyperactivity disorder, contraception, teenage pregnancy, and sexually transmitted infections. The chapters on adolescence include the latest information regarding substance abuse, adolescent immunizations, and the impact of adolescent nutrition on cardiovascular health.
UNIT SEVEN (Chapters 17 and 18) deals with children who have the same developmental needs as growing children but who, because of congenital or acquired physical, cognitive, or sensory impairment, require alternative interventions to facilitate development. Chapter 17 reflects current trends in the care of families and children with chronic illness or disability such as providing home care, normalizing children's lives, focusing on developmental needs, enabling and empowering families, and promoting early intervention. This chapter highlights common fears experienced by the child and family and includes discussion of symptom management and nurses' reactions to caring for dying children.
The content in Chapter 18 on cognitive or sensory impairment includes important updates on the definition and classification of cognitive impairment. Autism is discussed in this chapter to provide a cohesive overview of cognitive and sensory impairments.
UNIT EIGHT (Chapters 19 and 20) is concerned with the impact of hospitalization on the child and family and presents a comprehensive overview of the stressors imposed by hospitalization and discusses nursing interventions to prevent or eliminate them. New research on short-stay or outpatient admissions addresses preparing children for these experiences. Chapter 19 provides updated information on the effects of illness and hospitalization on children at specific ages and the effects on their development. The increasing role of ambulatory and outpatient settings for surgical procedures is also discussed. Chapter 20 includes numerous revised Evidence-Based Practice boxes that include QSEN competencies and are designed to provide rationales for the interventions discussed in the chapter. A major focus in this chapter is the evidence related to preparation of the child for procedures commonly performed by nurses. Recommendations for practice are based on the evidence and concisely presented in Evidence-Based Practice boxes throughout the chapter.
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UNITS NINE through TWELVE (Chapters 21 through 30) consider serious health problems of infants and children primarily from the biologic systems orientation, which has the practical organizational value of permitting health problems and nursing considerations to relate to specific pathophysiologic disturbances. The most common serious diseases in children are reviewed in these chapters. Important revisions include discussions of hepatitis, cardiopulmonary resuscitation, blood disorders, cancer, respiratory illnesses including influenza, acute lung injury and respiratory syncytial virus, tuberculosis, asthma, cystic fibrosis, effects of second-hand smoke exposure, seizures, acquired immunodeficiency syndrome, and diabetes mellitus. The information on orthopedic and muscular injuries in childhood as a result of sports participation or other injuries has been revised to reflect current treatment modalities. Chapter 28 includes focused attention on type 2 diabetes and the most up to date information on insulin preparations and types of glucose meters.
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Unifying Principles Several unifying principles have guided the organizational structure of this book since its inception. These principles continue to strengthen the book with each revision to produce a text that is consistent in approach throughout each chapter.
The Family as the Unit of Care The child is an essential member of the family unit. We refer to parents in this book as a mother and/or father but recognize parents include of a variety of individuals and do not undervalue the importance of any parent role or family structure.
Nursing care is most effective when it is delivered with the belief that the family is the patient. This belief permeates the book. When a child is healthy, the child's health is enhanced when the family is a fully functioning, health-promoting system. The family unit can be manifested in a myriad of structures; each has the potential to provide a caring, supportive environment in which the child can grow, mature, and maximize his or her human potential. In addition to the integration of family-centered care into every chapter, an entire chapter is devoted to understanding the family as the core focus in children's lives including the social, cultural, and religious influences that impact family beliefs. Separate sections in another chapter deal in depth with family communication and family assessment. The impact of illness and hospitalization, home care, community care, and the death of a child are covered extensively in additional chapters. The needs of the family are emphasized throughout the text under Nursing Care Management in a separate section on family support. Numerous Family-Centered Care boxes are included to assist nurses in understanding and providing helpful information to families.
An Integrated Approach to Development Children are not small adults but special individuals with unique minds, bodies, and needs. No book on pediatric nursing is complete without extensive coverage of communication, nutrition, play, safety, dental care, sexuality, sleep, self-esteem, and of course, parenting. Nurses promote the healthy expression of all these dimensions of personhood and need to understand how these functions are expressed by different children at different developmental ages and stages. Effective parenting depends on knowledge of development, and it is often the nurse's responsibility to provide parents with a developmental awareness of their children's needs. For these reasons, coverage of the many dimensions of childhood is integrated within the growth and development chapters rather than being presented in separate chapters. For example, safety concerns for a toddler are much different from those for an adolescent. Sleep needs change with age, as do nutritional needs. As a result, the units on each stage of childhood contain complete information on all these functions as they relate to the specific age. In the unit on school-age children, for instance, information is presented on nutritional needs, age-appropriate play and its significance, safety concerns characteristic of the age group, appropriate dental care, sleep characteristics, and means of promoting self-esteem—a particularly significant concern for school-age children. The challenges of being the parent of a school-age child are presented, and interventions are suggested that nurses can use to promote healthy parenting. Using the integrated approach, students gain an appreciation for the unique characteristics and needs of children at every age and stage of development.
Focus on Wellness and Illness: Child, Family, and Community In a pediatric nursing text, a focus on illness is expected. Children become ill, and nurses typically are involved in helping children get well. However, it is not sufficient to prepare nursing students to care primarily for sick children. First, health is more than the absence of disease. Being healthy is being whole in mind, body, and spirit. Therefore, the majority of the first half of the book is devoted to discussions that promote physical, emotional, psychosocial, mental, and spiritual wellness. Much emphasis is placed on anticipatory guidance of parents to prevent injury or illness in their children. Second, health care is more than ever prevention focused. The objectives set forth in the Healthy People 2020 report clearly establish a health care agenda in which solutions to medical and social
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problems lie in preventive strategies. Third, health care is moving from acute care settings to the community, the home, short-stay centers, and clinics. Nurses must be prepared to function in all settings. To be successful, they must understand the pathophysiology, diagnosis, and treatment of health conditions. Competent nursing care flows from this knowledge and is enhanced by an awareness of childhood development, family dynamics, and communication skills.
Nursing Care Although the information in this text incorporates information from numerous disciplines (medicine, pathophysiology, pharmacology, nutrition, psychology, sociology), its primary purpose is to provide information on the nursing care of children and families. Discussions of all disorders conclude with a section on Nursing Care Management. In addition, 14 care plans are included. Taken together, they cover the nursing care for many childhood diseases, disorders, and conditions. The purposes of the care plans, like every other feature of the book, are to teach and to convey information. They include current nursing diagnoses approved by NANDA International that have a potential bearing on the health problem. For every diagnosis, defining characteristics, appropriate patient outcomes, and select possible interventions with rationales are presented. The care plans are designed to stimulate critical thinking and encourage the student to individualize outcomes and interventions for the child rather than to provide an extensive picture of all nursing diagnoses, outcomes, and interventions for every given disease or condition.
Culturally Competent Care Increasing cultural diversity in this country requires nurses caring for children and their families to develop expertise in the care of children from numerous backgrounds. Culturally competent nursing care requires more than acquiring knowledge about ethnic and cultural groups. It encompasses not only awareness of the influence of culture on the child and family but also the ability to intervene appropriately and effectively. The nurse must learn objective skills to focus on the child's, family's and community's cultural characteristics. The nurse's self-awareness of unique personal cultural backgrounds must be acknowledged in order to understand how they contribute to cross-cultural communication. The importance of the environment of a cross-cultural care setting must be considered when providing clinical nursing care to culturally diverse families. This edition provides numerous learning experiences that examine cross-cultural communication, cultural assessment, cultural interpretation, and appropriate nursing interventions.
The Critical Role of Research and Evidence-Based Practice This tenth edition is the product of an extensive review of the literature published since the book was last revised. Many readers and researchers have come to rely on the copious references that reflect significant contributions from a broad audience of professionals. To ensure that information is accurate and current, most citations are less than 5 years old, and almost every chapter has entries dated within 1 year of publication. This book reflects the art and science of pediatric nursing. A central goal in every revision is to base care on research rather than on tradition. Evidence-based practice produces measurable outcomes that nurses can use to validate their unique role in the health care system. Throughout the book, Evidence-Based Practice boxes reflect the importance of the science of nursing care.
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Special Features
Much effort has been directed toward making this book easy to teach from and, more important, easy to learn from. In this edition, the following features have been included to benefit educators, students, and practitioners.
ATRAUMATIC CARE boxes emphasize the importance of providing competent care without creating undue physical and psychologic distress. Although many of the boxes provide suggestions for managing pain, atraumatic care also considers approaches to promoting self-esteem and preventing embarrassment.
COMMUNITY FOCUS boxes address issues that expand to the community, such as increasing immunization rates, preventing lead poisoning, and decreasing smoking among teens.
CRITICAL THINKING CASE STUDIES ask the nurse to examine the evidence, consider the assumptions, establish priorities, and evaluate alternative perspectives regarding each patient situation. Answers to the Case Studies are provided at the end of the text.
CULTURAL CONSIDERATIONS boxes integrate concepts of culturally sensitive care throughout the text. The emphasis is on the clinical application of the information, whether it focuses on toilet training or on male or female circumcision.
DRUG ALERTS highlight critical drug safety concerns for better therapeutic management. EMERGENCY TREATMENT boxes are flagged by colored thumb tabs, enabling the reader to
quickly locate interventions for crisis situations.
TRANSLATING EVIDENCE INTO PRACTICE boxes have been updated in this edition to focus the reader's attention on application of both research and critical thought processes to support and guide the outcomes of nursing care. The EBP boxes include QSEN competencies and provide measurable outcomes that nurses can use to validate their unique role in the health care system.
FAMILY-CENTERED CARE boxes present issues of special significance to families that have a child with a particular disorder. This feature is another method of highlighting the needs or concerns of families that should be addressed when family-centered care is provided.
NURSING ALERT features call the reader's attention to considerations that if ignored could lead to a deteriorating or emergency situation. Key assessment data, risk factors, and danger signs are among the kinds of information included.
NURSING CARE GUIDELINES summarize important nursing interventions for a variety of situations and conditions.
NURSING CARE PLANS include the latest NANDA nursing diagnoses and associated defining characteristics (signs and symptoms), which assist the nurse in the validation of the selected nursing diagnosis. Selected nursing interventions and Nursing Interventions Classification terminology are designed to guide the student to individualize the child's and family's care. The inclusion of NEW case studies that discuss clinical scenarios allows the student to visualize how the care plan develops as a clinical situation evolves over time.
NURSING PROCESS boxes streamline the nursing process information on major diseases and conditions for easy identification.
NURSING TIPS notes present handy information of a nonemergency nature that makes patients more comfortable and the nurse's job easier.
QUALITY PATIENT OUTCOMES are added throughout the text to provide a framework for measuring nursing care performance. Nursing-sensitive outcome measures are integrated into the outcome indicators used throughout the book.
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RESEARCH FOCUS boxes review new evidence on important topics in a concise way. SAFETY ALERTS highlight patient safety as part of the QSEN initiative for better outcomes of
nursing care.
Numerous pedagogic devices that enhance student learning have been retained from previous editions: • A functional and attractive FULL-COLOR DESIGN visually enhances the organization of each
chapter, as well as the special features. • EVOLVE at the beginning of each chapter highlight the companion site which includes additional
resources and information for the student. • A detailed, cross-referenced INDEX allows readers to quickly access discussions. • KEY TERMS are highlighted throughout each chapter to reinforce student learning. • Hundreds of TABLES and BOXES highlight key concepts and nursing interventions. • Many of the COLOR PHOTOGRAPHS are new, and anatomic drawings are easy to follow, with
color appropriately used to illustrate important aspects, such as saturated and desaturated blood. As an example, the full-color heart illustrations in Chapter 23 clearly depict congenital cardiac defects and associated hemodynamic changes.
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Acknowledgments
We are grateful to our mentor and colleague, Donna Wong, whose support made us better pediatric nurses. We are fortunate to have worked for many years with David Wilson who served as a Co-Editor on numerous editions. We miss him greatly with this edition. We are also grateful to the many nursing faculty members, practitioners, and students who have offered their comments, recommendations, and suggestions. We are especially grateful to the contributors and the many reviewers who brought constructive criticism, suggestions, and clinical expertise to this edition. This edition could not have been completed without the dedication of these special people.
No book is ever a reality without the dedication and perseverance of the editorial staff. Although it is impossible to list every individual at Elsevier who has made exceptional efforts to produce this text, we are especially grateful to Sandra Clark and Heather Bays for their support and commitment to excellence. We want to say very special thanks to Heather Bays who has served the Wong textbooks for many editions with a commitment to excellence that is so appreciated.
Finally, we thank our families and children—for the unselfish love and endless patience that allows us to devote such a large part of our lives to our careers. The children have given us the opportunity to directly observe the wonders of childhood.
Marilyn J. Hockenberry
Cheryl C. Rodgers
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U N I T 1 Children, Their Families, and the Nurse
OUTLINE 1 Perspectives of Pediatric Nursing 2 Family, Social, Cultural, and Religious Influences on Child Health Promotion 3 Developmental and Genetic Influences on Child Health Promotion
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Perspectives of Pediatric Nursing Marilyn J. Hockenberry
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Health Care for Children The major goal for pediatric nursing is to improve the quality of health care for children and their families. In 2014, almost 75 million children 0 to 17 years old lived in the United States, comprising 24% of the population (Federal Interagency Forum on Child and Family Statistics, 2015). The health status of children in the United States has improved in a number of areas, including increased immunization rates for all children, decreased adolescent birth rate, and improved child health outcomes. The 2015 America's Children in Brief—Indicators of Well-Being reveals that preterm births declined for the seventh straight year and that the adolescent birth rate reached a record low. Average mathematics scores for 4th- and 8th-grade students increased, and the violent crime victimization rate among youth decreased. Although the number of children living in poverty decreased slightly in 2013, overall the rate remain high at 22 percent. The percentage of children with at least one parent employed full time year round slightly increased (see Research Focus box) (Federal Interagency Forum on Child and Family Statistics, 2015).
R e s e a r c h F o c u s National Children's Study
The National Children's Study is the largest prospective, long-term study of children's health and development conducted in the United States. The study is designed to follow 100,000 children and their families from birth to 21 years old to understand the link between children's environments and their physical and emotional health and development (Duncan, Kirkendall, and Citro, 2014). Researchers hope that a study of this magnitude will provide information on innovative interventions for families, children, and health care providers to eradicate unhealthy diets, dental caries, and childhood obesity and to bring a significant reduction in violence, injury, substance abuse, and mental health disorders among the nation's children. This study supports the Healthy People 2020 primary goals to increase the quality and years of healthy life and eliminate health disparities related to race, ethnicity, and socioeconomic status (US Department of Health and Human Services, 2013a).
Millions of children and their families have no health insurance, which results in a lack of access to care and health promotion services. In addition, disparities in pediatric health care are related to race, ethnicity, socioeconomic status, and geographic factors (Flores and Lesley, 2014). Patterns of child health are shaped by medical progress and societal trends. Urgent priorities for health and health care of children in the United States are the focus for action toward new policy priorities (Box 1-1).
Box 1-1 H e a l t h a n d H e a l t h C a r e P r i o r i t i e s f o r A m e r i c a n C h i l d r e n Poverty
Hunger
Lack of health insurance
Child abuse and neglect
Overweight and obesity
Firearm deaths and injuries
Mental health
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Racial and ethnic disparities
Immigration
Adapted from Flores G, Lesley B: Children and US federal policy on health and health care: seen but not heard, JAMA Pediatr 168(12):1155-1163, 2014.
Health Promotion Child health promotion provides opportunities to reduce differences in current health status among members of different groups and to ensure equal opportunities and resources to enable all children to achieve their fullest health potential. The Healthy People 2020 Leading Health Indicators (Box 1- 2) provide a framework for identifying essential components for child health promotion programs designed to prevent future health problems in our nation's children. Bright Futures is a national health promotion initiative with a goal to improve the health of our nation's children (Bright Futures, 2014). Major themes of the Bright Futures guideline are promoting family support, child development, mental health, healthy nutrition that leads to healthy weight, physical activity, oral health, healthy sexual development and sexuality, safety and injury prevention, and the importance of community relationships and resources.* Throughout this book, developmentally appropriate health promotion strategies are discussed. Key examples of child health promotion themes essential for all age groups include promoting development, nutrition, and oral health. Bright Futures recommendations for preventative health care during infancy, early childhood and adolescents are found in Chapters 9, 11, 14, and 15.
Box 1-2 H e a l t h y Pe o p l e 2 0 2 0 Goals
Increase quality and length of healthy life
Eliminate health disparities
Leading Health Indicators
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunization
Access to health care
From US Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy People 2020, 2013, http://www.healthypeople.gov/.
Development
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Health promotion integrates surveillance of the physical, psychological, and emotional changes that occur in human beings between birth and the end of adolescence. Developmental processes are unique to each stage of development, and continuous screening and assessment are essential for early intervention when problems are found. The most dramatic time of physical, motor, cognitive, emotional, and social development occurs during infancy. Interactions between the parent and infant are central to promoting optimal developmental outcomes and are a key component of infant assessment. During early childhood, early identification of developmental delays is critical for establishing early interventions. Anticipatory guidance strategies ensure that parents are aware of the specific developmental needs of each developmental stage. Ongoing surveillance during middle childhood provides opportunities to strengthen cognitive and emotional attributes, communication skills, self-esteem, and independence. Recognition that adolescents differ greatly in their physical, social, and emotional maturity is important for surveillance throughout this developmental period.
Nutrition Nutrition is an essential component for healthy growth and development. Human milk is the preferred form of nutrition for all infants. Breastfeeding provides the infant with micronutrients, immunologic properties, and several enzymes that enhance digestion and absorption of these nutrients. A recent resurgence in breastfeeding has occurred due to the education of mothers and fathers regarding its benefits and increased social support.
Children establish lifelong eating habits during the first 3 years of life, and the nurse is instrumental in educating parents on the importance of nutrition. Most eating preferences and attitudes related to food are established by family influences and culture. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses like diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease.
Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake (Flores and Lesley, 2014). The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems.
Oral Health Oral health is an essential component of health promotion throughout infancy, childhood, and adolescence. Preventing dental caries and developing healthy oral hygiene habits must occur early in childhood. Dental caries is the single most common chronic disease of childhood. In the most recent National Surveys of Children's Health, minority children experience disparities in oral health care and were much more likely to have dental disease (Flores and Lin, 2013). The most common form of early dental disease is early childhood caries, which may begin before the first birthday and progress to pain and infection within the first 2 years of life (Kagihara, Niederhauser, and Stark, 2009). Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children. Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene, beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care. Oral health care practices established during the early years of development prevent destructive periodontal disease and dental decay.
Childhood Health Problems Changes in modern society, including advancing medical knowledge and technology, the proliferation of information systems, struggles with insurance disparities, economically troubled times, and various changes and disruptive influences on the family, are leading to significant medical problems that affect the health of children (Berdahl, Friedman, McCormick, et al, 2013; Leslie, Slaw, Edwards, et al, 2010). The new morbidity, also known as pediatric social illness, refers to the behavior, social, and educational problems that children face. Problems that can negatively impact a child's development include poverty, violence, aggression, noncompliance, school failure, and adjustment to parental separation and divorce. In addition, mental health issues cause challenges in childhood and adolescence. Recent concern has focused on groups of children who are
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at highest risk, such as children born prematurely or with very low birth weight (VLBW) or low birth weight (LBW), children attending child care centers, children who live in poverty or are homeless, children of immigrant families, and children with chronic medical and psychiatric illness and disabilities. In addition, these children and their families face multiple barriers to adequate health, dental, and psychiatric care. A perspective of several health problems facing children and the major challenges for pediatric nurses is discussed in the following sections.
Obesity and Type 2 Diabetes Childhood obesity, the most common nutritional problem among American children, is increasing in epidemic proportions (Martin, Saunders, Shenkin, et al, 2014; Giannini and Caprio, 2012). Obesity in children and adolescents is defined as a body mass index (BMI) at or greater than the 95th percentile for youth of the same age and gender. Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Over 30% of America's children are overweight and 17% are obese (Flores and Lesley, 2014).
Advancements in entertainment and technology, such as television, computers, and video games, have contributed to the growing childhood obesity problem in the United States. In the National Longitudinal Study of Adolescent Health, screen times (TV, video, computer use) interact with genetic factors to influence BMI changes (Graff, North, Monda, et al, 2011). Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low-income, minority children. Overweight youth have increased risk for cardiometabolic changes (a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, dyslipidemia, and abdominal obesity) in the future (Weiss, Bremer, and Lustig, 2013) (Fig. 1-1). The US Department of Health and Human Services (2013a) suggests that nurses focus on prevention strategies to reduce the incidence of overweight children from the current 20% in all ethnic groups to less than 6%.Emphasis is not on preventive strategies that start in infancy and even in the prenatal period. Lifestyle interventions show promise in preventing obesity and decreasing occurrence if targeted at children 6 to 12 years old (Martin, Saunders, Shenkin, et al, 2014; Waters, de Silva-Sanigorski, Hall, et al, 2011).
FIG 1-1 The American culture's intake of high-caloric, fatty food contributes to obesity in children.
Childhood Injuries Injuries are the most common cause of death and disability to children in the United States (Centers for Disease Control and Prevention, 2013) (Table 1-1). Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle accidents (MVAs) as the leading cause of injury mortality (Rockett, Regier, Kapusta, et al, 2012). Other unintentional injuries (head injuries, drowning, burns, and firearm accidents) take the lives of children every day.
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Implementing programs of accident prevention and health promotion could prevent many childhood injuries and fatalities.
TABLE 1-1 Mortality from Leading Types of Unintentional Injuries, United States, 1997 (Rate per 100,000 Population in Each Age-Group)
AGE (YEARS) Type of Accident <1 1-4 5-14 15-24 Males All causes 716.4 31.2 15.9 108.8 Unintentional injuries (all types) 33.3 10.5 5.8 48.1 Motor vehicle 2.8 (2) 3.0 (2) 3.0 (1) 29.5 (1) Drowning 1.1 (4) 3.4 (1) 0.9 (2) 2.3 (3) Fires and burns 0.5 (5) 1.1 (3) 0.5 (3) 0.4 (5) Firearms — — — — Choking 1.7 (3) 0.5 (5) — — Falls — — — 0.9 (4) Mechanical suffocation 25.0 (1) 0.6 (4) 0.2 (4) — Poisoning — — 0.1 (5) 11.2 (2) All other unintentional injuries 4.6 1.9 1.0 3.8 Accidents as a percent of all deaths 4.6% 33.7% 36.5% 44.2% Females All causes 591.7 24.7 12.0 39.2 Unintentional injuries (all types) 28.0 6.9 3.4 16.6 Motor vehicle 2.0 (2) 2.4 (1) 2.0 (1) 11.7 (1) Drowning 0.9 (4) 1.8 (2) 0.4 (2) 0.3 (3) Fires and burns 0.4 (5) 0.9 (3) 0.4 (2) 0.3 (3) Firearms — — — — Choking 1.1 (3) 0.3 (4) — — Falls — — — 0.2 (5) Mechanical suffocation 21.4 (1) 0.3 (4) 0.1 (4) — Poisoning — — 0.1 (4) 3.4 (2) All other unintentional injuries 2.1 1.1 0.4 0.8 Accidents as a percent of all deaths 4.7% 27.9% 28.3% 42.3%
Adapted from National Safety Council: Injury facts, 2012 Edition, Itaska, IL, 2012 Author. Data from National Center for Health Statistics and US Census Bureau.
The type of injury and the circumstances surrounding it are closely related to normal growth and development (Box 1-3). As children develop, their innate curiosity compels them to investigate the environment and to mimic the behavior of others. This is essential to acquire competency as an adult, but it can also predispose children to numerous hazards.
Box 1-3 C h i l d h o o d I n j u r i e s Risk Factors
• Sex—Preponderance of males; difference mainly the result of behavioral characteristics, especially aggression
• Temperament—Children with difficult temperament profile, especially persistence, high activity level, and negative reactions to new situations
• Stress—Predisposes children to increased risk taking and self-destructive behavior; general lack of self-protection
• Alcohol and drug use—Associated with higher incidence of motor vehicle injuries, drownings, homicides, and suicides
• History of previous injury—Associated with increased likelihood of another injury, especially if initial injury required hospitalization
• Developmental characteristics
• Mismatch between child's developmental level and skill required for activity (e.g., all-terrain vehicles)
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• Natural curiosity to explore environment
• Desire to assert self and challenge rules
• In older child, desire for peer approval and acceptance
• Cognitive characteristics (age specific)
• Infant—Sensorimotor: explores environment through taste and touch
• Young child—Object permanence: actively searches for attractive object; cause and effect: lacks awareness of consequential dangers; transductive reasoning: may fail to learn from experiences (e.g., perceives falling from a step as a different type of danger from climbing a tree); magical and egocentric thinking: is unable to comprehend danger to self or others
• School-age child—Transitional cognitive processes: is unable to fully comprehend causal relationships; attempts dangerous acts without detailed planning regarding consequences
• Adolescent—Formal operations: is preoccupied with abstract thinking and loses sight of reality; may lead to feeling of invulnerability
• Anatomic characteristics (especially in young children)
• Large head—Predisposes to cranial injury
• Large spleen and liver with wide costal arch—Predisposes to direct trauma to these organs
• Small and light body—May be thrown easily, especially inside a moving vehicle
• Other factors—Poverty, family stress (e.g., maternal illness, recent environmental change), substandard alternative child care, young maternal age, low maternal education, multiple siblings
The child's developmental stage partially determines the types of injuries that are most likely to occur at a specific age and helps provide clues to preventive measures. For example, small infants are helpless in any environment. When they begin to roll over or propel themselves, they can fall from unprotected surfaces. The crawling infant, who has a natural tendency to place objects in the mouth, is at risk for aspiration or poisoning. The mobile toddler, with the instinct to explore and investigate and the ability to run and climb, may experience falls, burns, and collisions with objects.
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As children grow older, their absorption with play makes them oblivious to environmental hazards such as street traffic or water. The need to conform and gain acceptance compels older children and adolescents to accept challenges and dares. Although the rate of injuries is high in children younger than 9 years old, most fatal injuries occur in later childhood and adolescence.
The pattern of deaths caused by unintentional injuries, especially from MVAs, drowning, and burns, is remarkably consistent in most Western societies. The leading causes of death from injuries for each age-group according to sex are presented in Table 1-1. The majority of deaths from injuries occur in boys. It is important to note that accidents continue to account for more than three times as many teen deaths as any other cause (Annie E Casey Foundation, 2014). Fortunately, prevention strategies such as the use of car restraints, bicycle helmets, and smoke detectors have significantly decreased fatalities for children. Nevertheless, the overwhelming causes of death in children are MVAs, including occupant, pedestrian, bicycle, and motorcycle deaths; these account for more than half of all injury deaths (Centers for Disease Control and Prevention, 2014) (Fig. 1-2).
FIG 1-2 Motor vehicle injuries are the leading cause of death in children older than 1 year of age. The majority of fatalities involve occupants who are unrestrained.
Pedestrian accidents involving children account for significant numbers of motor vehicle–related deaths. Most of these accidents occur at midblock, at intersections, in driveways, and in parking lots. Driveway injuries typically involve small children and large vehicles backing up.
Bicycle-associated injuries also cause a number childhood deaths. Children ages 5 to 9 years old are at greatest risk of bicycling fatalities. The majority of bicycling deaths are from traumatic head injuries (Centers for Disease Control, 2014). Helmets greatly reduce the risk of head injury, but few children wear helmets. Community-wide bicycle helmet campaigns and mandatory-use laws have resulted in significant increases in helmet use. Still, issues such as stylishness, comfort, and social acceptability remain important factors in noncompliance. Nurses can educate children and families about pedestrian and bicycle safety. In particular, school nurses can promote helmet wearing and encourage peer leaders to act as role models.
Drowning and burns are among the top three leading causes of deaths for males and females throughout childhood (Fig. 1-3). In addition, improper use of firearms is a major cause of death among males (Fig. 1-4). During infancy, more boys die from aspiration or suffocation than do girls (Fig. 1-5). Each year, more than 500,000 children ages 5 and under experience a potential poisoning related to medications (Bond, Woodward, and Ho, 2011). Currently, more children are brought to emergency departments for unintentional medication overdoses. Approximately 95% of medication-related emergency room visits in children under age 5 are due to ingesting medication while unsupervised (Budnitz and Salis, 2011) (Fig. 1-6). Intentional poisoning, associated with drug and alcohol abuse and suicide attempt, is the second leading cause of death in adolescent females and the third leading cause in adolescent males.
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FIG 1-3 A, Drowning is one of the leading causes of death. Children left unattended are unsafe even in shallow water. B, Burns are among the top three leading causes of death from injury in children 1 to 14
years old.
FIG 1-4 Improper use of firearms is the fourth leading cause of death from injury in children 5 to 14 years old. (©2012 Photos.com, a division of Getty Images. All rights reserved.)
FIG 1-5 Mechanical suffocation is the leading cause of death from injury in infants.
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FIG 1-6 Poisoning causes a considerable number of injuries in children younger than 4 years old. Medications should never be left where young children can reach them.
Violence Youth violence is a high-visibility, high-priority concern in every sector of American society (US Department of Health and Human Services, 2013b). Strikingly higher homicide rates are found among minority populations, especially African-American children. The causes of violence against children and self-inflicted violence are not fully understood. Violence seems to permeate American households through television programs, commercials, video games, and movies, all of which tend to desensitize the child toward violence. Violence also permeates the schools with the availability of guns, illicit drugs, and gangs. The problem of child homicide is extremely complex and involves numerous social, economic, and other influences. Prevention lies in a better understanding of the social and psychologic factors that lead to the high rates of homicide and suicide. Nurses need to be especially aware of young people who harm animals or start fires, are depressed, are repeatedly in trouble with the criminal justice system, or are associated with groups known to be violent. Prevention requires early identification and rapid therapeutic intervention by qualified professionals.
Pediatric nurses can assess children and adolescents for risk factors related to violence. Families that own firearms must be educated about their safe use and storage. The presence of a gun in a household increases the risk of suicide by about fivefold and the risk of homicide by about threefold. Technologic changes such as childproof safety devices and loading indicators could improve the safety of firearms (see Community Focus box).
C o m m u n i t y F o c u s Violence in Children
Community violence has reached epidemic proportions in the United States. The serious problem of community violence affects the lives of many children and expands throughout the family, schools, and the workplace. Nurses working with children, adolescents, and families have a critical role in reducing violence through early identification and symptom recognition of the mental- emotional stress that can result from these experiences.
Violent crimes continue to be a significant health issue for children, with homicide being the second leading cause of death in 15- to 19-year-olds (Annie E Casey Foundation, 2014). The multifaceted origins of violence include developmental factors, gang involvement, access to firearms, drugs, the media, poverty, and family conflict. Often the silent and underrecognized victims are the children who witness acts of community violence. Studies suggest that chronic exposure to violence has a negative effect on a child's cognitive, social, psychologic, and moral development. Also, multiple exposures to episodes of violence do not inoculate children against
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the negative effects; continued exposure can result in lasting symptoms of stress. National concern about the increasing prevalence of violent crimes has prompted nurses to
actively participate in ensuring that children grow up in safe environments. Pediatric nurses are positioned to assess children and adolescents for signs of exposure to violence and well-known risk factors; nurses also can provide nonviolent problem-solving strategies, counseling, and referrals. These activities affect community practice and expand the nurse's role in the future health environment. Professional resources include the following:
National Domestic Violence Hotline
PO Box 161810
Austin, TX 78716
800-799-SAFE
www.ndvh.org
Child Trends Child Trends Databank. Teen homicide, suicide, and firearm deaths. http://www.childtrends.org/?
indicators=teen-homicide-suicide-and-firearm-deaths; 2015.
Mental Health Problems One out of five children experience mental health problems, and one out of 10 has a serious emotional problem that affects daily functioning (Flores and Lesley, 2014). Currently the top five chronic conditions are related to mental health issues (Slomski, 2012). Psychosocial problems in children seen in primary care settings in rural areas are common (Polaha, Dalton, and Allen, 2011). Many adolescents with anxiety disorders and impulse control disorders (such as conduct disorder or attention-deficit/hyperactivity disorder [ADHD]) develop these during adolescence. Nurses should be alert to the symptoms of mental illness and potential suicidal ideation and be aware of potential resources for high-quality integrated mental health services.
Infant Mortality The infant mortality rate is the number of deaths during the first year of life per 1000 live births. It may be further divided into neonatal mortality (<28 days of life) and postneonatal mortality (28 days to 11 months). In the United States, infant mortality has decreased dramatically; the rate is approximately 200 infant deaths per 1000 live births (Center for Disease Control and Prevention, 2014).
From a worldwide perspective, however, the United States lags behind other nations in reducing infant mortality. In 2013 the United States ranked last among 29 nations recording 40,000 births or more. Japan, Finland, and Norway have the three lowest rates, with the United States ranked last behind Hungary and the Slovak Republic (Osterman, Kochanek, MacDorman, et al., 2015).
Birth weight is considered the major determinant of neonatal death in technologically developed countries. The relatively high incidence of LBW (<2500 g [5.5 pounds]) in the United States is considered a key factor in its higher neonatal mortality rate when compared with other countries. Access to and the use of high-quality prenatal care are promising preventive strategies to decrease early delivery and infant mortality.
As Table 1-2 demonstrates, many of the leading causes of death during infancy continue to occur during the perinatal period. The first four causes—congenital anomalies, disorders relating to short gestation and unspecified LBW, sudden infant death syndrome, and newborn affected by maternal complications of pregnancy—accounted for about half (52%) of all deaths of infants younger than 1 year old (Osterman, Kochanek, MacDorman, et al., 2015). Many birth defects are associated with LBW, and reducing the incidence of LBW will help prevent congenital anomalies. Infant mortality resulting from human immunodeficiency virus (HIV) infection decreased significantly during the 1990s.
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TABLE 1-2 Infant Mortality Rate and Percentage of Total Deaths for 10 Leading Causes of Infant Death in 2013 (Rate per 1000 Live Births)
Rank Cause of Death (Based on International Classification of Diseases, 10th Revision) Percent Rate All races, all causes 100.00% 596.1
1 Congenital anomalies 20.3 121 2 Disorders relating to short gestation and unspecified low birth weight 17.9 106.9 3 Newborn affected by maternal complication of pregnancy 6.7 39.7 4 Sudden infant death syndrome 6.1 40.6 5 Accidents (unintentional injuries) 4.9 29.4 6 Newborn affected by complications of placenta, cord, and membranes 4.1 24.2 7 Bacterial sepsis of newborn 2.5 14.7 8 Respiratory distress of newborn 2.2 13.3 9 Diseases of circulatory system 2.0 11.6 10 Neonatal hemorrhage 2.1 9.9
Modified from Osterman MJK, Kochanek KD, MacDorman MF, et al: Annual summary of vital statistics: 2012-2013, Pediatrics 135(6): 1115-1125.
When infant death rates are categorized according to race, a disturbing difference is seen. Infant mortality for Caucasians is considerably lower than for all other races in the United States, with African-Americans having twice the rate of Caucasians. The LBW rate is also much higher for African-American infants than for any other group. One encouraging note is that the gap in mortality rates between Caucasian and non-Caucasian races (other than African-Americans) has narrowed in recent years. Infant mortality rates for Hispanics and Asian-Pacific Islanders have decreased dramatically during the past two decades.
Childhood Mortality Death rates for children older than 1 year of age have always been lower than those for infants. Children ages 5 to 14 years have the lowest rate of death. However, a sharp rise occurs during later adolescence, primarily from injuries, homicide, and suicide (Table 1-3). In 2013, accidental injuries accounted for 34.4% of all deaths. The second leading cause of death was homicide, accounting for 10.7% of all deaths (Osterman, Kochanek, MacDorman, et al., 2015). The trend in racial differences that occurs in infant mortality is also apparent in childhood deaths for all ages and for both sexes. Caucasians have fewer deaths for all ages, and male deaths outnumber female deaths.
TABLE 1-3 Five Leading Causes of Death in Children in the United States: Selected Age Intervals, 2013 (Rate per 100,000 Population)
1 TO 4 YEARS OLD 5 TO 9 YEARS OLD 10 TO 14 YEARS OLD 15 TO 19 YEARS OLD Rank Cause Rate Cause Rate Cause Rate Cause Rate
All causes 25.5 All causes 11.8 All causes 14.1 All causes 44.8 1 Accidents 8.3 Accidents 3.6 Accidents 3.8 Accidents 17.3 2 Congenital anomalies 3.0 Cancer 2.2 Cancer 2.2 Suicide 8.3 3 Homicide 2.1 Congenital anomalies 0.9 Suicide 1.9 Homicide 6.6 4 Cancer 2.1 Homicide 0.6 Congenital anomalies 0.8 Cancer 3.0 5 Heart disease 1.1 Respiratory Disease 0.4 Homicide 0.7 Heart disease 1.4
Modified from Osterman MJK, Kochanek KD, MacDorman MF, et al: Annual summary of vital statistics: 2012-2013, Pediatrics 135(6): 1115-1125.
After 1 year of age, the cause of death changes dramatically, with unintentional injuries (accidents) being the leading cause from the youngest ages to the adolescent years. Violent deaths have been steadily increasing among young people ages 10 through 25 years, especially African- Americans and males. Homicide is the third leading cause of death in the 15- to 19-year age-group (see Table 1-3). Children 12 years old and older tend to be killed by nonfamily members (acquaintances and gangs, typically of the same race) and most frequently by firearms. Suicide, a form of self-violence, continues to be a leading cause of death among children and adolescents 10 to 19 years old.
Childhood Morbidity Acute illness is defined as an illness with symptoms severe enough to limit activity or require medical attention. Respiratory illness accounts for approximately 50% of all acute conditions, 11% are caused by infections and parasitic disease, and 15% are caused by injuries. The chief illness of childhood is the common cold.
The types of diseases that children contract during childhood vary according to age. For example,
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upper respiratory tract infections and diarrhea decrease in frequency with age, whereas other disorders, such as acne and headaches, increase. Children who have had a particular type of problem are more likely to have that problem again. Morbidity is not distributed randomly in children. Recent concern has focused on groups of children who have increased morbidity: homeless children, children living in poverty, LBW children, children with chronic illnesses, foreign-born adopted children, and children in day care centers. A number of factors place these groups at risk for poor health. A major cause is barriers to health care, especially for the homeless, the poverty stricken, and those with chronic health problems. Other factors include improved survival of children with chronic health problems, particularly infants of VLBW.
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The Art of Pediatric Nursing Philosophy of Care Nursing of infants, children, and adolescents is consistent with the American Nurses Association (2010) definition of nursing as the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, and populations.
Family-Centered Care The philosophy of family-centered care recognizes the family as the constant in a child's life. Family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families (Institute for Patient- and Family-Centered Care, 2014). Nurses support families in their natural caregiving and decision-making roles by building on their unique strengths and acknowledging their expertise in caring for their child both within and outside the hospital setting. The nurse considers the needs of all family members in relation to the care of the child (Box 1-4). The philosophy acknowledges diversity among family structures and backgrounds; family goals, dreams, strategies, and actions; and family support, service, and information needs.
Box 1-4 K e y E l e m e n t s o f F a m i l y - C e n t e r e d C a r e • Incorporating into policy and practice the recognition that the family is the constant in a child's
life, whereas the service systems and support personnel within those systems fluctuate
• Facilitating family-professional collaboration at all levels of hospital, home, and community care:
• Care of an individual child
• Program development, implementation, and evaluation
• Policy formation
• Exchanging complete and unbiased information between family members and professionals in a supportive manner at all times
• Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality within and across all families, including ethnic, racial, spiritual, social, economic, educational, and geographic diversity
• Recognizing and respecting different methods of coping and implementing comprehensive policies and programs that provide developmental, educational, emotional, environmental, and financial support to meet the diverse needs of families
• Encouraging and facilitating family-to-family support and networking
• Ensuring that home, hospital, and community service and support systems for children needing specialized health and developmental care and their families are flexible, accessible, and comprehensive in responding to diverse family-identified needs
• Appreciating families as families and children as children, recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support
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From Shelton TL, Stepanek JS: Family-centered care for children needing specialized health and developmental services. Bethesda, MD, 1994, Association for the Care of Children's Health.
Two basic concepts in family-centered care are enabling and empowerment. Professionals enable families by creating opportunities and means for all family members to display their current abilities and competencies and to acquire new ones to meet the needs of the child and family. Empowerment describes the interaction of professionals with families in such a way that families maintain or acquire a sense of control over their family lives and acknowledge positive changes that result from helping behaviors that foster their own strengths, abilities, and actions.
Although caring for the family is strongly emphasized throughout this text, it is highlighted in features such as Cultural Considerations and Family-Centered Care boxes.
Atraumatic Care Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and their families in the health care system. Therapeutic care encompasses the prevention, diagnosis, treatment, or palliation of acute or chronic conditions. Setting refers to the place in which that care is given—the home, the hospital, or any other health care setting. Personnel include anyone directly involved in providing therapeutic care. Interventions range from psychologic approaches, such as preparing children for procedures, to physical interventions, such as providing space for a parent to room in with a child. Psychologic distress may include anxiety, fear, anger, disappointment, sadness, shame, or guilt. Physical distress may range from sleeplessness and immobilization to disturbances from sensory stimuli, such as pain, temperature extremes, loud noises, bright lights, or darkness. Thus atraumatic care is concerned with the where, who, why, and how of any procedure performed on a child for the purpose of preventing or minimizing psychologic and physical stress (Wong, 1989).
The overriding goal in providing atraumatic care is: First, do no harm. Three principles provide the framework for achieving this goal: (1) prevent or minimize the child's separation from the family, (2) promote a sense of control, and (3) prevent or minimize bodily injury and pain. Examples of providing atraumatic care include fostering the parent-child relationship during hospitalization, preparing the child before any unfamiliar treatment or procedure, controlling pain, allowing the child privacy, providing play activities for expression of fear and aggression, providing choices to children, and respecting cultural differences.
Role of the Pediatric Nurse The pediatric nurse is responsible for promoting the health and well-being of the child and family. Nursing functions vary according to regional job structures, individual education and experience, and personal career goals. Just as patients (children and their families) have unique backgrounds, each nurse brings an individual set of variables that affect the nurse-patient relationship. No matter where pediatric nurses practice, their primary concern is the welfare of the child and family.
Therapeutic Relationship The establishment of a therapeutic relationship is the essential foundation for providing high- quality nursing care. Pediatric nurses need to have meaningful relationships with children and their families and yet remain separate enough to distinguish their own feelings and needs. In a therapeutic relationship, caring, well-defined boundaries separate the nurse from the child and family. These boundaries are positive and professional and promote the family's control over the child's health care. Both the nurse and the family are empowered and maintain open communication. In a nontherapeutic relationship, these boundaries are blurred, and many of the nurse's actions may serve personal needs, such as a need to feel wanted and involved, rather than the family's needs.
Exploring whether relationships with patients are therapeutic or nontherapeutic helps nurses identify problem areas early in their interactions with children and families (see Nursing Care Guidelines box). Although questions regarding the nurse's involvement may label certain actions negative or positive, no one action makes a relationship therapeutic or nontherapeutic. For example, a nurse may spend additional time with the family but still recognize his or her own needs and
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maintain professional separateness. An important clue to nontherapeutic relationships is the staff's concerns about their peer's actions with the family.
N u r s i n g C a r e G u i d e l i n e s Exploring Your Relationships with Children and Families
To foster therapeutic relationships with children and families, you must first become aware of your caregiving style, including how effectively you take care of yourself. The following questions should help you understand the therapeutic quality of your professional relationships.
Negative Actions
• Are you overinvolved with children and their families?
• Do you work overtime to care for the family?
• Do you spend off-duty time with children's families, either in or out of the hospital?
• Do you call frequently (either the hospital or home) to see how the family is doing?
• Do you show favoritism toward certain patients?
• Do you buy clothes, toys, food, or other items for the child and family?
• Do you compete with other staff members for the affection of certain patients and families?
• Do other staff members comment to you about your closeness to the family?
• Do you attempt to influence families' decisions rather than facilitate their informed decision making?
• Are you underinvolved with children and families?
• Do you restrict parent or visitor access to children, using excuses such as the unit is too busy?
• Do you focus on the technical aspects of care and lose sight of the person who is the patient?
• Are you overinvolved with children and underinvolved with their parents?
• Do you become critical when parents do not visit their children?
• Do you compete with parents for their children's affection?
Positive Actions
• Do you strive to empower families?
• Do you explore families' strengths and needs in an effort to increase family involvement?
• Have you developed teaching skills to instruct families rather than doing everything for them?
• Do you work with families to find ways to decrease their dependence on health care providers?
• Can you separate families' needs from your own needs?
• Do you strive to empower yourself?
• Are you aware of your emotional responses to different people and situations?
• Do you seek to understand how your own family experiences influence reactions to patients and
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families, especially as they affect tendencies toward overinvolvement or underinvolvement?
• Do you have a calming influence, not one that will amplify emotionality?
• Have you developed interpersonal skills in addition to technical skills?
• Have you learned about ethnic and religious family patterns?
• Do you communicate directly with persons with whom you are upset or take issue?
• Are you able to “step back” and withdraw emotionally, if not physically, when emotional overload occurs, yet remain committed?
• Do you take care of yourself and your needs?
• Do you periodically interview family members to determine their current issues (e.g., feelings, attitudes, responses, wishes), communicate these findings to peers, and update records?
• Do you avoid relying on initial interview data, assumptions, or gossip regarding families?
• Do you ask questions if families are not participating in care?
• Do you assess families for feelings of anxiety, fear, intimidation, worry about making a mistake, a perceived lack of competence to care for their child, or fear of health care professionals overstepping their boundaries into family territory, or vice versa?
• Do you explore these issues with family members and provide encouragement and support to enable families to help themselves?
• Do you keep communication channels open among self, family, physicians, and other care providers?
• Do you resolve conflicts and misunderstandings directly with those who are involved?
• Do you clarify information for families or seek the appropriate person to do so?
• Do you recognize that from time to time a therapeutic relationship can change to a social relationship or an intimate friendship?
• Are you able to acknowledge the fact when it occurs and understand why it happened?
• Can you ensure that there is someone else who is more objective who can take your place in the therapeutic relationship?
Family Advocacy and Caring Although nurses are responsible to themselves, the profession, and the institution of employment, their primary responsibility is to the consumer of nursing services: the child and family. The nurse must work with family members, identify their goals and needs, and plan interventions that best address the defined problems. As an advocate, the nurse assists the child and family in making informed choices and acting in the child's best interest. Advocacy involves ensuring that families are aware of all available health services, adequately informed of treatments and procedures, involved in the child's care, and encouraged to change or support existing health care practices.
As nurses care for children and families, they must demonstrate caring, compassion, and empathy for others. Aspects of caring embody the concept of atraumatic care and the development of a therapeutic relationship with patients. Parents perceive caring as a sign of quality in nursing care, which is often focused on the nontechnical needs of the child and family. Parents describe “personable” care as actions by the nurse that include acknowledging the parent's presence, listening, making the parent feel comfortable in the hospital environment, involving the parent and child in the nursing care, showing interest in and concern for their welfare, showing affection and sensitivity to the parent and child, communicating with them, and individualizing the nursing care.
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Parents perceive personable nursing care as being integral to establishing a positive relationship.
Disease Prevention and Health Promotion Every nurse involved in caring for children must understand the importance of disease prevention and health promotion. A nursing care plan must include a thorough assessment of all aspects of child growth and development, including nutrition, immunizations, safety, dental care, socialization, discipline, and education. If problems are identified, the nurse intervenes directly or refers the family to other health care providers or agencies.
The best approach to prevention is education and anticipatory guidance. In this text, each chapter on health promotion includes sections on anticipatory guidance. An appreciation of the hazards or conflicts of each developmental period enables the nurse to guide parents regarding childrearing practices aimed at preventing potential problems. One significant example is safety. Because each age-group is at risk for special types of injuries, preventive teaching can significantly reduce injuries, lowering permanent disability and mortality rates.
Prevention also involves less obvious aspects of caring for children. The nurse is responsible for providing care that promotes mental well-being (e.g., enlisting the help of a child life specialist during a painful procedure, such as an immunization).
Health Teaching Health teaching is inseparable from family advocacy and prevention. Health teaching may be the nurse's direct goal, such as during parenting classes, or may be indirect, such as helping parents and children understand a diagnosis or medical treatment, encouraging children to ask questions about their bodies, referring families to health-related professional or lay groups, supplying patients with appropriate literature, and providing anticipatory guidance.
Health teaching is one area in which nurses often need preparation and practice with competent role models, because it involves transmitting information at the child's and family's level of understanding and desire for information. As an effective educator, the nurse focuses on providing the appropriate health teaching with generous feedback and evaluation to promote learning.
Injury Prevention Each year, injuries kill or disable more children older than 1 year old than all childhood diseases combined. The nurse plays an important role in preventing injuries by using a developmental approach to safety counseling for parents of children of all ages. Realizing that safety concerns for a young infant are completely different than injury risks of adolescents, the nurse discusses appropriate injury preventions tips to parents and children as part of routine patient care.
Support and Counseling Attention to emotional needs requires support and, sometimes, counseling. The role of child advocate or health teacher is supportive by virtue of the individualized approach. The nurse can offer support by listening, touching, and being physically present. Touching and physical presence are most helpful with children, because they facilitate nonverbal communication. Counseling involves a mutual exchange of ideas and opinions that provides the basis for mutual problem solving. It involves support, teaching, techniques to foster the expression of feelings or thoughts, and approaches to help the family cope with stress. Optimally, counseling not only helps resolve a crisis or problem but also enables the family to attain a higher level of functioning, greater self- esteem, and closer relationships. Although counseling is often the role of nurses in specialized areas, counseling techniques are discussed in various sections of this text to help students and nurses cope with immediate crises and refer families for additional professional assistance.
Coordination and Collaboration The nurse, as a member of the health care team, collaborates and coordinates nursing care with the care activities of other professionals. A nurse working in isolation rarely serves the child's best interests. The concept of holistic care can be realized through a unified, interdisciplinary approach by being aware of individual contributions and limitations and collaborating with other specialists to provide high-quality health services. Failure to recognize limitations can be nontherapeutic at best and destructive at worst. For example, the nurse who feels competent in counseling but who is
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really inadequate in this area may not only prevent the child from dealing with a crisis but also impede future success with a qualified professional. Nursing should be seen as a major contributor to assuring a health care team focuses on high-quality, safe care.
Ethical Decision Making Ethical dilemmas arise when competing moral considerations underlie various alternatives. Parents, nurses, physicians, and other health care team members may reach different but morally defensible decisions by assigning different weights to competing moral values. These competing moral values may include autonomy, the patient's right to be self-governing; nonmaleficence, the obligation to minimize or prevent harm; beneficence, the obligation to promote the patient's well-being; and justice, the concept of fairness. Nurses must determine the most beneficial or least harmful action within the framework of societal mores, professional practice standards, the law, institutional rules, the family's value system and religious traditions, and the nurse's personal values.
Nurses must prepare themselves systematically for collaborative ethical decision making. They can accomplish this through formal course work, continuing education, contemporary literature, and work to establish an environment conducive to ethical discourse.
The nurse also uses the professional code of ethics for guidance and as a means for professional self-regulation. Nurses may face ethical issues regarding patient care, such as the use of lifesaving measures for VLBW newborns or the terminally ill child's right to refuse treatment. They may struggle with questions regarding truthfulness, balancing their rights and responsibilities in caring for children with acquired immune deficiency syndrome (AIDS), whistle-blowing, or allocating resources. Conflicting ethical arguments are presented to help nurses clarify their value judgments when confronted with sensitive issues.
Research and Evidence-Based Practice Nurses should contribute to research because they are the individuals observing human responses to health and illness. The current emphasis on measurable outcomes to determine the efficacy of interventions (often in relation to the cost) demands that nurses know whether clinical interventions result in positive outcomes for their patients. This demand has influenced the current trend toward evidence-based practice (EBP), which implies questioning why something is effective and whether a better approach exists. The concept of EBP also involves analyzing and translating published clinical research into the everyday practice of nursing. When nurses base their clinical practice on science and research and document their clinical outcomes, they will be able to validate their contributions to health, wellness, and cure, not only to their patients, third-party payers, and institutions but also to the nursing profession. Evaluation is essential to the nursing process, and research is one of the best ways to accomplish this.
EBP is the collection, interpretation, and integration of valid, important, and applicable patient- reported, nurse-observed, and research-derived information. Using the PICOT (population/patient problem, intervention, comparison, outcome and time) question to clearly define the problem of interest, nurses are able to obtain the best evidence to impact care. Evidence-based nursing practice combines knowledge with clinical experience and intuition. It provides a rational approach to decision-making that facilitates best practice (Melnyk and Fineholt-Overholt, 2014). EBP is an important tool that complements the nursing process by using critical thinking skills to make decisions based on existing knowledge. The traditional nursing process approach to patient care can be used to conceptualize the essential components of EBP nursing. During the assessment and diagnostic phases of the nursing process, the nurse establishes important clinical questions and completes a critical review of existing knowledge. EBP also begins with identification of the problem. The nurse asks clinical questions in a concise, organized way that allows for clear answers. Once the specific questions are identified, extensive searching for the best information to answer the question begins. The nurse evaluates clinically relevant research, analyzes findings from the history and physical examinations, and reviews the specific pathophysiology of the defined problem. The third step in the nursing process is to develop a care plan. In evidence-based nursing practice, the care plan is established on completion of a critical appraisal of what is known and not known about the defined problem. Next, in the traditional nursing process, the nurse implements the care plan. By integrating evidence with clinical expertise, the nurse focuses care on the patient's unique needs. The final step in EBP is consistent with the final phase of the nursing process—to evaluate the
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effectiveness of the care plan. Searching for evidence in this modern era of technology can be overwhelming. For nurses to
implement EBP, they must have access to appropriate, recent resources such as online search engines and journals. In many institutions, computer terminals are available on patient care units, with the Internet and online journals easily accessible. Another important resource for the implementation of EBP is time. The nursing shortage and ongoing changes in many institutions have compounded the issue of nursing time allocation for patient care, education, and training. In some institutions, nurses are given paid time away from performing patient care to participate in activities that promote EBP. This requires an organizational environment that values EBP and its potential impact on patient care. As knowledge is generated regarding the significant impact of EBP on patient care outcomes, it is hoped that the organizational culture will change to support the staff nurse's participation in EBP. As the amount of available evidence increases, so does our need to critically evaluate the evidence.
Throughout this book, Evidence-Based Practice boxes summarize the existing evidence that promotes excellence in clinical care. The GRADE criteria are used to evaluate the quality of research articles used to develop practice guidelines (Guyatt, Oxman, Vist, et al, 2008). Table 1-4 defines how the nurse rates the quality of the evidence using the GRADE criteria and establishes a strong versus weak recommendation. Each Evidence-Based Practice box rates the quality of existing evidence and the strength of the recommendation for practice change.
TABLE 1-4 The Grade Criteria to Evaluate the Quality of the Evidence
Quality Type of Evidence High Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies Moderate Evidence from RCTs with important limitations (inconsistent results, flaws in methodology, indirect evidence, or imprecise results) or unusually strong evidence from unbiased
observational studies Low Evidence for at least one critical outcome from observational studies, from RCTs with serious flaws, or from indirect evidence Very Low
Evidence for at least one of the critical outcomes from unsystematic clinical observations or very indirect evidence
Quality Recommendation Strong Desirable effects clearly outweigh undesirable effects, or vice versa Weak Desirable effects closely balanced with undesirable effects
RCT, Randomized clinical trial. Adapted from Guyatt GH, Oxman AD, Vist GE, et al: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, BMJ 336:924-926, 2008.
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Clinical Reasoning and the Process of Providing Nursing Care to Children and Families Clinical Reasoning A systematic thought process is essential to a profession. It assists the professional in meeting the patient's needs. Clinical reasoning is a cognitive process that uses formal and informal thinking to gather and analyze patient data, evaluate the significant of the information, and consider alternative actions (Simmons, 2010). It is based on the scientific method of inquiry, which is also the basis for the nursing process. Clinical reasoning and the nursing process are considered crucial to professional nursing in that they constitute a holistic approach to problem solving.
Clinical reasoning is a complex developmental process based on rational and deliberate thought. Clinical reasoning provides a common denominator for knowledge that exemplifies disciplined and self-directed thinking. The knowledge is acquired, assessed, and organized by thinking through the clinical situation and developing an outcome focused on optimum patient care. Clinical reasoning transforms the way in which individuals view themselves, understand the world, and make decisions. In recognition of the importance of this skill, Critical Thinking Exercises included in this text demonstrate the importance of clinical reasoning. These exercises present a nursing practice situation that challenges the student to use the skills of clinical reasoning to come to the best conclusion. A series of questions lead the student to explore the evidence, assumptions underlying the problem, nursing priorities, and support for nursing interventions that allow the nurse make a rational and deliberate response. These exercises are designed to enhance nursing performance in clinical reasoning.
Nursing Process The nursing process is a method of problem identification and problem solving that describes what the nurse actually does. The nursing process model includes assessment, diagnosis outcomes identification, planning, implementation, and evaluation (American Nurses Association, 2010).
Assessment Assessment is a continuous process that operates at all phases of problem solving and is the foundation for decision-making. Assessment involves multiple nursing skills and consists of the purposeful collection, classification, and analysis of data from a variety of sources. To provide an accurate and comprehensive assessment, the nurse must consider information about the patient's biophysical, psychologic, sociocultural, and spiritual background.
Diagnosis The next stage of the nursing process is problem identification and nursing diagnosis. At this point, the nurse must interpret and make decisions about the data gathered. Not all children have actual health problems; some have a potential health problem, which is a risk state that requires nursing intervention to prevent the development of an actual problem. Potential health problems may be indicated by risk factors, or signs and predispose a child and family to a dysfunctional health pattern and are limited to individuals at greater risk than the population as a whole. Nursing interventions are directed toward reducing risk factors. To differentiate actual from potential health problems, the word risk is included in the nursing diagnosis statement (e.g., Risk for Infection).
Signs and symptoms refer to a cluster of cues and defining characteristics that are derived from patient assessment and indicate actual health problems. When a defining characteristic is essential for the diagnosis to be made, it is considered critical. These critical defining characteristics help differentiate between diagnostic categories. For example, in deciding between the diagnostic categories related to family function and coping, the nurse uses defining characteristics to choose the most appropriate nursing diagnosis (see Family-Centered Care box).
F a m i l y - C e n t e r e d C a r e
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Using Defining Characteristics to Select an Appropriate Nursing Diagnosis
An 18-month-old only child is admitted with respiratory distress and a presumptive diagnosis of epiglottitis. Initial nursing actions focus on the child's physiologic status. As the condition stabilizes, the nurse gathers family assessment data. The child's immunizations are current, he is clean and well nourished, and his developmental age is appropriate. The parents are both present at admission. The mother is distraught about the sudden onset of respiratory distress. She states that earlier her child had only a “runny nose,” and she thought it was just a cold. When the child suddenly began to have difficulty breathing, she felt helpless and unable to relieve her child's discomfort. She states, “Nothing I did made him any better. If I had known this could happen, I would have brought him to the hospital sooner. I feel like a bad mother.” In the hospital, after explanations by the nurses, the mother understands that epiglottitis is a sudden illness that typically follows symptoms of a cold. She is cooperative and asks what she can do to make her child more comfortable. She implements all the suggestions of the health care team. The father supports both the child and mother, although he assumes a more passive “listening” role.
Three nursing diagnoses that relate to family and parent situations may be relevant. The first step is to review the diagnoses and the defining characteristics and decide which one is most appropriate:
1. Parenting, Impaired—Inability of the primary caretaker to create, maintain, or regain an environment that nurtures the child's growth and development Selected defining characteristics:
• Insecure (or lack of) attachment to infant
• Poor or inappropriate caretaking skills
2. Conflict, Parental Role—Parent experience of role confusion and conflict in response to crisis Selected defining characteristics:
• Parent expressing concerns about changes in parental role
• A demonstrated disruption in care or caretaking routines
• Parent expressing concerns or feelings of inadequacy to provide for the child's physical and emotional needs during hospitalization or in the home
• Parent verbalizing or demonstrating feelings of guilt, anger, fear, anxiety, or frustration about effect of child's illness on family process
3. Family Processes, Interrupted—A change in family relationships or functioning Selected defining characteristics:
• Expressions of conflict within the family
• Changes in communication patterns among family members
Of these three diagnoses, the most relevant one is Conflict, Parental Role. The parents demonstrate attachment behavior to their child and are attentive to his needs. They appear to have
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appropriate parenting skills and are able to communicate effectively with each other. Neither parent expressed any conflict within the family. The sudden onset of this child's illness has interrupted the mother's usual role and caused her to feel inadequate, anxious, and guilty. However, the mother is able to adapt to this crisis. She demonstrates an ability to cope by learning and implementing new comforting skills for her child. The defining characteristics of the other two diagnoses require maladaptive characteristics that are clearly not demonstrated by these parents.
Outcomes Identification The goal for outcomes identification is to establish priorities and select expected patient outcomes or goals. The nurse organizes information during assessment and diagnosis and clusters these data into categories to identify significant areas and makes one of the following decisions: • No dysfunctional health problems are evident; health promotion is emphasized. • Risk for dysfunctional health problems exists; interventions are needed for health promotion and
illness prevention. • Actual dysfunctional health problems are evident; interventions are needed for illness
management, illness prevention, and health promotion. • Specific outcomes are formulated to address the realistic patient- and family-focused goals.
Planning After identifying specific patient- and family-focused goals, the nurse develops a care plan specific to the identified outcomes. The outcome is the projected or expected change in a patient's health status, clinical condition, or behavior that occurs after nursing interventions have been instituted. The care plan must be established before specific nursing interventions are developed and implemented.
Implementation The implementation phase begins when the nurse puts the selected intervention into action and accumulates feedback data regarding its effects (or the patient's response to the intervention). The feedback returns in the form of observation and communication and provides a database on which to evaluate the outcome of the nursing intervention. It is imperative that continual assessment of the patient's status occurs throughout all phases of the nursing process, thus making the process a dynamic rather than static problem-solving method. Throughout the implementation stage, the main concerns are the patient's physical safety and psychologic comfort in terms of atraumatic care.
Evaluation Evaluation is the last step in the nursing care process. The nurse gathers, sorts, and analyzes data to determine whether (1) the established outcome has been met, (2) the nursing interventions were appropriate, (3) the plan requires modification, or (4) other alternatives should be considered. The evaluation phase either completes the nursing process (outcome is met) or serves as the basis for selecting alternative interventions to solve the specific problem.
With the current focus on patient outcomes in health care, the patient's care is evaluated not only at discharge but thereafter as well to ensure that the outcomes are met and there is adequate care for resolving existing or potential health problems. One federal agency that has developed clinical guidelines is the Agency for Healthcare Research and Quality.*
Documentation Although documentation is not one of the steps of the nursing process, it is essential for evaluation. The nurse can assess, diagnose, and identify problems; plan; and implement without documentation; however, evaluation is best performed with written evidence of progress toward outcomes. The patient's medical record should include evidence of those elements listed in the Nursing Care Guidelines box.
N u r s i n g C a r e G u i d e l i n e s Documentation of Nursing Care
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• Initial assessments and reassessments
• Nursing diagnoses and/or patient care needs
• Interventions identified to meet the patient's nursing care needs
• Nursing care provided
• Patient's response to, and the outcomes of, the care provided
• Abilities of patient and/or, as appropriate, significant other(s) to manage continuing care needs after discharge
Quality Outcome Measures Quality of care refers to the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 2000).
To provide a perspective on the importance of quality in health care, in March 2011, the US Department of Health and Human Services released the inaugural report to Congress on the National Strategy for Quality Improvement in Health Care (National Strategy for Quality Improvement in Health Care, 2012). The National Quality Strategy† focuses on six domains that establish the priorities for health care quality improvement. These domains are: • Patient and family engagement • Patient safety • Care coordination • Population/public health • Efficient use of health care resources • Clinical process/effectiveness
A 2013 Hastings Center Report stresses the importance of viewing health care institutions as learning health care systems committed to carrying out quality patient care activities. As health care systems continue to evolve, it is evident that clinical practice cannot be of the highest quality if it is independent of its connection with ongoing, systematic learning (Kass, Faden, and Goodman, 2013). Learning health care systems, described in the Hastings Center Report, view clinical practice as an ongoing source of data to be used for continuously changing and improving patient care. Because nurses are the principal caregivers within health care institutions, high-quality outcomes that are specific to direct nursing care are used as a nursing-sensitive indicator of the ability to provide excellence in patient care.
The Quality and Safety Education for Nurses Institute has defined quality and safety competencies for nursing. The Quality and Safety Education for Nurses Institute is now being hosted by faculty at the Case Western Reserve University and provides a comprehensive overview for the development of knowledge, skills, and attitudes related to quality and safety in health care.* In this book, each Translating Evidence into Practice box includes the Quality and Safety Education for Nurses Institute competencies related to knowledge, skills, and attitudes for evidence-based nursing practice.
Throughout the chapters that focus on serious health problems, we have developed examples of quality outcome measures for specific diseases that reflect patient-centered outcomes. Quality outcome measures promote interdisciplinary teamwork, and the boxes throughout this book exemplify measures of effective collaboration to improve care. Quality Patient Outcomes boxes throughout this book are developed to assist nurses in identifying appropriate measures that evaluate the quality of patient care.
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NCLEX Review Questions 1. Because injuries are the most common cause of death and disability in children in the United
States, which stage of development correctly determines the type of injury that may occur? Select all that apply. a. A newborn may roll over and fall off an elevated surface. b. The need to conform and gain acceptance from his peers may make a child accept a dare. c. Toddlers who can run and climb may be susceptible to burns, falls, and collisions with objects. d. A preschooler may ride her two-wheel bike in a reckless manner. e. A crawling infant may aspirate due to the tendency to place objects in his mouth.
2. The National Children's Study is the largest prospective, long-term study of children's health and development in the United States. Which of these options are the goals of this study? Select all that apply. a. Ensure that every child is immunized at the appropriate age. b. Provide information for families to eradicate unhealthy diets, dental caries, and childhood
obesity. c. Enlist the help of school lunch programs to reach the goal of vegetables and fruits as 30% of
each lunch. d. Significantly reduce violence, substance abuse, and mental health disorders among the nation's
children. e. Decrease tardiness and truancy and increase the high school graduation rate in each state over
the next 5 years. 3. The newest nurse on the pediatric unit is concerned about maintaining a professional distance in
her relationship with a patient and the patient's family. Which comment indicates that she needs more mentoring regarding her patient-nurse relationship? a. “I realize that caring for the child means I can visit them on my days off if they ask me.” b. “When the mother asks if I will care for her daughter every day, I explain that the assignments
change based on the needs of the unit.” c. “When the mother asks me questions about my family, I answer politely, but I offer only
pertinent information.” d. “I engage in multidisciplinary rounds and listen to the family's concerns.”
4. What is the overriding goal of atraumatic care? a. Prevent or minimize the child's separation from the family b. Do no harm c. Promote a sense of control d. Prevent or minimize bodily injury and pain
5. A family you are caring for on the pediatric unit asks you about nutrition for their baby. What facts will you want to include in this nutritional information? Select all that apply. a. Breastfeeding provides micronutrients and immunological properties. b. Eating preferences and attitudes related to food are established by family influences and
culture. c. Most children establish lifelong eating habits by 18 months old. d. During adolescence, parental influence diminishes and adolescents make food choices related
to peer acceptability and sociability. e. Due to the stress of returning to work, most mothers use this as a time to stop breastfeeding.
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Correct Answers 1. b, c, e; 2. b, d;
3. a; 4. b;
5. a, b, d
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American Nurses Association: Silver Spring, MD; 2010. Annie E Casey Foundation. 2014 Kids count data book: state profiles of child well-being. The
Foundation: Baltimore, MD; 2014. Berdahl TA, Friedman BS, McCormick MC, et al. Annual report on health care for children
and youth in the United States: trends in racial/ethnic, income, and insurance disparities over time, 2002-2009. Acad Pediatr. 2013;13(3):191–293.
Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr. 2011;160(2):265–270.
Bright Futures. Prevention and health promotion for infants, children, adolescents, and their families. http://brightfutures.aap.org/index.html; 2014.
Budnitz DS, Salis S. Preventing medication overdoses in young children: an opportunity for harm elimination. Pediatr. 2011;127(6):e1597–e1599.
Centers for Disease Control and Prevention. Put your medicines up and away and out of sight. http://www.cdc.gov/features/medicationstorage/; 2013.
Centers for Disease Control and Prevention. Injury and violence prevention and control. http://www.cdc.gov/injury; 2014.
Duncan GJ, Kirkendall NJ, Citro CJ. Panel on the design of the national children's study and implications for the generalizability of results. Institute of Medicine, National Academies Press: Washington, DC; 2014.
Federal Interagency Forum on Child and Family Statistics. America's Children: Key National Indicators of Well-Being. U.S. Government Printing Office: Washington, DC; 2015 http://www.childstats.gov/americaschildren/index.asp.
Flores G, Lesley B. Children and US federal policy on health and health care. JAMA Pediatr. 2014;168(12):1155–1163.
Flores G, Lin H. Trends in racial/ethnic disparities in medical and oral health, access to care and use of services in US children: has anything changed over the years? Int J Equity Health. 2013;12:10 http://www.equityhealthj.com/content/12/1/10.
Giannini C, Caprio S. Islet function in obese adolescents. Diabetes Obes Metab. 2012;14(Suppl 3):40–45.
Graff M, North KE, Monda KL, et al. The combined influence of genetic factors and sedentary activity on body mass changes from adolescence to young adulthood: the National Longitudinal Adolescent Health Study. Diabetes Metab Res Rev. 2011;27(1):63–69.
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926.
Institute for Patient- and Family-Centered Care. What is patient- and family-centered health care?. http://www.ipfcc.org/faq.html; 2014.
Institute of Medicine. Crossing the quality chasm. The Institute: Washington, DC; 2000. Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early
childhood caries. J Am Acad Nurse Pract. 2009;21(1):1–10. Kass NE, Faden RR, Goodman SN, et al. The research-treatment distinction: a problematic
approach for determining which activities should have ethical oversight. Hastings Cent Rep. 2013;Jan-Feb:S4–S15.
Leslie LK, Slaw KM, Edwards A, et al. Peering into the future: pediatrics in a changing world. Pediatr. 2010;126(5):982–988.
Martin A, Saunders DH, Shenkin SD, et al. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database Syst Rev. 2014;(3) [CD009728].
Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. Lippincott Williams & Wilkins: Philadelphia; 2014.
National Safety Council. Injury facts. The Council: Itasca, IL; 2000. National Strategy for Quality Improvement in Health Care. Annual progress report to congress.
US Department of Health and Human Services: Washington, DC; 2012. Osterman MJK, Kochanek KD, MacDorman MF, et al: Annual summary of vital statistics:
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2012-2013, Pediatrics 135(6):1115–1125. Polaha J, Dalton WT 3rd, Allen S. The prevalence of emotional and behavior problems in
pediatric primary care serving rural children. J Pediatr Psychol. 2011;36(6):652–660. Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional
injury mortality: United States, 2000-2009. Am J Public Health. 2012;102(11):e84–e92. Simmons B. Clinical reasoning: concept analysis. J Adv Nurs. 2010;66(5):1151–1158. Slomski A. Chronic mental health issues in children now loom larger than physical problems.
JAMA. 2012;308(3):223–225. US Department of Health and Human Services. Healthy people 2020.
http://www.healthypeople.gov/; 2013. US Department of Health and Human Services. Youth violence: a report of the surgeon general.
http://www.ncbi.nlm.nih.gov/books/NBK44294/; 2013. Waters E, de Silva-Sanigorski A, Hall BJ, et al. Intervention for preventing obesity in children.
Cochrane Database Syst Rev. 2011;(12) [CD001871]. Weiss R, Bremer AA, Lustig RH. What is metabolic syndrome, and why are children getting
it? Ann N Y Acad Sci. 2013;1281:123–140. Wong D. Principles of atraumatic care. Feeg V. Pediatric nursing: forum on the future: looking
toward the 21st century. Anthony J Jannetti: Pitman, NJ; 1989. *Bright Futures is supported by the American Academy of Pediatrics and can be found at: http://brightfutures.aap.org/about.html *540 Gaither Road, Suite 2000, Rockville, MD 20850; 301-427-1364; email: [email protected]; www.ahrq.gov. †National Quality Strategy information can be found at: http://www.ahrq.gov/workingforquality/about.htm#priorities *Quality and Safety Education for Nurses Institute, Frances Payne Bolton School of Nursing, Case Western Reserve University, email: [email protected]
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Family, Social, Cultural, and Religious Influences on Child Health Promotion Quinn Franklin, Kim Mooney-Doyle
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General Concepts Definition of Family The term family has been defined in many different ways according to the individual's own frame of reference, values, or discipline. There is no universal definition of family; a family is what an individual considers it to be. Biology describes the family as fulfilling the biologic function of perpetuation of the species. Psychology emphasizes the interpersonal aspects of the family and its responsibility for personality development. Economics views the family as a productive unit providing for material needs. Sociology depicts the family as a social unit interacting with the larger society, creating the context within which cultural values and identity are formed. Others define family in terms of the relationships of the persons who make up the family unit. The most common type of relationships are consanguineous (blood relationships), affinal (marital relationships), and family of origin (family unit a person is born into).
Earlier definitions of family emphasized that family members were related by legal ties or genetic relationships and lived in the same household with specific roles. Later definitions have been broadened to reflect both structural and functional changes. A family can be defined as an institution where individuals, related through biology or enduring commitments, and representing similar or different generations and genders, participate in roles involving mutual socialization, nurturance, and emotional commitment (Kaakinen, Gedaly-Duff, and Hanson, 2009).
Considerable controversy has surrounded the newer concepts of family, such as communal families, single-parent families, and homosexual families. To accommodate these and other varieties of family styles, the descriptive term household is frequently used.
N u r s i n g A l e r t The nurse's knowledge and the sensitivity with which he or she assesses a household will determine the types of interventions that are appropriate to support family members.
Nursing care of infants and children is intimately involved with care of the child and the family. Family structure and dynamics can have an enduring influence on a child, affecting the child's health and well-being (American Academy of Pediatrics, 2003). Consequently, nurses must be aware of the functions of the family, various types of family structures, and theories that provide a foundation for understanding the changes within a family and for directing family-oriented interventions.
Family Theories A family theory can be used to describe families and how the family unit responds to events both within and outside the family. Each family theory makes assumptions about the family and has inherent strengths and limitations (Kaakinen, Gedaly-Duff, and Hanson, 2009). Most nurses use a combination of theories in their work with children and families. Commonly used theories are family systems theory, family stress theory, and developmental theory (Table 2-1).
TABLE 2-1 Summary of Family Theories and Application
Assumptions Strengths Limitations Applications Family Systems Theory A change in any one part of a family
system affects all other parts of the family system (circular causality).
Family systems are characterized by periods of rapid growth and change and periods of relative stability.
Both too little change and too much change are dysfunctional for the family system; therefore, a balance between morphogenesis (change) and morphostasis (no change) is necessary.
Family systems can initiate change, as well as react to it.
Applicable for family in normal everyday life, as well as for family dysfunction and pathology.
Useful for families of varying structure and various stages of life cycle.
More difficult to determine cause- and-effect relationships because of circular causality.
Mate selection, courtship processes, family communication, boundary maintenance, power and control within family, parent-child relationships, adolescent pregnancy and parenthood.
Family Stress Theory
Stress is an inevitable part of family life, Potential to explain and predict Relationships between all Transition to parenthood and other normative transitions, single-
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stressful for family. Family encounters both normative
expected stressors and unexpected situational stressors over life cycle.
Stress has a cumulative effect on family. Families cope with and respond to
stressors with a wide range of responses and effectiveness.
stressors and to develop effective interventions to promote family adaptation.
Focuses on positive contribution of resources, coping, and social support to adaptive outcomes.
Can be used by many disciplines in health field.
adequately described. Not yet known if certain
combinations of resources and coping strategies are applicable to all stressful events.
earner family, unemployment), acute or chronic childhood illness or disability, infertility, death of a child, divorce, and teenage pregnancy and parenthood.
Developmental Theory Families develop and change over time in
similar and consistent ways. Family and its members must perform
certain time-specific tasks set by themselves and by persons in the broader society.
Family role performance at one stage of family life cycle influences family's behavioral options at next stage.
Family tends to be in stage of disequilibrium when entering a new life cycle stage and strives toward homeostasis within stages.
Provides a dynamic, rather than static, view of family.
Addresses both changes within family and changes in family as a social system over its life history.
Anticipates potential stressors that normally accompany transitions to various stages and when problems may peak because of lack of resources.
Traditional model more easily applied to two-parent families with children.
Use of age of oldest child and marital duration as marker of stage transition sometimes problematic (e.g., in stepfamilies, single-parent families).
Anticipatory guidance, educational strategies, and developing or strengthening family resources for management of transition to parenthood; family adjustment to children entering school, becoming adolescents, leaving home; management of “empty nest” years and retirement.
Family Systems Theory Family systems theory is derived from general systems theory, a science of “wholeness” that is characterized by interaction among the components of the system and between the system and the environment (Bomar, 2004; Papero, 1990). General systems theory expanded scientific thought from a simplistic view of direct cause and effect (A causes B) to a more complex and interrelated theory (A influences B, but B also affects A). In family systems theory, the family is viewed as a system that continually interacts with its members and the environment. The emphasis is on the interaction between the members; a change in one family member creates a change in other members, which in turn results in a new change in the original member. Consequently, a problem or dysfunction does not lie in any one member but rather in the type of interactions used by the family. Because the interactions, not the individual members, are viewed as the source of the problem, the family becomes the patient and the focus of care. Examples of the application of family systems theory to clinical problems are nonorganic failure to thrive and child abuse. According to family systems theory, the problem does not rest solely with the parent or child but with the type of interactions between the parent and the child and the factors that affect their relationship.
The family is viewed as a whole that is different from the sum of the individual members. For example, a household of parents and one child consists of not only three individuals, but also four interactive units. These units include three dyads (the marital relationship, the mother-child relationship, and the father-child relationship) and a triangle (the mother-father-child relationship). In this ecologic model, the family system functions within a larger system, with the family dyads in the center of a circle surrounded by the extended family, the subculture, and the culture, with the larger society at the periphery.
Bowen's family systems theory emphasizes that the key to healthy family function is the members' ability to distinguish themselves from one another both emotionally and intellectually (Kaakinen, Gedaly-Duff, and Hanson, 2009; Papero, 1990). The family unit has a high level of adaptability. When problems arise within the family, change occurs by altering the interaction or feedback messages that perpetuate disruptive behavior. Feedback refers to processes in the family that help identify strengths and needs and determine how well goals are accomplished. Positive feedback initiates change; negative feedback resists change (Goldenberg and Goldenberg, 2008). When the family system is disrupted, change can occur at any point in the system.
A major factor that influences a family's adaptability is its boundary, an imaginary line that exists between the family and its environment (Kaakinen, Gedaly-Duff, and Hanson, 2009). Families have varying degrees of openness and closure in these boundaries. For example, one family has the capacity to reach out for help, whereas another considers help threatening. Knowledge of boundaries is critical when teaching or counseling families. Families with open boundaries may demonstrate a greater receptivity to interventions, whereas families demonstrating closed boundaries often require increased sensitivity and skill on the part of the nurse to gain their trust and acceptance. The nurse who uses family systems theory should assess the family's ability to accept new ideas, information, resources, and opportunities and to plan strategies.
Family Stress Theory Family stress theory explains how families react to stressful events and suggests factors that promote adaptation to stress (Kaakinen, Gedaly-Duff, and Hanson, 2009). Families encounter stressors (events that cause stress and have the potential to effect a change in the family social
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system), including those that are predictable (e.g., parenthood) and those that are unpredictable (e.g., illness, unemployment). These stressors are cumulative, involving simultaneous demands from work, family, and community life. Too many stressful events occurring within a relatively short period (usually 1 year) can overwhelm the family's ability to cope and place it at risk for breakdown or physical and emotional health problems among its members. When the family experiences too many stressors for it to cope adequately, a state of crisis ensues. For adaptation to occur, a change in family structure or interaction is necessary.
The resiliency model of family stress, adjustment, and adaptation emphasizes that the stressful situation is not necessarily pathologic or detrimental to the family but demonstrates that the family needs to make fundamental structural or systemic changes to adapt to the situation (McCubbin and McCubbin, 1994).
Developmental Theory Developmental theory is an outgrowth of several theories of development. Duvall (1977) described eight developmental tasks of the family throughout its life span (Box 2-1). The family is described as a small group, a semiclosed system of personalities that interacts with the larger cultural social system. As an interrelated system, the family does not have changes in one part without a series of changes in other parts.
Box 2-1 D u va l l ' s D e ve l o p m e n t a l S t a g e s o f t h e F a m i l y Stage I—Marriage and an Independent Home: The Joining of Families
Reestablish couple identity.
Realign relationships with extended family.
Make decisions regarding parenthood.
Stage II—Families with Infants
Integrate infants into the family unit.
Accommodate to new parenting and grandparenting roles.
Maintain marital bond.
Stage III—Families with Preschoolers
Socialize children.
Parents and children adjust to separation.
Stage IV—Families with Schoolchildren
Children develop peer relations.
Parents adjust to their children's peer and school influences.
Stage V—Families with Teenagers
Adolescents develop increasing autonomy.
Parents refocus on midlife marital and career issues.
Parents begin a shift toward concern for the older generation.
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Stage VI—Families as Launching Centers
Parents and young adults establish independent identities.
Parents renegotiate marital relationship.
Stage VII—Middle-Aged Families
Reinvest in couple identity with concurrent development of independent interests.
Realign relationships to include in-laws and grandchildren.
Deal with disabilities and death of older generation.
Stage VIII—Aging Families
Shift from work role to leisure and semiretirement or full retirement.
Maintain couple and individual functioning while adapting to the aging process.
Prepare for own death and dealing with the loss of spouse and/or siblings and other peers.
Modified from Wright LM, Leahey M: Nurses and families: a guide to family assessment and intervention, Philadelphia, 1984, Davis.
Developmental theory addresses family change over time using Duvall's family life cycle stages, based on the predictable changes in the family's structure, function, and roles, with the age of the oldest child as the marker for stage transition. The arrival of the first child marks the transition from stage I to stage II. As the first child grows and develops, the family enters subsequent stages. In every stage, the family faces certain developmental tasks. At the same time, each family member must achieve individual developmental tasks as part of each family life cycle stage.
Developmental theory can be applied to nursing practice. For example, the nurse can assess how well new parents are accomplishing the individual and family developmental tasks associated with transition to parenthood. New applications should emerge as more is learned about developmental stages for nonnuclear and nontraditional families.
Family Nursing Interventions In working with children, the nurse must include family members in their care plan. Research confirms parents' desire and expectation to participate in their child's care (Power and Franck, 2008). To discover family dynamics, strengths, and weaknesses, a thorough family assessment is necessary (see Chapter 4). The nurse's choice of interventions depends on the theoretic family model that is used (Box 2-2). For example, in family systems theory, the focus is on the interaction of family members within the larger environment (Goldenberg and Goldenberg, 2008). In this case, using group dynamics to involve all members in the intervention process and being a skillful communicator are essential. Systems theory also presents excellent opportunities for anticipatory guidance. Because each family member reacts to every stress experienced by that system, nurses can intervene to help the family prepare for and cope with changes. In family stress theory, the nurse employs crisis intervention strategies to help family members cope with the challenging event. In developmental theory, the nurse provides anticipatory guidance to prepare members for transition to the next family stage. Nurses who think family involvement plays a key role in the care of a child are more likely to include families in the child's daily care (Fisher, Lindhorst, Matthews, et al, 2008).
Box 2-2 F a m i l y N u r s i n g I n t e r ve n t i o n • Behavior modification
• Case management and coordination
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• Collaborative strategies
• Contracting
• Counseling, including support, cognitive reappraisal, and reframing
• Empowering families through active participation
• Environmental modification
• Family advocacy
• Family crisis intervention
• Networking, including use of self-help groups and social support
• Providing information and technical expertise
• Role modeling
• Role supplementation
• Teaching strategies, including stress management, lifestyle modifications, and anticipatory guidance
From Friedman MM, Bowden VR, Jones EG: Family nursing: research theory and practice, ed 5, Upper Saddle River, NJ, 2003, Prentice Hall.
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Family Structure and Function Family Structure The family structure, or family composition, consists of individuals, each with a socially recognized status and position, who interact with one another on a regular, recurring basis in socially sanctioned ways (Kaakinen, Gedaly-Duff, and Hanson, 2009). When members are gained or lost through events such as marriage, divorce, birth, death, abandonment, or incarceration, the family composition is altered and roles must be redefined or redistributed.
Traditionally, the family structure was either a nuclear or extended family. In recent years, family composition has assumed new configurations, with the single-parent family and blended family becoming prominent forms. The predominant structural pattern in any society depends on the mobility of families as they pursue economic goals and as relationships change. It is not uncommon for children to belong to several different family groups during their lifetime.
Nurses must be able to meet the needs of children from many diverse family structures and home situations. A family's structure affects the direction of nursing care. The US Census Bureau uses four definitions for families: (1) the traditional nuclear family, (2) the nuclear family, (3) the blended family or household, and (4) the extended family or household. In addition, numerous other types of families have been defined, such as single-parent, binuclear, polygamous, communal, and lesbian/gay/bisexual/transgender (LGBT) families.
Traditional Nuclear Family A traditional nuclear family consists of a married couple and their biologic children. Children in this type of family live with both biologic parents and, if siblings are present, only full brothers and sisters (i.e., siblings who share the same two biologic parents). No other persons are present in the household (i.e., no step relatives, foster or adopted children, half-siblings, other relatives, or nonrelatives).
Nuclear Family The nuclear family is composed of two parents and their children. The parent-child relationship may be biologic, step, adoptive, or foster. Sibling ties may be biologic, step, half, or adoptive. The parents are not necessarily married. No other relatives or nonrelatives are present in the household.
Blended Family A blended family or household, also called a reconstituted family, includes at least one stepparent, stepsibling, or half-sibling. A stepparent is the spouse of a child's biologic parent but is not the child's biologic parent. Stepsiblings do not share a common biologic parent; the biologic parent of one child is the stepparent of the other. Half-siblings share only one biologic parent.
Extended Family An extended family or household includes at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. Parent-child and sibling relationships may be biologic, step, adoptive, or foster.
In many nations and among many ethnic and cultural groups, households with extended families are common. Within the extended family, grandparents often find themselves rearing their grandchildren (Fig. 2-1). Young parents are often considered too young or too inexperienced to make decisions independently. Often, the older relative holds the authority and makes decisions in consultation with the young parents. Sharing residence with relatives also assists with the management of scarce resources and provides child care for working families. A resource for extended families is the Grandparent Information Center.*
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FIG 2-1 Children benefit from interaction with grandparents, who sometimes assume the parenting role.
Single-Parent Family In the United States, an estimated 24.6 million children live in single-parent families (Annie E. Casey Foundation, 2015a). The contemporary single-parent family has emerged partially as a consequence of the women's rights movement and also as a result of more women (and men) establishing separate households because of divorce, death, desertion, or single parenthood. In addition, a more liberal attitude in the courts has made it possible for single people, both male and female, to adopt children. Although mothers usually head single-parent families, it is becoming more common for fathers to be awarded custody of dependent children in divorce settlements. With women's increased psychological and financial independence and the increased acceptability of single parents in society, more unmarried women are deliberately choosing mother-child families. Frequently, these mothers and children are absorbed into the extended family. The challenges of single-parent families are discussed later in the chapter.
Binuclear Family The term binuclear family refers to parents continuing the parenting role while terminating the spousal unit. The degree of cooperation between households and the time the child spends with each can vary. In joint custody, the court assigns divorcing parents equal rights and responsibilities concerning the minor child or children. These alternate family forms are efforts to view divorce as a process of reorganization and redefinition of a family rather than as a family dissolution. Joint custody and co-parenting are discussed later in this chapter.
Polygamous Family Although it is not legally sanctioned in the United States, the conjugal unit is sometimes extended by the addition of spouses in polygamous matings. Polygamy refers to either multiple wives (polygyny) or, rarely, husbands (polyandry). Many societies practice polygyny that is further designated as sororal, in which the wives are sisters, or nonsororal, in which the wives are unrelated. Sororal polygyny is widespread throughout the world. Most often, mothers and their children share a husband and father, with each mother and her children living in the same or separate household.
Communal Family The communal family emerged from disenchantment with most contemporary life choices. Although communal families may have divergent beliefs, practices, and organization, the basic impetus for formation is often dissatisfaction with the nuclear family structure, social systems, and goals of the larger community. Relatively uncommon today, communal groups share common ownership of property. In cooperatives, property ownership is private, but certain goods and services are shared and exchanged without monetary consideration. There is strong reliance on
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group members and material interdependence. Both provide collective security for nonproductive members, share homemaking and childrearing functions, and help overcome the problem of interpersonal isolation or loneliness.
Lesbian, Gay, Bisexual, and Transgender Families A same-sex, homosexual, or LGBT family is one in which there is a legal or common-law tie between two persons of the same sex who have children (Blackwell, 2007). There are a growing number of families with same-sex parents in the United States, with an estimated one fifth of all same-sex couples raising children (O'Connell and Feliz, 2011; US Census Bureau, 2011). Although some children in LGBT households are biologic from a former marriage relationship, children may be present in other circumstances. They may be foster or adoptive parents, lesbian mothers may conceive through artificial fertilization, or a gay male couple may become parents through use of a surrogate mother.
When children are brought up in LGBT families, the relationships seem as natural to them as heterosexual parents do to their offspring. In other cases, however, disclosure of parental homosexuality (“coming out”) to children can be a concern for families. There are a number of factors to consider before disclosing this information to children. Parents should be comfortable with their own sexual preference and should discuss this with the children as they become old enough to understand relationships. Discussions should be planned and take place in a quiet setting where interruptions are unlikely.
Nurses need to be nonjudgmental and to learn to accept differences rather than demonstrate prejudice that can have a detrimental effect on the nurse-child-family relationship (Blackwell, 2007). Moreover, the more nurses know about the child's family and lifestyle, the more they can help the parents and the child.
Family Strengths and Functioning Style Family function refers to the interactions of family members, especially the quality of those relationships and interactions (Bomar, 2004). Researchers are interested in family characteristics that help families to function effectively. Knowledge of these factors guides the nurse throughout the nursing process and helps the nurse to predict ways that families may cope and respond to a stressful event, to provide individualized support that builds on family strengths and unique functioning style, and to assist family members in obtaining resources.
Family strengths and unique functioning styles are significant resources that nurses can use to meet family needs (Box 2-3). Building on qualities that make a family work well and strengthening family resources make the family unit even stronger. All families have strengths as well as vulnerabilities.
Box 2-3 Q u a l i t i e s o f S t r o n g F a m i l i e s • A belief and sense of commitment toward promoting the well-being and growth of individual
family members, as well as the family unit
• Appreciation for the small and large things that individual family members do well and encouragement to do better
• Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event
• A sense of purpose that permeates the reasons and basis for “going on” in both bad and good times
• A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs
• The ability to communicate with one another in a way that emphasizes positive interactions
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• A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior
• A varied repertoire of coping strategies that promote positive functioning in dealing with both normative and nonnormative life events
• The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources
• The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and problems as an opportunity to learn and grow
• Flexibility and adaptability in the roles necessary to procure resources to meet needs
• A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future
From Dunst C, Trivette C, Deal A: Enabling and empowering families: principles and guidelines for practice, Cambridge, MA, 1988, Brookline Books.
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Family Roles and Relationships Each individual has a position, or status, in the family structure and plays culturally and socially defined roles in interactions within the family. Each family also has its own traditions and values and sets its own standards for interaction within and outside the group. Each determines the experiences the children should have, those they are to be shielded from, and how each of these experiences meets the needs of family members. When family ties are strong, social control is highly effective, and most members conform to their roles willingly and with commitment. Conflicts arise when people do not fulfill their roles in ways that meet other family members' expectations, either because they are unaware of the expectations or because they choose not to meet them.
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Parental Roles In all family groups, the socially recognized status of father and mother exists with socially sanctioned roles that prescribe appropriate sexual behavior and childrearing responsibilities. The guides for behavior in these roles serve to control sexual conflict in society and provide for prolonged care of children. The degree to which parents are committed and the way they play their roles are influenced by a number of variables and by the parents' unique socialization experience.
Parental role definitions have changed as a result of the changing economy and increased opportunities for women (Bomar, 2004). As the woman's role has changed, the complementary role of the man has also changed. Many fathers are more active in childrearing and household tasks. As the redefinition of sex roles continues in American families, role conflicts may arise in many families because of a cultural lag of the persisting traditional role definitions.
Role Learning Roles are learned through the socialization process. During all stages of development, children learn and practice, through interaction with others and in their play, a set of social roles and the characteristics of other roles. They behave in patterned and more or less predictable ways, because they learn roles that define mutual expectations in typical social relationships. Although role definitions are changing, the basic determinants of parenting remain the same. Several determinants of parenting infants and young children are parental personality and mental well- being, systems of support, and child characteristics. These determinants have been used as consistent measurements to determine a person's success in fulfilling the parental role.
Parents, peers, authority figures, and other socializing agents who use positive and negative sanctions to ensure conformity to their norms transmit role conceptions. Role behaviors positively reinforced by rewards such as love, affection, friendship, and honors are strengthened. Negative reinforcement takes the form of ridicule, withdrawal of love, expressions of disapproval, or banishment.
In some cultures, the role behavior expected of children conflicts with desirable adult behavior. One of the family's responsibilities is to develop culturally appropriate role behavior in children. Children learn to perform in expected ways consistent with their position in the family and culture. The observed behavior of each child is a single manifestation—a combination of social influences and individual psychological processes. In this way, the uniting of the child's intrapersonal system (the self) with the interpersonal system (the family) is simultaneously understood as the child's conduct.
Role structuring initially takes place within the family unit, in which the children fulfill a set of roles and respond to the roles of their parents and other family members (Kaakinen, Gedaly-Duff, and Hanson, 2009). Children's roles are shaped primarily by the parents, who apply direct or indirect pressures to induce or force children into the desired patterns of behavior or direct their efforts toward modification of the role responses of the child on a mutually acceptable basis. Parents have their own techniques and determine the course that the socialization process follows.
Children respond to life situations according to behaviors learned in reciprocal transactions. As they acquire important role-taking skills, their relationships with others change. For instance, when a teenager is also the mother but lives in a household with the grandmother, the teenager may be viewed more as an adolescent than as a mother. Children become proficient at understanding others as they acquire the ability to discriminate their own perspectives from those of others. Children who get along well with others and attain status in the peer group have well-developed role-taking skills.
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Parenting Parenting Styles Children respond to their environment in a variety of ways. A child's temperament heavily influences his or her response (see Chapter 11), but styles of parenting have also been shown to affect a child and lead to particular behavioral responses. Parenting styles are often classified as authoritarian, permissive, or authoritative (Baumrind, 1971, 1996). Authoritarian parents try to control their children's behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly. The message is: “Do it because I say so.” Punishment need not be corporal but may be stern withdrawal of love and approval. Careful training often results in rigidly conforming behavior in the children who tend to be sensitive, shy, self-conscious, retiring, and submissive. They are more likely to be courteous, loyal, honest, and dependable but docile. These behaviors are more typically observed when close supervision and affection accompany parental authority. If not, this style of parenting may be associated with both defiant and antisocial behaviors.
Permissive parents exert little or no control over their children's actions. They avoid imposing their own standards of conduct and allow their children to regulate their own activity as much as possible. These parents consider themselves to be resources for the children, not role models. If rules do exist, the parents explain the underlying reason, elicit the children's opinions, and consult them in decision-making processes. They employ lax, inconsistent discipline; do not set sensible limits; and do not prevent the children from upsetting the home routine. These parents rarely punish the children.
Authoritative parents combine practices from both of the previously described parenting styles. They direct their children's behavior and attitudes by emphasizing the reason for rules and negatively reinforcing deviations. They respect the individuality of each child and allow the child to voice objections to family standards or regulations. Parental control is firm and consistent but tempered with encouragement, understanding, and security. Control is focused on the issue, not on withdrawal of love or the fear of punishment. These parents foster “inner-directedness,” a conscience that regulates behavior based on feelings of guilt or shame for wrongdoing, not on fear of being caught or punished. Parents' realistic standards and reasonable expectations produce children with high self-esteem who are self-reliant, assertive, inquisitive, content, and highly interactive with other children.
There are differing philosophies in regard to parenting. Childrearing is a culturally bound phenomenon, and children are socialized to behave in ways that are important to their family. In the authoritative style, authority is shared and children are included in discussions, fostering an independent and assertive style of participation in family life. When working with individual families, nurses should give these differing styles equal respect.
Limit Setting and Discipline In its broadest sense, discipline means “to teach” or refers to a set of rules governing conduct. In a narrower sense, it refers to the action taken to enforce the rules after noncompliance. Limit setting refers to establishing the rules or guidelines for behavior. For example, parents can place limits on the amount of time children spend watching television or chatting online. The clearer the limits that are set and the more consistently they are enforced, the less need there is for disciplinary action.
Nurses can help parents establish realistic and concrete “rules.” Limit setting and discipline are positive, necessary components of childrearing and serve several useful functions as they help children: • Test their limits of control • Achieve in areas appropriate for mastery at their level • Channel undesirable feelings into constructive activity • Protect themselves from danger • Learn socially acceptable behavior
Children want and need limits. Unrestricted freedom is a threat to their security and safety. By
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testing the limits imposed on them, children learn the extent to which they can manipulate their environment and gain reassurance from knowing that others are there to protect them from potential harm.
Minimizing Misbehavior The reasons for misbehavior may include attention, power, defiance, and a display of inadequacy (e.g., the child misses classes because of a fear that he or she is unable to do the work). Children may also misbehave because the rules are not clear or consistently applied. Acting-out behavior, such as a temper tantrum, may represent uncontrolled frustration, anger, depression, or pain. The best approach is to structure interactions with children to prevent or minimize unacceptable behavior (see Family-Centered Care box).
F a m i l y - C e n t e r e d C a r e Minimizing Misbehavior
• Set realistic goals for acceptable behavior and expected achievements.
• Structure opportunities for small successes to lessen feelings of inadequacy.
• Praise children for desirable behavior with attention and verbal approval.
• Structure the environment to prevent unnecessary difficulties (e.g., place fragile objects in an inaccessible area).
• Set clear and reasonable rules; expect the same behavior regardless of the circumstances; if exceptions are made, clarify that the change is for one time only.
• Teach desirable behavior through own example, such as using a quiet, calm voice rather than screaming.
• Review expected behavior before special or unusual events, such as visiting a relative or having dinner in a restaurant.
• Phrase requests for appropriate behavior positively, such as “Put the book down,” rather than “Don't touch the book.”
• Call attention to unacceptable behavior as soon as it begins; use distraction to change the behavior or offer alternatives to annoying actions, such as exchanging a quiet toy for one that is too noisy.
• Give advance notice or “friendly reminders,” such as “When the TV program is over, it is time for dinner,” or “I'll give you to the count of three, and then we have to go.”
• Be attentive to situations that increase the likelihood of misbehaving, such as overexcitement or fatigue, or decreased personal tolerance to minor infractions.
• Offer sympathetic explanations for not granting a request, such as “I am sorry I can't read you a story now, but I have to finish dinner. Then we can spend time together.”
• Keep any promises made to children.
• Avoid outright conflicts; temper discussions with statements, such as “Let's talk about it and see what we can decide together,” or “I have to think about it first.”
• Provide children with opportunities for power and control.
General Guidelines for Implementing Discipline Regardless of the type of discipline used, certain principles are essential to ensure the efficacy of the
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approach (see Family-Centered Care box). Many strategies, such as behavior modification, can only be implemented effectively when principles of consistency and timing are followed. A pattern of intermittent or occasional enforcement of limits actually prolongs the undesired behavior, because children learn that if they are persistent, the behavior is permitted eventually. Delaying punishment weakens its intent, and practices such as telling the child, “Wait until your father comes home,” are not only ineffectual but also convey negative messages about the other parent.
F a m i l y - C e n t e r e d C a r e Implementing Discipline
• Consistency: Implement disciplinary action exactly as agreed on and for each infraction.
• Timing: Initiate discipline as soon as child misbehaves; if delays are necessary, such as to avoid embarrassment, verbally disapprove of the behavior and state that disciplinary action will be implemented.
• Commitment: Follow through with the details of the discipline, such as timing of minutes; avoid distractions that may interfere with the plan, such as telephone calls.
• Unity: Make certain that all caregivers agree on the plan and are familiar with the details to prevent confusion and alliances between child and one parent.
• Flexibility: Choose disciplinary strategies that are appropriate to child's age and temperament and the severity of the misbehavior.
• Planning: Plan disciplinary strategies in advance and prepare child if feasible (e.g., explain use of time-out); for unexpected misbehavior, try to discipline when you are calm.
• Behavior orientation: Always disapprove of the behavior, not the child, with statements, such as “That was a wrong thing to do. I am unhappy when I see behavior like that.”
• Privacy: Administer discipline in private, especially with older children, who may feel ashamed in front of others.
• Termination: After the discipline is administered, consider child as having a “clean slate,” and avoid bringing up the incident or lecturing.
Types of Discipline To deal with misbehavior, parents need to implement appropriate disciplinary action. Many approaches are available. Reasoning involves explaining why an act is wrong and is usually appropriate for older children, especially when moral issues are involved. However, young children cannot be expected to “see the other side” because of their egocentrism. Children in the preoperative stage of cognitive development (toddlers and preschoolers) have a limited ability to distinguish between their point of view and that of others. Sometimes children use “reasoning” as a way of gaining attention. For example, they may misbehave, thinking the parents will give them a lengthy explanation of the wrongdoing and knowing that negative attention is better than no attention. When children use this technique, parents should end the explanation by stating, “This is the rule, and this is how I expect you to behave. I won't explain it any further.”
Unfortunately, reasoning is often combined with scolding, which sometimes takes the form of shame or criticism. For example, the parent may state, “You are a bad boy for hitting your brother.” Children take such remarks seriously and personally, believing that they are bad.
N u r s i n g A l e r t When reprimanding children, focus only on the misbehavior, not on the child. Use of “I” messages rather than “you” messages expresses personal feelings without accusation or ridicule. For example, an “I” message attacks the behavior (“I am upset when Johnny is punched; I don't like to
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see him hurt”) not the child.
Positive and negative reinforcement is the basis of behavior modification theory—behavior that is rewarded will be repeated; behavior that is not rewarded will be extinguished. Using rewards is a positive approach. By encouraging children to behave in specified ways, the parents can decrease the tendency to misbehave. With young children, using paper stars is an effective method. For older children, the “token system” is appropriate, especially if a certain number of stars or tokens yields a special reward, such as a trip to the movies or a new book. In planning a reward system, the parents must explain expected behaviors to the child and establish rewards that are reinforcing. They should use a chart to record the stars or tokens and always give an earned reward promptly. Verbal approval should always accompany extrinsic rewards.
Consistently ignoring behavior will eventually extinguish or minimize the act. Although this approach sounds simple, it is difficult to implement consistently. Parents frequently “give in” and resort to previous patterns of discipline. Consequently, the behavior is actually reinforced because the child learns that persistence gains parental attention. For ignoring to be effective, parents should (1) understand the process, (2) record the undesired behavior before using ignoring to determine whether a problem exists and to compare results after ignoring is begun, (3) determine whether parental attention acts as a reinforcer, and (4) be aware of “response burst.” Response burst is a phenomenon that occurs when the undesired behavior increases after ignoring is initiated because the child is “testing” the parents to see if they are serious about the plan.
The strategy of consequences involves allowing children to experience the results of their misbehavior. It includes three types:
1. Natural: Those that occur without any intervention, such as being late and having to clean up the dinner table
2. Logical: Those that are directly related to the rule, such as not being allowed to play with another toy until the used ones are put away
3. Unrelated: Those that are imposed deliberately, such as no playing until homework is completed or the use of time-out
Natural or logical consequences are preferred and effective if they are meaningful to children. For example, the natural consequence of living in a messy room may do little to encourage cleaning up but allowing no friends over until the room is neat can be motivating! Withdrawing privileges is often an unrelated consequence. After the child experiences the consequence, the parent should refrain from any comment, because the usual tendency is for the child to try to place blame for imposing the rule.
Time-out is a refinement of the common practice of sending the child to his or her room and is a type of unrelated consequence. It is based on the premise of removing the reinforcer (i.e., the satisfaction or attention the child is receiving from the activity). When placed in an unstimulating and isolated place, children become bored and consequently agree to behave in order to reenter the family group (Fig. 2-2). Time-out avoids many of the problems of other disciplinary approaches. No physical punishment is involved; no reasoning or scolding is given; and the parent does not need to be present for all of the time-out, thus facilitating consistent application of this type of discipline. Time-out offers both the child and the parent a “cooling-off” time. To be effective, however, time- out must be planned in advance (see Family-Centered Care box). Implement time-out in a public place by selecting a suitable area, or explain to children that time-out will be spent immediately on returning home.
F a m i l y - C e n t e r e d C a r e Using Time-Out
• Select an area for time-out that is safe, convenient, and unstimulating, but where the child can be monitored, such as the bathroom, hallway, or laundry room.
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• Determine what behaviors warrant a time-out.
• Make certain children understand the “rules” and how they are expected to behave.
• Explain to children the process of time-out:
• When they misbehave, they will be given one warning. If they do not obey, they will be sent to the place designated for time-out.
• They are to sit there for a specified period.
• If they cry, refuse, or display any disruptive behavior, the time-out period will begin after they quiet down.
• When they are quiet for the duration of the time, they can then leave the room.
• A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record the time rather than a watch.
FIG 2-2 Time-out is an excellent disciplinary strategy for young children.
Corporal or physical punishment most often takes the form of spanking (Larzelere, 2008). Based on the principles of aversive therapy, inflicting pain through spanking causes a dramatic short-term decrease in the behavior. However, this approach has serious flaws: (1) it teaches children that violence is acceptable; (2) it may physically harm the child if it is the result of parental rage; and (3) children become “accustomed” to spanking, requiring more severe corporal punishment over time. Spanking can result in severe physical and psychological injury, and it interferes with effective parent-child interaction (Cain, 2008). In addition, when the parents are not around, children are likely to misbehave, because they have not learned to behave well for their own sake. Parental use of corporal punishment may also interfere with the child's development of moral reasoning.
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Special Parenting Situations Parenting is a demanding task under ideal circumstances, but when parents and children face situations that deviate from “the norm,” the potential for family disruption is increased. Situations that are encountered frequently are divorce, single parenthood, blended families, adoption, and dual-career families. In addition, as cultural diversity increases in our communities, many immigrants are making the transition to parenthood and a new country, culture, and language simultaneously. Other situations that create unique parenting challenges are parental alcoholism, homelessness, and incarceration. Although these topics are not addressed here, the reader may wish to investigate them further.
Parenting the Adopted Child Adoption establishes a legal relationship between a child and parents who are not related by birth but who have the same rights and obligations that exist between children and their biologic parents. In the past, the biologic mother alone made the decision to relinquish the rights to her child. In recent years, the courts have acknowledged the legal rights of the biologic father regarding this decision. Concerned child advocates have questioned whether decisions that honor the father's rights are in the best interests of the child. As the child's rights have become recognized, older children have successfully dissolved their legal bond with their biologic parents to pursue adoption by adults of their choice. Furthermore, there is a growing interest and demand within the LGBT community to adopt.
Unlike biologic parents, who prepare for their child's birth with prenatal classes and the support of friends and relatives, adoptive parents have fewer sources of support and preparation for the new addition to their family. Nurses can provide the information, support, and reassurance needed to reduce parental anxiety regarding the adoptive process and refer adoptive parents to state parental support groups. Such sources can be contacted through a state or county welfare office.
The sooner infants enter their adoptive home, the better the chances of parent-infant attachment. However, the more caregivers the infant had before adoption, the greater the risk for attachment problems. The infant must break the bond with the previous caregiver and form a new bond with the adoptive parents. Difficulties in forming an attachment depend on the amount of time he or she has spent with caregivers early in life as well as the number of caregivers (e.g., the birth mother, nurse, adoption agency personnel).
Siblings, adopted or biologic, who are old enough to understand, should be included in decisions regarding the commitment to adopt with reassurance that they are not being replaced. Ways that the siblings can interact with the adopted child should be stressed (Fig. 2-3).
FIG 2-3 An older sister lovingly embraces her adopted sister.
Issues of Origin
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The task of telling children that they are adopted can be a cause of deep concern and anxiety. There are no clear-cut guidelines for parents to follow in determining when and at what age children are ready for the information. Parents are naturally reluctant to present such potentially unsettling news. However, it is important that parents not withhold the adoption from the child, because it is an essential component of the child's identity.
The timing arises naturally as parents become aware of the child's readiness. Most authorities believe that children should be informed at an age young enough so that, as they grow older, they do not remember a time when they did not know they were adopted. The time is highly individual, but it must be right for both the parents and the child. It may be when children ask where babies come from, at which time children can also be told the facts of their adoption. If they are told in a way that conveys the idea that they were active participants in the selection process, they will be less likely to feel that they were abandoned victims in a helpless situation. For example, parents can tell children that their personal qualities drew the parents to them. It is wise for parents who have not previously discussed adoption to tell children that they are adopted before the children enter school to avoid having them learn it from third parties. Complete honesty between parents and children strengthens the relationship.
Parents should anticipate behavior changes after the disclosure, especially in older children. Children who are struggling with the revelation that they are adopted may benefit from individual and family counseling. Children may use the fact of their adoption as a weapon to manipulate and threaten parents. Statements such as, “My real mother would not treat me like this,” or “You don't love me as much because I'm adopted,” hurt parents and increase their feelings of insecurity. Such statements may also cause parents to become over permissive. Adopted children need the same undemanding love, combined with firm discipline and limit setting, as any other child.
Adolescence Adolescence may be an especially trying time for parents of adopted children. The normal confrontations of adolescents and parents assume more painful aspects in adoptive families. Adolescents may use their adoption to defy parental authority or as a justification for aberrant behavior. As they attempt to master the task of identity formation, they may begin to have feelings of abandonment by their biologic parents. Gender differences in reacting to adoption may surface.
Adopted children fantasize about their biologic parents and may feel the need to discover their parents' identity to define themselves and their own identity. It is important for parents to keep the lines of communication open and to reassure their child that they understand the need to search for their identity. In some states, birth certificates are made legally available to adopted children when they come of age. Parents should be honest with questioning adolescents and tell them of this possibility. (The parents themselves are unable to obtain the birth certificate; it is the children's responsibility if they desire it.)
Cross-Racial and International Adoption Adoption of children from racial backgrounds different from that of the family is commonplace. In addition to the problems faced by adopted children in general, children of a cross-racial adoption must deal with physical and sometimes cultural differences. It is advised that parents who adopt children with different ethnic background do everything to preserve the adopted children's racial heritage.
N u r s i n g A l e r t As a health care provider, it is important not to ask the wrong questions, such as:
• “Is she yours, or is she adopted?”
• “What do you know about the ‘real’ mother?”
• “Do they have the same father?”
• “How much did it cost to adopt him?”
Although the children are full-fledged members of an adopting family and citizens of the
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adopted country, if they have a strikingly different appearance from other family members or exhibit distinct racial or ethnic characteristics, challenges may be encountered outside the family. Bigotry may appear among relatives and friends. Strangers may make thoughtless comments and talk about the children as though they were not members of the family. It is vital that family members declare to others that this is their child and a cherished member of the family.
In international adoptions, the medical information the parents receive may be incomplete or sketchy; weight, height, and head circumference are often the only objective information present in the child's medical record. Many internationally adopted children were born prematurely, and common health problems, such as infant diarrhea and malnutrition, delay growth and development. Some children have serious or multiple health problems that can be stressful for the parents.
Parenting and Divorce Since the mid-1960s, a marked change in the stability of families has been reflected in increased rates of divorce, single parenthood, and remarriage. In 2011, the divorce rate for the United States was 3.4 per 1000 total population (Centers for Disease Control and Prevention, 2011). The divorce rate has changed little since 1987. In the decade before that, the rate increased yearly, with a peak in 1979. Although almost half of all divorcing couples are childless, it is estimated that more than 1 million children experience divorce each year.
The process of divorce begins with a period of marital conflict of varying length and intensity, followed by a separation, the actual legal divorce, and the reestablishment of different living arrangements (Box 2-4). Because a function of parenthood is to provide for the security and emotional welfare of children, disruption of the family structure often engenders strong feelings of guilt in the divorcing parents (Fig. 2-4).
Box 2-4 T h e D i v o r c e P r o c e s s Acute Phase
• The married couple makes the decision to separate.
• This phase includes the legal steps of filing for dissolution of the marriage and, usually, the departure of the father from the home.
• This phase lasts from several months to more than a year and is accompanied by familial stress and a chaotic atmosphere.
Transitional Phase
• The adults and children assume unfamiliar roles and relationships within a new family structure.
• This phase is often accompanied by a change of residence, a reduced standard of living and altered lifestyle, a larger share of the economic responsibility being shouldered by the mother, and radically altered parent-child relationships.
Stabilizing Phase
• The post-divorce family reestablishes a stable, functioning family unit.
• Remarriage frequently occurs with concomitant changes in all areas of family life.
Modified from Wallerstein JS: Children of divorce: stress and developmental tasks. In Garmezy N, Rutter M, editors: Stress, coping, and development in children, New York, 1988, McGraw-Hill.
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FIG 2-4 Quality time spent with a child during a divorce is essential to a family's health and well-being.
During a divorce, parents' coping abilities may be compromised. The parents may be preoccupied with their own feelings, needs, and life changes and be unavailable to support their children. Newly employed parents, usually mothers, are likely to leave children with new caregivers, in strange settings, or alone after school. The parent may also spend more time away from home, searching for or establishing new relationships. Sometimes, however, the adult feels frightened and alone and begins to depend on the child as a substitute for the absent parent. This dependence places an enormous burden on the child.
Common characteristics in the custodial household after separation and divorce include disorder, coercive types of control, inflammable tempers in both parents and children, reduced parental competence, a greater sense of parental helplessness, poorly enforced discipline, and diminished regularity in household routines. Noncustodial parents are seldom prepared for the role of visitor, may assume the role of recreational and “fun” parent, and may not have a residence suitable for children's visits. They may also be concerned about maintaining the arrangement over the years to follow.
Impact of Divorce on Children Parental divorce is an additional childhood adversity that contributes to poor mental health outcomes, especially when combined with child abuse. Parental psychopathology may be one possible mechanism to explain the relationships between child abuse, parental divorce, and psychiatric disorders and suicide attempts (Afifi, Boman, Fleisher, et al, 2009). Even when a divorce is amicable and open, children recall parental separation with the same emotions felt by victims of a natural disaster: loss, grief, and vulnerability to forces beyond their control.
The impact of divorce on children depends on several factors, including the age and sex of the children, the outcome of the divorce, and the quality of the parent-child relationship and parental care during the years following the divorce. Family characteristics are more crucial to the child's well-being than specific child characteristics, such as age or sex. High levels of ongoing family conflict are related to problems of social development, emotional stability, and cognitive skills for the child (see Research Focus box).
R e s e a r c h F o c u s Impact of Divorce
Children who reported that their divorced parents were cooperative had better relationships with their parents, grandparents, stepparents, and siblings (Ahrons, 2007). Complications associated with divorce include efforts on the part of one parent to subvert the child's loyalties to the other, abandonment to other caregivers, and adjustment to a stepparent.
A major problem occurs when children are “caught in the middle” between the divorced parents.
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They become the message bearer between the parents, are often quizzed about the other parent's activities, and have to listen to one parent criticize the other. A nurse may be able to help the child get out of the middle by stating “I messages” based on the formula of “I feel (state the feeling) when you (state the source). I would like it if you…” An example of an “I message” is: “I do not feel comfortable when you ask me questions about mom; maybe you could ask her yourself.” This approach enables the child to feel in control.
Feelings of children toward divorce vary with age (Box 2-5). Previously, researchers believed that divorce had a greater impact on younger children, but recent observations indicate that divorce constitutes a major disruption for children of all ages. The feelings and behaviors of children may be different for various ages and gender, but all children suffer stress second only to the stress produced by the death of a parent. Although considerable research has looked at sex differences in children's adjustments to divorce, the findings are not conclusive.
Box 2-5 F e e l i n g s a n d B e h a v i o r s o f C h i l d r e n R e l a t e d t o D i v o r c e Infancy
• Effects of reduced mothering or lack of mothering
• Increased irritability
• Disturbance in eating, sleeping, and elimination
• Interference with attachment process
Early Preschool Children (2 to 3 Years Old)
• Frightened and confused
• Blame themselves for the divorce
• Fear of abandonment
• Increased irritability, whining, tantrums
• Regressive behaviors (e.g., thumb sucking, loss of elimination control)
• Separation anxiety
Later Preschool Children (3 to 5 Years Old)
• Fear of abandonment
• Blame themselves for the divorce; decreased self-esteem
• Bewilderment regarding all human relationships
• Become more aggressive in relationships with others (e.g., siblings, peers)
• Engage in fantasy to seek understanding of the divorce
Early School–Age Children (5 to 6 Years Old)
• Depression and immature behavior
• Loss of appetite and sleep disorders
• May be able to verbalize some feelings and understand some divorce-related changes
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• Increased anxiety and aggression
• Feelings of abandonment by departing parent
Middle School–Age Children (6 to 8 Years Old)
• Panic reactions
• Feelings of deprivation—loss of parent, attention, money, and secure future
• Profound sadness, depression, fear, and insecurity
• Feelings of abandonment and rejection
• Fear regarding the future
• Difficulty expressing anger at parents
• Intense desire for reconciliation of parents
• Impaired capacity to play and enjoy outside activities
• Decline in school performance
• Altered peer relationships—become bossy, irritable, demanding, and manipulative
• Frequent crying, loss of appetite, sleep disorders
• Disturbed routine, forgetfulness
Later School–Age Children (9 to 12 Years Old)
• More realistic understanding of divorce
• Intense anger directed at one or both parents
• Divided loyalties
• Ability to express feelings of anger
• Ashamed of parental behavior
• Desire for revenge; may wish to punish the parent they hold responsible
• Feelings of loneliness, rejection, and abandonment
• Altered peer relationships
• Decline in school performance
• May develop somatic complaints
• May engage in aberrant behavior, such as lying, stealing
• Temper tantrums
• Dictatorial attitude
Adolescents (12 to 18 Years Old)
• Able to disengage themselves from parental conflict
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• Feelings of a profound sense of loss—of family, childhood
• Feelings of anxiety
• Worry about themselves, parents, siblings
• Expression of anger, sadness, shame, embarrassment
• May withdraw from family and friends
• Disturbed concept of sexuality
• May engage in acting-out behaviors
Some children feel a sense of shame and embarrassment concerning the family situation. Sometimes children see themselves as different, inferior, or unworthy of love, especially if they feel responsible for the family dissolution. Although the social stigma attached to divorce no longer produces the emotions it did in the past, such feelings may still exist in small towns or in some cultural groups and can reinforce children's negative self-image. The lasting effects of divorce depend on the children's and the parents' adjustment to the transition from an intact family to a single-parent family and, often, to a reconstituted family.
Although most studies have concentrated on the negative effects of divorce on youngsters, some positive outcomes of divorce have been reported. A successful post-divorce family, either a single- parent or a reconstituted family, can improve the quality of life for both adults and children. If conflict is resolved, a better relationship with one or both parents may result, and some children may have less contact with a disturbed parent. Greater stability in the home setting and the removal of arguing parents can be a positive outcome for the child's long-term well-being.
Telling the Children Parents are understandably hesitant to tell children about their decision to divorce. Most parents neglect to discuss either the divorce or its inevitable changes with their preschool child. Without preparation, even children who remain in the family home are confused by the parental separation. Frequently, children are already experiencing vague, uneasy feelings that are more difficult to cope with than being told the truth about the situation.
If possible, the initial disclosure should include both parents and siblings, followed by individual discussions with each child. Sufficient time should be set aside for these discussions, and they should take place during a period of calm, not after an argument. Parents who physically hold or touch their children provide them with a feeling of warmth and reassurance. The discussions should include the reason for the divorce, if age appropriate, and reassurance that the divorce is not the fault of the children.
Parents should not fear crying in front of the children, because their crying gives the children permission to cry also. Children need to ventilate their feelings. Children may feel guilt, a sense of failure, or that they are being punished for misbehavior. They normally feel anger and resentment and should be allowed to communicate these feelings without punishment. They also have feelings of terror and abandonment. They need consistency and order in their lives. They want to know where they will live, who will take care of them, if they will be with their siblings, and if there will be enough money to live on. Children may also wonder what will happen on special days such as birthdays and holidays, whether both parents will come to school events, and whether they will still have the same friends. Children fear that if their parents stopped loving each other, they could stop loving them. Their need for love and reassurance is tremendous at this time.
Custody and Parenting Partnerships In the past, when parents separated, the mother was given custody of the children with visitation agreements for the father. Now both parents and the courts are seeking alternatives. Current belief is that neither fathers nor mothers should be awarded custody automatically. Custody should be awarded to the parent who is best able to provide for the children's welfare. In some cases, children experience severe stress when living or spending time with a parent. Many fathers have demonstrated both their competence and their commitment to care for their children.
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Often overlooked are the changes that may occur in the children's relationships with other relatives, especially grandparents. Grandparents are increasingly involved in the care of young children (Fergusson, Maughan, and Golding, 2008). Grandparents on the noncustodial side are often kept from their grandchildren, whereas those on the custodial side may be overwhelmed by their adult child's return to the household with grandchildren.
Two other types of custody arrangements are divided custody and joint custody. Divided custody, or split custody, means that each parent is awarded custody of one or more of the children, thereby separating siblings. For example, sons might live with the father and daughters with the mother.
Joint custody takes one of two forms. In joint physical custody, the parents alternate the physical care and control of the children on an agreed-on basis while maintaining shared parenting responsibilities legally. This custody arrangement works well for families who live close to each other and whose occupations permit an active role in the care and rearing of the children. In joint legal custody, the children reside with one parent, but both parents are the children's legal guardians, and both participate in childrearing.
Co-parenting offers substantial benefits for the family. Children can be close to both parents, and life with each parent can be more normal (as opposed to having a disciplinarian mother and a recreational father). To be successful, parents in these arrangements must be highly committed to provide normal parenting and to separate their marital conflicts from their parenting roles. No matter what type of custody arrangement is awarded, the primary consideration is the welfare of the children.
Single Parenting An individual may acquire single-parent status as a result of divorce, separation, death of a spouse, or birth or adoption of a child. In 2013, 35% of children younger than 18 years old lived in single- parent families, and the majority of single parents were women (Annie E. Casey Foundation, 2015a; Kreider and Elliott, 2009). Although some women are single parents by choice, most never planned on being single parents, and many feel pressure to marry or remarry.
Managing shortages of money, time, and energy is often a concern for single parents. Studies repeatedly confirm the financial difficulties of single-parent families, particularly single mothers. In 2013, 34% of single-parent families had household incomes below the poverty line (Annie E. Casey Foundation, 2015a). In fact, the stigma of poverty may be more keenly felt than the discrimination associated with being a single parent. These families are often forced by their financial status to live in communities with inadequate housing and personal safety concerns. Single parents often feel guilty about the time spent away from their children. Divorced mothers, from marriages in which the father assumed the role of breadwinner and the mother the household maintenance and parenting roles, have considerable difficulty adjusting to their new role of breadwinner. Many single parents have trouble arranging for adequate child care, particularly for a sick child.
Social supports and community resources needed by single-parent families include health care services that are open on evenings and weekends; high-quality child care; respite child care to relieve parental exhaustion and prevent burnout; and parent enhancement centers for advancing education and job skills, providing recreational activities, and offering parenting education. Single parents need social contacts separate from their children for their own emotional growth and that of their children.
Single Fathers Fathers who have custody of their children have many of the same problems as divorced mothers. They feel overburdened by the responsibility; depressed; and concerned about their ability to cope with the emotional needs of the children, especially girls. Some fathers lack homemaking skills. They may find it difficult at first to coordinate household tasks, school visits, and other activities associated with managing a household alone (Fig. 2-5).
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FIG 2-5 Fathers who assume care of their children may feel more comfortable and successful in their parenting role.
Parenting in Reconstituted Families In the United States, many of the children living in homes where parents have divorced will experience another major change in their lives, such as the addition of a stepparent or new siblings (Kaakinen, Gedaly-Duff, and Hanson, 2009). The entry of a stepparent into a ready-made family requires adjustments for all family members. Some obstacles to the role adjustments and family problem solving include disruption of previous lifestyles and interaction patterns, complexity in the formation of new ones, and lack of social supports. Despite these problems, most children from divorced families want to live in a two-parent home.
Cooperative parenting relationships can allow more time for each set of parents to be alone to establish their own relationship with the children. Under ideal circumstances, power conflicts between the two households can be reduced, and tension and anxiety can be lessened for all family members. In addition, the children's self-esteem can be increased, and there is a greater likelihood of continued contact with grandparents. Flexibility, mutual support, and open communication are critical in successful relationships in stepfamilies and stepparenting situations (Fig. 2-6).
FIG 2-6 Learning new roles in reconstituted families as a mother and father can enhance parenting relationships.
Parenting in Dual-Earner Families No change in family lifestyle has had more impact than the large numbers of women moving away from the traditional homemaker role and entering the workplace (Kaakinen, Gedaly-Duff, and Hanson, 2009). The trend toward increased numbers of dual-earner families is unlikely to diminish significantly. As a result, the family is subject to considerable stress as members attempt to meet
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often competing demands of occupational needs and those regarded as necessary for a rich family life.
Role definitions are frequently altered to arrange a more equitable division of time and labor, as well as to resolve conflict, especially conflict related to traditional cultural norms. Overload is a common source of stress in a dual-earner family, and social activities are significantly curtailed. Time demands and scheduling are major problems for all individuals who work. When the individuals are parents, the demands can be even more intense. Dual-earner couples may increase the strain on themselves to avoid creating stress for their children. Although there is no evidence to indicate that the dual-earner lifestyle is stressful to children, the stress experienced by the parents may affect the children indirectly.
Working Mothers Working mothers have become the norm in the United States. Maternal employment may have variable effects on preschool children's health (Mindlin, Jenkins, and Law, 2009). The quality of child care is a persistent concern for all working parents. Determinants of child care quality are based on health and safety requirements, responsive and warm interaction between staff and children, developmentally appropriate activities, trained staff, limited group size, age-appropriate caregivers, adequate staff-to-child ratios, and adequate indoor and outdoor space. Nurses play an important role in helping families find suitable sources of child care and prepare children for this experience (see Alternate Child Care Arrangements, Chapter 9).
Kinship Care Since the 1980s, the proportion of children in out-of-home care placed with relatives has increased rapidly. More than 2.7 million American children are cared for by extended family or close family friends at some time in their lives (Annie E. Casey Foundation, 2012). According to US Census Bureau data, kinship caregivers are more likely to be poor, single, older, less educated, and unemployed than families in which at least one parent is present.
Foster Parenting Foster care can be defined as the placement of a child in a stable and approved environment with a non-related family. The living situation may be an approved foster home, possibly with other children, or a pre-adoptive home. Each state provides a standard for the role of foster parent and a process by which to become one. These “parents” contract with the state to provide a home for children for a limited duration. Most states require about 27 hours of training before being on contract and at least 12 hours of continuing education a year. Foster parents may be required to attend a foster parent support group that is often separate from a state agency. Each state has guidelines regarding the relative health of the prospective foster parents and their families, background checks regarding legal issues for the adults, personal interviews, and a safety inspection of the residence and surroundings (Chamberlain, Price, Leve, et al, 2008).
Foster homes include both kinship and nonrelative placements. Since the 1980s, the proportion of children in out-of-home care placed with relatives has increased rapidly and been accompanied by a decrease in the number of foster families. As with their nonfoster counterparts, much of the child's adjustment depends on the family's stability and available resources. Even though foster homes are designed to provide short-term care, it is not unusual for children to stay for many years.
Nurses should be aware that on any given day over 55,000 children are in the child welfare system (Annie E. Casey Foundation, 2015b). Children from lower-income, single-mother, and mother-partner families are considerably more likely to be living in foster care (Berger and Waldfogel, 2004). Children in foster care tend to have a higher than normal incidence of acute and chronic health problems and may experience feelings of isolation or confusion. Foster children are often at risk because of their previous caretaking environment. Nurses should strive to implement strategies to improve the health care for this group of children. In particular, assessment and case management skills are required to involve other disciplines in meeting their needs.
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Sociocultural Influences upon the Child and Family A child and his or her immediate family are nested within a local community of school, peers, and extended family and within a larger community that may be bound by common geography, background, traditions, and an even broader community that incorporates the social, political, and economic elements that influence many aspects of family life. This section of this chapter delves into a deeper discussion of such factors.
Bronfenbrenner (1979) offers a perspective of viewing children and their families within the context of various circles of influence, called an ecological framework. This framework posits that individuals adapt in response to changes in their surrounding environments, whether that be the environment of the immediate family, the school, the neighborhood in which the family lives, or the socioeconomic forces that may shape job availability in their geographic area. In addition, he argues that a person's behavior results from the interaction of his or her traits and abilities with the environment. No single factor can explain the totality of a child and his or her family's health behaviors. Children possess their own factors that influence their behavior (i.e., personal history or biologic factors). In turn, they are surrounded by relationships with family, friends, and peers who influence their behavior. Children and their families are then situated within a community that establishes the context in which social relationships develop. Finally, wider sociocultural factors exist that influence whether a behavior is encouraged or prohibited (i.e., social policy on smoking, cultural norms of mothers as primary caregivers of young children, media that can influence how a teen thinks he or she should look) (Centers for Disease Control and Prevention, 2009; Perry-Jenkins, Newkirk, and Ghunney, 2013) (Fig. 2-7).
FIG 2-7 Youngsters from different cultural backgrounds interact within the larger culture.
Promoting the health of children requires a nurse to understand social, cultural, and religious influences on children and their families. The American population is constantly evolving. Patients experience negative health outcomes when social, cultural, and religious factors are not considered as influencing their health care (Chavez, 2012; Williams, 2012). Educating health care providers is one way to reduce disparities in health care.
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Influences in the Surrounding Environment Schools When children enter school, their radius of relationships extends to include a wider variety of peers and a new source of authority. Although parents continue to exert the major influence on children, in the school environment, teachers have the most significant psychological impact on children's development and socialization. In addition to academic and cognitive progress, teachers are concerned with the emotional and social development of the children in their care. Both parents and teachers act to model, shape, and promote positive behavior, constrain negative behavior, and enforce standards of conduct. Ideally, parents and teachers work together for the benefit of the children in their care.
Schools serve as a major source of socialization for children. Next to the family, schools exert a major force in providing continuity and passing down culture from one generation to the next. This, in turn, prepares children to carry out the social roles they are expected to assume as they develop into adults. School is the center of cultural diffusion wherein the cultural standards of the larger group are disseminated into the community. It governs what is taught and, to a great extent, how it is taught. School rules and regulations regarding attendance, authority relationships, and the system of rewards and penalties based on achievement transmit to children the expectations of the adult world of employment and relationships. School is an important institution in which children systematically learn about the negative consequences of behavior that departs from social expectations. School also serves as an avenue for children to participate in the larger society in rewarding ways, to promote social mobility, and to connect the family with new knowledge and services. Like parents, teachers are responsible for transmitting knowledge and culture (i.e., values on which there is a broad consensus) to the children in their care. Teachers are also expected to stimulate and guide children's intellectual development and creative problem solving. Traditionally, the socialization process of school began when children entered kindergarten. However, this process is starting at younger ages as children enter various child care settings with more than 60% of mothers working outside the home.
Peer Cultures Peer groups also have an impact on the socialization of children. Peer relationships become increasingly important and influential as children proceed through school. In school, children have what can be regarded as a culture of their own. This is even more apparent in unsupervised playgroups because the culture in school is partly produced by adults.
During their lives, children are subjected to many influential factors, such as family, religious community, and social class. In peer-group interactions, they confront a variety of these sets of values. The values imposed by the peer group are especially compelling because children must accept and conform to them to be accepted as members of the group. When the peer values are not too different from those of family and teachers, the mild conflict created by these small differences serves to separate children from the adults in their lives and to strengthen the feeling of belonging to the peer group.
The kind of socialization provided by the peer group depends on the subculture that develops from its members' background, interests, and capabilities. Some groups support school achievement, others focus on athletic prowess, and still others are decidedly against educative goals. Many conflicts between teachers and students and between parents and students can be attributed to fear of rejection by peers. What is expected from parents regarding academic achievement and what is expected from the peer culture often conflict, especially during adolescence.
Although the peer group has neither the traditional authority of the parents nor the legal authority of the schools for teaching information, it manages to convey a substantial amount of information to its members, especially on taboo subjects such as sex and drugs. Children's need for the friendship of their peers brings them into an increasingly complex social system. Through peer relationships, children learn to deal with dominance and hostility and to relate with persons in positions of leadership and authority. Other functions of the peer subculture are to relieve boredom and to provide recognition that individual members do not receive from teachers and other
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authority figures. The peer-group culture has secrets, mores, and codes of ethics that promote group solidarity and
detachment from adults. They have traditions, including age-related games and other activities that are transferred from “generation to generation” of schoolchildren and that have a great influence over the behavior of all group members. As children move from one level to the next, they discard the folkways of the younger group as they adopt those of the new group. For example, a school-age child rides a bicycle to school, whereas the high school student prefers a car. As they advance, children are forward oriented only—they look forward with anticipation but may look backward with contempt.
Social Roles Much of children's self-concept comes from their ideas about their social roles. Roles are cultural creations; therefore, the culture prescribes patterns of behavior for persons in a variety of social positions. All persons who hold similar social positions have an obligation to behave in a particular manner. A role prohibits some behaviors and allows others. Because culture outlines and clarifies roles, it is a significant influence on the development of children's self-concept (i.e., attitudes and beliefs they have about themselves). To establish their place in the group, children learn to follow a mode of behavior that is in agreement with the standards specific to the group and learn how they can expect others to behave toward them. They take their cues by observing and imitating those to whom they are exposed consistently.
Co-Cultural or Subcultural Influences Except in rare circumstances, children grow and develop in a blend of cultures. Subcultures or co- cultures are groups within a cultural group that possess their own standards and mores (Dysart- Gale, 2006). For example, nursing or medicine constitutes a subculture or co-culture. In a large, complex society like the United States, different groups have their own sets of standards, values, and expectations within the collective ways of the larger culture. Most of these co-cultures were formed when groups of people clustered together by preferences, external pressure from the majority culture, or geographic isolation. Although cultural differences may be related to geographic boundaries, co-cultures are not always restricted by location, especially in the context of Internet support groups and social media. Considering children, in particular, some subcultures are even related to the stages of development. For example, the behavior of school-age children and adolescents demonstrate age-related subcultures. Although there are countless subcultures or co- cultures within the United States, those that seem to exert great influence upon children and their families are ethnicity, social class, minority group membership, religion/spirituality, schools, communities, and peer groups.
Communities Communities can be sites of opportunity and growth for children and families. Communities can also be a site where poverty and disenfranchisement are minimized through connections with high- quality early childhood education; job training for adolescents and parents; and safe, effective schools. Communities can also contribute to toxic stress if violence and poverty are pervasive and resources absent (Annie E. Casey Foundation, 2013). Recent research with over 1 million youth in the United States has shown that assets within a community can bolster healthy decision-making, minimize high-risk behaviors, and support positive child and adolescent development (Search Institute, 2009). The child's or adolescent's community is made up of family, school, neighborhood, youth organizations, and other members.
Four categories of external assets that youth receive from the community are (Search Institute, 2009):
1. Support: Young people need to feel support, care, and love from their families, neighbors, et al. They also need organizations and institutions that offer positive, supportive environments.
2. Empowerment: Young people need to feel valued by their community and be able to contribute to others. They need to feel safe and secure.
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3. Boundaries and expectations: Young people need to know what is expected of them and what activities and behaviors are within the community boundaries and what are outside of them.
4. Constructive use of time: Young people need opportunities for growth through constructive, enriching opportunities and through quality time at home.
Internal assets must also be nurtured in the community's young members. These internal qualities guide choices and create a sense of centeredness, purpose, and focus. The four categories of internal assets are (Search Institute, 2009):
1. Commitment to learning: Young people need to develop a commitment to education and lifelong learning.
2. Positive values: Youth need to have a strong sense of values that direct their choices.
3. Social competencies: Young people need competencies that help them make positive choices and build relationships.
4. Positive identity: Young people need a sense of their own power, purpose, worth, and promise.
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Broader Sociocultural Influences upon the Child and Family Race and Ethnicity Race and ethnicity are socially constructed terms used to group people who share similar characteristics, traditions, or historical experience together. Race is a term that groups together people by their outward, physical appearance. Ethnicity is a classification aimed at grouping “individuals who consider themselves, or are considered by others, to share common characteristics that differentiate them from the other collectivities in a society, and from which they develop their distinctive cultural behavior” (Scott and Marshall, 2009). Ethnicities may be differentiated from one another by customs and language and may influence family structure, food preferences, and expressions of emotion. The composition and definition of ethnic and racial groups can be fluid in response to changes in geography (i.e., moving from one country to another) and changing social definitions over time (Roberts, 2011). Race and ethnicity influence a family's health when they are used as criteria by which a child or family is discriminated against. There is a significant body of work that describes this. In fact, 100 years of research describe racial gaps in health (Williams, 2012).
Racism remains an important social determinant of health (Smedley, 2012). According to Williams (2012), for minority or other groups who experience stigmatization, “inequalities in health are created by larger inequalities in society,” meaning that prevailing social conditions and obstacles to equal opportunities for all influences the health of all individuals. For example, from birth forward, African-American and Native American children have a higher mortality rate than Caucasian children in general. There is also a higher death rate for babies of African-American and Hispanic women versus Caucasian women. Even when controlling for maternal levels of education, the infant mortality rate for college-educated African-American women is 2.5 times higher than Hispanic and Caucasian women of similar education level (Williams, 2012). These numbers demonstrate that children and families ultimately feel the effects of such health disparities.
Children and families may also experience perceived racism, which also has negative consequences. For example, in a study of more than 5000 fifth-graders, 15% of Hispanic youth and 20% of African-American youth reported that they had experienced racial discrimination. Such experiences were then associated with a higher risk of mental health symptoms (Coker, Elliot, Kanouse, et al, 2009). Teens also report racial discrimination through online communities, social networking sites, and texting, which is related to increased anxiety and depression (Tynes, Giang, Williams, et al, 2008).
Ethnocentrism is the emotional attitude that one's own ethnic group is superior to others; that one's values, beliefs, and perceptions are the correct ones; and that the group's ways of living and behaving are the best (Spector, 2009). Ethnocentrism implies that all other groups are inferior. Stereotyping or labeling stems from ethnocentric beliefs. It is a common attitude among the dominant ethnic group and strongly influences a person's ability to evaluate objectively the beliefs and behaviors of others. Nurses must overcome the natural tendency to have ethnocentric attitudes when caring for people from backgrounds different from their own (Scott and Marshall, 2009).
Social Class The influence of social class cannot be overlooked. This relates to the family's economic and educational levels and their ability to access resources needed to thrive in daily life. Strength of family relationships is not tied to social class. A family of lower socioeconomic status may have fewer resources, but they may be well connected to the broader family network and rely on them for support to meet physical and emotional needs. Families in higher socioeconomic groups may have access to resources that reach beyond their extended family but may be disconnected because of pressures of work and outside obligations (i.e., children's activities).
Poverty Consider the following statistics. More than 25% of all children in the United States are receiving Supplemental Nutrition Assistance program (i.e., food stamps). In the United States, in 2011, more
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than 16 million children were poor (Isaacs and Healy, 2012), and almost 8 million children were affected by foreclosures associated with the financial crisis from 2007 to 2009 (Isaacs, 2012). The United States has the second largest share of children living under the relative poverty line among wealthy nations (UNICEF, 2013), and less than 8% of the federal US budget is invested in children. Taken together, these statistics illustrate the difficulties affecting many families in the United States. This lack of basic resources has a deleterious effect on the health of children and their families. Poverty is a relative concept that is usually associated with the general standards of a population. It implies both physical and invisible impoverishment. Physical poverty refers to a lack of money or material resources, which includes poor nutrition, insufficient clothing, poor sanitation, and deteriorating housing. Invisible poverty refers to social and cultural deprivation, such as limited employment opportunities, lack of or inferior health care services, and an absence of public services.
An absolute standard of poverty attempts to delimit a basic set of resources needed for adequate existence. A relative standard reflects the median standard of living in a society and is the term used in referring to childhood poverty in the United States—in other words, what appears to be deprivation in one area may be the standard or norm in another. Growth in the number of poor children over the past decade has not been attributable to an increase in the number of families receiving government assistance but to the growing ranks of the working poor. Approximately 20% of children in the United States live below the national poverty threshold, which is currently estimated at $23,550 for two adults and two children (US Department of Health and Human Services, 2013). In addition, 20% of children live in neighborhoods where more than 20% of the population lives below the federal poverty threshold. Taken together, such information tells us that not only might resources be limited in a family home but also the community surrounding that home, which can affect opportunities for child growth and development (i.e., safe, thriving schools and places to play).
A disproportionate number of African-American, Native American, and Hispanic children are affected by poverty, which reveals an intersection of race and poverty (Annie E. Casey Foundation, 2013). According to 2010 data, 38% of African-American children, 35% of Native American children, and 32% of Hispanic children live in poverty, compared with the national average of 22%. Specifically, African-American children and Hispanic children are nine and six times more likely to live in poverty than non-Hispanic Caucasian children, respectively (Annie E. Casey Foundation, 2013). The experience of poverty in childhood can have enduring effects on developmental, health, and educational status, among other indicators. Thus nurses can work to assist children living in poverty by offering support to their parents, other caring adults, and the community.
A high correlation between poverty and illness has long been observed. Impoverished families suffer from poor nutrition, and without medical insurance, families have little access to preventive health care and services. More than 14 million children are underinsured, meaning that their parents report spending a significant amount of money on out-of-pocket expenses related to their children's health. Day-to-day needs for clothing, food, and lodging take precedence over health care as long as the ill person is able to perform his or her daily tasks. The passage of major health care legislation, both the Children's Health Insurance Plan Reauthorization Act and the Affordable Care Act, has expanded health insurance to 3.7 million children since 2008 (Sommers and Schwartz, 2011). Hopefully, this will lead to improved health of children and families.
Evolving Demographics in the United States The United States has more racial and ethnic diversity than any other nation. By 2018, no one racial/ethnic group will be a majority group (Annie E. Casey Foundation, 2014). For example, the 2010 US Census revealed that more than 300 million people live in the United States. In 2010, individuals who identified as Hispanic made up over 16% of the population (Humes, Jones, and Ramirez, 2011); this will be one of the fastest-growing groups in the United States. Individuals who identify as Asian are expanding at an even faster rate in the United States (Hoeffel, Rastogi, Kim, et al, 2012). In addition, the 2010 Census data demonstrated that almost half of all 1-year-old children in the United States were from a racial ethnic minority (Frey, 2011). In light of these findings, it becomes even more important for pediatric nurses to care for children and families in an open, culturally humble manner.
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Religious Influences The family's religious orientation dictates a code of behavior and influences the family's attitudes toward education, male and female role identity, and their ultimate destiny. It may also influence the school that the children attend or the community in which the family embeds itself. Religious beliefs are such an integral part of many cultures that it is difficult to distinguish the culture from the religion. In a few instances, such as in the Mennonite and Amish communities, religion is the basis for a common way of life that determines where the children are raised and their lifestyle. It is also important to remember that families that do not subscribe to a particular religion or that are atheist also have beliefs and convictions about family, the surrounding world, and life in general that influence the children in these families.
Religious Beliefs Religious and spiritual dimensions are among the most important influences in many people's lives (Fig. 2-8). The terms religion and spirituality are often used interchangeably, but this is incorrect. According to Mercer (2006), spirituality is “concerned with the deepest levels of human experiencing, the places of deepest … meaning in and for our lives.” According to Yates (2011), spirituality is “a dynamic and personal experiential process.” For children in particular, spirituality possesses a relational consciousness; it concerns the child in relation to the source of power (God, Allah) that gives meaning to the relationship, other people, the surrounding world, and within oneself (Mercer, 2006). Religion, on the other hand, is a particular and culturally influenced representation of human spirituality. Children and teens who are supported in their spiritual expression can develop a foundation for understanding social relationships, making lifestyle decisions, and demonstrating resilience. Spirituality and religion can also have deleterious effects on children's health if preventive health care or treatment of health conditions is discouraged or if it promotes or allows abusive behavior (Mueller, 2010). Nurses promote holistic nursing care through an integration of spiritual and psychosocial care. The care focuses on activities that support a person's system of beliefs and worship, such as praying, reading religious materials, and performing religious rituals. In addition, it means being attentive and open to children's unique spiritual experiences and insights. Mueller (2010) states, “Children are spiritual beings, but may be limited by adults' ability to understand them.” Unfortunately, as Mercer (2006) reports, “such insights may be dismissed as cute or the product of an overactive imagination.” Meeting the spiritual needs of both the child and the family can provide strength and promote connection between the family and the nurse, whereas unmet spiritual needs can result in spiritual distress and debilitation and challenge the nurse-family relationship (Yates, 2011). It is also important to remember children may have different spiritual needs across the illness experience. For example, Petersen (2014) notes that nurses can help seriously ill children meet their spiritual needs through assessment, helping children express feelings and strengthen relationships, helping the child with legacy work to be remembered by family and friends, and helping the child find meaning in the illness experience. In practice, application of the nursing process for spiritual care (Box 2-6) can enhance the spiritual well-being of both the child and the family.
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FIG 2-8 Soon after an infant is born, many families have special religious ceremonies.
Box 2-6 G u i d e l i n e s f o r I n t e g r a t i n g S p i r i t u a l C a r e i n t o Pe d i a t r i c N u r s i n g P r a c t i c e • Respect the child and family's religious beliefs and practices.
• Consider the child's development when talking about spiritual concerns.
• Contact the institution's chaplaincy department for patients and families who have symptoms of spiritual distress or ask for specific religious rituals.
• Become knowledgeable about the religious worldviews of cultural groups found in the patients you care for.
• Encourage visitation with family members, members of the patient's spiritual community, and spiritual leaders.
• Allow children and families to teach you about the specifics of their religious beliefs.
• Develop awareness of your own spiritual perspective.
• Listen for understanding rather than agreement or disagreement.
Adapted from Brooks B: Spirituality. In Kline N, editor: Essentials of pediatric oncology nursing: a core curriculum, ed 2, Glenview, IL, 2004, Association of Pediatric Oncology Nurses; Barnes LL, Plotnikoff GA, Fox K, et al: Spirituality, religion, and pediatrics: intersecting worlds of healing, Pediatrics 106(4 suppl):899–908, 2000.
Religious beliefs that relate to health care and that may be a source of conflict between a family and the health care team remind us of the power of ordinary, daily life experiences (e.g., childrearing and food preparation) to bring to life the concept of what is sacred (Mercer, 2006). Religion and spirituality influence how individuals view an illness, a treatment regimen, and the role and utility of the health care provider. They also influence actions of food preparation and dietary restrictions and rituals surrounding birth and death. A key role of nurses is to keep communication between the family and health care team open, convey an attitude of openness and concern, and ask about such influences (Yates, 2011). For example, such information is important to keep in mind during a physical exam or preparation for surgery.
In some instances, the rights of the family and the responsibility of the state may be in conflict. For example, Jehovah's Witnesses refuse blood transfusions for themselves and for their children.
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Parents, by law, have the primary obligation to care for and make decisions about their minor children. However, the legal principle of parens patriae says that the state has an overriding interest in the health and welfare of its citizens. Parents' refusal of medical treatment for their child that is deemed essential can be interpreted as neglect. In addition to advocating for the child and family, the nurse's role may include assuming the role of consultant to the staff and family regarding new, alternative methods of transfusion and, if necessary, coordinating with officials to petition juvenile or family court for temporary guardianship of the child. Nevertheless, even in the face of disagreement, collaborative communication can exist. This is characterized by open, respectful exchange of accurate medical information between the family and the clinical team caring for the child. Such communication maintains a central focus upon the healing and health of the child and focuses on points of agreement between the family and the clinicians (Yates, 2011).
Mass Media Fifty years of research has demonstrated that the media is an influential teacher and can exert a significant impact upon the health of children and adolescents. The message conveyed in and through the media can be both positive and negative. The adults in society and in the life of children are charged with increasing the positive, pro-social effect of media and diminishing its ill effects, which can influence important health problems that afflict children across the spectrum (Strasburger, Jordan, and Donnerstein, 2012).
Children in the United States spend approximately 7 hours per day interfacing with media of some sort (i.e., television, computer, video games, smart phones). From a public health perspective, media contributes to 10% to 20% of health problems in the United States (Strasburger, Jordan, and Donnerstein, 2012). Thus, although certain media may not be a direct cause of health care problems in children, a relationship exists that nurses and other health care providers should be aware of in order to provide the best evidence-based care to children and families.
Children and adolescents utilize both “old” and “new” media. For example, television remains a popular media outlet for children and teens. What is new, however, is that television shows may be viewed from a number of platforms at any given time on mobile devices (Strasburger, Jordan, and Donnerstein, 2012), thus potentially increasing access. The increased mobility of devices and wireless Internet allows teens to participate in social media or explore the Internet independently, which has the potential for positive or negative ramifications. Strasburger, Jordan, and Donnerstein (2012) found that half of all 16- and 17-year-olds admitted to talking on their cell phones while driving, and one third of them have texted while driving.
What is the effect of this media on children and adolescents? Research has demonstrated that media can be quite influential, impacting attitudes, beliefs, and behaviors. There may be a “displacement effect” whereby the time that is spent interacting with media competes with time the child could be running, playing, or participating in a sport or creative activity. Three additional theories that conceptualize how children and teens experience media are: (1) social learning theory, which emphasizes learning through observation and imitation; (2) script theory, which posits that media provide youth with a “script” or directions for how to behave in new situations; and (3) “super-peer” theory, which describes media as an extreme source of peer pressure on youth to participate in what is shown to be normal behavior (i.e., adolescents not practicing safe sex).
Both old and new media are thought to play a role in various health issues that are particularly relevant to youth. Table 2-2 describes these in greater detail. Media also has great potential to exert a positive effect upon children and their families. Properly used, media can introduce young children to learning and promote school-readiness (i.e., Sesame Street), can serve as an outlet for adolescent expression of individuality, can connect youth who may otherwise feel isolated (i.e., those with specialized health care needs), or can be a source of exercise and activity (i.e., video games, exercise videos).
TABLE 2-2 Media Effects on Children and Adolescents
Media Effect Potential Consequences
Violence Government, medical, and public health data show exposure to media violence as one factor in violent and aggressive behavior. Both adults and children become desensitized by violence witnessed through various media, including television (including children's programming), movies (including G rated), music, and video games. In addition, cyber- bullying and harassment via text messages are a growing concern among middle school and high school students.
Sex A significant body of research shows that sexual content in the media can contribute to beliefs and attitudes about sex, sexual behavior, and initiation of intercourse. Teens
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access sexual content through a variety of media: television, movies, music, magazines, Internet, social media, and mobile devices. Current issues receiving attention for the role they play in teen sexual behavior include sending of sexual images via mobile devices (i.e., sexting), impact of violent media on youth views of women and forced sex/rape, cyber-bullying LGBT youth. Media can also serve as a positive source of sexual information (i.e., information, apps, social media about sexually transmitted infections, teen pregnancy, and promoting acceptance and support of LGBT youth).
Substance use and abuse
Although the causes of teen substance use and abuse are numerous, media plays a significant role. Alcohol and tobacco are still heavily marketed to adolescents/young adults. Television and movies featuring the use of these substances can influence initiation of use. Media also shows substance use to be pervasive and without consequences. Finally, content shared over social networking sites can serve as a form of peer pressure and can influence likelihood of use.
Obesity Obesity is a highly prevalent public health issue among children of all ages, and rates are increasing around the world. A number of studies have demonstrated a link between the amount of screen time and obesity. Advertising of unhealthy food to children is a long-standing marketing practice, which may increase snacking in the face of decreased activity. In addition, both increased screen time and unhealthy eating may also be related to unhealthy sleep.
Body image
Media may play a significant role in the development of body image awareness, expectations, and body dissatisfaction among young and older adolescent girls. Their beliefs may be influenced by images on television, movies, and magazines. New media also contributes to this through Internet images, social network sites, and websites that encourage disordered eating (e.g., pro-Ana sites) (Strasburger, Jordan, and Donnerstein, 2012).
LGBT, Lesbian/gay/bisexual/transgender.
Box 2-7 discusses some recommendations that nurses can make to families and other adults charged with promoting the well-being of youth and families. Families may find it difficult to limit the use of technology in their homes for a number of reasons, including the potential for greater conflict in the family (especially between siblings and between parent and child) and may lack the resources to provide other safe entertainment (Evans, Jordan, and Horner, 2011).
Box 2-7 A c t i o n s t o P r o m o t e P o s i t i ve M e d i a Parents
• Follow American Academy of Pediatrics recommendations for 2 hours (total) of screen time daily for children 2 years old and older.
• Establish clear guidelines for Internet use and provide direct supervision. Have frank discussions of what youth may encounter in viewing media. Be mindful of own media use in the home.
• Encourage unstructured play in the home and plan to help kids readjust to this change in family dynamic. Consider planned, deliberate use of media to experience the benefits (i.e., watching a television show together to bond or start a sensitive discussion).
Nurses/Health Care Providers
• Dedicate a few minutes of each visit to provide media screening and counseling.
• Discourage presence of electronic devices in children's rooms.
• Be sensitive to the challenges that parents face in carrying this out.
Schools
• Offer timely, accurate sexuality and drug education.
• Promote resilience.
• Develop programs to educate youth on wise use of technology.
• Develop and implement policies on dealing with cyber-bullying and sexting.
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Understanding Cultures in the Health Care Encounter Bridging the Gap Some health care institutions may depend on teachings about cultural competence to ensure that holistic care is provided to their clientele. Teachings based on cultural competence, while informative, do not provide nurses with the skills to effectively engage with families and are a short-sighted way to approach this contextualized part of children's lives. Cultural competence does spur reflection upon elements of society that perpetuate social inequity or injustices, such as racism, ageism, or homophobia. Cultural humility, on the other hand, recognizes that children and families are affected by the intersection of social elements of society and this can contribute to health inequity or poor health outcomes. For example, migrant children may face special challenges because of poverty or low-wage work, the family's undocumented status, and community attitudes toward immigration. Cultural humility is a “commitment and active engagement in a lifelong process that individuals enter into for an ongoing basis with patients, communities, colleagues, and themselves” (Tervalon and Murray-Garcia, 1998). It requires that health care providers participate in a continual process of self-reflection and self-critique that recognizes the power of the health care provider role, views the patient and family as full members of the health care team, and does not end after reading one chapter or attending one course; it is an evolving aspect of being a health care provider. Similarly, Furlong and Wright (2011) encourage health care providers to be “critically aware.” This means that nurses should engage with children and families from a stance of curiosity and “informed not-knowing” by changing the dynamic of the encounter to learn from the family, rather than only being the expert clinician (Furlong and Wright, 2011). This liberates the nurse from a reliance on static knowledge that may not be relevant for the client, and it allows the nurse to be a “knowledge-seeker” who tries to understand what life is like for the child and family. This critical awareness also calls nurses to assess their own history and the contextual factors that have shaped their own life. Critical awareness draws us to reflect on aspects of North American culture that may be invisible or taken-for-granted, such as emphasis on independence and individualism, and the ways in which this doesn't match the needs of children and families.
A family's religious and sociocultural backgrounds can influence their decisions about health care and the religious traditions and clergy they want to include during their loved one's illness. It also influences how they discuss serious topics with their children—for example, their own health conditions; the significance of illness, suffering, pain, death, and dying; and the rituals and traditions associated with important life events, such as birth and death (Weiner, McConnell, Latella, et al, 2013).
Cultural Definitions Culture characterizes a particular group with its values, beliefs, norms, patterns, and practices that are learned, shared, and transmitted from one generation to another (Leininger, 2002). Culture is not the same as race or ethnicity. Race is a socially constructed term with roots in anthropology, distinguishing variety in humans by physical traits. Ethnicity is the affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. Gender is an individual's self- identification as man or woman, and sex is the biologic designation of male or female. Social class is a complex social construction that usually incorporates levels of education in the family, occupation, income, and access to resources. Culture is a complex whole in which each part is interrelated. It is an umbrella term that holds together many interrelated yet unique aspects of humanity, including beliefs, tradition, lifeways, and heritage. It is much more than a country of origin or a demographic designation, such as African-American or Caucasian. Meeting the needs of children and families from a variety of backgrounds requires fluidity in understanding the many layers of influence within a family and understanding that a child and family must be understood contextually.
Cultures and co-cultures contribute to the uniqueness of child members in such a subtle way and at such an early age that children grow up believing their beliefs, attitudes, values, and practices are the “correct” or “normal” ones. A set of values learned in childhood may characterize children's attitudes and behaviors for life, influencing long-range goals and short-range impulses. Thus every ongoing society socializes each succeeding generation to its cultural heritage.
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Components of Cultural Humility Cultural humility includes the following tenets (Chavez, 2012; Tervalon and Murray-Garcia, 1998):
Lifelong commitment to self-reflection and critique
Addressing the power imbalances in the nurse-client relationship
Developing mutually beneficial and nonpaternalistic partnerships with the community in which one is working
The manner and sequence of the growth and development phenomenon are universal and fundamental features of all children; however, children's varied behavioral responses to similar events are often determined by their culture. Culture plays a critical role in the parenting behaviors that facilitate children's development (Melendez, 2005). Children acquire the skills, knowledge, beliefs, and values that are important to their own family and culture.
Cultures may also differ in whether status in a group is based on age or skill. Even children's play and their types of games are culturally determined. In some cultures, children play in groups composed of members of the same gender; and in others, they play in mixed-gender groups. In some cultures, team games predominate; and in others, most play is limited to individual games.
Standards and norms vary from culture to culture and from location to location; a practice that is accepted in one area may meet with disapproval or create tension in another. The extent to which cultures tolerate divergence from the established norm also varies among cultures and subcultural groups. Although conforming to cultural norms provides a degree of security, it is a decided deterrent to change.
N u r s i n g A l e r t American cultures and co-cultures can be so diverse that it is essential that nurses be aware of and knowledgeable about the predominant groups in their work community and apply this knowledge in their practice. It is also essential that nurses practice with an openness to learning about cultures and co-cultures different from their own and have a few open-ended questions that they can use to ask families about what shapes their lives, what they find meaningful, and how they carry that out in their lives. These questions should be simple and open-ended, such as “What is important to you in caring for your child?” “Please tell me a little bit about your family,” and “What is important to you as a family?”
Observing the various influences on the child's and the family's lives can help us understand how these factors affect their health and how they make decisions about their own health.
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Health Beliefs and Practices For many families, traditional practices and beliefs are an integral part of their daily lives. Health care workers should be aware that other people might live by different rules and priorities that decisively influence their health-related behaviors. Guidelines for exploring a family's culture are provided in Box 2-8.
Box 2-8 E x p l o r i n g a F a m i l y ' s C u l t u r e , I l l n e s s , a n d C a r e • What do you think caused your child's health problem?
• Why do you think it started when it did?
• How severe is your child's sickness? Will it have a short or long course?
• How do you think your child's sickness affects your family?
• What are the chief problems your child's sickness has caused?
• What kind of treatment do you think your child should receive?
• What are the most important results you hope to receive from your child's treatment?
• What do you fear most about your child's sickness?
A model for learning about health traditions that differ from the Western, or modern, health care system is based on three dimensions:
1. What are the physical aspects of caring for the body (e.g., are there special clothes, foods, medicines)?
2. What are the mental parts of caring for health (e.g., feelings, attitudes, rituals, actions)?
3. What are the spiritual aspects of health (e.g., who I am, spiritual customs, prayers, healers)?
For each of these dimensions, one must consider the cultural traditions used to maintain health, protect health, and restore health (Spector, 2009).
Health Beliefs The beliefs related to the causes of illness and the maintenance of health are integral parts of a family's cultural heritage. Often related to religious beliefs, they influence the way families cope with health problems and respond to health care providers. Predominant among most cultures are beliefs related to natural forces, supernatural forces, and an imbalance between forces.
Natural and Supernatural Forces The most common natural forces blamed for ill health if the body is not adequately protected are cold air entering the body and impurities in the air. For example, a Chinese parent may overdress an infant in an effort to keep cold wind from entering the child's body. The innate energy, chi, is an example of this. A lack of chi is believed to cause fatigue and a variety of ailments. Alternatively, some cultures view supernatural forces as a cause of illness, especially illnesses that cannot be explained by other means. Examples of such forces include voodoo, witchcraft, or evil spirits. Belief in the “evil eye” is another example of this. It stems from a belief in health as a state of balance and illness as a state of imbalance. As long as an individual's strength and weakness remain in balance, he or she is unlikely to become a victim of the evil eye. Weaknesses are not necessarily physical. For
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example, an excess of some emotion, such as envy, can create weakness. Infants and small children, because of immature development of their internal strength-weakness states, are especially vulnerable to the gaze of the evil eye.
Imbalance of Forces The concept of balance or equilibrium is widespread throughout the world. One of the most common imbalances is the one between “hot” and “cold.” This belief derived from the ancient Greek concept of body humors, which states that illness is caused by imbalance of the four humors. Such imbalance is thought to cause internal damage or altered function. Treatment of the illness is directed at restoring balance. The hot and cold understanding of disease is based in this concept. Diseases, areas of the body, foods, and illnesses are classified as either “hot” or “cold.” Foods and beverages are designated hot or cold based on the effect they exert, not their actual temperature. In Chinese health belief, the forces are termed yin (cold) and yang (hot) (Spector, 2009).
Health care workers who are aware of this belief are better able to understand why some persons refuse to eat certain foods. It is often useful to discuss the diet with the family to determine their beliefs regarding food choices. It is possible to help families devise a diet that contains the necessary balance of basic food groups prescribed by the medical subculture while conforming to the beliefs of the ethnic subculture. By determining a family's preferences during well-child visits or prior to discharge, the nurse can help prevent any adverse effects.
Health Practices Cultures have numerous similarities regarding prevention and treatment of illness. Folk healers are powerful members of the community and can acquire information about an illness without resorting to probing questions. They “speak the language” of the family who seeks help and often combine their rituals with the family or community spirituality. They also are able to create an atmosphere conducive to successful management. Furthermore, they exhibit a sincere interest in the family and their problems.
Some folk remedies are compatible with the medical regimen and are useful to reinforce the treatment plan. For example, aspirin (a “hot” medication) is an appropriate therapy for “cold” diseases, such as arthritis. It is common to discover that a folk prescription has a scientific basis. In any case, nurses must respect practices that do not harm patients. A folk healer may also be requested to perform certain rituals. For example, the Chicano curandero ascertains that the condition is truly the result of the evil eye by performing an assessment ritual and then performs a curative ritual. Sometimes faith in the folk practitioner delays obtaining needed medical treatment, although the practitioner usually suggests medical care if his or her efforts are unsuccessful.
Health practices of different cultures may also present problems of assessment and interpretation. For example, certain cultural practices or remedies can be mistakenly judged as evidence of child abuse by uninformed professionals (Box 2-9). It is important to keep the lines of communication open with families and approach the situation with a sense of cultural humility.
Box 2-9 C u l t u r a l P r a c t i c e s t h e D o m i n a n t C u l t u r e M a y C o n s i d e r A b u s i ve • Coining: A Vietnamese practice that may produce welt-like lesions on the child's back when the
edge of a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of disease.
• Cupping: An Old World practice (also practiced by the Vietnamese) of placing a container (e.g., tumbler, bottle, jar) containing steam against the skin to “draw out the poison” or other evil element. When the heated air in the container cools, a vacuum is created that produces a bruise- like blemish on the skin directly beneath the mouth of the container.
• Burning: A practice of some Southeast Asian groups whereby small areas of skin are burned to treat enuresis and temper tantrums.
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• Female genital mutilation (female circumcision): Removal of or injury to any part of the female genitalia; practiced in Africa, the Middle East, Latin America, India, Asia, North America, Australia, and Western Europe.
• Forced kneeling: A child discipline measure of some Caribbean groups in which a child is forced to kneel for a long time.
• Topical garlic application: A practice of Yemenite Jews in which crushed garlic cloves or garlic– petroleum jelly plaster is applied to the wrists to treat infectious disease. The practice can result in blisters or garlic burns.
• Traditional remedies that contain lead: Greta and azarcon (Mexico; used for digestive problems), paylooah (Southeast Asia; used for rash or fever), and surma (India; used as a cosmetic to improve eyesight.
Faith healing and religious rituals are closely allied with many folk-healing practices. Wearing of amulets, medals, and other religious relics believed by the culture to protect the individual and facilitate healing is a common practice. It is important for health workers to recognize the value of this practice and keep the items where the family has placed them or nearby. It offers comfort and support and rarely impedes medical and nursing care. If an item must be removed during a procedure, it should be replaced, if possible, when the procedure is completed. The nurse should explain the reason for its temporary removal to the family to reassure them that their wishes will be respected (see Family-Centered Care box).
F a m i l y - C e n t e r e d C a r e Cultural Awareness
A 15-month-old Bosnian girl in status epilepticus was carried in by her parents. They were frightened and spoke little English. I learned that the child had received a measles, mumps, and rubella (MMR) immunization the day before. As I proceeded to unwrap her from the blanket she was in, I quickly assessed the ABCs (airway, breathing, and circulation). I noticed that she was warm (probably a febrile seizure) and that a rag soaked in alcohol was tied around each thigh. Focusing on her potential airway compromise and trying to calm the parents, I put an oxygen mask on her, undressed her for a full assessment, and removed the alcohol rags. I spoke to the parents all the while in a calm, soothing voice. Once I had established an intravenous line and given her lorazepam (Ativan), the seizures stopped. So did the communication between her parents and me. I noticed that they would no longer give me eye contact, and the mother would not even speak to me after the seizures stopped. It wasn't until I was returning to the department from admitting her that I realized why they might have stopped communicating with me: I had removed the rags! Had I only thought to replace the rags or asked their permission to remove the rags, things might have been different.
Laura L. Kuensting, MSN(R), RN Cardinal Glennon Children's Hospital St. Louis, Missouri
Concepts that come from medical anthropology can provide a framework for addressing health care issues. These concepts can have a direct impact on patient care. They lead the nurse away from an ethnocentric or medicine-based view of the health care encounter into the health care reality as constructed by the patient and family. This is relevant for addressing many of the problems that plague the American health care system, including patient dissatisfaction with the health care they receive, unequal distribution of high-quality health care, and excessive costs (Kleinman and Benson, 2006).
It is also important for nurses to recognize that disease and illness are distinct entities. Clinicians diagnose and treat diseases, abnormalities in the structure and function of body organs and systems. Illness and disease are not interchangeable; illness may occur even when disease is not present, and the course of a disease may vary substantially from the experience of illness.
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Illness is culturally constructed; an individual's culture influences how a sickness is perceived, labeled, and explained. Culture also influences the meaning assigned to the illness, the role the individual with the sickness adopts, and the response of the family and community to the sickness.
Tension may arise when the perception of the illness and disease varies widely among the patient, family, and health care team. Failure of health care providers to recognize these disparities may be partially to blame in cases of noncompliance, delivery of inadequate care, and patient or family dissatisfaction. To begin addressing these issues, it is important for nurses to understand the various domains of health care in which individuals operate in American society, including professional (health care providers and institutions), popular (family, community, and lay literature), and folk (nonprofessional healers). Each domain possesses a method for defining and explaining the sickness and what should be done to address it. The challenges for nurses and other health care providers are to address this disconnect with families and develop mutually agreed-on goals. Nurses are in a prime position to bring the various parties together because understanding the human response to disease is central to their role. In addition, collaboration with the child and family is central to the role of the pediatric nurse.
One method to address this disconnect with families and begin collaboration is by understanding the family's explanatory model of illness. Nurses can use these questions to discern areas of discrepancy for further dialogue, negotiation, and collaboration. This discussion, when conducted with a genuine interest in the family and child's perspective, is a significant step in building trusting relationships, promoting adherence and equity, decreasing disparities, and increasing health care satisfaction.
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NCLEX Review Questions 1. What does Duvall's Developmental Stages of the Family include? Select all that apply.
a. Stages an individual progresses through in their moral and spiritual development b. Stages families progress through in adulthood c. Stages that designate how parenting progresses as a child develops d. Stages that designate appropriate discipline related to developmental stages e. Stages that describe the journey a couple will take as their children mature
2. What does family systems theory include? a. Direct causality, meaning each change affects the whole family b. Family systems react to changes as they take place, not initiate it c. A balance between morphogenesis and morphostasis is necessary d. Theory is used primarily for family dysfunction and pathology
3. The nurse is explaining the strategy of consequences to a parent he is working with. Which response by the parent indicates more teaching is needed when he describes the types of consequences? a. Natural: Those that occur without any intervention b. Logical: Those that are directly related to the rule c. Transforming: Allowing the child to come to the conclusion on his or her own d. Unrelated: Those that are imposed deliberately
4. Culture includes which of the following? Select all that apply. a. Cultural competence, which includes building skills in the health care provider, such as
offering lists of common foods, health care beliefs, and important rituals b. Cultural humility, which requires that health care providers participate in a continual process
of self-reflection and self-critique c. Recognizing the power of the health care provider role that views the patient and family as full
members of the health care team d. A particular group with its values, beliefs, norms, patterns, and practices that are learned,
shared, and transmitted from one generation to another e. A complex whole in which each part is interrelated, including beliefs, tradition, lifeways, and
heritage
5. What is a way to integrate spiritual practices into nursing care? a. Explaining the religious practices you personally take part in b. Realizing that young children have little understanding regarding their spirituality c. Agreeing with children and their families when they explain their religious beliefs so that they
are not offended d. Becoming knowledgeable about the religious worldviews of cultural groups found in the
patients you care for
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Correct Answers 1. b, c, e; 2. c;
3. c; 4. b, c, d, e;
5. d
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Developmental and Genetic Influences on Child Health Promotion Quinn Franklin, Cynthia A. Prows
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Growth and Development Foundations of Growth and Development Growth and development, usually referred to as a unit, express the sum of the numerous changes that take place during the lifetime of an individual. The entire course is a dynamic process that encompasses several interrelated dimensions:
Growth—an increase in number and size of cells as they divide and synthesize new proteins; results in increased size and weight of the whole or any of its parts
Development—a gradual change and expansion; advancement from lower to more advanced stages of complexity; the emerging and expanding of the individual's capacities through growth, maturation, and learning
Maturation—an increase in competence and adaptability; aging; usually used to describe a qualitative change; a change in the complexity of a structure that makes it possible for that structure to begin functioning; to function at a higher level
Differentiation—processes by which early cells and structures are systematically modified and altered to achieve specific and characteristic physical and chemical properties; sometimes used to describe the trend of mass to specific; development from simple to more complex activities and functions
All of these processes are interrelated, simultaneous, and ongoing; none occurs apart from the others. The processes depend on a sequence of endocrine, genetic, constitutional, environmental, and nutritional influences (Seidel, Ball, Dains, et al, 2007). The child's body becomes larger and more complex; the personality simultaneously expands in scope and complexity. Very simply, growth can be viewed as a quantitative change and development as a qualitative change.
Stages of Development Most authorities in the field of child development categorize child growth and behavior into approximate age stages or in terms that describe the features of a developmental age period. The age ranges of these stages are arbitrary, because they do not take into account individual differences and cannot be applied to all children with any degree of precision. Categorization does provide a convenient means to describe the characteristics associated with the majority of children at periods when distinctive developmental changes appear and specific developmental tasks must be accomplished. (A developmental task is a set of skills and competencies specific to each developmental stage that children must accomplish or master to function effectively within their environment.) It is also significant for nurses to know that there are characteristic health problems related to each major phase of development. The sequence of descriptive age periods and subperiods that are used here and elaborated in subsequent chapters is listed in Box 3-1.
Box 3-1 D e ve l o p m e n t a l A g e Pe r i o d s Prenatal Period—Conception to Birth
Germinal: Conception to approximately 2 weeks old
Embryonic: 2 to 8 weeks old
Fetal: 8 to 40 weeks old (birth)
A rapid growth rate and total dependency make this one of the most crucial periods in the developmental process. The relationship between maternal health and certain manifestations in the newborn emphasizes the importance of adequate prenatal care to the health and well-being of the
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infant.
Infancy Period—Birth to 12 Months Old
Neonatal: Birth to 27 or 28 days old
Infancy: 1 to approximately 12 months old
The infancy period is one of rapid motor, cognitive, and social development. Through mutuality with the caregiver (parent), the infant establishes a basic trust in the world and the foundation for future interpersonal relationships. The critical first month of life, although part of the infancy period, is often differentiated from the remainder because of the major physical adjustments to extrauterine existence and the psychological adjustment of the parent.
Early Childhood—1 to 6 Years Old
Toddler: 1 to 3 years old
Preschool: 3 to 6 years old
This period, which extends from the time children attain upright locomotion until they enter school, is characterized by intense activity and discovery. It is a time of marked physical and personality development. Motor development advances steadily. Children at this age acquire language and wider social relationships, learn role standards, gain self-control and mastery, develop increasing awareness of dependence and independence, and begin to develop a self- concept.
Middle Childhood—6 to 11 or 12 Years Old Frequently referred to as the school age, this period of development is one in which the child is directed away from the family group and centered around the wider world of peer relationships. There is steady advancement in physical, mental, and social development with emphasis on developing skill competencies. Social cooperation and early moral development take on more importance with relevance for later life stages. This is a critical period in the development of a self- concept.
Later Childhood—11 to 19 Years Old
Prepubertal: 10 to 13 years old
Adolescence: 13 to approximately 18 years old
The tumultuous period of rapid maturation and change known as adolescence is considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world—usually high school graduation. Biologic and personality maturation are accompanied by physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent period, the young person begins to internalize all previously learned values and to focus on an individual, rather than a group, identity.
Patterns of Growth and Development There are definite and predictable patterns in growth and development that are continuous, orderly, and progressive. These patterns, or trends, are universal and basic to all human beings, but each human being accomplishes these in a manner and time unique to that individual.
Directional Trends Growth and development proceed in regular, related directions or gradients and reflect the physical development and maturation of neuromuscular functions (Fig. 3-1). The first pattern is the cephalocaudal, or head-to-tail, direction. The head end of the organism develops first and is large and complex, whereas the lower end is small and simple and takes shape at a later period. The physical evidence of this trend is most apparent during the period before birth, but it also applies to postnatal behavior development. Infants achieve control of the heads before they have control of
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their trunks and extremities, hold their backs erect before they stand, use their eyes before their hands, and gain control of their hands before they have control of their feet.
FIG 3-1 Directional trends in growth.
Second, the proximodistal, or near-to-far, trend applies to the midline-to-peripheral concept. A conspicuous illustration is the early embryonic development of limb buds, which is followed by rudimentary fingers and toes. In infants, shoulder control precedes mastery of the hands, the whole hand is used as a unit before the fingers can be manipulated, and the central nervous system develops more rapidly than the peripheral nervous system.
These trends or patterns are bilateral and appear symmetric—each side develops in the same direction and at the same rate as the other. For some of the neurologic functions, this symmetry is only external because of unilateral differentiation of function at an early stage of postnatal development. For example, by the age of approximately 5 years, children have demonstrated a decided preference for the use of one hand over the other, although previously either one had been used.
The third trend, differentiation, describes development from simple operations to more complex activities and functions, from broad, global patterns of behavior to more specific, refined patterns. All areas of development (physical, cognitive, social, and emotional) proceed in this direction. Through the process of development and differentiation, early embryonal cells with vague, undifferentiated functions progress to an immensely complex organism composed of highly specialized and diversified cells, tissues, and organs. Generalized development precedes specific or specialized development; gross, random muscle movements take place before fine muscle control.
Sequential Trends In all dimensions of growth and development, there is a definite, predictable sequence, with each child passing through every stage. For example, children crawl before they creep, creep before they stand, and stand before they walk. Later facets of the personality are built on the early foundation of trust. The child babbles, then forms words, and finally sentences; writing emerges from scribbling.
Developmental Pace Although development has a fixed, precise order, it does not progress at the same rate or pace. There are periods of accelerated growth and periods of decelerated growth in both total body growth and the growth of subsystems. Not all areas of development progress at the same pace. When a spurt occurs in one area (such as, gross motor), minimal advances may take place in
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language, fine motor, or social skills. After the gross motor skill has been achieved, the focus will shift to another area of development. The rapid growth before and after birth gradually levels off throughout early childhood. Growth is relatively slow during middle childhood, markedly increases at the beginning of adolescence, and levels off in early adulthood. Each child grows at his or her own pace. Distinct differences are observed among children as they reach developmental milestones.
N u r s i n g T i p Research suggests that normal growth, particularly height in infants, may occur in brief (possibly even 24-hour) bursts that punctuate long periods in which no measurable growth takes place. The researchers noted sex differences, with girls growing in length during the week they gained weight and boys growing in the week after a significant weight gain. Sex-specific growth hormone pulse patterns may coordinate body composition, weight gain, and linear growth (Lampl, Johnson, and Frongillo, 2001; Lampl, Thompson, and Frongillo, 2005). Furthermore, findings indicate a stuttering or saltatory pattern of growth that follows no regular cycle and can occur after “quiet” periods that last as long as 4 weeks.
Sensitive Periods There are limited times during the process of growth when the organism interacts with a particular environment in a specific manner. Periods termed critical, sensitive, vulnerable, and optimal are the times in the lifetime of an organism when it is more susceptible to positive or negative influences.
The quality of interactions during these sensitive periods determines whether the effects on the organism will be beneficial or harmful. For example, physiologic maturation of the central nervous system is influenced by the adequacy and timing of contributions from the environment, such as stimulation and nutrition. The first 3 months of prenatal life is a sensitive period in the physical growth of fetuses.
Psychosocial development also appears to have sensitive periods when an environmental event has maximal influence on the developing personality. For example, primary socialization occurs during the first year when the infant makes the initial social attachments and establishes a basic trust in the world. A warm and consistently responsive relationship with a parent figure is fundamental to a healthy personality. The same concept might be applied to readiness for learning skills, such as toilet training or reading. In these instances, there appears to be an opportune time when the skill is best learned.
Individual Differences Each child grows in his or her own unique and personal way. The sequence of events is predictable; the exact timing is not. Rates of growth vary, and measurements are defined in terms of ranges to allow for individual differences. Periods of fast growth, such as the pubescent growth spurt, may begin earlier or later in some children than in others. Children may grow fast or slowly during the spurt and may finish sooner or later than other children. Gender is an influential factor because girls seem to be more advanced in physiologic growth at all ages.
Biologic Growth and Physical Development As children grow, their external dimensions change. These changes are accompanied by corresponding alterations in structure and function of internal organs and tissues that reflect the gradual acquisition of physiologic competence. Each part has its own rate of growth, which may be directly related to alterations in the size of the child (e.g., the heart rate). Skeletal muscle growth approximates whole body growth; brain, lymphoid, adrenal, and reproductive tissues follow distinct and individual patterns (Fig. 3-2). When growth deficiency has a secondary cause, such as severe illness or acute malnutrition, recovery from the illness or the establishment of an adequate diet will produce a dramatic acceleration of the growth rate that usually continues until the child's individual growth pattern is resumed.
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FIG 3-2 Growth rates for the body as a whole and three types of tissues. General—body as a whole; external dimension; and respiratory, digestive, renal, circulatory, and musculoskeletal systems. Lymphoid —thymus, lymph nodes, and intestinal lymph masses. Neural—brain, dura, spinal cord, optic apparatus, and head dimensions. (Jackson, Patterson, and Harris, 1930). (Data from Jackson JA, Patterson DG, Harris RE: The
measurement of man, Minneapolis, 1930, University of Minnesota Press.)
External Proportions Variations in the growth rate of different tissues and organ systems produce significant changes in body proportions during childhood. The cephalocaudal trend of development is most evident in total body growth as indicated by these changes. During fetal development, the head is the fastest growing body part, and at 2 months of gestation, the head constitutes 50% of total body length. During infancy, growth of the trunk predominates; the legs are the most rapidly growing part during childhood; in adolescence, the trunk again elongates. In newborn infants, the lower limbs are one third the total body length but only 15% of the total body weight; in adults, the lower limbs constitute half of the total body height and 30% or more of the total body weight. As growth proceeds, the midpoint in head-to-toe measurements gradually descends from a level even with the umbilicus at birth to the level of the symphysis pubis at maturity.
Biologic Determinants of Growth and Development The most prominent feature of childhood and adolescence is physical growth (Fig. 3-3). Throughout development, various tissues in the body undergo changes in growth, composition, and structure. In some tissues, the changes are continuous (e.g., bone growth and dentition); in others, significant alterations occur at specific stages (e.g., appearance of secondary sex characteristics). When these measurements are compared with standardized norms, a child's developmental progress can be determined with a high degree of confidence (Table 3-1). Growth in children with Down syndrome differs from that in other children. They have slower growth velocity between 6 months and 3 years and then again in adolescence. Puberty occurs earlier, and they achieve shorter stature. This population of patients is frequent users of the health care system, often with multiple providers, and benefit from the use of the Down syndrome growth chart to monitor their growth (Cronk, Crocker, Pueschel, et al, 1988; Myrelid, Gustafsson, Ollars, et al, 2002).
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FIG 3-3 Changes in body proportions occur dramatically during childhood.
TABLE 3-1 General Trends in Height and Weight Gain during Childhood
Age Group Weight* Height* Birth to 6 months old
Weekly gain: 140 to 200 g (5 to 7 oz) Birth weight doubles by end of first 4 to 7
months†
Monthly gain: 2.5 cm (1 inch)
6 to 12 months old Weight gain: 85 to 140 g (3 to 5 ounces) Birth weight triples by end of first year
Monthly gain: 1.25 cm (0.5 inch) Birth length increases by ≈50% by end of first year
Toddlers Birth weight quadruples by age years
Height at age 2 years is ≈50% of eventual adult height Gain during second year: About 12 cm (4.7 inches) Gain during third year: About 6 to 8 cm (2.4 to 3.1 inches)
Preschoolers Yearly gain: 2 to 3 kg (4.5 to 6.5 pounds) Birth length doubles by 4 years old Yearly gain: 5 to 7.5 cm (2 to 3 inches)
School-age children Yearly gain: 2 to 3 kg (4.5 to 6.5 pounds) Yearly gain after age 7 years: 5 cm (2 inches) Birth length triples by about 13 years old
Pubertal Growth Spurt Females: 10 to 14 years
Weight gain: 7 to 25 kg (15.5 to 55 pounds) Mean: 17.5 kg (38.5 pounds)
Height gain: 5 to 25 cm (2 to 10 inches); ≈95% of mature height achieved by onset of menarche or skeletal age of 13 years old
Mean: 20.5 cm (8 inches) Males: 11 to 16 years Weight gain: 7 to 30 kg (15.5 to 66 pounds)
Mean: 23.7 kg (52.2 pounds) Height gain: 10 to 30 cm (4 to 12 inches); ≈95% of mature height achieved by skeletal age of 15 years old Mean: 27.5 cm (11 inches)
*Yearly height and weight gains for each age group represent averaged estimates from a variety of sources. †Jung FE, Czajka-Narins DM: Birth weight doubling and tripling times: an updated look at the effects of birth weight, sex, race, and type of feeding, Am J Clin Nutr 42(2):182–189, 1985.
Linear growth, or height, occurs almost entirely as a result of skeletal growth and is considered a stable measurement of general growth. Growth in height is not uniform throughout life but ceases when maturation of the skeleton is complete. The maximum rate of growth in length occurs before birth, but newborns continue to grow at a rapid, although slower, rate.
N u r s i n g T i p Double the child's height at the age of 2 years to estimate how tall he or she may be as an adult.
At birth, weight is more variable than height and is, to a greater extent, a reflection of the intrauterine environment. The average newborn weighs from 3175 to 3400 g (7 to 7.5 pounds). In general, the birth weight doubles by 4 to 7 months old and triples by the end of the first year. By 2 to years old, the birth weight usually quadruples. After this point, the “normal” rate of weight gain, just as the growth in height, assumes a steady annual increase of approximately 2 to 2.75 kg (4.4 to 6 pounds) per year until the adolescent growth spurt.
Both bone age determinants and state of dentition are used as indicators of development. Because both are discussed elsewhere, neither is elaborated here (see the next section for bone age; see Chapters 11 and 12 for dentition).
Skeletal Growth and Maturation The most accurate measure of general development is skeletal or bone age, the radiologic determination of osseous maturation. Skeletal age appears to correlate more closely with other measures of physiologic maturity (e.g., onset of menarche) than with chronologic age or height. Bone age is determined by comparing the mineralization of ossification centers and advancing bony form to age-related standards.
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Bone formation begins during the second month of fetal life when calcium salts are deposited in the intercellular substance (matrix) to form calcified cartilage first and then true bone. Bone formation exhibits some differences. In small bones, the bone continues to form in the center, and cartilage continues to be laid down on the surfaces. In long bones, the ossification begins in the diaphysis (the long central portion of the bone) and continues in the epiphysis (the end portions of the bone). Between the diaphysis and the epiphysis, an epiphyseal cartilage plate (or growth plate) unites with the diaphysis by columns of spongy tissue, the metaphysis. Active growth in length takes place in the epiphyseal growth plate. Interference with this growth site by trauma or infection can result in deformity.
The first centers of ossification appear in 2-month-old embryos; and at birth, the number is approximately 400, about half the number at maturity. New centers appear at regular intervals during the growth period and provide the basis for assessment of bone age. Postnatally, the earliest centers to appear (at 5 to 6 months old) are those of the capitate and hamate bones in the wrist. Therefore radiographs of the hand and wrist provide the most useful areas for screening to determine skeletal age, especially before 6 years old. These centers appear earlier in girls than in boys.
Nurses must understand that the growing bones of children possess many unique characteristics. Bone fractures occurring at the growth plate may be difficult to discover and may significantly affect subsequent growth and development (Urbanski and Hanlon, 1996). Factors that may influence skeletal muscle injury rates and types in children and adolescents include the following (Caine, DiFiori, and Maffulli, 2006; Kaczander, 1997): • Less protective sports equipment for children • Less emphasis on conditioning, especially flexibility • In adolescents, fractures that are more common than ligamentous ruptures because of the rapid
growth rate of the physeal (segment of tubular bone that is concerned mainly with growth) zone of hypertrophy
Neurologic Maturation In contrast to other body tissues, which grow rapidly after birth, the nervous system grows proportionately more rapidly before birth. Two periods of rapid brain cell growth occur during fetal life, a dramatic increase in the number of neurons between 15 and 20 weeks of gestation and another increase at 30 weeks, which extends to 1 year of age. The rapid growth of infancy continues during early childhood and then slows to a more gradual rate during later childhood and adolescence.
Postnatal growth consists of increasing the amount of cytoplasm around the nuclei of existing cells, increasing the number and intricacy of communications with other cells, and advancing their peripheral axons to keep pace with expanding body dimensions. This allows for increasingly complex movement and behavior. Neurophysiologic changes also provide the foundation for language, learning, and behavior development. Neurologic or electroencephalographic development is sometimes used as an indicator of maturational age in the early weeks of life.
Lymphoid Tissues Lymphoid tissues contained in the lymph nodes, thymus, spleen, tonsils, adenoids, and blood lymphocytes follow a growth pattern unlike that of other body tissues. These tissues are small in relation to total body size, but they are well developed at birth. They increase rapidly to reach adult dimensions by 6 years old and continue to grow. At about 10 to 12 years old, they reach a maximum development that is approximately twice their adult size. This is followed by a rapid decline to stable adult dimensions by the end of adolescence.
Development of Organ Systems All tissues and organ systems undergo changes during development. Some are striking; others are subtle. Many have implications for assessment and care. Because the major importance of these changes relates to their dysfunction, the developmental characteristics of various systems and organs are discussed throughout the book as they relate to these areas. Physical characteristics and physiologic changes that vary with age are included in age-group descriptions.
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Physiologic Changes Physiologic changes that take place in all organs and systems are discussed as they relate to dysfunction. Other changes, such as pulse and respiratory rates and blood pressure, are an integral part of physical assessment (see Chapter 4). In addition, there are changes in basic functions, including metabolism, temperature, and patterns of sleep and rest.
Metabolism The rate of metabolism when the body is at rest (basal metabolic rate, or BMR) demonstrates a distinctive change throughout childhood. Highest in newborn infants, the BMR closely relates to the proportion of surface area to body mass, which changes as the body increases in size. In both sexes, the proportion decreases progressively to maturity. The BMR is slightly higher in boys at all ages and further increases during pubescence over that in girls.
The rate of metabolism determines the caloric requirements of the child. The basal energy requirement of infants is about 108 kcal/kg of body weight and decreases to 40 to 45 kcal/kg at maturity. Water requirements throughout life remain at approximately 1.5 ml/calorie of energy expended. Children's energy needs vary considerably at different ages and with changing circumstances. The energy requirement to build tissue steadily decreases with age following the general growth curve; however, energy needs vary with the individual child and may be considerably higher. For short periods (e.g., during strenuous exercise) and more prolonged periods (e.g., illness) the needs can be very high.
N u r s i n g A l e r t Each degree of fever increases the basal metabolism 10%, with a correspondingly increased fluid requirement.
Temperature Body temperature, reflecting metabolism, decreases over the course of development (see inside back cover). Thermoregulation is one of the most important adaptation responses of infants during the transition from intrauterine to extrauterine life. In healthy neonates, hypothermia can result in several negative metabolic consequences, such as hypoglycemia, elevated bilirubin levels, and metabolic acidosis. Skin-to-skin care, also referred to as kangaroo care, is an effective way to prevent neonatal hypothermia in infants. Unclothed, diapered infants are placed on the parent's bare chest after birth, promoting thermoregulation and attachment (Galligan, 2006). After the unstable regulatory ability in the neonatal period, heat production steadily declines as the infant grows into childhood. Individual differences of 0.5° F to 1° F are normal, and occasionally a child normally displays an unusually high or low temperature. Beginning at approximately 12 years old, girls display a temperature that remains relatively stable, but the temperature in boys continues to fall for a few more years. Females maintain a temperature slightly above that of males throughout life.
Even with improved temperature regulation, infants and young children are highly susceptible to temperature fluctuations. Body temperature responds to changes in environmental temperature and is increased with active exercise, crying, and emotional stress. Infections can cause a higher and more rapid temperature increase in infants and young children than in older children. In relation to body weight, an infant produces more heat per unit than adolescents. Consequently, during active play or when heavily clothed, an infant or small child is likely to become overheated.
Sleep and Rest Sleep, a protective function in all organisms, allows for repair and recovery of tissues after activity. As in most aspects of development, there is wide variation among individual children in the amount and distribution of sleep at various ages. As children mature, there is a change in the total time they spend in sleep and the amount of time they spend in deep sleep.
Newborn infants sleep much of the time that is not occupied with feeding and other aspects of their care. As infants grow older, the total time spent sleeping gradually decreases, they remain awake for longer periods, and they sleep longer at night. For example, the length of a sleep cycle increases from approximately 50 to 60 minutes in newborn infants to approximately 90 minutes in adolescents (Anders, Sadeh, and Appareddy, 2005). During the latter part of the first year, most
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children sleep through the night and take one or two naps during the day. By the time they are 12 to 18 months old, most children have eliminated the second nap. After age 3 years, children have usually given up daytime naps except in cultures in which an afternoon nap or siesta is customary. Sleep time declines slightly from 4 to 10 years old and then increases somewhat during the pubertal growth spurt.
The quality of sleep changes as children mature. As children develop through adolescence, their need for sleep does not decline, but their opportunity for sleep may be affected by social, activity, and academic schedules.
Nutrition Nutrition is probably the single most important influence on growth. Dietary factors regulate growth at all stages of development, and their effects are exerted in numerous and complex ways. During the rapid prenatal growth period, poor nutrition may influence development from the time of implantation of the ovum until birth. During infancy and childhood, the demand for calories is relatively great, as evidenced by the rapid increase in both height and weight. At this time, protein and caloric requirements are higher than at almost any period of postnatal development. As the growth rate slows, with its concomitant decrease in metabolism, there is a corresponding reduction in caloric and protein requirements.
Growth is uneven during the periods of childhood between infancy and adolescence, when there are plateaus and small growth spurts. Children's appetites fluctuate in response to these variations until the turbulent growth spurt of adolescence, when adequate nutrition is extremely important but may be subjected to numerous emotional influences. Adequate nutrition is closely related to good health throughout life, and an overall improvement in nourishment is evidenced by the gradual increase in size and early maturation of children in this century (see Community Focus box).
C o m m u n i t y F o c u s Healthy Food Choices
Current research indicates that new lower fat recipes in school lunch programs are well accepted by children (Matvienko, 2007). However, less-healthy foods are still more readily available than more-healthy foods in our nation's schools (Delva, O'Malley, and Johnston, 2007).
Temperament Temperament is defined as “the manner of thinking, behaving, or reacting characteristic of an individual” (Chess and Thomas, 1999) and refers to the way in which a person deals with life. From the time of birth, children exhibit marked individual differences in the way they respond to their environment and the way others, particularly the parents, respond to them and their needs. A genetic basis has been suggested for some differences in temperament. Nine characteristics of temperament have been identified through interviews with parents (Box 3-2). Temperament refers to behavioral tendencies, not to discrete behavioral acts. There are no implications of good or bad. Most children can be placed into one of three common categories based on their overall pattern of temperamental attributes:
The easy child: Easygoing children are even tempered, are regular and predictable in their habits, and have a positive approach to new stimuli. They are open and adaptable to change and display a mild to moderately intense mood that is typically positive. Approximately 40% of children fall into this category.
The difficult child: Difficult children are highly active, irritable, and irregular in their habits. Negative withdrawal responses are typical, and they require a more structured environment. These children adapt slowly to new routines, people, and situations. Mood expressions are usually intense and primarily negative. They exhibit frequent periods of crying, and frustration often produces violent tantrums. This group represents about 10% of children.
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The slow-to-warm-up child: Slow-to-warm-up children typically react negatively and with mild intensity to new stimuli and, unless pressured, adapt slowly with repeated contact. They respond with only mild but passive resistance to novelty or changes in routine. They are inactive and moody but show only moderate irregularity in functions. Fifteen percent of children demonstrate this temperament pattern.
Box 3-2 At t r i b u t e s o f Te m p e r a m e n t Activity: Level of physical motion during activity, such as sleep, eating, play, dressing, and bathing
Rhythmicity: Regularity in the timing of physiologic functions, such as hunger, sleep, and elimination
Approach-withdrawal: Nature of initial responses to a new stimulus, such as people, situations, places, foods, toys, and procedures (Approach responses are positive and are displayed by activity or expression; withdrawal responses are negative expressions or behaviors.)
Adaptability: Ease or difficulty with which the child adapts or adjusts to new or altered situations
Threshold of responsiveness (sensory threshold): Amount of stimulation, such as sounds or light, required to evoke a response in the child
Intensity of reaction: Energy level of the child's reactions regardless of quality or direction
Mood: Amount of pleasant, happy, friendly behavior compared with unpleasant, unhappy, crying, unfriendly behavior exhibited by the child in various situations
Distractibility: Ease with which a child's attention or direction of behavior can be diverted by external stimuli
Attention span and persistence: Length of time a child pursues a given activity (attention) and the continuation of an activity despite obstacles (persistence)
Thirty-five percent of children either have some, but not all, of the characteristics of one of the categories or are inconsistent in their behavioral responses. Many normal children demonstrate this wide range of behavioral patterns.
Significance of Temperament Observations indicate that children who display the difficult or slow-to-warm-up patterns of behavior are more vulnerable to the development of behavior problems in early and middle childhood. Any child can develop behavior problems if there is dissonance between the child's temperament and the environment. Demands for change and adaptation that are in conflict with the child's capacities can become excessively stressful. However, authorities emphasize that it is not the temperament patterns of children that place them at risk; rather, it is the degree of fit between children and their environment, specifically their parents, that determines the degree of vulnerability. The potential for optimum development exists when environmental expectations and demands fit with the individual's style of behavior and the parents' ability to navigate this period (Chess and Thomas, 1999) (see Growth Failure [Failure to Thrive], Chapter 10).
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Development of Personality and Cognitive Function Personality and cognitive skills develop in much the same manner as biologic growth—new accomplishments build on previously mastered skills. Many aspects depend on physical growth and maturation. This is not a comprehensive account of the multiple facets of personality and behavior development. Many aspects are integrated with the child's social and emotional development in later discussion of various age groups. Table 3-2 summarizes some of the developmental theories.
TABLE 3-2 Summary of Personality, Cognitive, and Moral Development Theories
Psychosexual (Freud) Psychosocial (Erikson) Cognitive (Piaget) Moral Judgment (Kohlberg)
Oral Trust vs. mistrust Sensorimotor (birth to 2 years old) Anal Autonomy vs. shame and
doubt Preoperational thought, preconceptual phase (transductive reasoning [e.g., specific to specific]) (2 to 4 years old)
Preconventional (premoral) level Punishment and obedience orientation
Phallic Initiative vs. guilt Preoperational thought, intuitive phase (transductive reasoning) (4 to 7 years old) Preconventional (premoral) level Naive instrumental orientation
Latency Industry vs. inferiority Concrete operations (inductive reasoning and beginning logic) (7 to 11 years old) Conventional level Good-boy, nice-girl orientation Law-and-order orientation
Genital Identity vs. role confusion Formal operations (deductive and abstract reasoning) (11 to 15 years old) Postconventional or principled level Social-contract orientation
Theoretical Foundations of Personality Development Psychosexual Development (Freud) According to Freud, all human behavior is energized by psychodynamic forces, and this psychic energy is divided among three components of personality: the id, ego, and superego (Freud, 1933). The id, the unconscious mind, is the inborn component that is driven by instincts. The id obeys the pleasure principle of immediate gratification of needs, regardless of whether the object or action can actually do so. The ego, the conscious mind, serves the reality principle. It functions as the conscious or controlling self that is able to find realistic means for gratifying the instincts while blocking the irrational thinking of the id. The superego, the conscience, functions as the moral arbitrator and represents the ideal. It is the mechanism that prevents individuals from expressing undesirable instincts that might threaten the social order.
Freud considered the sexual instincts to be significant in the development of the personality (Freud, 1964). However, he used the term psychosexual to describe any sensual pleasure. During childhood, certain regions of the body assume a prominent psychological significance as the source of new pleasures and new conflicts gradually shifts from one part of the body to another at particular stages of development:
Oral stage (birth to 1 year old): During infancy, the major source of pleasure seeking is centered on oral activities, such as sucking, biting, chewing, and vocalizing. Children may prefer one of these over the others, and the preferred method of oral gratification can provide some indication of the personality they develop.
Anal stage (1 to 3 years old): Interest during the second year of life centers in the anal region as sphincter muscles develop and children are able to withhold or expel fecal material at will. At this stage, the climate surrounding toilet training can have lasting effects on children's personalities.
Phallic stage (3 to 6 years old): During the phallic stage, the genitalia become an interesting and sensitive area of the body. Children recognize differences between the sexes and become curious about the dissimilarities. This is the period around which the controversial issues of the Oedipus and Electra complexes, penis envy, and castration anxiety are centered.
Latency period (6 to 12 years old): During the latency period, children elaborate on previously acquired traits and skills. Physical and psychic energy are channeled into acquisition of knowledge and vigorous play.
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Genital stage (12 years old and older): The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The genital organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friendships and preparing for marriage.
Psychosocial Development (Erikson) The most widely accepted theory of personality development is that advanced by Erikson (1963). Although built on Freudian theory, it is known as psychosocial development and emphasizes a healthy personality as opposed to a pathologic approach. Erikson also uses the biologic concepts of critical periods and epigenesis, describing key conflicts or core problems that the individual strives to master during critical periods in personality development. Successful completion or mastery of each of these core conflicts is built on the satisfactory completion or mastery of the previous stage.
Each psychosocial stage has two components—the favorable and the unfavorable aspects of the core conflict—and progress to the next stage depends on resolution of this conflict. No core conflict is ever mastered completely but remains a recurrent problem throughout life. No life situation is ever secure. Each new situation presents the conflict in a new form. For example, when children who have satisfactorily achieved a sense of trust encounter a new experience (e.g., hospitalization), they must again develop a sense of trust in those responsible for their care in order to master the situation. Erikson's life-span approach to personality development consists of eight stages; however, only the first five relating to childhood are included here:
Trust versus mistrust (birth to 1 year old): The first and most important attribute to develop for a healthy personality is basic trust. Establishment of basic trust dominates the first year of life and describes all of the child's satisfying experiences at this age. Corresponding to Freud's oral stage, it is a time of “getting” and “taking in” through all the senses. It exists only in relation to something or someone; therefore, consistent, loving care by a mothering person is essential for development of trust. Mistrust develops when trust-promoting experiences are deficient or lacking or when basic needs are inconsistently or inadequately met. Although shreds of mistrust are sprinkled throughout the personality, from a basic trust in parents stems trust in the world, other people, and oneself. The result is faith and optimism.
Autonomy versus shame and doubt (1 to 3 years old): Corresponding to Freud's anal stage, the problem of autonomy can be symbolized by the holding on and letting go of the sphincter muscles. The development of autonomy during the toddler period is centered on children's increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selecting and decision making. Much of their learning is acquired by imitating the activities and behavior of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control. The favorable outcomes are self-control and willpower.
Initiative versus guilt (3 to 6 years old): The stage of initiative corresponds to Freud's phallic stage and is characterized by vigorous, intrusive behavior; enterprise; and a strong imagination. Children explore the physical world with all their senses and powers (Fig. 3-4). They develop a conscience. No longer guided only by outsiders, they have an inner voice that warns and threatens. Children sometimes undertake goals or activities that are in conflict with those of parents or others, and being made to feel that their activities or imaginings are bad produces a sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights and privileges of others. The lasting outcomes are direction and purpose.
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FIG 3-4 The stage of initiative is characterized by physical activity and imagination while children explore the physical world around them.
Industry versus inferiority (6 to 12 years old): The stage of industry is the latency period of Freud. Having achieved the more crucial stages in personality development, children are ready to be workers and producers. They want to engage in tasks and activities that they can carry through to completion; they need and want real achievement. Children learn to compete and cooperate with others, and they learn the rules. It is a decisive period in their social relationships with others. Feelings of inadequacy and inferiority may develop if too much is expected of them or if they believe that they cannot measure up to the standards set for them by others. The ego quality developed from a sense of industry is competence.
Identity versus role confusion (12 to 18 years old): Corresponding to Freud's genital period, the development of identity is characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appear in the eyes of others compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society, and to come to a decision regarding an occupation. An inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity to others and to values and ideologies.
Theoretical Foundations of Cognitive Development The term cognition refers to the process by which developing individuals become acquainted with the world and the objects it contains. Children are born with inherited potentials for intellectual growth, but they must develop that potential through interaction with the environment. By assimilating information through the senses, processing it, and acting on it, they come to understand relationships between objects and between themselves and their world. With cognitive development, children acquire the ability to reason abstractly, to think in a logical manner, and to organize intellectual functions or performances into higher order structures. Language, morals, and spiritual development emerge as cognitive abilities advance.
Cognitive Development (Piaget) Jean Piaget (1969), a Swiss psychologist, developed a stage theory to better understand the way a child thinks. According to Piaget, intelligence enables individuals to make adaptations to the environment that increase the probability of survival, and through their behavior, individuals establish and maintain equilibrium with the environment. Each stage of cognitive development is derived from and builds on the accomplishments of the previous stage in a continuous, orderly process. This course of development is both maturational and invariant and is divided into the following four stages (ages are approximate):
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Sensorimotor (birth to 2 years old): The sensorimotor stage of intellectual development consists of six substages that are governed by sensations in which simple learning takes place (see Chapter 9 and Chapter 11). Children progress from reflex activity through simple repetitive behaviors to imitative behavior. They develop a sense of cause and effect as they direct behavior toward objects. Problem solving is primarily by trial and error. They display a high level of curiosity, experimentation, and enjoyment of novelty and begin to develop a sense of self as they are able to differentiate themselves from their environment. They become aware that objects have permanence—that an object exists even though it is no longer visible. Toward the end of the sensorimotor period, children begin to use language and representational thought.
Preoperational (2 to 7 years old): The predominant characteristic of the preoperational stage of intellectual development is egocentrism, which in this sense does not mean selfishness or self- centeredness but the inability to put oneself in the place of another. Children interpret objects and events not in terms of general properties but in terms of their relationships or their use to them. They are unable to see things from any perspective other than their own; they cannot see another's point of view, nor can they see any reason to do so (see Cognitive Development, Chapter 12). Preoperational thinking is concrete and tangible. Children cannot reason beyond the observable, and they lack the ability to make deductions or generalizations. Thought is dominated by what they see, hear, or otherwise experience. However, they are increasingly able to use language and symbols to represent objects in their environment. Through imaginative play, questioning, and other interactions, they begin to elaborate concepts and to make simple associations between ideas. In the latter stage of this period, their reasoning is intuitive (e.g., the stars have to go to bed just as they do), and they are only beginning to deal with problems of weight, length, size, and time. Reasoning is also transductive—because two events occur together, they cause each other, or knowledge of one characteristic is transferred to another (e.g., all women with big bellies have babies).
Concrete operations (7 to 11 years old): At this age, thought becomes increasingly logical and coherent. Children are able to classify, sort, order, and otherwise organize facts about the world to use in problem solving. They develop a new concept of permanence—conservation (see Cognitive Development [Piaget], Chapter 14); that is, they realize that physical factors (such as, volume, weight, and number) remain the same even though outward appearances are changed. They are able to deal with a number of different aspects of a situation simultaneously. They do not have the capacity to deal in abstraction; they solve problems in a concrete, systematic fashion based on what they can perceive. Reasoning is inductive. Through progressive changes in thought processes and relationships with others, thought becomes less self-centered. They can consider points of view other than their own. Thinking has become socialized.
Formal operations (11 to 15 years old): Formal operational thought is characterized by adaptability and flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. For example, they can solve the following question: If A is larger than B and B is larger than C, which symbol is the largest? (The answer is A.) They can make hypotheses and test them; they can consider abstract, theoretic, and philosophic matters. Although they may confuse the ideal with the practical, most contradictions in the world can be dealt with and resolved.
Language Development Children are born with the mechanism and capacity to develop speech and language skills. However, they do not speak spontaneously. The environment must provide a means for them to acquire these skills. Speech requires intact physiologic structure and function (including respiratory, auditory, and cerebral) plus intelligence, a need to communicate, and stimulation.
The rate of speech development varies from child to child and is directly related to neurologic competence and cognitive development. Gesture precedes speech. As speech develops, gesture recedes but never disappears entirely. Research suggests that infants can learn sign language before vocal language and that it may enhance the development of vocal language (Thompson, Cotner- Bichelman, McKerchar, et al, 2007). At all stages of language development, children's comprehension vocabulary (what they understand) is greater than their expressed vocabulary (what they can say), and this development reflects a continuing process of modification that
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involves both the acquisition of new words and the expanding and refining of word meanings previously learned. By the time they begin to walk, children are able to attach names to objects and persons.
The first parts of speech used are nouns, sometimes verbs (e.g., “go”), and combination words (e.g., “bye-bye”). Responses are usually structurally incomplete during the toddler period, although the meaning is clear. Next, they begin to use adjectives and adverbs to qualify nouns followed by adverbs to qualify nouns and verbs. Later, pronouns and gender words are added (e.g., “he” and “she”). By the time children enter school, they are able to use simple, structurally complete sentences that average five to seven words.
Moral Development (Kohlberg) Children also acquire moral reasoning in a developmental sequence. Moral development, as described by Kohlberg (1968), is based on cognitive developmental theory and consists of three major levels, each of which has two stages:
Preconventional level: The preconventional level of moral development parallels the preoperational level of cognitive development and intuitive thought. Culturally oriented to the labels of good/bad and right/wrong, children integrate these in terms of the physical or pleasurable consequences of their actions. At first, children determine the goodness or badness of an action in terms of its consequences. They avoid punishment and obey without question those who have the power to determine and enforce the rules and labels. They have no concept of the basic moral order that supports these consequences. Later, children determine that the right behavior consists of that which satisfies their own needs (and sometimes the needs of others). Although elements of fairness, give and take, and equal sharing are evident, they are interpreted in a practical, concrete manner without loyalty, gratitude, or justice.
Conventional level: At the conventional stage, children are concerned with conformity and loyalty. They value the maintenance of family, group, or national expectations regardless of consequences. Behavior that meets with approval and pleases or helps others is considered good. One earns approval by being “nice.” Obeying the rules, doing one's duty, showing respect for authority, and maintaining the social order are the correct behaviors. This level is correlated with the stage of concrete operations in cognitive development.
Postconventional, autonomous, or principled level: At the postconventional level, the individual has reached the cognitive stage of formal operations. Correct behavior tends to be defined in terms of general individual rights and standards that have been examined and agreed on by the entire society. Although procedural rules for reaching consensus become important, with emphasis on the legal point of view, there is also emphasis on the possibility for changing law in terms of societal needs and rational considerations.
The most advanced level of moral development is one in which self-chosen ethical principles guide decisions of conscience. These are abstract and ethical but universal principles of justice and human rights with respect for the dignity of persons as individuals. It is believed that few persons reach this stage of moral reasoning.
Development of Self-Concept Self-concept is how an individual describes him- or herself. The term self-concept includes all of the notions, beliefs, and convictions that constitute an individual's self-knowledge and that influence that individual's relationships with others. It is not present at birth but develops gradually as a result of unique experiences within the self, significant others, and the realities of the world. However, an individual's self-concept may or may not reflect reality.
In infancy, the self-concept is primarily an awareness of one's independent existence learned in part as a result of social contacts and experiences with others. The process becomes more active during toddlerhood as children explore the limits of their capacities and the nature of their impact on others. School-age children are more aware of differences among people, are more sensitive to social pressures, and become more preoccupied with issues of self-criticism and self-evaluation. During early adolescence, children focus more on physical and emotional changes taking place and
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on peer acceptance. Self-concept is crystallized during later adolescence as young people organize their self-concept around a set of values, goals, and competencies acquired throughout childhood.
Body Image A vital component of self-concept, body image refers to the subjective concepts and attitudes that individuals have toward their own bodies. It consists of the physiologic (the perception of one's physical characteristics), psychological (values and attitudes toward the body, abilities, and ideals), and social nature of one's image of self (the self in relation to others). All three of the components interrelate with one another. Body image is a complex phenomenon that evolves and changes during the process of growth and development. Any actual or perceived deviation from the “norm” (no matter how this is interpreted) is cause for concern. The extent to which a characteristic, defect, or disease affects children's body image is influenced by the attitudes and behavior of those around them.
The significant others in their lives exert the most important and meaningful impact on children's body image. Labels that are attached to them (e.g., “skinny,” “pretty,” or “fat”) or body parts (e.g., “ugly mole,” “bug eyes,” or “yucky skin”) are incorporated into the body image. Because they lack the understanding of deviations from the physical standard or norm, children notice prominent differences in others and unwittingly make rude or cruel remarks about such minor deviations as large or widely spaced front teeth, large or small eyes, moles, or extreme variations in height.
Infants receive input about their bodies through self-exploration and sensory stimulation from others. As they begin to manipulate their environment, they become aware of their bodies as separate from others. Toddlers learn to identify the various parts of their bodies and are able to use symbols to represent objects. Preschoolers become aware of the wholeness of their bodies and discover the genitalia. Exploration of the genitalia and the discovery of differences between the sexes become important. At this age, children have only a vague concept of internal organs and function (Stuart and Laraia, 2000).
School-age children begin to learn about internal body structure and function and become aware of differences in body size and configuration. They are highly influenced by the cultural norms of society and current fads. Children whose bodies deviate from the norm are often criticized or ridiculed. Adolescence is the age when children become most concerned about the physical self. The unfamiliar body changes, and the new physical self must be integrated into the self-concept. Adolescents face conflicts over what they see and what they visualize as the ideal body structure. Body image formation during adolescence is a crucial element in the shaping of identity, the psychosocial crisis of adolescence.
Self-Esteem Self-esteem is the value that an individual places on oneself and refers to an overall evaluation of oneself (Willoughby, King, and Polatajko, 1996). Whereas self-esteem is described as the affective component of the self, self-concept is the cognitive component; however, the two terms are almost indistinguishable and are often used interchangeably.
The term self-esteem refers to a personal, subjective judgment of one's worthiness derived from and influenced by the social groups in the immediate environment and individuals' perceptions of how they are valued by others. Self-esteem changes with development. Highly egocentric toddlers are unaware of any difference between competence and social approval. On the other hand, preschool and early school-age children are increasingly aware of the discrepancy between their competencies and the abilities of more advanced children. Being accepted by adults and peers outside the family group becomes more important to them. Positive feedback enhances their self- esteem; they are vulnerable to feelings of worthlessness and are anxious about failure.
As children's competencies increase and they develop meaningful relationships, their self-esteem rises. Their self-esteem is again at risk during early adolescence when they are defining an identity and sense of self in the context of their peer group. Unless children are continually made to feel incompetent and of little worth, a decrease in self-esteem during vulnerable times is only temporary.
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Role of Play in Development Through the universal medium of play, children learn what no one can teach them. They learn about their world and how to deal with this environment of objects, time, space, structure, and people. They learn about themselves operating within that environment—what they can do, how to relate to things and situations, and how to adapt themselves to the demands society makes on them. Play is the work of children. In play, children continually practice the complicated, stressful processes of living, communicating, and achieving satisfactory relationships with other people.
Classification of Play From a developmental point of view, patterns of children's play can be categorized according to content and social character. In both, there is an additive effect; each builds on past accomplishments, and some element of each is maintained throughout life. At each stage in development, the new predominates.
Content of Play The content of play involves primarily the physical aspects of play, although social relationships cannot be ignored. The content of play follows the directional trend of the simple to the complex:
Social-affective play: Play begins with social-affective play, wherein infants take pleasure in relationships with people. As adults talk, touch, nuzzle, and in various ways elicit responses from an infant, the infant soon learns to provoke parental emotions and responses with such behaviors as smiling, cooing, or initiating games and activities. The type and intensity of the adult behavior with children vary among cultures.
Sense-pleasure play: Sense-pleasure play is a nonsocial stimulating experience that originates from without. Objects in the environment—light and color, tastes and odors, textures and consistencies —attract children's attention, stimulate their senses, and give pleasure. Pleasurable experiences are derived from handling raw materials (water, sand, food), body motion (swinging, bouncing, rocking), and other uses of senses and abilities (smelling, humming) (Fig. 3-5).
FIG 3-5 Children derive pleasure from handling raw materials. (Paints in this picture are nontoxic.)
Skill play: After infants have developed the ability to grasp and manipulate, they persistently demonstrate and exercise their newly acquired abilities through skill play, repeating an action over and over again. The element of sense-pleasure play is often evident in the practicing of a new ability, but all too frequently, the determination to conquer the elusive skill produces pain and frustration (e.g., putting paper in and taking it out of a toy car) (Fig. 3-6).
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FIG 3-6 After infants develop new skills to grasp and manipulate, they begin to conquer new abilities, such as putting paper in a toy car and taking it out.
Unoccupied behavior: In unoccupied behavior, children are not playful but focusing their attention momentarily on anything that strikes their interest. Children daydream, fiddle with clothes or other objects, or walk aimlessly. This role differs from that of onlookers, who actively observe the activity of others.
Dramatic, or pretend, play: One of the vital elements in children's process of identification is dramatic play, also known as symbolic or pretend play. It begins in late infancy (11 to 13 months) and is the predominant form of play in preschool children. After children begin to invest situations and people with meanings and to attribute affective significance to the world, they can pretend and fantasize almost anything. By acting out events of daily life, children learn and practice the roles and identities modeled by the members of their family and society. Children's toys, replicas of the tools of society, provide a medium for learning about adult roles and activities that may be puzzling and frustrating to them. Interacting with the world is one way children get to know it. The simple, imitative, dramatic play of toddlers, such as using the telephone, driving a car, or rocking a doll, evolves into more complex, sustained dramas of preschoolers, which extend beyond common domestic matters to the wider aspects of the world and the society, such as playing police officer, storekeeper, teacher, or nurse. Older children work out elaborate themes, act out stories, and compose plays.
Games: Children in all cultures engage in games alone and with others. Solitary activity involving games begins as very small children participate in repetitive activities and progress to more complicated games that challenge their independent skills, such as puzzles, solitaire, and computer or video games. Very young children participate in simple, imitative games such as pat-a-cake and peek-a-boo. Preschool children learn and enjoy formal games, beginning with ritualistic, self-sustaining games, such as ring-around-a-rosy and London Bridge. With the exception of some simple board games, preschool children do not engage in competitive games. Preschoolers hate to lose and try to cheat, want to change rules, or demand exceptions and opportunities to change their moves. School-age children and adolescents enjoy competitive games, including cards, checkers, and chess, and physically active games, such as baseball.
Social Character of Play The play interactions of infancy are between the child and an adult. Children continue to enjoy the company of adults but are increasingly able to play alone. As age advances, interaction with age- mates increases in importance and becomes an essential part of the socialization process. Through interaction, highly egocentric infants, unable to tolerate delay or interference, ultimately acquire concern for others and the ability to delay gratification or even to reject gratification at the expense of another. A pair of toddlers will engage in considerable combat because their personal needs cannot tolerate delay or compromise. By the time they reach 5 or 6 years old, children are able to arrive at compromises or make use of arbitration, usually after they have attempted but failed to gain their own way. Through continued interaction with peers and the growth of conceptual abilities and social skills, children are able to increase participation with others in the following types of play:
Onlooker play: During onlooker play, children watch what other children are doing but make no
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attempt to enter into the play activity. There is an active interest in observing the interaction of others but no movement toward participating. Watching an older sibling bounce a ball is a common example of the onlooker role.
Solitary play: During solitary play, children play alone with toys different from those used by other children in the same area. They enjoy the presence of other children but make no effort to get close to or speak to them. Their interest is centered on their own activity, which they pursue with no reference to the activities of the others.
Parallel play: During parallel activities, children play independently but among other children. They play with toys similar to those the children around them are using but as each child sees fit, neither influencing nor being influenced by the other children. Each plays beside, but not with, other children (Fig. 3-7). There is no group association. Parallel play is the characteristic play of toddlers, but it may also occur in other groups of any age. Individuals who are involved in a creative craft with each person separately working on an individual project are engaged in parallel play.
FIG 3-7 Parallel play at the beach.
Associative play: In associative play, children play together and are engaged in a similar or even identical activity, but there is no organization, division of labor, leadership assignment, or mutual goal. Children borrow and lend play materials, follow each other with wagons and tricycles, and sometimes attempt to control who may or may not play in the group. Each child acts according to his or her own wishes; there is no group goal (Fig. 3-8). For example, two children play with dolls, borrowing articles of clothing from each other and engaging in similar conversation, but neither directs the other's actions or establishes rules regarding the limits of the play session. There is a great deal of behavioral contagion: When one child initiates an activity, the entire group follows the example.
FIG 3-8 Associative play.
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Cooperative play: Cooperative play is organized, and children play in a group with other children (Fig. 3-9). They discuss and plan activities for the purposes of accomplishing an end—to make something, attain a competitive goal, dramatize situations of adult or group life, or play formal games. The group is loosely formed, but there is a marked sense of belonging or not belonging. The goal and its attainment require organization of activities, division of labor, and role playing. The leader–follower relationship is definitely established, and the activity is controlled by one or two members who assign roles and direct the activity of the others. The activity is organized to allow one child to supplement another's function to complete the goal.
FIG 3-9 Cooperative play.
Functions of Play Sensorimotor Development Sensorimotor activity is a major component of play at all ages and is the predominant form of play in infancy. Active play is essential for muscle development and serves a useful purpose as a release for surplus energy. Through sensorimotor play, children explore the nature of the physical world. Infants gain impressions of themselves and their world through tactile, auditory, visual, and kinesthetic stimulation. Toddlers and preschoolers revel in body movement and exploration of objects in space. With increasing maturity, sensorimotor play becomes more differentiated and involved. Whereas very young children run for the sheer joy of body movement, older children incorporate or modify the motions into increasingly complex and coordinated activities, such as races, games, roller skating, and bicycle riding.
Intellectual Development Through exploration and manipulation, children learn colors, shapes, sizes, textures, and the significance of objects. They learn the significance of numbers and how to use them; they learn to associate words with objects; and they develop an understanding of abstract concepts and spatial relationships, such as up, down, under, and over. Activities such as puzzles and games help them develop problem-solving skills. Books, stories, films, and collections expand knowledge and provide enjoyment as well. Play provides a means to practice and expand language skills. Through play, children continually rehearse past experiences to assimilate them into new perceptions and relationships. Play helps children comprehend the world in which they live and distinguish between fantasy and reality.
Socialization From very early infancy, children show interest and pleasure in the company of others. Their initial social contact is with the mothering person, but through play with other children, they learn to establish social relationships and solve the problems associated with these relationships. They learn to give and take, which is more readily learned from critical peers than from more tolerant adults.
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They learn the sex role that society expects them to fulfill, as well as approved patterns of behavior and deportment. Closely associated with socialization is development of moral values and ethics. Children learn right from wrong, the standards of the society, and to assume responsibility for their actions.
Creativity In no other situation is there more opportunity to be creative than in play. Children can experiment and try out their ideas in play through every medium at their disposal, including raw materials, fantasy, and exploration. Creativity is stifled by pressure toward conformity; therefore, striving for peer approval may inhibit creative endeavors in school-age or adolescent children. Creativity is primarily a product of solitary activity, yet creative thinking is often enhanced in group settings where listening to others' ideas stimulates further exploration of one's own ideas. After children feel the satisfaction of creating something new and different, they transfer this creative interest to situations outside the world of play.
Self-Awareness Beginning with active explorations of their bodies and awareness of themselves as separate from their mothers, the process of developing a self-identity is facilitated through play activities. Children learn who they are and their place in the world. They become increasingly able to regulate their own behavior, to learn what their abilities are, and to compare their abilities with those of others. Through play, children are able to test their abilities, assume and try out various roles, and learn the effects their behavior has on others. They learn the sex role that society expects them to fulfill, as well as approved patterns of behavior and deportment.
Therapeutic Value Play is therapeutic at any age (Fig. 3-10). In play, children can express emotions and release unacceptable impulses in a socially acceptable fashion. Children are able to experiment and test fearful situations and can assume and vicariously master the roles and positions that they are unable to perform in the world of reality. Children reveal much about themselves in play. Through play, children are able to communicate to the alert observer the needs, fears, and desires that they are unable to express with their limited language skills. Throughout their play, children need the acceptance of adults and their presence to help them control aggression and to channel their destructive tendencies.
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FIG 3-10 Play is therapeutic at any age and provides a means for release of tension and stress.
Morality Although children learn at home and at school those behaviors considered right and wrong in the culture, the interaction with peers during play contributes significantly to their moral training. Nowhere is the enforcement of moral standards as rigid as in the play situation. If they are to be acceptable members of the group, children must adhere to the accepted codes of behavior of the culture (e.g., fairness, honesty, self-control, consideration for others). Children soon learn that their peers are less tolerant of violations than are adults and that to maintain a place in the play group, they must conform to the standards of the group (Fig. 3-11).
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FIG 3-11 Peers become increasingly important as children develop friendships outside the family group.
Toys The type of toys chosen by or provided for children can support and enhance children's development in the areas just described. Although no scientific evidence shows that any toy is necessary for optimal learning, toys offer an opportunity to bring children and parents together. Research has indicated that a positive parent-child interaction can enhance early childhood brain development (Glassy, Romano, Committee on Early Childhood, Adoption, and Dependent Care, et al, 2003). Toys that are small replicas of the culture and its tools help children assimilate into their culture. Toys that require pushing, pulling, rolling, and manipulating teach them about physical properties of the items and help develop muscles and coordination. Rules and the basic elements of cooperation and organization are learned through board games.
Because they can be used in a variety of ways, raw materials with which children can exercise their own creativity and imaginations are sometimes superior to ready-made items. For example, building blocks can be used to construct a variety of structures, count, and learn shapes and sizes.
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Developmental Assessment One of the most essential components of a complete health appraisal is assessment of developmental function. Screening procedures are designed to identify quickly and reliably children whose developmental level is below normal for their age and who therefore require further investigation. They also provide a means of recording objective measurements of present developmental function for future reference. Since the passage of Public Law 99-457, the Education of the Handicapped Act Amendments of 1986, much greater emphasis is placed on developmental assessment of children with disabilities, and nurses can play a vital role in providing this service. It is estimated that 16% of children are affected by developmental disabilities, but fewer than 30% of these children are identified before kindergarten (Wagner, Jenkins, and Smith, 2006). There are numerous developmental screening tools and each uses a different approach.
In the past, the most widely used developmental screening tests for young children are the series of tests known as the Denver Developmental Screening Test (DDST) and its revision, the DDST-R, that have been revised, re-standardized, and renamed the Denver II. The American Academy of Neurology and the Child Neurology Society state that research has found that the Denver-II is insensitive and lacks specificity, and neither the American Academy of Neurology nor the Child Neurology Society recommends use of the Denver-II for primary care developmental screening (Filipek, Accardo, Ashwal, et al, 2000). A comprehensive list of child development assessment tools has been developed by the National Early Childhood Technical Assistance Center as part of its cooperative agreement with the US Office of Special Education Programs. The pediatric health promotion chapters include detailed information on developmental assessment that is unique to the age and each developmental stage of the child.
Ages and Stages Ages and stages is a term used to broadly outline key periods in the human development timeline. During each stage, growth and development occur in the primary developmental domains, including physical, intellectual, language, and social-emotional. The Ages & Stages Questionnaires (ASQ)* are high-quality screening tools that include 19 age-specific surveys that ask parents about developmental skills common in daily life for children 1 month to years old (Box 3-3). Parents or other caregivers answer questions regarding their child's abilities (e.g., “Does your child climb on an object such as a chair to reach something he wants?” “When your child wants something, does she tell you by pointing at it?”). Children whose development appears to fall significantly below results of other children their age are flagged for further evaluation. The ASQ can be used as a universal screening tool in pediatric clinics to identify children at risk for social-emotional developmental delays (Briggs, Stettler, Silver, et al, 2012).
Box 3-3 A g e s & S t a g e s Q u e s t i o n n a i r e s* • Type of screening: Developmental (ASQ-3) and social-emotional (ASQ:SE)
• Age range: 1 to 66 months old for ASQ-3, 3 to 66 months old for ASQ:SE
• Number of questionnaires: 21 for ASQ-3, 8 for ASQ:SE
• Number of items: About 30 per questionnaire
• Online components: Data management and questionnaire completion
• Reading level of items: 4th to 6th grade
• Who completes it: Parents
• Time to complete: 10 to 15 minutes
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• Who scores it: Professionals
• Time to score: 2 to 3 minutes
• Languages: English and Spanish (for other languages, visit www.agesandstages.com)
*Information on the Ages & Stages Questionnaires (ASQ) can be found at www.agesandstages.com.
There are several additional parent report developmental screening tools that are reliable and valid. Some of the most common in addition to the ASQ, Parents' Evaluation of Developmental Status (PEDS), Child Development Inventory, and the Pediatric Symptom Checklist. Although it is beyond the scope of this chapter to describe each screening tool, using a tool can aid the nurse in providing anticipatory guidance and appropriate referral (Wagner, Jenkins, and Smith, 2006). Throughout this book, each of the health promotion chapters include detailed information on development unique to the age and stage of the child.
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Genetic Factors That Influence Development Overview of Genetics and Genomics Nurses and other health care providers are increasingly faced with incorporating genetic and genomic information into their practice. In response to this need, the Consensus Panel on Genetic/Genomic Nursing Competencies was established in 2006. This independent panel of nurse leaders from clinical, research, and academic settings established essential minimal competencies necessary for nurses to deliver competent genetic- and genomic-focused nursing care (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009). In a similar manner, genetic and genomic competencies were created and published for nurses with graduate degrees (Greco, Tinley, and Seibert, 2012). Using these documents as resources, the American Association of Colleges of Nursing published the revised The Essentials of Baccalaureate Education for Professional Nursing Practice (2008, http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf) identified genetics and genomics as strong forces influencing the role of nurses in patient care. This brief overview identifies key terms and concepts and highlights essential genetics and genomics competencies for all nurses.
Genes, Genetics, and Genomics Genes are segments of deoxyribonucleic acid (DNA) that contain genetic information necessary to control a certain physiologic function or characteristic. These segments are often referred to as sites or loci, indicating a physical or “geographic” location on a chromosome. Variant forms of a gene commonly occur within a population. When referring to a particular form of a gene, the term allele is used. Variant forms of a gene (variant alleles) may lead to no measureable or observable differences, may cause the person to be susceptible to clinically recognizable pathology within specific environmental contexts, may cause a clinically recognized disease or disorder, or may prove advantageous within a particular environmental context.
In earlier times, human diseases were thought to be either clearly genetic or typically environmental. However, the observation that some genetic disorders are congenital (present at birth) but others are expressed later in life has led scientists to conclude that many, if not most, diseases are caused by a genetic predisposition that can be activated by an environmental trigger. Examples of such interactions are found in single-gene disorders, such as phenylketonuria (PKU) and sickle cell disease, and multifactorial conditions, such as cancer and neural tube defects (NTDs). PKU is a disorder resulting from the (genetically determined) absence of an enzyme that metabolizes the amino acid phenylalanine. However, the deleterious effects in the infant are expressed only after sufficient ingestion of phenylalanine-containing substances, such as milk (environmental trigger). Even in the case of a “classic” genetic condition, such as sickle cell disease, its acute symptoms are precipitated by certain conditions, such as lowered oxygen tension, infection, or dehydration.
Congenital Anomalies Embryogenesis and fetal development are an intricate and precisely timed series of events in which all parts must be properly integrated to ensure a coordinated whole. Insults during development or abnormalities in differentiation or in the proper timing of organogenesis may result in a variety of congenital anomalies. Congenital anomalies, or birth defects, occur in 2% to 4% of all live-born children and are often classified as deformations, disruptions, dysplasias, or malformations. Deformations are often caused by extrinsic mechanical forces on normally developing tissue. Club foot is an example of a deformation often caused by uterine constraint. Disruptions result from the breakdown of previously normal tissue. Congenital amputations caused by amniotic bands (fibrous strands of amnion that wrap around different body parts during development) are examples of disruption anomalies. Dysplasias result from abnormal organization of cells into a particular tissue type. Congenital abnormalities of the teeth, hair, nails, or sweat glands may be manifestations of one of the more than 100 different ectodermal dysplasia syndromes (National Foundation for Ectodermal Dysplasias, 2015). Malformations are abnormal formations of organs or body parts resulting from an abnormal developmental process. Most malformations occur before 12 weeks of gestation. Cleft lip, an example of a malformation, occurs at approximately 5 weeks of gestation
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when the developing embryo naturally has two clefts in the area. Normally, between 5 and 7 weeks, cells rapidly divide and migrate to fill in those clefts. If there is an abnormality in this developmental process, the embryo is left with either a unilateral or bilateral cleft lip that may also involve the palate.
The types of anomalies that can result from genetic or prenatal environmental causes can be major structural abnormalities with serious medical, surgical, or quality-of-life consequences, or they can be minor anomalies or normal variants with no serious consequences, such as a sacral dimple, an extra nipple, or a café-au-lait spot. Congenital anomalies can occur in isolation, such as congenital heart defect, or multiple anomalies may be present. A recognized pattern of anomalies resulting from a single specific cause is called a syndrome (e.g., Down syndrome, fetal alcohol syndrome). A nonrandom pattern of malformations for which a cause has not been determined is called an association (e.g., VACTERL [vertebral defects, anal atresia, cardiac defect, tracheoesophageal fistula, and renal and limb defects] association). When a single anomaly leads to a cascade of additional anomalies, the pattern of defects is referred to as a sequence. Pierre Robin sequence begins with the abnormal development of the mandible, resulting in abnormal placement of the tongue during development. The normal developmental process for the palate is prevented because the tongue obstructs the migration of the palatal shelves toward the midline, and a cleft palate remains. Consequently, infants born with Pierre Robin sequence have a recessed mandible and an abnormally placed tongue and are at risk for obstructive apnea. NTDs, cleft lip and palate, deafness, congenital heart defects, and cognitive impairment are examples of congenital malformations that can occur in isolation or as part of a syndrome, association, or sequence and can have different causes, such as single-gene or chromosome abnormalities, prenatal exposures, or multifactorial causes.
Disorders of the Intrauterine Environment The intrauterine environment can have a profound and permanent effect on developing fetuses with or without chromosome or single-gene abnormalities. Intrauterine growth restriction, for example, can occur with many genetic syndromes, such as Down, Russell-Silver, Prader-Willi, and Turner syndromes (Rimoin, Pyeritz, and Korf, 2013), or it can be caused by nongenetic factors, such as maternal alcohol ingestion. Placental abnormalities are increasingly being found to be the etiologic factor in neurodevelopmental disorders (e.g., cerebral palsy and cognitive impairment) that were previously attributed to asphyxia during delivery (McIntyre, Taitz, Keogh, et al, 2013).
Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin [Accutane]), chemicals (ethyl alcohol, cocaine, lead), infectious agents (rubella, cytomegalovirus), physical agents (maternal ionizing radiation, hyperthermia), and metabolic agents (maternal PKU). Many of these teratogenic exposures and the resulting effects are completely preventable. For example, pregnant women can avoid having a child with one of the fetal alcohol spectrum disorders by not ingesting alcohol during pregnancy.
Genetic Disorders Genetic disorders can be caused by chromosome abnormalities as seen in Turner syndrome, Down syndrome, or velocardiofacial syndrome (VCFS); single-gene mutations as seen in sickle cell anemia, neurofibromatosis, or Duchenne muscular dystrophy; a combination of genetic and environmental factors as seen in NTDs or maturity-onset diabetes in the young; and mitochondrial deoxyribonucleic acid (mtDNA) mutations as seen in nonsyndromic deafness susceptibility caused by aminoglycoside sensitivity.
Both numeric and large structural abnormalities of autosomes (all chromosomes except the X and Y chromosomes) account for a variety of syndromes usually characterized by cognitive deficiencies. Nurses often note dysmorphic facial features, behavioral characteristics such as an unusual cry and poor feeding behavior, and other neurologic manifestations such as hypotonia or abnormal reflex responses, which may alert them to these and other chromosome abnormalities.
Somatic cells contain 44 autosomes (the 22 pairs of chromosomes that do not greatly influence sex determination at conception) and two sex chromosomes, XX in females and XY in males. For the purpose of cytogenetic studies, chromosomes are usually displayed in a karyotype, the laboratory- made arrangement of specially prepared chromosomes according to their size, centromere position,
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and band pattern. Numeric chromosome abnormalities occur whenever entire chromosomes are added or deleted. Down syndrome is an example of a condition caused by having an extra autosome, chromosome 21. Turner syndrome is the only example of a condition compatible with life that is caused by the absence of a chromosome. Children with Turner syndrome have one X chromosome. Chromosomes are subject to structural alterations resulting from breakage and rearrangement. A chromosome deletion occurs when chromosome breakage results in loss of the broken fragment at a chromosome's terminal end or within the chromosome. Some structural chromosome abnormalities are too small to reliably visualize under a light microscope but are still clinically relevant. Fragile, or weak, sites associated with expanded triplet repeats have been identified on both the autosomes and the X chromosome. A classic example is fragile X syndrome. Contiguous gene syndromes are disorders characterized by a microdeletion or microduplication of smaller chromosome segments, which may require special analysis techniques or molecular testing to detect (Bar-Shira, Rosner, Rosner, et al, 2006).
Chromosome anomalies typically affect large numbers of genes; however, a single-gene disorder is caused by an abnormality within a gene or in a gene's regulatory region. Single-gene disorders can affect all body systems and may have mild to severe expressions. Single-gene disorders display a Mendelian pattern of dominant or recessive inheritance that was first delineated in the mid- nineteenth century by Gregor Mendel's experiments with plants.
Mendelian inheritance laws allow for risk prediction in single-gene disorders; however, phenotypic expression may be altered by incomplete penetrance or variable expressivity of the responsible allele. An allele is said to have reduced or incomplete penetrance in a population when a proportion of persons who possess that allele do not express the phenotype. An allele is said to have variable expressivity when individuals possessing that allele display the features of the syndrome in various degrees, from mild to severe. If a person expresses even the mildest possible phenotype, the allele is penetrant in that individual.
Role of Nurses in Genetics All nurses need to be prepared to use genetic and genomic information and technology when providing care. The professional practice domains of the essential genetic and genomic competencies include applying and integrating genetic knowledge into nursing assessment; identifying and referring clients who may benefit from genetic information or services; identifying genetics resources and services to meet clients' needs; and providing care and support before, during, and after providing genetic information and services (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009). Often a nurse is the first one to recognize the need for genetic evaluation by identifying an inherited disorder in a family history or by noting physical, cognitive, or behavioral abnormalities when performing a nursing assessment (Box 3-4).
Box 3-4 Pe d i a t r i c I n d i c a t i o n s f o r G e n e t i c C o n s u l t a t i o n Family History
• Family history of hereditary diseases, birth defects, or developmental problems
• Family history of sudden cardiac death or early-onset cancer
• Family history of mental illness
Medical History
• Abnormal newborn screen
• Abnormal genetic test result ordered by a nongenetics professional who lacks the knowledge and experience to discuss the implications of results
• Excessive bleeding or excessive clotting
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• Progressive neurologic condition
• Recurrent infection or immunodeficiency
Developmental History
• Behavioral disorders
• Cognitive impairment or autism
• Development and speech delays or loss of developmental milestones
Physical Assessment
• Major congenital anomaly
• Minor anomalies and dysmorphic features
• Growth abnormalities
• Skeletal abnormalities
• Visual or hearing problems
• Metabolic disorder (unusual odor of breath, urine, or stool)
• Sexual development abnormalities or delayed puberty
• Skin disorders or abnormalities
Parental Requests
• Parent requests that child be evaluated by a genetics professional
Adapted from Pletcher BA, Toriello HV, Noblin SJ, et al: Indications for genetic referral: a guide for healthcare providers, Genet Med 9(6):385–389, 2007.
Nursing Assessment: Applying and Integrating Genetic and Genomic Knowledge Family health history is an important tool to identify individuals and families at increased risk for disease, risk factors for disease (e.g., obesity), and inheritance patterns of diseases. Because of its importance, all nurses need to be able to elicit family history information and, when feasible, document the collected information in pedigree format.
When eliciting a family health history, nurses should collect information about all family members within a minimum of three generations. This process usually takes 20 to 30 minutes. When possible, it is best to include both parents in the interview to elicit information about relatives on both sides of the family. Medical records, birth and death records, family Bibles, and photograph albums are helpful resources, and persons being interviewed should be instructed to bring such items if they are available. It may be necessary to consult other members of the family. The level of education and the degree of understanding vary widely among informants and influence their reliability. The informants may be reticent, particularly if they view the disorder as something to be ashamed of or in some way threatening. Sometimes true relationships may be concealed, such as adoption or misattributed paternity.
In addition to family history, nurses caring for children and families need to collect pregnancy, labor and delivery, perinatal, medical, and developmental histories. Although it is common for genetics nurses to obtain all of these histories before or during an initial genetics consultation, not all nurses are expected to obtain all of these assessment data from each patient during a pediatric encounter. Electronic health records are making it more practical to construct a comprehensive set of histories even when many health care professionals contribute only a portion of the total history.
All nurses are taught to perform physical assessments, but they are seldom taught to recognize minor anomalies and dysmorphology that may suggest a genetic disorder. Yet nurses are keen in
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recognizing delays in development, behavior differences, and global appearances that raise concern that a newborn, infant, child, or adolescent needs further evaluation (Prows, Hopkin, Barnoy, et al, 2013). Although dysmorphology is beyond the scope of this chapter, readers are encouraged to review the January 2009 issue of American Journal of Medical Genetics (Carey, Cohen, Curry, et al, 2009). Drawings and photographs of normal and abnormal morphologic characteristics are provided for the head, face, and extremities together with accepted dysmorphology terminology. Nurses knowledgeable in dysmorphology are able to articulate specific concerns about a child's appearance rather than relying on the outdated and offensive phrase “funny looking kid.” When a major anomaly is identified, nurses should raise suspicion that the child could have additional congenital anomalies. When three or more minor anomalies are identified, nurses should suspect the possibility of an underlying syndrome. However, it is important to consider the biologic parents' physical appearance, development, and behavior when considering the relevance of the child's combination of minor anomalies.
Identification and Referral It is nurses' responsibility to learn basic genetic principles, to be alert to situations in which families could benefit from genetic evaluation and counseling, to know about special services that can help manage and support affected children, and to be familiar with facilities in their areas where these services are available. In this way, nurses are able to direct individuals and families to needed services and be active participants in the genetic evaluation and counseling process. A regularly updated resource for locating genetics clinics can be found at http://ghr.nlm.nih.gov/handbook/ (click on link for Genetic Consultation). In addition, state health departments either offer services or can help identify health professionals with specialty training in genetics.
Early identification of a genetic disorder allows anticipation of associated conditions and implementation of available preventive measures and therapy to avoid potential complications and to enhance the child's health. It may also prevent the unexpected birth of another affected child in the immediate or extended family. Nurses have an important role in identifying patients and families who have or are at risk for developing or transmitting a genetic condition (see Box 3-4). When facilitating genetics consultations, nurses should share with the genetics professional the findings in the histories they collected that triggered the consultation. Nurses can also help the referral process by determining and communicating the family's initial concerns, their state of knowledge about the reason for referral, and their attitudes and beliefs concerning genetics.
Genetic evaluation for diagnostic purposes may occur at any point in the life span. In the newborn period, birth defects and abnormal newborn screen results are obvious reasons for referral. Beyond the newborn period, indicators for referral include metabolic disorders, developmental delays, growth delays, behavioral problems, cognitive delays, abnormal or delayed sexual development, and medical problems known to be associated with genetic diseases. For example, a preschooler with hyperactivity and autistic-like behaviors may need evaluation for fragile X syndrome, and a 17-year-old girl with primary amenorrhea and short stature should be evaluated for Turner syndrome.
With so many recent advances in genetic testing, it is not unusual for a child or adult with longstanding medical problems, including cognitive impairment, to be referred for reevaluation of his or her condition as a possible genetic disorder that might not have been diagnosable a few years earlier, such as microdeletion disorders or single-gene mutations. If a genetic diagnosis is made, the patient is usually referred back to the primary care physician with recommendations for routine management.
Providing Education, Care, and Support Maintaining contact with the family or making a referral to a health care practice or an agency that can provide a sustained relationship is critical. It is becoming more common for genetics health care professionals to provide regular follow up and management, particularly for children with rare genetic disorders. However, some families choose not to have follow-up visits with genetic experts.
Regardless of whether families choose to receive continued care with a genetics center, clinic, or professional, nurses can help patients and families process and clarify the information they receive during a genetics visit. Misunderstanding of this information can have many causes, including cultural differences, the disparity of knowledge between the counselor and the family, and the heightened emotion surrounding genetic counseling. Family members have difficulty absorbing all
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of the information presented during a genetics evaluation and counseling session. Knowing this, genetics professionals write and send clinic summary letters to families. The nurse may need to help the family understand terminology in the letter, help them identify and articulate remaining questions or areas of clarification, and coach them through the process of accessing genetics health professionals to get remaining questions and concerns answered. Information often needs to be repeated several times before the family understands the content and its implications.
Nurses must assess for and address parents' feelings of guilt about carrying “bad genes” or having “made my child sick.” Depending on the type of cytogenetic disorder, the nurse may be able to absolve the parents of guilt by explaining the random nature of segregation during both gamete formation and fertilization. If the condition is a Mendelian-inherited or mitochondrial disorder, it is important to assess parents' understanding of recurrence risk, help them understand the chances that a subsequent pregnancy will be affected and will not be affected, and ensure they have been given information about their options for future children (preimplantation diagnosis, use of donor egg or sperm, prenatal diagnosis, or adoption). Families often try to reason that some unrelated event caused the abnormality (e.g., a fall, a urinary tract infection, or “one glass of wine”) before the mother was aware that she was pregnant. These misconceptions need to be assessed and dispelled.
After a genetics visit, and sometimes before the visit, parents often use the Internet to find answers to their questions. During the initial genetics evaluation, a diagnosis may not be possible. Instead, findings in medical, developmental, and family histories lead the professional to order genetic tests and other diagnostic procedures. Diagnoses under consideration are discussed briefly with the parents. Some parents are satisfied with the brief information and do not care to find out more until the actual diagnosis is established. Other parents go home and seek as much information as they can about the diagnoses under consideration. The information they find can be terrifying and overwhelming and inaccurate or misleading. Nurses can play an important role in helping parents identify reliable, accurate resources for information at whatever time they desire it. It is also important to stress that everything that is described for a genetic condition may not be relevant to their child. Before the follow-up genetics visit when test and procedure results are discussed, nurses can help parents identify and write down the questions and concerns they need addressed before leaving the clinic.
After a genetic diagnosis is made or a genetic predisposition to a delayed-onset disorder is identified, nurses need to have frequent contact with patients and families as they attempt to incorporate recommended therapies or disease-prevention strategies into their daily lives. For example, a disorder such as PKU requires conscientious diet management; therefore, it is important to make certain that the family understands and follows instructions and is able to navigate the health care system to access the essential formula and low-phenylalanine food products. An infant evaluated for cleft palate and cardiac defect and subsequently found to have VCFS requires surgical intervention for the congenital malformations. Such an infant also benefits from early intervention services and eventually an individualized education plan in school because developmental delays and eventual learning problems are common.
Initial and ongoing assessment of the family's coping abilities, resources, and support systems is vital to determine their need for additional assistance and support. As with any family who has a child with chronic health care needs, nurses must teach the family to become the child's advocate. Nurses can help families locate agencies and clinics specializing in a specific disorder or its consequences that can provide services (e.g., equipment, medication, and rehabilitation), educational programs, and parent support groups. Referral to local and national support groups or contact with a local family that has a child with the same condition can be helpful for new parents. Privacy and confidentiality are imperative, and both families must give permission before their contact information is given. Nurses can also be instrumental in helping parents start a support group when none is available.
Parental attachment and adjustment to the baby can be supported and facilitated by nursing interventions. Assessing the parents' understanding of the child's disorder and providing simple and truthful explanations can help them begin to understand their child's health issues. Guiding the parents in recognizing their child's cues, responses, and strengths can be helpful even for experienced parents. A caring attitude conveys the value of their child and, by extension, their value as parents. The nurse can help the parents identify their strengths as a family and identify support that is available to them.
Giving birth to and raising a child with a genetic disorder is not necessarily a lifetime burden. It is important for nurses to ask parents to describe their experience raising their child with a particular
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genetic condition. What has been the impact on their family? Although parents may initially experience negative outcomes, such as shock, emotional distress, and grief, families can adapt and thrive. Resources for managing stress and restoring balance in the lives of families affected by a genetic condition can help. Van Riper's (2007) research has identified nursing interventions that can promote resilience and adaptation in families of children with Down syndrome. Van Riper's recommendations are useful for families of children with any type of genetic disorder: • Recognize multiple stressors, strains, and transitions in their lives (e.g., unmet family needs). • Discuss and implement strategies for reducing family demands (e.g., setting priorities and
reducing the number of outside activities family members are involved in). • Identify and use individual, family, and community resources (e.g., humor, family flexibility,
supportive extended family, respite care, local support groups, and Internet resources). • Expand the range and efficacy of their coping strategies (e.g., increase the use of active strategies
such as reframing, mobilize their ability to acquire and accept help, and decrease the use of passive appraisal).
• Encourage the use of an affirming style of family problem-solving communication (e.g., one that conveys support and caring and exerts a calming influence).
Some families do struggle after learning their child has a genetic disorder. Families may feel ashamed of a hereditary disorder and seek to blame their partner for transmitting a faulty gene or chromosome. Intra-familial strife, hostility, and marital or couple disharmony, sometimes to the point of family disintegration, can occur. Nurses should be alert for evidence of risk factors that indicate poor adjustment (e.g., child abuse, divorce, or other maladaptive behaviors). Referral to psychosocial professionals for crisis intervention may be necessary.
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Review Questions 1. The nurse may be called upon to have knowledge about sex chromosome aneuploidies. In
answering families' questions, the nurse can report: a. “Some of the most common genetic disorders caused by sex chromosome aneuploidies are
Klinefelter, XXY, triple X female, and Turner syndromes.” b. “Klinefelter syndrome is the most common of all sex chromosome aneuploidies, and mental
development is normal in most cases.” c. “Triple X females have premature menarche and delayed menopause.” d. “Turner syndrome girls have a prepubertal growth spurt and then mostly stop growing.”
2. When parents consider genetic testing, especially after having a child born with an anomaly, which information could the nurse use to further instruct the family? Select all that apply. a. Genetic screening can provide early recognition of a disease, before signs and symptoms occur,
for which effective intervention and therapy exists. b. Screening can occur at different times in a person's life: preconceptual, newborn screening, or
maternal screening after delivery, depending on the circumstances. c. Genetic testing can help identify carriers of a genetic disease for the purpose of maximizing
parenthood planning options. d. A thorough history by the nurse will include the parents' siblings, the parents, and the
grandparents. e. Recognizing a genetic disorder can further facilitate a genetic evaluation by collecting
pregnancy, labor and delivery, perinatal, medical, and developmental histories.
3. A mother brings her 3-year-old daughter to the well-child clinic and expresses concern that the child's behavior is worrisome and possibly requires therapy or medication at minimum. The mother further explains that the child constantly responds to the mother's simple requests with a “no” answer even though the activity has been a favorite in the recent past. Furthermore, the child has had an increase in the number of temper tantrums at bedtime and refuses to go to bed. The mother is afraid her daughter will hurt herself during a temper tantrum because she holds her breath until the mother picks her up and gives in to her request. The nurse's best response to the mother is that: a. The child probably would benefit from some counseling with a trained therapist. b. The mother and father should evaluate their childrearing practices. c. The child's behavior is normal for a toddler and may represent frustration with control of her
emotions; further exploration of events surrounding temper tantrums and possible interventions should be explored.
d. The child's behavior is typical of toddlers, and the parents should just wait for the child to finish this phase, because this will end soon as well.
4. The mother of a 4-year-old health clinic patient asks the nurse about night terrors. Which statement by the mother reveals a need for further teaching? Select all that apply. a. He will grow out of this stage when he is a little older. b. Getting into a specific routine is helpful and can be calming to my son. c. Watching TV with an adult is helpful so that he understands what is real. d. I can help my child with sleep by giving him his favorite stuffed animal or using a nightlight. e. Our family often sleeps together, and this seems to help.
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Correct Answers 1. b; 2. a, b, c, e;
3. c; 4. a, c, e
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Lampl M, Thompson A, Frongillo EA. Sex differences in the relationships among weight gain, subcutaneous skinfold tissue and salutatory length growth spurts in infancy. Pediatr Res. 2005;58(6):1238–1242.
Matvienko O. Impact of a nutrition education curriculum on snack choices of children ages six and seven years. J Nutr Educ Behav. 2007;39(5):281–285.
Mcintyre S, Taitz D, Keogh J, et al. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol. 2013;55(6):499–508.
Myrelid A, Gustafsson J, Ollars B, et al. Growth charts for Down's syndrome from birth to 18 years of age. Arch Dis Child. 2002;87(2):97–103.
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Piaget J. The theory of stages in cognitive development. McGraw-Hill: New York; 1969. Prows CA, Hopkin RJ, Barnoy S, et al. An update of childhood genetic disorders. J Nurs
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St. Louis; 2007. Stuart GW, Laraia MT. Principles and practice of psychiatric nursing. ed 7. Mosby: St. Louis; 2000. Thompson R, Cotner-Bichelman N, McKerchar P, et al. Enhancing early communication
through infant sign training. J Appl Behav Anal. 2007;40(1):15–23. Urbanski LF, Hanlon DP. Pediatric orthopedics. Top Emerg Med. 1996;18(2):73–90. Van Riper M. Families of children with Down syndrome: responding to “a change in plans”
with resilience. J Pediatr Nurs. 2007;22(2):116–128. Wagner J, Jenkins B, Smith J. Nurses' utilization of parent questionnaires for developmental
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U N I T 2 Assessment of the Child and Family
OUTLINE 4 Communication and Physical Assessment of the Child and Family 5 Pain Assessment and Management in Children 6 Childhood Communicable and Infectious Diseases
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Communication and Physical Assessment of the Child and Family Jan M. Foote
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Guidelines for Communication and Interviewing The most widely used method of communicating with parents on a professional basis is the interview process. Unlike social conversation, interviewing is a specific form of goal-directed communication. As nurses converse with children and adults, they focus on the individuals to determine the kind of persons they are, their usual mode of handling problems, whether they need help, and the way they react to counseling. Developing interviewing skills requires time and practice, but following some guiding principles can facilitate this process. An organized approach is most effective when using interviewing skills in patient teaching.
Establishing a Setting for Communication Appropriate Introduction Introduce yourself and ask the name of each family member who is present. Address parents or other adults by their appropriate titles, such as “Mr.” and “Mrs.,” unless they specify a preferred name. Record the preferred name on the medical record. Using formal address or their preferred names, rather than using first names or “mother” or “father,” conveys respect and regard for the parents or other caregivers (Ball, Dains, Flynn, et al, 2014).
At the beginning of the visit, include children in the interaction by asking them their name, age, and other information. Nurses often direct all questions to adults even when children are old enough to speak for themselves. This only terminates one extremely valuable source of information —the patient. When including the child, follow the general rules for communicating with children given in the Nursing Care Guidelines box later in the chapter.
Assurance of Privacy and Confidentiality The place where the nurse conducts the interview is almost as important as the interview itself. The physical environment should allow for as much privacy as possible with distractions (such as, interruptions, noise, or other visible activity) kept to a minimum. At times, it is necessary to turn off a television, radio, or mobile phone. The environment should also have some play provision for young children to keep them occupied during the parent–nurse interview (Fig. 4-1). Parents who are constantly interrupted by their children are unable to concentrate fully and tend to give brief answers to finish the interview as quickly as possible.
FIG 4-1 Child plays while nurse interviews parents.
Confidentiality is another essential component of the initial phase of the interview. Because the interview is usually shared with other members of the health care team or the teacher (in the case of students), be certain to inform the family of the limits regarding confidentiality. If confidentiality is
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a concern in a particular situation, such as when talking to a parent suspected of child abuse or a teenager contemplating suicide, deal with this directly and inform the person that in such instances, confidentiality cannot be ensured. However, the nurse judiciously protects information of a confidential nature.
Computer Privacy and Applications in Nursing The use of computer technology to store and retrieve health information has become widespread; most clinics and hospitals now maintain electronic health records for patients. The health care community is increasingly concerned about the privacy and security of this health information and all nurses are engaged in protecting confidentiality of health care records. Any person accessing confidential health information is charged with managing safeguards for disclosure including password protection to prevent violation of patient privacy and confidentiality.
Telephone Triage and Counseling Telephone triage care management has increased access to high-quality health care services and empowered parents to participate in their child's health care. Consequently, patient satisfaction has significantly improved. Unnecessary emergency department and clinic visits have decreased, saving health care costs and time (with less absence from work) for families in need of health care.
Telephone triage is more than “just a phone call” because a child's life is a high price to pay for poorly managed or incompetent telephone assessment skills. Typically, guidelines for telephone triage include asking screening questions; determining when to immediately refer to emergency medical services (dial 911) or the emergency department; and determining when to refer to same- day appointments, appointments in 24 to 72 hours, appointments in 4 days or more, or home care (Box 4-1). Successful outcomes are based on the consistency and accuracy of the information provided. A systematic review of 49 studies where nurses triaged calls found that the appropriateness of a decision and subsequent compliance often varied (Blank, Coster, O'Cathain, et al, 2012). A meta-analysis of 13 studies provided further insight and found patient compliance with triage recommendations were influenced by the quality of provider communication (Purc- Stephenson and Thrasher, 2012). The importance of nurse-patient communication is reinforced as an essential aspect of telephone triage training. Training of communication skills that are patient and family-centered and specifically address active listening and advising skills offers the greatest opportunity for success. Assessment skills used in direct nurse-to-patient interactions are not directly transferable to the telephone and provide further support for training in decision-making skills for phone triage (Purc-Stephenson and Thrasher, 2010). Evidence-based clinical protocols for telephone triage can provide a structured method for assessment (Stacey, Macartney, Carley, et al, 2013).
Box 4-1 Te l e p h o n e T r i a g e G u i d e l i n e s Date and time
Background
• Name, age, sex, contact information
• Chronic illness
• Allergies, current medications, treatments, or recent immunizations
Chief complaint
General symptoms
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• Severity
• Duration
• Other symptoms
• Pain
Systems review
Steps taken
• Advised to call emergency medical services (911)
• Advised to go to emergency department
• Advised to see practitioner (today, tomorrow, or later appointment)
• Advised regarding home care
• Advised to call back if symptoms worsen or fail to improve
Resources for Telephone Triage Protocols Beaulieu R, Jumphreys J. Evaluation of a telephone advice nurse in a nursing faculty managed
pediatric community clinic. J Pediatr Health Care. 2008;22(3):175–181. Marklund B, Ström M, Månsson J, et al. Computer-supported telephone nurse triage: an
evaluation of medical quality and costs. J Nurs Manage. 2007;15:180–187. Schmitt BD. Pediatric telephone protocols: office version. ed 14. American Academy of Pediatrics:
Elk Grove Village, IL; 2012. Simonsen SM. Telephone assessment: guidelines for practice. ed 2. Mosby: St Louis; 2001.
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Communicating with Families Communicating with Parents Although the parent and the child are separate and distinct individuals, the nurse's relationship with the child is frequently mediated by the parent, particularly with younger children. For the most part, nurses acquire information about the child by direct observation and through communication with the parents. Usually it can be assumed that because of the close contact with the child, the parent gives reliable information. Assessing the child requires input from the child (verbal and nonverbal), information from the parent, and the nurse's own observations of the child and interpretation of the relationship between the child and the parent. When children are old enough to be active participants in their own health care, the parent becomes a collaborator.
Encouraging the Parents to Talk Interviewing parents not only offers the opportunity to determine the child's health and developmental status but also offers information about factors that influence the child's life. Whatever the parent sees as a problem should be a concern of the nurse. These problems are not always easy to identify. Nurses need to be alert for clues and signals by which a parent communicates worries and anxieties. Careful phrasing with broad, open-ended questions (such as, “What is Jimmy eating now?”) provides more information than several single-answer questions (such as, “Is Jimmy eating what the rest of the family eats?”).
Sometimes the parent will take the lead without prompting. At other times, it may be necessary to direct another question on the basis of an observation, such as “Connie seems unhappy today,” or “How do you feel when David cries?” If the parent appears to be tired or distraught, consider asking, “What do you do to relax?” or “What help do you have with the children?” A comment such as “You handle the baby very well. What kind of experience have you had with babies?” to new parents who appear comfortable with their first child gives positive reinforcement and provides an opening for questions they might have on the infant's care. Often all that is required to keep parents talking is a nod or saying “yes” or “uh-huh.”
Directing the Focus Directing the focus of the interview while allowing maximum freedom of expression is one of the most difficult goals in effective communication. One approach is the use of open-ended or broad questions followed by guiding statements. For example, if the parent proceeds to list the other children by name, say, “Tell me their ages, too.” If the parent continues to describe each child in depth, which is not the purpose of the interview, redirect the focus by stating, “Let's talk about the other children later. You were beginning to tell me about Paul's activities at school.” This approach conveys interest in the other children but focuses the assessment on the patient.
Listening and Cultural Awareness Listening is the most important component of effective communication. When the purpose of listening is to understand the person being interviewed, it is an active process that requires concentration and attention to all aspects of the conversation—verbal, nonverbal, and abstract. Major blocks to listening are environmental distraction and premature judgment.
Although it is necessary to make some preliminary judgments, listen with as much objectivity as possible by clarifying meanings and attempting to see the situation from the parent's point of view. Effective interviewers consciously control their reactions and responses and the techniques they use (see Cultural Considerations box).
C u l t u r a l C o n s i d e r a t i o n s Interviewing without Judgment
It is easy to inject one's own attitudes and feelings into an interview. Often nurses' own prejudices and assumptions, which may include racial, religious, and cultural stereotypes, influence their
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perceptions of a parent's behavior. What the nurse may interpret as a parent's passive hostility or lack of interest may be shyness or an expression of anxiety. For example, in Western cultures, eye contact and directness are signs of paying attention. However, in many non-Western cultures, including that of Native Americans, directness (e.g., looking someone in the eye) is considered rude. Children are taught to avert their gaze and to look down when being addressed by an adult, especially one with authority (Ball, Dains, Flynn, et al, 2014). Therefore nurses must make judgments about “listening,” as well as verbal interactions, with an appreciation of cultural differences.
Careful listening relies on the use of clues, verbal leads, or signals from the interviewee to move the interview along. Frequent references to an area of concern, repetition of certain key words, or a special emphasis on something or someone serve as cues to the interviewer for the direction of inquiry. Concerns and anxieties are often mentioned in a casual, offhand manner. Even though they are casual, they are important and deserve careful scrutiny to identify problem areas. For example, a parent who is concerned about a child's habit of bedwetting may casually mention that the child's bed was “wet this morning.”
Using Silence Silence as a response is often one of the most difficult interviewing techniques to learn. The interviewer requires a sense of confidence and comfort to allow the interviewee space in which to think without interruptions. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. Silence can also be a cue for the interviewer to go more slowly, reexamine the approach, and not push too hard (Ball, Dains, Flynn, et al, 2014).
Sometimes it is necessary to break the silence and reopen communication. Do this in a way that encourages the person to continue talking about what is considered important. Breaking a silence by introducing a new topic or by prolonged talking essentially terminates the interviewee's opportunity to use the silence. Suggestions for breaking the silence include statements such as the following: • “Is there anything else you wish to say?” • “I see you find it difficult to continue. How may I help?” • “I don't know what this silence means. Perhaps there is something you would like to put into
words but find difficult to say.”
Being Empathic Empathy is the capacity to understand what another person is experiencing from within that person's frame of reference; it is often described as the ability to put oneself in another's shoes. The essence of empathic interaction is accurate understanding of another's feelings. Empathy differs from sympathy, which is having feelings or emotions similar to those of another person, rather than understanding those feelings.
Providing Anticipatory Guidance The ideal way to handle a situation is to deal with it before it becomes a problem. The best preventive measure is anticipatory guidance. Traditionally, anticipatory guidance focused on providing families information on normal growth and development and nurturing childrearing practices. For example, one of the most significant areas in pediatrics is injury prevention. Beginning prenatally, parents need specific instructions on home safety. Because of the child's maturing developmental skills, parents must implement home safety changes early to minimize risks to the child.
Unprepared parents can be disturbed by many normal developmental changes, such as a toddler's diminished appetite, negativism, altered sleeping patterns, and anxiety toward strangers. The chapters on health promotion (see Chapters 7, 9, 11) provide nurses with information for counseling parents. However, anticipatory guidance should extend beyond giving general information to empowering families to use the information as a means of building competence in their parenting abilities (Dosman and Andrews, 2012). To achieve this level of anticipatory guidance, the nurse should do the following: • Base interventions on needs identified by the family, not by the professional
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• View the family as competent or as having the ability to be competent • Provide opportunities for the family to achieve competence
Avoiding Blocks to Communication A number of blocks to communication can adversely affect the quality of the helping relationship. The interviewer introduces many of these blocks, such as giving unrestricted advice or forming prejudged conclusions. Another type of block occurs primarily with the interviewees and concerns information overload. When individuals receive too much information or information that is overwhelming, they often demonstrate signs of increasing anxiety or decreasing attention. Such signals should alert the interviewer to give less information or to clarify what has been said. Box 4-2 lists some of the more common blocks to communication, including signs of information overload.
Box 4-2 B l o c k s t o C o m m u n i c a t i o n Communication Barriers (Nurse)
Socializing
Giving unrestricted and sometimes unsought advice
Offering premature or inappropriate reassurance
Giving over-ready encouragement
Defending a situation or opinion
Using stereotyped comments or clichés
Limiting expression of emotion by asking directed, closed-ended questions
Interrupting and finishing the person's sentence
Talking more than the interviewee
Forming prejudged conclusions
Deliberately changing the focus
Signs of Information Overload (Patient)
Long periods of silence
Wide eyes and fixed facial expression
Constant fidgeting or attempting to move away
Nervous habits (e.g., tapping, playing with hair)
Sudden interruptions (e.g., asking to go to the bathroom)
Looking around
Yawning, eyes drooping
Frequently looking at a watch or clock
Attempting to change the topic of discussion
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The nurse can correct communication blocks by careful analysis of the interview process. One of the best methods for improving interviewing skills is audiotape or videotape feedback. With supervision and guidance, the interviewer can recognize the blocks and consciously avoid them.
Communicating with Families through an Interpreter Sometimes communication is impossible because two people speak different languages. In this case, it is necessary to obtain information through a third party: the interpreter. When using an interpreter, the nurse follows the same interviewing guidelines. Specific guidelines for using an interpreter are given in the Nursing Care Guidelines box.
N u r s i n g C a r e G u i d e l i n e s Using an Interpreter
• Explain to interpreter the reason for the interview and the type of questions that will be asked.
• Clarify whether a detailed or brief answer is required and whether the translated response can be general or literal.
• Introduce the interpreter to family, and allow some time before the interview for them to become acquainted.
• Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore the interpreter.
• Pose questions to elicit only one answer at a time, such as “Do you have pain?” rather than “Do you have any pain, tiredness, or loss of appetite?”
• Refrain from interrupting family members and the interpreter while they are conversing.
• Avoid commenting to the interpreter about family members, because they may understand some English.
• Be aware that some medical words, such as allergy, may have no similar word in another language; avoid medical jargon whenever possible.
• Be aware that cultural differences may exist regarding views on puberty, sex, marriage, or pregnancy.
• Allow time after the interview for the interpreter to share something that he or she thought could not be said earlier; ask about the interpreter's impression of nonverbal clues to communication and family members' reliability or ease in revealing information.
• Arrange for family to speak with the same interpreter on subsequent visits whenever possible.
Communicating with families through an interpreter requires sensitivity to cultural, legal, and ethical considerations (see Cultural Considerations box). In some cultures, class differences between the interpreter and the family may cause the family to feel intimidated and less inclined to offer information. Therefore, it is important to choose the interpreter carefully and provide time for the interpreter and family to establish rapport.
C u l t u r a l C o n s i d e r a t i o n s Using Children as Interpreters
When no one else is readily available to interpret, there may be temptation to use a bilingual child within the family as an interpreter. However, the use of children in health care interpreting is
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strongly discouraged, because they are often not mature enough to understand health care questions, answers, or messages (American Academy of Pediatrics, 2011). Children may inadvertently commit interpretive errors, such as inaccuracies, omissions, or substitutions. In addition, children can be adversely affected by serious or sensitive information that may be discussed. In some cultures, using a child as an interpreter is considered an insult to an adult because children are expected to show respect by not questioning their elders. Note that some institutions prohibit the use of children as interpreters; check institutional policy for compliance. If a trained on-site or community-based interpreter is not available, a language line using a telephonic interpreter may be an option.
In obtaining informed consent through an interpreter, the nurse should fully inform the family of all aspects of the particular procedure to which they are consenting. Issues of confidentiality may arise when family members related to another patient are asked to interpret for the family, thus revealing sensitive information that may be shared with other families on the unit. With increased sensitivity toward patient rights and confidentiality, many institutions now require consent forms translated in the patient's primary language.
N u r s i n g A l e r t When using translated materials, such as a health history form, be certain the informant is literate in the foreign language.
Communicating with Children Although the greatest amount of verbal communication is usually carried out with the parent, do not exclude the child during the interview. Pay attention to infants and younger children through play or by occasionally directing questions or remarks to them. Include older children as active participants so that they can share their own experiences and perspectives.
In communication with children of all ages, the nonverbal components of the communication process convey the most significant messages. It is difficult to disguise feelings, attitudes, and anxiety when relating to children. They are alert to surroundings and attach meaning to every gesture and move that is made; this is particularly true of very young children.
Active attempts to make friends with children before they have had an opportunity to evaluate an unfamiliar person tend to increase their anxiety. Continue to talk to the child and parent but go about activities that do not involve the child directly, thus allowing the child to observe from a safe position. If the child has a special toy or doll, “talk” to the doll first. Ask simple questions, such as “Does your teddy bear have a name?” to ease the child into conversation. Other guidelines for communicating with children are in the Nursing Care Guidelines box. Specific guidelines for preparing children for procedures are provided in Chapter 20.
N u r s i n g C a r e G u i d e l i n e s Communicating with Children
• Allow children time to feel comfortable.
• Avoid sudden or rapid advances, broad smiles, extended eye contact, and other gestures that may be seen as threatening.
• Talk to the parent if the child is initially shy.
• Communicate through transition objects (such as dolls, puppets, and stuffed animals) before questioning a young child directly.
• Give older children the opportunity to talk without the parents present.
• Assume a position that is at eye level with the child (Fig. 4-2).
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FIG 4-2 Nurse assumes position at child's level.
• Speak in a quiet, unhurried, and confident voice.
• Speak clearly, be specific, and use simple words and short sentences.
• State directions and suggestions positively.
• Offer a choice only when one exists.
• Be honest with children.
• Allow children to express their concerns and fears.
• Use a variety of communication techniques.
Communication Related to Development of Thought Processes The normal development of language and thought offers a frame of reference for communicating with children. Thought processes progress from sensorimotor to perceptual to concrete and finally to abstract, formal operations. An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication.
Infancy Because they are unable to use words, infants primarily use and understand nonverbal communication. Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Adults interpret this to mean that an infant needs something and consequently try to alleviate the discomfort by meeting their physical needs, speaking softly, and communicating through touch.
Infants respond to adults' nonverbal behaviors. They become quiet when they are cuddled, rocked, or receive other forms of gentle physical contact. They receive comfort from the sound of a soft voice even though they do not understand the words that are spoken. Until infants reach the age at which they experience stranger anxiety, they readily respond to any firm, gentle handling and quiet, calm speech. Loud, harsh sounds and sudden movements are frightening.
Early Childhood Children younger than 5 years old are egocentric. They see things only in relation to themselves and from their point of view. Therefore focus communication on them. Tell them what they can do
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or how they will feel. Experiences of others are of no interest to them. It is futile to use another child's experience in an attempt to gain the cooperation of small children. Allow them to touch and examine articles they will come in contact with. A stethoscope bell will feel cold; palpating a neck might tickle. Although they have not yet acquired sufficient language skills to express their feelings and wants, toddlers can effectively use their hands to communicate ideas without words. They push an unwanted object away, pull another person to show them something, point, and cover the mouth that is saying something they do not wish to hear.
Everything is direct and concrete to small children. They are unable to work with abstractions and interpret words literally. Analogies escape them because they are unable to separate reality from fantasy. For example, they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” and “coughing your head off.” Children who are told they will get “a little stick in the arm” may not be able to envision an injection (Fig. 4-3). Therefore, use simple, direct language rather than phrases that might be misinterpreted by a small child.
FIG 4-3 A young child may take the expression “a little stick in the arm” literally.
School-Age Years Younger school-age children rely less on what they see and more on what they know when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. For example, to explain a procedure such as taking blood pressure, show the child how squeezing the bulb pushes air into the cuff and makes the “arrow” move. Let the child operate the bulb. An explanation for the procedure might be as simple as, “I want to see how far the arrow moves when the cuff squeezes your arm.” Consequently, the child becomes an enthusiastic participant.
School-age children have a heightened concern about body integrity. Because of the special importance they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of treasured objects. Encouraging children to communicate their needs and voice their concerns enables the nurse to provide reassurance, to dispel myths and fears, and to implement activities that reduce their anxiety. For example, if a shy child dislikes being the center of attention, ignore that particular child by talking and relating to other children in the family or group. When children feel more comfortable, they will usually interject personal ideas, feelings, and interpretations of events.
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Adolescence As children move into adolescence, they fluctuate between child and adult thinking and behavior. They are riding a current that is moving them rapidly toward a maturity that may be beyond their coping ability. Therefore, when tensions rise, they may seek the security of the more familiar and comfortable expectations of childhood. Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently, and encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes is common. It is as much a mistake to regard an adolescent as an adult with an adult's wisdom and control as it is to assume that a teenager has the concerns and expectations of a child.
Interviewing an adolescent presents some special issues. The first may be whether to talk with the adolescent alone or with the adolescent and parents together. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the interpersonal relationship. However, talking with the parents initially may provide insight into the family relationship. In either case, give both parties an opportunity to be included in the interview. If time is limited (such as during history taking), clarify this at the onset to avoid appearing to “take sides” by talking more with one person than with the other.
Privacy and confidentiality are of great importance when communicating with adolescents because it is consistent with developmental maturity and autonomy. Explain to parents and teenagers the legal and ethical protections and limits of confidentiality. Nurses need to know and understand the state and federal consent and confidentiality laws pertaining to adolescent circumstances, such as suspected abuse, alcohol or other drug use, suicidal or homicidal ideation, contraceptive care, pregnancy, sexually transmitted infections, and sexual assault (Broner, Embry, Gremminger, et al, 2013).
Another dilemma in interviewing adolescents is that two views of a problem frequently exist: the teenager's and the parents'. Clarification of the problem is a major task. However, providing both parties an opportunity to discuss their perceptions in an open and unbiased atmosphere can, by itself, be therapeutic. Demonstrating positive communication skills can help families with adolescents to communicate more effectively (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Communicating with Adolescents
Build a Foundation
Spend time together.
Encourage expression of ideas and feelings.
Respect their views.
Tolerate differences.
Praise good points.
Respect their privacy.
Set a good example.
Communicate Effectively
Give undivided attention.
Listen, listen, listen.
Be courteous, calm, honest, and open minded.
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Try not to overreact. If you do, take a break.
Avoid judging or criticizing.
Avoid the “third degree” of continuous questioning.
Choose important issues when taking a stand.
After taking a stand:
• Think through all options.
• Make expectations clear.
Communication Techniques Nurses use a variety of verbal techniques to encourage communication. Some of these techniques are useful to pose questions or explore concerns in a less threatening manner. Others can be presented as word games, which are often well received by children. However, for many children and adults, talking about feelings is difficult, and verbal communication may be more stressful than supportive. In such instances, use several nonverbal techniques to encourage communication.
Box 4-3 describes both verbal and nonverbal techniques. Because of the importance of play in communicating with children, play is discussed more extensively in the next section. Any of the verbal or nonverbal techniques can give rise to strong feelings that surface unexpectedly. Be prepared to handle them or to recognize when issues go beyond your ability to deal with them. At that point, consider an appropriate referral.
Box 4-3 C r e a t i ve C o m m u n i c a t i o n Te c h n i q u e s w i t h C h i l d r e n Verbal Techniques “I” Messages
Relate a feeling about a behavior in terms of “I.”
Describe effect behavior had on the person.
Avoid use of “you.”
“You” messages are judgmental and provoke defensiveness.
Example: “You” message: “You are being uncooperative about doing your treatments.”
Example: “I” message: “I am concerned about how the treatments are going because I want to see you get better.”
Third-Person Technique
Express a feeling in terms of a third person (“he,” “she,” “they”). This is less threatening than directly asking children how they feel because it gives them an opportunity to agree or disagree without being defensive.
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Example: “Sometimes when a person is sick a lot, he feels angry and sad because he cannot do what others can.” Either wait silently for a response or encourage a reply with a statement, such as “Did you ever feel that way?”
This approach allows children three choices: (1) to agree and, one hopes, express how they feel; (2) to disagree; or (3) to remain silent, which means they probably have such feelings but are unable to express them at this time.
Facilitative Response
Listen carefully and reflect back to patients the feelings and content of their statements.
Responses are empathic and nonjudgmental and legitimize the person's feelings.
Formula for facilitative responses: “You feel _________ because _________.”
Example: If child states, “I hate coming to the hospital and getting needles,” a facilitative response is, “You feel unhappy because of all the things that are done to you.”
Storytelling
Use the language of children to probe into areas of their thinking while bypassing conscious inhibitions or fears.
The simplest technique is asking children to relate a story about an event, such as “being in the hospital.”
Other approaches:
• Show children a picture of a particular event, such as a child in a hospital with other people in the room, and ask them to describe the scene.
• Cut out comic strips, remove words, and have child add statements for scenes.
Mutual Storytelling
Reveal the child's thinking and attempt to change his or her perceptions or fears by retelling a somewhat different story (more therapeutic approach than storytelling).
Begin by asking the child to tell a story about something; then tell another story that is similar to child's tale but with differences that help the child in problem areas.
Example: Child's story is about going to the hospital and never seeing his or her parents again. Nurse's story is also about a child (using different names but similar circumstances) in a hospital whose parents visit every day, but in the evening after work, until the child
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is better and goes home with them.
Bibliotherapy
Use books in a therapeutic and supportive process.
Provide children with an opportunity to explore an event that is similar to their own but sufficiently different to allow them to distance themselves from it and remain in control.
General guidelines for using bibliotherapy are:
1. Assess the child's emotional and cognitive development in terms of readiness to understand the book's message.
2. Be familiar with the book's content (intended message or purpose) and the age for which it is written.
3. Read the book to the child if child is unable to read.
4. Explore the meaning of the book with the child by having the child:
○ Retell the story.
○ Read a special section with the nurse or parent.
○ Draw a picture related to the story and discuss the drawing.
○ Talk about the characters.
○ Summarize the moral or meaning of the story.
Dreams
Dreams often reveal unconscious and repressed thoughts and feelings.
Ask the child to talk about a dream or nightmare.
Explore with the child what meaning the dream could have.
“What If” Questions
Encourage child to explore potential situations and to consider different problem-solving options.
Example: “What if you got sick and had to go the hospital?” Children's responses reveal what they know already and what they are curious about, providing an opportunity for them to learn coping skills, especially in potentially dangerous situations.
Three Wishes
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Ask, “If you could have any three things in the world, what would they be?”
If the child answers, “That all my wishes come true,” ask the child for specific wishes.
Rating Game
Use some type of rating scale (numbers, sad to happy faces) to have the child rate an event or feeling.
Example: Instead of asking youngsters how they feel, ask how their day has been “on a scale of 1 to 10, with 10 being the best.”
Word Association Game
State key words and ask children to say the first word they think of when they hear the word.
Start with neutral words and then introduce more anxiety-producing words, such as “illness,” “needles,” “hospitals,” and “operation.”
Select key words that relate to some relevant event in the child's life.
Sentence Completion
Present a partial statement and have the child complete it. Some sample statements are
• The thing I like best (least) about school is _________.
• The best (worst) age to be is _________.
• The most (least) fun thing I ever did was _________.
• The thing I like most (least) about my parents is _________.
• The one thing I would change about my family is _________.
• If I could be anything I wanted, I would be _________.
• The thing I like most (least) about myself is _________.
Pros and Cons
Select a topic, such as “being in the hospital,” and have the child list “five good things and five bad things” about it.
This is an exceptionally valuable technique when applied to relationships, such as things family members like and dislike about each other.
Nonverbal Techniques Writing
Writing is an alternative communication approach for older children and adults.
Specific suggestions include:
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• Keep a journal or diary.
• Write down feelings or thoughts that are difficult to express.
• Write “letters” that are never mailed (a variation is making up a “pen pal” to write to).
Keep an account of the child's progress from both a physical and an emotional viewpoint.
Drawing
Drawing is one of the most valuable forms of communication—both nonverbal (from looking at the drawing) and verbal (from the child's story of the picture).
Children's drawings tell a great deal about them because they are projections of their inner selves.
Spontaneous drawing involves giving child a variety of art supplies and providing the opportunity to draw.
Directed drawing involves a more specific direction, such as “draw a person” or the “three themes” approach (state three things about child and ask the child to choose one and draw a picture).
Guidelines for Evaluating Drawings
Use spontaneous drawings and evaluate more than one drawing whenever possible.
Interpret the drawings in light of other available information about child and family, including the child's age and stage of development.
Interpret the drawings as a whole rather than focusing on specific details of the drawings.
Consider individual elements of the drawings that may be significant:
• Sex of figure drawn first: Usually relates to the child's perception of his or her own sex role
• Size of individual figures: Expresses importance, power, or authority
• Order in which figures are drawn: Expresses priority in terms of importance
• Child's position in relation to other family members: Expresses feelings of status or alliance
• Exclusion of a member: May denote feeling of not belonging or desire to eliminate
• Accentuated parts: Usually express concern for areas of special importance (e.g., large hands may be a sign of aggression)
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• Absence of or rudimentary arms and hands: Suggest timidity, passivity, or intellectual immaturity; tiny, unstable feet may express insecurity; and hidden hands may mean guilt feelings
• Placement of drawing on the page and type of stroke: Free use of paper and firm, continuous strokes express security, whereas drawings restricted to a small area and lightly drawn in broken or wavering lines may be signs of insecurity
• Erasures, shading, or cross-hatching: Expresses ambivalence, concern, or anxiety with a particular area
Magic
Use simple magic tricks to help establish rapport with child, encourage compliance with health interventions, and provide effective distraction during painful procedures.
Although the “magician” talks, no verbal response from the child is required.
Play
Play is the universal language and “work” of children.
It tells a great deal about children because they project their inner selves through the activity.
Spontaneous play involves giving child a variety of play materials and providing the opportunity to play.
Directed play involves a more specific direction, such as providing medical equipment or a dollhouse for focused reasons, such as exploring child's fear of injections or exploring family relationships.
Play Play is a universal language of children. It is one of the most important forms of communication and can be an effective technique in relating to them. The nurse can often pick up on clues about physical, intellectual, and social developmental progress from the form and complexity of a child's play behaviors. Play requires minimum equipment or none at all. Many providers use therapeutic play to reduce the trauma of illness and hospitalization (see Chapter 19) and to prepare children for therapeutic procedures (see Chapter 20).
Because their ability to perceive precedes their ability to transmit, infants respond to activities that register with their physical senses. Patting, stroking, and other skin play convey messages. Repetitive actions, such as stretching infants' arms out to the side while they are lying on their back and then folding the arms across the chest or raising and revolving the legs in a bicycling motion, will elicit pleasurable sounds. Colorful items to catch the eye or interesting sounds, such as a ticking clock, chimes, bells, or singing, can be used to attract infants' attention.
Older infants respond to simple games. The old game of peek-a-boo is an excellent means of initiating communication with infants while maintaining a “safe,” nonthreatening distance. After this intermittent eye contact, the nurse is no longer viewed as a stranger but as a friend. This can be followed by touch games. Clapping an infant's hands together for pat-a-cake or wiggling the toes for “this little piggy” delights an infant or small child. Talking to a foot or other part of the child's body is another effective tactic. Much of the nursing assessment can be carried out with the use of games and simple play equipment while the infant remains in the safety of the parent's arms or lap.
The nurse can capitalize on the natural curiosity of small children by playing games, such as “Which hand do you take?” and “Guess what I have in my hand,” or by manipulating items such as
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a flashlight or stethoscope. Finger games are useful. More elaborate materials, such as puppets and replicas of familiar or unfamiliar items, serve as excellent means of communicating with small children. The variety and extent are limited only by the nurse's imagination.
Through play, children reveal their perceptions of interpersonal relationships with their family, friends, or health care personnel. Children may also reveal the wide scope of knowledge they have acquired from listening to others around them. For example, through needle play, children may reveal how carefully they have watched each procedure by precisely duplicating the technical skills. They may also reveal how well they remember those who performed procedures. In one example, a child painstakingly reenacted every detail of a tedious medical procedure, including the role of the physician who had repeatedly shouted at her to be still for the long ordeal. Her anger at him was most evident during the play session and revealed the cause for her abrupt withdrawal and passive hostility toward the medical and nursing staff after the test.
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History Taking Performing a Health History The format used for history taking may be (1) direct, in which the nurse asks for information via direct interview with the informant; or (2) indirect, in which the informant supplies the information by completing some type of questionnaire. The direct method is superior to the indirect approach or a combination of both. However, because time is limited, the direct approach is not always practical. If the nurse cannot use the direct approach, he or she should review the parents' written responses and question them regarding any unusual answers. The categories listed in Box 4-4 encompass children's current and past health status and information about their psychosocial environment.
Box 4-4 O u t l i n e o f a Pe d i a t r i c H e a l t h H i s t o r y Identifying information
1. Name
2. Address
3. Telephone
4. Birth date and place
5. Race or ethnic group
6. Sex
7. Religion
8. Date of interview
9. Informant
Chief complaint (CC): To establish the major specific reason for the child's and parents' seeking of health care
Present illness (PI): To obtain all details related to the chief complaint
Past history (PH): To elicit a profile of the child's previous illnesses, injuries, or surgeries
1. Birth history (pregnancy, labor and delivery, perinatal history)
2. Previous illnesses, injuries, or surgeries
3. Allergies
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4. Current medications
5. Immunizations
6. Growth and development
7. Habits
Review of systems (ROS): To elicit information concerning any potential health problem
1. Constitutional
2. Integument
3. Eyes
4. Ears/nose/mouth/throat
5. Neck
6. Chest
7. Respiratory
8. Cardiovascular
9. Gastrointestinal
10. Genitourinary
11. Gynecologic
12. Musculoskeletal
13. Neurologic
14. Genitourinary
15. Gynecologic
16. Musculoskeletal
17. Neurologic
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18. Endocrine
Family medical history: To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child's health, such as smoking and chemical use
Psychosocial history: To elicit information about the child's self-concept
Sexual history: To elicit information concerning the child's sexual concerns or activities and any pertinent data regarding adults' sexual activity that influences the child
Family history: To develop an understanding of the child as an individual and as a member of a family and a community
1. Family composition
2. Home and community environment
3. Occupation and education of family members
4. Cultural and religious traditions
5. Family function and relationships
Nutritional assessment: To elicit information on the adequacy of the child's nutritional intake and needs
1. Dietary intake
2. Clinical examination
Identifying Information Much of the identifying information may already be available from other recorded sources. However, if the parent and child seem anxious, use this opportunity to ask about such information to help them feel more comfortable.
Informant One of the important elements of identifying information is the informant, the person(s) who furnishes the information. Record (1) who the person is (child, parent, or other), (2) an impression of reliability and willingness to communicate, and (3) any special circumstances such as the use of an interpreter or conflicting answers by more than one person.
Chief Complaint The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It may be the theme, with the present illness viewed as the description of the problem. Elicit the chief complaint by asking open-ended, neutral questions (such as, “What seems to be the matter?” “How may I help you?” or “Why did you come here today?”). Avoid labeling-type questions (such as, “How are you sick?” or “What is the problem?”). It is possible that the reason for the visit is not an illness or problem.
Occasionally, it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation, be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom prompted them to seek help
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now may help them focus on the most immediate concern.
Present Illness The history of the present illness* is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are the details of onset, a complete interval history, the present status, and the reason for seeking help now. The focus of the present illness is on all factors relevant to the main problem even if they have disappeared or changed during the onset, interval, and present.
Analyzing a Symptom Because pain is often the most characteristic symptom denoting the onset of a physical problem, it is used as an example for analysis of a symptom. Assessment includes type, location, severity, duration, and influencing factors (see Nursing Care Guidelines box; see also Pain Assessment, Chapter 5).
N u r s i n g C a r e G u i d e l i n e s Analyzing the Symptom: Pain
Type Be as specific as possible. With young children, asking the parents how they know the child is in pain may help describe its type, location, and severity. For example, a parent may state, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help.” Help older children describe the “hurt” by asking them if it is sharp, throbbing, dull, or stabbing. Record whatever words they use in quotes.
Location Be specific. “Stomach pain” is too general a description. Children can better localize the pain if they are asked to “point with one finger to where it hurts” or to “point to where mommy or daddy would put a Band-Aid.” Determine if the pain radiates by asking, “Does the pain stay there or move? Show me with your finger where the pain goes.”
Severity Severity is best determined by finding out how it affects the child's usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. Assess pain intensity using a rating scale, such as a numeric or Wong-Baker FACES Pain Rating Scale (see Chapter 5).
Duration Include the duration, onset, and frequency. Describe these in terms of activity and behavior, such as “pain reported to last all night; child refused to sleep and cried intermittently.”
Influencing Factors Include anything that causes a change in the type, location, severity, or duration of the pain: (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down), and (5) associated events (meals, stress, coughing).
History The history contains information relating to all previous aspects of the child's health status and concentrates on several areas that are ordinarily passed over in the history of an adult, such as birth history, detailed feeding history, immunizations, and growth and development. Because this section includes a great deal of information, use a combination of open-ended and fact-finding questions. For example, begin interviewing for each section with an open-ended statement (such as, “Tell me about your child's birth”) to provide the informants the opportunity to relate what they
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think is most important. Ask fact-finding questions related to specific details whenever necessary to focus the interview on certain topics.
Birth History The birth history includes all data concerning (1) the mother's health during pregnancy, (2) the labor and delivery, and (3) the infant's condition immediately after birth. Because prenatal influences have significant effects on a child's physical and emotional development, a thorough investigation of the birth history is essential. Because parents may question what relevance pregnancy and birth have on the child's present condition, particularly if the child is past infancy, explain why such questions are included. An appropriate statement may be, “I will be asking you some questions about your pregnancy and ____'s [refer to child by name] birth. Your answers will give me a more complete picture of his [or her] overall health.”
Because emotional factors also affect the outcome of pregnancy and the subsequent parent–child relationship, investigate concurrent crises during pregnancy and prenatal attitudes toward the fetus. It is best to approach the topic of parental acceptance of pregnancy through indirect questioning. Asking the parents if the pregnancy was planned is a leading statement, because they may respond affirmatively for fear of criticism if the pregnancy was unexpected. Rather, encourage parents to state their true reactions by referring to specific facts relating to the pregnancy, such as the spacing between offspring, an extended or short interval between marriage and conception, or a pregnancy during adolescence. The parent can choose to explore such statements with further explanations or, for the moment, may not be able to reveal such feelings. If the parent remains silent, return to this topic later in the interview.
Dietary History Because parental concerns are common and nursing interventions are important in ensuring optimum nutrition, the dietary history is discussed in detail later in the Nutritional Assessment section in this chapter.
Previous Illnesses, Injuries, and Surgeries When inquiring about past illnesses, begin with a general question (such as, “What other illnesses has your child had?”). Because parents are most likely to recall serious health problems, ask specifically about colds, earaches, and childhood diseases, such as measles, rubella (German measles), chickenpox, mumps, pertussis (whooping cough), diphtheria, tuberculosis, scarlet fever, strep throat, recurrent ear infections, gastroesophageal reflux, tonsillitis, or allergic manifestations.
In addition to illnesses, ask about injuries that required medical intervention, surgeries, procedures, and hospitalizations, including the dates of each incident. Focus on injuries (such as accidental falls, poisoning, choking, concussion, fractures, or burns) because these may be potential areas for parental guidance.
Allergies Ask about commonly known allergic disorders, such as hay fever and asthma; unusual reactions to drugs, food, or latex products; and reactions to other contact agents, such as poisonous plants, animals, household products, or fabrics. If asked appropriate questions, most people can give reliable information about drug reactions (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Taking an Allergy History
• Has your child ever taken any prescription or over-the-counter medications that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of this medication(s)?
• Can you describe the reaction?
• Was the medication taken by mouth (as a tablet or syrup), or was it an injection?
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• How soon after starting the medication did the reaction happen?
• How long ago did this happen?
• Did anyone tell you it was an allergic reaction, or did you decide for yourself?
• Has your child ever taken this medication, or a similar one, again? If yes, did your child experience the same problems?
• Have you told the physicians or nurses about your child's reaction or allergy?
N u r s i n g A l e r t Information about allergic reactions to drugs or other products is essential. Failure to document a serious reaction places the child at risk if the agent is given.
Current Medications Inquire about current medications, including vitamins, antipyretics (especially aspirin), antibiotics, antihistamines, decongestants, nutritional supplements, or herbs and homeopathic medications. List all medications, including name, dose, schedule, duration, and reasons for use. Often parents are unaware of a medication's actual name. Whenever possible, ask the parents to bring the containers with them to the next visit, or ask for the name of the pharmacy and call for a list of all the child's recent prescription medications. However, this list will not include over-the-counter medications, which are important to know.
Immunizations A record of all immunizations is essential. As many parents are unaware of the exact name and date of each immunization, sources of information include the child's health care provider, school record, and the state's centralized immunization registry. All immunizations and “boosters” are listed, stating (1) the name of the specific disease, (2) the number of injections, (3) the dosage (sometimes lesser amounts are given if a reaction is anticipated), (4) the date when administered, and (5) the occurrence of any reaction following immunization. Children should be screened for contraindications and precautions before every vaccine is administered (see Immunizations, Chapter 7).
Growth and Development Review the child's growth including: • Measurements of weight, length, and head circumference at birth • Patterns of growth on the growth chart and any significant deviations from previous percentiles • Concerns about growth from the family or child
Developmental milestones include: • Age of holding up head steadily • Age of sitting alone without support • Age of walking without assistance • Age of saying first words with meaning • Age of achieving bladder and bowel control • Present grade in school • Scholastic performance • If the child has a best friend • Interactions with other children, peers, and adults
Use specific and detailed questions when inquiring about each developmental milestone. For example, “sitting up” can mean many different activities, such as sitting propped up, sitting in someone's lap, sitting with support, sitting up alone but in a hyperflexed position for assisted balance, or sitting up unsupported with the back slightly rounded. A clue to misunderstanding of
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the requested activity may be an unusually early age of achievement (see Developmental Assessment, Chapter 3).
Habits Habits are an important area to explore (Box 4-5). Parents frequently express concerns during this part of the history. Encourage their input by saying, “Please tell me any concerns you have about your child's habits, activities, or development.” Investigate further any concerns that parents express.
Box 4-5 H a b i t s t o E x p l o r e D u r i n g a H e a l t h I n t e r v i e w • Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood
substances), rituals (“security” blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes)
• Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting
• Unusual disposition; response to frustration
• Use or abuse of alcohol, drugs, coffee, or tobacco
One of the most common concerns relates to sleep. Many children develop a normal sleep pattern, and all that is required during the assessment is a general overview of nighttime sleep and nap schedules. However, a number of children develop sleep problems (see Sleep Problems, Chapters 10 and 13). When sleep problems occur, the nurse needs a more detailed sleep history to guide appropriate interventions.
Habits related to use of chemicals apply primarily to older children and adolescents. If a youngster admits to smoking, drinking, or using drugs, ask about the quantity and frequency. Questions such as “Many kids your age are experimenting with drugs and alcohol; have you ever had any drugs or alcohol?” may give more reliable data than questions such as “How much do you drink?” or “How often do you drink or take drugs?” Clarify that “drinking” includes all types of alcohol, including beer and wine. When quantities such as a “glass” of wine or a “can” of beer are given, ask about the size of the container.
If older children deny use of chemical substances, inquire about past experimentation. Asking, “You mean you never tried to smoke or drink?” implies that the nurse expects some such activity, and the youngster may be more inclined to answer truthfully. Be aware of the confidential nature of such questioning, the adverse effect that the parents' presence may have on the adolescent's willingness to answer, and the fact that self-reporting may not be an accurate account of chemical abuse.
Reproductive Health History The reproductive health history is an essential component of adolescents' health assessment. The history uncovers areas of concern related to sexual activity, alerts the nurse to circumstances that may indicate screening for sexually transmitted infections or testing for pregnancy, and provides information related to the need for reproductive health counseling, such as safer sex practices. Box 4-6 gives guidelines for anticipatory guidance topics for parents and adolescents.
Box 4-6 A n t i c i p a t o r y G u i d a n c e — S e x u a l i t y 12 to 14 Years Old
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Have adolescent identify a supportive adult with whom to discuss sexuality issues and concerns.
Discuss the advantages of delaying sexual activity.
Discuss making responsible decisions regarding normal sexual feelings.
Discuss the roles of gender, peer pressure, and the media in sexual decision making.
Discuss contraceptive options (advantages and disadvantages).
Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks and discuss condoms.
Discuss abuse prevention, including avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defense.
Have the adolescent clarify his or her values, needs, and ability to be assertive.
If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
Have a confidential interview with the adolescent (including a sexual history).
Discuss the evolution of sexual identity and expression.
Discuss breast examination or testicular examination.
15 to 18 Years Old
Support delaying sexual activity.
Discuss alternatives to intercourse.
Discuss “When are you ready for sex?”
Clarify values; encourage responsible decision making.
Discuss consequences of unprotected sex: Early pregnancy; STIs, including HIV infection.
Discuss negotiating with partners and barriers to safer sex.
If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.
Emphasize that sex should be safe and pleasurable for both partners.
Have a confidential interview with the adolescent.
Discuss concerns about sexual expression and identity.
Data from Wright K: Anticipatory guidance: developing a healthy sexuality, Pediatr Ann 26(2 suppl):S142–S144, C3, 1997; Fonseca H, Greydanus D: Sexuality in the child, teen and young adult: concepts for the clinician, Prim Care Clin Office Pract 34:275–292, 2007.
One approach to initiating a conversation about reproductive health concerns is to begin with a history of peer interactions. Open-ended statements and questions (such as, “Tell me about your social life” or “Who are your closest friends?”) generally lead into a discussion of dating and sexual issues. To probe further, include questions about the adolescent's attitudes on such topics as sex education, “going steady,” “living together,” and premarital sex. Phrase questions to reflect concern rather than judgment or criticism of sexual practices.
In any conversation regarding reproductive health history, be aware of the language that is used
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in either eliciting or conveying sexual information. For example, avoid asking whether the adolescent is “sexually active,” because this term is broadly defined. “Are you having sex with anyone?” is probably the most direct and best understood question. Because same-sex experimentation may occur, refer to all sexual contacts in non-gender terms, such as “anyone” or “partners,” rather than “girlfriends” or “boyfriends.”
Family Health History The family health history is used primarily to discover any genetic or chronic diseases affecting the child's family members. Assess for the presence or absence of consanguinity (if anyone in the family is related to their spouse's/partner's family). Family health history is generally confined to first- degree relatives (parents, siblings, grandparents, and immediate aunts and uncles). Information includes age, marital status, health status, cause of death if deceased, and any evidence of conditions, such as early heart disease, stroke, sudden death from unknown cause, hypercholesterolemia, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergies, asthma, seizures, tuberculosis, abnormal bleeding, sickle cell disease, cognitive impairment, hearing or visual deficits, and psychiatric disorders (such as, depression or psychosis, and emotional problems). Confirm the accuracy of the reported disorders by inquiring about the symptoms, course, treatment, and sequelae of each diagnosis.
Geographic Location One of the important areas to explore when assessing the family health history is geographic location, including the birthplace and travel to different areas in or outside of the country, for identification of possible exposure to endemic diseases. Include current and past housing, whether they rent or own, reside in an urban or rural location, the age of the home and whether there are significant threats such as molds or pests within the housing structure. Although the primary interest is the child's temporary residence in various localities, also inquire about close family members' travel, especially during tours of military service or business trips. Children are especially susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases, such as those from mosquitoes or ticks in warm and humid or heavily wooded regions.
Family Structure Assessment of the family, both its structure and function, is an important component of the history- taking process. Because the quality of the functional relationship between the child and family members is a major factor in emotional and physical health, family assessment is discussed separately and in greater detail apart from the more traditional health history.
Family assessment is the collection of data about the composition of the family and the relationships among its members. In its broadest sense, family refers to all those individuals who are considered by the family member to be significant to the nuclear unit, including relatives, friends, and social groups (such as the school and church). Although family assessment is not family therapy, it can and frequently is therapeutic. Involving family members in discussing family characteristics and activities can provide insight into family dynamics and relationships.
Because of the time involved in performing an in-depth family assessment as presented here, be selective in deciding when knowledge of family function may facilitate nursing care (see Nursing Care Guidelines box). During brief contacts with families, a full assessment is not appropriate, and screening with one or two questions from each category may reflect the health of the family system or the need for additional assessment.
N u r s i n g C a r e G u i d e l i n e s Initiating a Comprehensive Family Assessment
Perform a comprehensive assessment on:
• Children receiving comprehensive well-child care
• Children experiencing major stressful life events (e.g., chronic illness, disability, parental divorce,
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death of a family member)
• Children requiring extensive home care
• Children with developmental delays
• Children with repeated accidental injuries and those with suspected child abuse
• Children with behavioral or physical problems that could be caused by family dysfunction
The most common method of eliciting information on the family structure is to interview family members. The principal areas of concern are family composition, home and community environment, occupation and education of family members, and cultural and religious traditions (Box 4-7).
Box 4-7 F a m i l y A s s e s s m e n t I n t e r v i e w General Guidelines
Schedule the interview with the family at a time that is most convenient for all parties; include as many family members as possible; clearly state the purpose of the interview.
Begin the interview by asking each person's name and their relationships to one another.
Restate the purpose of the interview and the objective.
Keep the initial conversation general to put members at ease and to learn the “big picture” of the family.
Identify major concerns and reflect these back to the family to be certain that all parties receive the same message.
Terminate the interview with a summary of what was discussed and a plan for additional sessions if needed.
Structural Assessment Areas Family Composition
Immediate members of the household (names, ages, and relationships)
Significant extended family members
Previous marriages, separations, death of spouses, or divorces
Home and Community Environment
Type of dwelling, number of rooms, occupants
Sleeping arrangements
Number of floors, accessibility of stairs and elevators
Adequacy of utilities
Safety features (fire escape, smoke and carbon monoxide detectors, guardrails on windows, use of car restraint)
Environmental hazards (e.g., chipped paint, poor sanitation, pollution, heavy street traffic)
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Availability and location of health care facilities, schools, play areas
Relationship with neighbors
Recent crises or changes in home
Child's reaction and adjustment to recent stresses
Occupation and Education of Family Members
Types of employment
Work schedules
Work satisfaction
Exposure to environmental or industrial hazards
Sources of income and adequacy
Effect of illness on financial status
Highest degree or grade level attained
Cultural and Religious Traditions
Religious beliefs and practices
Cultural and ethnic beliefs and practices
Language spoken in home
Assessment questions include
• Does the family identify with a particular religious or ethnic group? Are both parents from that group?
• How is religious or ethnic background part of family life?
• What special religious or cultural traditions are practiced in the home (e.g., food choices and preparation)?
• Where were family members born, and how long have they lived in this country?
• What language does the family speak most frequently?
• Do they speak and understand English?
• What do they believe causes health or illness?
• What religious or ethnic beliefs influence the family's perception of illness and its treatment?
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• What methods are used to prevent or treat illness?
• How does the family know when a health problem needs medical attention?
• Who does the family contact when a member is ill?
• Does the family rely on cultural or religious healers or remedies? If so, ask them to describe the type of healer or remedy.
• Who does the family go to for support (clergy, medical healer, relatives)?
• Does the family experience discrimination because of their race, beliefs, or practices? Ask them to describe.
Functional Assessment Areas Family Interactions and Roles
Interactions refer to ways family members relate to each other. The chief concern is the amount of intimacy and closeness among the members, especially spouses.
Roles refer to behaviors of people as they assume a different status or position.
Observations include:
• Family members' responses to each other (cordial, hostile, cool, loving, patient, short tempered)
• Obvious roles of leadership versus submission
• Support and attention shown to various members
Assessment questions include:
• What activities does the family perform together?
• Who do family members talk to when something is bothering them?
• What are members' household chores?
• Who usually oversees what is happening with the children, such as at school or health care?
• How easy or difficult is it for the family to change or accept new responsibilities for household tasks?
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Power, Decision Making, and Problem Solving
Power refers to individual member's control over others in family; it is manifested through family decision making and problem solving.
Chief concern is clarity of boundaries of power between parents and children.
One method of assessment involves offering a hypothetical conflict or problem, such as a child failing school, and asking family how they would handle this situation.
Assessment questions include:
• Who usually makes the decisions in the family?
• If one parent makes a decision, can the child appeal to the other parent to change it?
• What input do children have in making decisions or discussing rules?
• Who makes and enforces the rules?
• What happens when a rule is broken?
Communication
Communication is concerned with clarity and directness of communication patterns.
Further assessment includes periodically asking family members if they understood what was just said and to repeat the message.
Observations include:
• Who speaks to whom
• If one person speaks for another or interrupts
• If members appear uninterested when certain individuals speak
• If there is agreement between verbal and nonverbal messages
Assessment questions include:
• How often do family members wait until others are through talking before “having their say?”
• Do parents or older siblings tend to lecture and preach?
• Do parents tend to “talk down” to the children?
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Expression of Feelings and Individuality
Expressions are concerned with personal space and freedom to grow, with limits and structure needed for guidance.
Observing patterns of communication offers clues to how freely feelings are expressed.
Assessment questions include:
• Is it okay for family members to get angry or sad?
• Who gets angry most of the time? What do they do?
• If someone is upset, how do other family members try to comfort this person?
• Who comforts specific family members?
• When someone wants to do something, such as try out for a new sport or get a job, what is the family's response (offer assistance, discouragement, or no advice)?
Psychosocial History The traditional medical history includes a personal and social section that concentrates on children's personal status, such as school adjustment and any unusual habits, and the family and home environment. Because several personal aspects are covered under development and habits, only those issues related to children's ability to cope and their self-concept are presented here.
Through observation, obtain a general idea of how children handle themselves in terms of confidence in dealing with others, answering questions, and coping with new situations. Observe the parent–child relationship for the types of messages sent to children about their coping skills and self-worth. Do the parents treat the child with respect, focusing on strengths, or is the interaction one of constant reprimands with emphasis on weaknesses and faults? Do the parents help the child learn new coping strategies or support the ones the child uses?
Parent–child interactions also convey messages about body image. Do the parents label the child and body parts (such as “bad boy,” “skinny legs,” or “ugly scar”)? Do the parents handle the child gently, using soothing touch to calm an anxious child, or do they treat the child roughly, using force or restraint to make the child obey? If the child touches certain parts of the body, such as the genitalia, do the parents make comments that suggest a negative connotation?
With older children, many of the communication strategies discussed earlier in this chapter are useful in eliciting more definitive information about their coping and self-concept. Children can name or write down five things they like and dislike about themselves. The nurse can use sentence completion statements, such as “The thing I like best (or worst) about myself is ________;” “If I could change one thing about myself, it would be ________;” or “When I am scared, I ________.”
Review of Systems The review of systems is a specific review of each body system, following an order similar to that of the physical examination (see Nursing Care Guidelines box). Often the history of the present illness provides a complete review of the system involved in the chief complaint. Because asking questions about other body systems may appear irrelevant to the parents or child, precede the questioning with an explanation of why the data are necessary (similar to the explanation concerning the relevance of the birth history) and reassure the parents that the child's main problem has not been forgotten.
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N u r s i n g C a r e G u i d e l i n e s Review of Systems
Constitutional: Overall state of health, fatigue, recent or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), general ability to carry out activities of daily living
Integument: Pruritus, pigment or other color changes (including birthmarks), acne, eruptions, rashes (location), bruises, petechiae, excessive dryness, general texture, tattoos or piercings, disorders or deformities of nails, hair growth or loss, hair color change (for adolescents, use of hair dyes or other potentially toxic substances, such as hair straighteners)
Eyes: Visual problems (behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting close to television, holding a book close to face, writing with head near desk, squinting, rubbing the eyes, bending head in an awkward position), cross-eyes (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last vision examination
Ears/nose/mouth/throat: Earaches, ear discharge, evidence of hearing loss (ask about behaviors, such as the need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell, mouth breathing, gum bleeding, number of teeth and pattern of eruption/loss, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), sore throats, difficulty swallowing, choking, hoarseness or other voice irregularities
Neck: Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses
Chest: Breast enlargement, discharge, masses; for adolescent girls, ask about breast self-examination
Respiratory: Chronic cough, wheezing, shortness of breath at rest or on exertion, difficulty breathing, snoring, sputum production, infections (pneumonia, tuberculosis), skin reaction from tuberculin testing
Cardiovascular: Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, tachycardia, syncope, edema
Gastrointestinal: Appetite, nausea, vomiting (not associated with eating; may be indicative of brain tumor or increased intracranial pressure), abdominal pain, jaundice or yellowing skin or sclera, belching, flatulence, distention, diarrhea, constipation, recent change in bowel habits, blood in stools
Genitourinary: Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, enuresis, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date and result of last urinalysis; for adolescents, sexually transmitted infection and type of treatment; for adolescent boys, ask about testicular self-examination
Gynecologic: Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus; if sexually active, type of contraception, sexually transmitted infection and type of treatment; if sexually active with weakened immune system or if 21 years old and older, date and result of last Papanicolaou (Pap) smear; obstetric history (as discussed under birth history, when applicable)
Musculoskeletal: Weakness, clumsiness, lack of coordination, unusual movements, scoliosis, back pain, joint pain or swelling, muscle pains or cramps, abnormal gait, deformity, fractures, serious
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sprains, activity level
Neurologic: Headaches, seizures, tremors, tics, dizziness, loss of consciousness episodes, loss of memory, developmental delays or concerns
Endocrine: Intolerance to heat or cold, excessive thirst or urination, excessive sweating, salt craving, rapid or slow growth, signs of early or late puberty
Hematologic/lymphatic: Easy bruising or bleeding, anemia, date and result of last blood count, blood transfusions, swollen or painful lymph nodes (cervical, axillary, inguinal)
Allergic/immunologic: Allergic responses, anaphylaxis, eczema, rhinitis, unusual sneezing, autoimmunity, recurrent infections, infections associated with unusual complications
Psychiatric: General affect, anxiety, depression, mood changes, hallucinations, attention span, tantrums, behavior problems, suicidal ideation, substance abuse
Begin the review of a specific system with a broad statement (such as, “How has your child's general health been?” or “Has your child had any problems with his eyes?”). If the parent states that the child has had problems with some body function, pursue this with an encouraging statement, such as “Tell me more about that.” If the parent denies any problems, query for specific symptoms (e.g., “Any headaches, bumping into objects, or squinting?”). If the parent confirms the absence of such symptoms, record positive statements in the history, such as “Mother denies headaches, bumping into objects, and squinting.” In this way, anyone who reviews the health history is aware of exactly what symptoms were investigated.
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Nutritional Assessment Dietary Intake Knowledge of the child's dietary intake is an essential component of a nutritional assessment. However, it is also one of the most difficult factors to assess. Individuals' recall of food consumption, especially amounts eaten, is frequently unreliable. The food intake history of children and adolescents is prone to reporting error, mostly in the form of underreporting. People from different cultures may have difficulty adequately describing the types of food they eat. Despite these obstacles, a dietary evaluation is a vital element of the child's health assessment.
The Dietary Reference Intakes (DRIs) are a set of four evidence-based nutrient reference values that provide quantitative estimates of nutrient intake for use in assessing and planning dietary intake (US Department of Agriculture, National Agricultural Library, 2014). The specific DRIs are:
Estimated Average Requirement (EAR): Estimated to meet the nutrient requirement of half of healthy individuals for a specific age and gender group
Recommended Dietary Allowance (RDA): Sufficient to meet the nutrient requirement of nearly all healthy individuals for a specific age and gender group
Adequate Intake (AI): Based on estimates of nutrient intake by healthy individuals
Tolerable Upper Intake Level (UL): Highest nutrient intake level likely to pose no risk of adverse health effects
The US Department of Agriculture has an online interactive DRI tool for health care professionals to calculate nutrient requirements based on age, gender, height, weight, and activity, although it is important to note that individual requirements may vary (available at http://fnic.nal.usda.gov/fnic/interactiveDRI/).
Fig. 4-4 illustrates ChooseMyPlate.gov, which describes the five food groups forming the foundation for a healthy diet. MyPlate Kids' Place provides resources to help families build healthy meals and be active. Specific questions used to conduct a nutritional assessment are given in Box 4- 8. Every nutritional assessment should begin with a dietary history. The exact questions used to elicit a dietary history vary with the child's age. In general, the younger the child, the more specific and detailed the history should be. The overview elicited from the dietary history can be helpful in evaluating food frequency records. The history is also concerned with financial and cultural factors that influence food selection and preparation (see Cultural Considerations box).
C u l t u r a l C o n s i d e r a t i o n s Food Practices
Because cultural practices are prevalent in food preparation, consider carefully the kinds of questions that are asked and the judgments made during counseling. For example, some cultures, such as Hispanic, African American, and Native American, include many vegetables, legumes, and starches in their diet that together provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low (see Food Customs, Chapter 2).
The most common and probably easiest method of assessing daily intake is the 24-hour recall. The child or parent recalls every item eaten in the past 24 hours and the approximate amounts. The 24-hour recall is most beneficial when it represents a typical day's intake. Some of the difficulties with a daily recall are the family's inability to remember exactly what was eaten and inaccurate estimation of portion size. To increase accuracy of reporting portion sizes, the use of food models and additional questions are recommended. In general, this method is most useful in providing qualitative information about the child's diet.
To improve the reliability of the daily recall, the family can complete a food diary by recording every food and liquid consumed for a certain number of days. A 3-day record consisting of 2 weekdays and 1 weekend day is representative for most people. Providing specific charts to record
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intake can improve compliance. The family should record items immediately after eating.
FIG 4-4 MyPlate. MyPlate advocates building a healthy plate by making half of your plate fruits and vegetables and the other half grains and lean protein. Avoiding oversized portions, making half your grains
whole grains, and drinking fat-free or low-fat (1%) milk are among the recommendations for a healthy diet. (From US Department of Agriculture, Center for Nutrition Policy and Promotion: MyPlate, 2015, www.ChooseMyPlate.gov.)
Box 4-8 D i e t a r y R e f e r e n c e I n t a k e s f o r a n I n d i v i d u a l Estimated Average Requirement (EAR): Used to examine the possibility of inadequacy.
Recommended Dietary Allowance (RDA): Dietary intake at or above this level usually has a low probability of inadequacy.
Adequate Intake (AI): Dietary intake at or above this level usually has a low probability of inadequacy.
Tolerable Upper Intake Level (UL): Dietary intake above this level usually places an individual at risk of adverse effects from excessive nutrient intake.
Dietary History
What are the family's usual mealtimes?
Do family members eat together or at separate times?
Who does the family grocery shopping and meal preparation?
How much money is spent to buy food each week?
How are most foods prepared—baked, broiled, fried, other?
How often does the family or your child eat out?
• What kinds of restaurants do you go to?
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• What kinds of food does your child typically eat at restaurants?
Does your child eat breakfast regularly?
Where does your child eat lunch?
What are your child's favorite foods, beverages, and snacks?
• What are the average amounts eaten per day?
• What foods are artificially sweetened?
• What are your child's snacking habits?
• When are sweet foods usually eaten?
• What are your child's tooth brushing habits?
What special cultural practices are followed? What ethnic foods are eaten?
What foods and beverages does your child dislike?
How would you describe your child's usual appetite (hearty eater, picky eater)?
What are your child's feeding habits (breast, bottle, cup, spoon, eats by self, needs assistance, any special devices)?
Does your child take vitamins or other supplements? Do they contain iron or fluoride?
Does your child have any known or suspected food allergies? Is your child on a special diet?
Has your child lost or gained weight recently?
Are there any feeding problems (excessive fussiness, spitting up, colic, difficulty sucking or swallowing)? Are there any dental problems or appliances, such as braces, that affect eating?
What types of exercise does your child do regularly?
Is there a family history of cancer, diabetes, heart disease, high blood pressure, or obesity?
Additional Questions for Infants
What was the infant's birth weight? When did it double? Triple?
Was the infant premature?
Are you breastfeeding or have you breastfed your infant? For how long?
If you use a formula, what is the brand?
• How long has the infant been taking it?
• How many ounces does the infant drink a day?
Are you giving the infant cow's milk (whole, low fat, skim)?
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• When did you start?
• How many ounces does the infant drink a day?
Do you give your infant extra fluids (water, juice)?
If the infant takes a bottle to bed at nap or nighttime, what is in the bottle?
At what age did the child start on cereal, vegetables, meat or other protein sources, fruit or juice, finger food, and table food?
Do you make your own baby food or use commercial foods, such as infant cereal?
Does the infant take a vitamin or mineral supplement? If so, what type?
Has the infant had an allergic reaction to any food(s)? If so, list the foods and describe the reaction.
Does the infant spit up frequently; have unusually loose stools; or have hard, dry stools? If so, how often?
How often do you feed your infant?
How would you describe your infant's appetite?
Modified from Murphy SP, Poos MI: Dietary reference intakes: summary of applications in dietary assessment, Pub Health Nutr 5(Suppl 6A):843–849, 2002.
Clinical Examination of Nutrition A significant amount of information regarding nutritional deficiencies comes from a clinical examination, especially from assessing the skin, hair, teeth, gums, lips, tongue, and eyes. Hair, skin, and mouth are vulnerable because of the rapid turnover of epithelial and mucosal tissue. Table 4-1 summarizes some clinical signs of possible nutritional deficiency or excess. Few are diagnostic for a specific nutrient, and if suspicious signs are found, they must be confirmed with dietary and biochemical data. Failure to thrive is discussed in Chapter 10. Obesity and eating disorders are discussed in Chapter 16.
TABLE 4-1 Clinical Assessment of Nutritional Status
Evidence of Adequate Nutrition Evidence of Deficient or Excess Nutrition Deficiency or Excess* General Growth Normal weight gain, growth velocity, and head growth for age and gender
Weight loss or poor weight gain, growth failure Protein, calories, fats, and other essential nutrients, especially vitamin A, pyridoxine, niacin, calcium, iodine, manganese, zinc
Excess weight gain Excess calories Sexual development appropriate for age Delayed sexual development Excess vitamins A, D Skin Smooth, slightly dry to touch Elastic and firm Absence of lesions Color appropriate to genetic background
Hardening and scaling Vitamin A Seborrheic dermatitis Excess niacin Dry, rough, petechiae Riboflavin Delayed wound healing Vitamin C Scaly dermatitis on exposed surfaces Riboflavin, vitamin C, zinc Wrinkled, flabby Niacin Crusted lesions around orifices, especially nares Protein, calories, zinc Pruritus Excess vitamin A, riboflavin, niacin Poor turgor Water, sodium Edema Protein, thiamine
Excess sodium Yellow tinge (jaundice) Vitamin B12
Excess vitamin A, niacin Depigmentation Protein, calories Pallor (anemia) Pyridoxine, folic acid, vitamins B12, C, E (in premature infants), iron
Excess vitamin C, zinc Paresthesia Excess riboflavin
Hair Lustrous, silky, strong, elastic Stringy, friable, dull, dry, thin Protein, calories
Alopecia Protein, calories, zinc Depigmentation Protein, calories, copper Raised areas around hair follicles Vitamin C
Head Even molding, occipital prominence,
symmetric facial features Fused sutures after 18 months
Softening of cranial bones, prominence of frontal bones, skull flat and depressed toward middle
Vitamin D
Delayed fusion of sutures Vitamin D
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Hard, tender lumps in occiput Excess vitamin A Headache Excess thiamine
Neck Thyroid not visible, palpable in midline Thyroid enlarged, may be grossly visible Iodine Eyes Clear, bright Hardening and scaling of cornea and conjunctiva Vitamin A Good night vision Night blindness Vitamin A Conjunctiva—pink, glossy Burning, itching, photophobia, cataracts, corneal
vascularization Riboflavin
Ears Tympanic membrane—pliable Calcified (hearing loss) Excess vitamin D Nose Smooth, intact nasal angle Irritation and cracks at nasal angle Riboflavin
Excess vitamin A Mouth Lips—smooth, moist, darker color than skin Fissures and inflammation at corners Riboflavin
Excess vitamin A Gums—firm, coral pink, stippled Spongy, friable, swollen, bluish red or black, bleed easily Vitamin C Mucous membranes—bright pink, smooth, moist
Stomatitis Niacin
Tongue—rough texture, no lesions, taste sensation
Glossitis Niacin, riboflavin, folic acid Diminished taste sensation Zinc
Teeth—uniform white color, smooth, intact Brown mottling, pits, fissures Excess fluoride Defective enamel Vitamins A, C, D; calcium; phosphorus Caries Excess carbohydrates
Chest In infants, shape almost circular Depressed lower portion of rib cage Vitamin D In children, lateral diameter increased in proportion to anteroposterior diameter
Sharp protrusion of sternum Vitamin D
Smooth costochondral junctions Enlarged costochondral junctions Vitamins C, D Breast development—normal for age Delayed development See under General Growth; especially zinc Cardiovascular System Pulse and BP within normal limits Palpitations Thiamine
Rapid pulse Potassium Excess thiamine
Arrhythmias Magnesium, potassium Excess niacin, potassium
Increased BP Excess sodium Decreased BP Thiamine
Excess niacin Abdomen In young children, cylindric and prominent Distended, flabby, poor musculature Protein, calories
Prominent, large Excess calories In older children, flat Potbelly, constipation Vitamin D Normal bowel habits Diarrhea Niacin
Excess vitamin C Constipation Excess calcium, potassium
Musculoskeletal System Muscles—firm, well-developed, equal strength bilaterally
Flabby, weak, generalized wasting Protein, calories Weakness, pain, cramps Thiamine, sodium, chloride, potassium, phosphorus, magnesium
Excess thiamine Muscle twitching, tremors Magnesium Muscular paralysis Excess potassium
Spine—cervical and lumbar curves (double S curve)
Kyphosis, lordosis, scoliosis Vitamin D
Extremities—symmetric; legs straight with minimum bowing
Bowing of extremities, knock knees Vitamin D, calcium, phosphorus Epiphyseal enlargement Vitamins A, D Bleeding into joints and muscles, joint swelling, pain Vitamin C
Joints—flexible, full range of motion, no pain or stiffness
Thickening of cortex of long bones with pain and fragility, hard tender lumps in extremities
Excess vitamin A
Osteoporosis of long bones Calcium Excess vitamin D
Neurologic System Behavior—alert, responsive, emotionally stable Listless, irritable, lethargic, apathetic (sometimes
apprehensive, anxious, drowsy, mentally slow, confused) Thiamine, niacin, pyridoxine, vitamin C, potassium, magnesium, iron, protein, calories Excess vitamins A, D, thiamine, folic acid, calcium
Absence of tetany, convulsions Masklike facial expression, blurred speech, involuntary laughing
Excess manganeseThiamine, pyridoxine, vitamin D, calcium, magnesium Excess phosphorus (in relation to calcium)
Convulsions Intact peripheral nervous system Peripheral nervous system toxicity (unsteady gait, numb feet
and hands, fine motor clumsiness) Excess pyridoxine
Intact reflexes Diminished or absent tendon reflexes Thiamine, vitamin E
*Nutrients listed are deficient unless specified as excess. BP, Blood pressure.
Anthropometry, an essential parameter of nutritional status, is the measurement of height, weight, head circumference, proportions, skinfold thickness, and arm circumference in children. Height and head circumference reflect past nutrition, whereas weight, skinfold thickness, and arm circumference reflect present nutritional status, especially of protein and fat reserves. Skinfold thickness is a measurement of the body's fat content because approximately half the body's total fat stores are directly beneath the skin. The upper arm muscle circumference is correlated with measurements of total muscle mass. Because muscle serves as the body's major protein reserve, this measurement is considered an index of the body's protein stores. Ideally, growth measurements are recorded over time, and comparisons are made regarding the velocity of growth and weight gain based on previous and present values.
Numerous biochemical tests are available for assessing nutritional status. The most common laboratory studies to assess children for undernutrition are hemoglobin, red blood cell indices, and serum albumin or prealbumin. For obese children, fasting serum glucose, lipids, and liver function studies may be performed to assess for complications.
Evaluation of Nutritional Assessment
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After collecting the data needed for a thorough nutritional assessment, evaluate the findings to plan appropriate counseling. From the data, assess whether the child is malnourished, at risk for becoming malnourished, well-nourished with adequate reserves, or overweight or obese.
Analyze the daily food diary for the variety and amounts of foods suggested in MyPlate (see Fig. 4-4). For example, if the list includes no vegetables, inquire about this rather than assuming that the child dislikes vegetables, because it is possible that none were served that day. Also, evaluate the information in terms of the family's ethnic practices and financial resources. Encouraging increased protein intake with additional meat is not always feasible for families on a limited budget and may conflict with food practices that use meat sparingly, such as in Asian meal preparation.
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General Approaches Toward Examining the Child Sequence of the Examination Ordinarily, the sequence for examining patients follows a head-to-toe direction. The main function of such a systematic approach is to provide a general guideline for assessment of each body area to avoid omitting segments of the examination. The standard recording of data also facilitates exchange of information among different professionals. In examining children, this orderly sequence is frequently altered to accommodate the child's developmental needs, although the examination is recorded following the head-to-toe model. Using developmental and chronologic age as the main criteria for assessing each body system accomplishes several goals: • Minimizes stress and anxiety associated with assessment of various body parts • Fosters a trusting nurse–child–parent relationship • Allows for maximum preparation of the child • Preserves the essential security of the parent–child relationship, especially with young children • Maximizes the accuracy and reliability of assessment findings
Preparation of the Child Although the physical examination consists of painless procedures, for some children the use of a tight arm cuff, probes in the ears and mouth, pressure on the abdomen, and a cold piece of metal to listen to the chest are stressful. Therefore the nurse should use the same considerations discussed in Chapter 20 for preparing children for procedures. In addition to that discussion, general guidelines related to the examining process are given in the Nursing Care Guidelines box.
N u r s i n g C a r e G u i d e l i n e s Performing Pediatric Physical Examination
Perform the examination in an appropriate, nonthreatening area:
• Have room well-lit and decorated with neutral colors.
• Have room temperature comfortably warm.
• Place all strange and potentially frightening equipment out of sight.
• Have some toys, dolls, stuffed animals, and games available for child.
• If possible, have rooms decorated and equipped for different-age children.
• Provide privacy, especially for school-age children and adolescents.
• Provide time for play and becoming acquainted.
Observe behaviors that signal the child's readiness to cooperate:
• Talking to the nurse
• Making eye contact
• Accepting the offered equipment
• Allowing physical touching
• Choosing to sit on the examining table rather than parent's lap
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If signs of readiness are not observed, use the following techniques:
• Talk to parent while essentially “ignoring” child; gradually focus on child or a favorite object, such as a doll.
• Make complimentary remarks about child, such as about his or her appearance, dress, or a favorite object.
• Tell a funny story or play a simple magic trick.
• Have a nonthreatening “friend” available, such as a hand puppet, to “talk” to child for the nurse (see Fig. 4-26, A).
If the child refuses to cooperate, use the following techniques:
• Assess reason for uncooperative behavior; consider that a child who is unduly afraid may have had a traumatic experience.
• Try to involve child and parent in process.
• Avoid prolonged explanations about examining procedure.
• Use a firm, direct approach regarding expected behavior.
• Perform examination as quickly as possible.
• Have attendant gently restrain child.
• Minimize any disruptions or stimulation.
• Limit number of people in room.
• Use isolated room.
• Use quiet, calm, confident voice.
Begin the examination in a nonthreatening manner for young children or children who are fearful:
• Use activities that can be presented as games, such as test for cranial nerves (see Table 4-11) or parts of developmental screening tests (see Chapter 3).
• Use approaches such as Simon Says to encourage child to make a face, squeeze a hand, stand on one foot, and so on.
• Use paper-doll technique:
1. Lay child supine on an examining table or floor that is covered with a large sheet of paper.
2. Trace around child's body outline.
3. Use body outline to demonstrate what will be examined, such as drawing a heart and listening with a stethoscope before performing activity on the child.
If several children in the family will be examined, begin with the most cooperative child to
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model desired behavior. Involve the child in examination process:
• Provide choices, such as sitting on table or in parent's lap.
• Allow child to handle or hold equipment.
• Encourage child to use equipment on a doll, family member, or examiner.
• Explain each step of the procedure in simple language.
Examine child in a comfortable and secure position:
• Sitting in parent's lap
• Sitting upright if in respiratory distress
Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions:
• Alter sequence to accommodate needs of different-age children (Table 4-2).
TABLE 4-2 Age-Specific Approaches to Physical Examination During Childhood
Position Sequence Preparation Infant Before able to sit alone—supine or prone, preferably in parent's lap;
before 4 to 6 months, can place on examining table After able to sit alone—sitting in parent's lap whenever possible; if
on table, place with parent in full view
If quiet, auscultate heart, lungs, and abdomen.
Record heart and respiratory rates. Palpate and percuss same areas. Proceed in usual head-to-toe direction. Perform traumatic procedures last
(eyes, ears, mouth [while crying]). Elicit reflexes as body part is examined. Elicit Moro reflex last.
Completely undress if room temperature permits. Leave diaper on male infant. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft, gentle voice. Pacify with bottle of sugar water or feeding. Enlist parent's aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.
Toddler Sitting or standing on or by parent Prone or supine in parent's lap
Inspect body area through play: “Count fingers,” “tickle toes.”
Use minimum physical contact initially.
Introduce equipment slowly. Auscultate, percuss, palpate whenever
quiet. Perform traumatic procedures last
(same as for infant).
Have parent remove outer clothing. Remove underwear as body part is examined. Allow toddler to inspect equipment; demonstrating use of equipment is
usually ineffective. If uncooperative, perform procedures quickly. Use restraint when appropriate; request parent's assistance. Talk about examination if cooperative; use short phrases. Praise for cooperative behavior.
Preschool Child Prefer standing or sitting Usually cooperative prone or supine Prefer parent's closeness
If cooperative, proceed in head-to-toe direction.
If uncooperative, proceed as with toddler.
Request self-undressing. Allow to wear underpants if shy. Offer equipment for inspection; briefly demonstrate use. Make up story about procedure (e.g., “I'm seeing how strong your
muscles are” [blood pressure]). Use paper-doll technique. Give choices when possible. Expect cooperation; use positive statements (e.g., “Open your mouth”).
School-Age Child Prefer sitting Cooperative in most positions Younger child prefers parent's presence Older child may prefer privacy
Proceed in head-to-toe direction. May examine genitalia last in older
child.
Respect need for privacy. Request self-undressing. Allow to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure, such as
otoscope to see eardrum, which is necessary for hearing. Teach about body function and care.
Adolescent Same as for school-age child Offer option of parent's presence
Same as older school-age child. May examine genitalia last.
Allow to undress in private. Give gown. Expose only area to be examined. Respect need for privacy. Explain findings during examination (e.g., “Your muscles are firm and
strong”). Matter-of-factly comment about sexual development (e.g., “Your breasts
are developing as they should be”). Emphasize normalcy of development. Examine genitalia as any other body part; may leave to end.
• Examine painful areas last.
• In emergency situation, examine vital functions (airway, breathing, and circulation) and injured area first.
Reassure child throughout the examination, especially about bodily concerns that arise during puberty.
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Discuss findings with family at the end of the examination. Praise child for cooperation during the examination; give a reward such as a small toy or sticker.
The physical examination should be as pleasant as possible, as well as educational. The paper- doll technique is a useful approach to teaching children about the body part that is being examined (Fig. 4-5). At the conclusion of the visit, the child can bring home the paper doll as a memento.
FIG 4-5 Using the paper-doll technique to prepare a child for physical examination.
Table 4-2 summarizes guidelines for positioning, preparing, and examining children at various ages. Because no child fits precisely into one age category, it may be necessary to vary the approach after a preliminary assessment of the child's developmental achievements and needs. Even with the best approach, many toddlers are uncooperative and inconsolable for much of the physical examination. However, some seem intrigued by the new surroundings and unusual equipment and respond more like preschoolers than toddlers. Likewise, some early preschoolers may require more of the “security measures” used with younger children, such as continued parent–child contact, and less of the preparatory measures used with preschoolers, such as playing with the equipment before and during the actual examination (Fig. 4-6).
FIG 4-6 Preparing children for physical examination.
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Physical Examination Although the approach to and sequence of the physical examination differ according to the child's age, the following discussion outlines the traditional model for physical assessment. The focus includes all pediatric age groups (see Chapter 7 for a detailed discussion of a newborn assessment). Because the physical examination is a vital part of preventive pediatric care, Fig. 4-7 gives a schedule for periodic health visits.
FIG 4-7 Preventive pediatric health care chart. (Adapted from American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup: 2015 Recommendations for pediatric preventive pediatric
health care, 2015, https://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf.)
Growth Measurements Measurement of physical growth in children is a key element in evaluating their health status. Physical growth parameters include weight, height (length), skinfold thickness, arm circumference, and head circumference. Values for these growth parameters are plotted on percentile charts, and the child's measurements in percentiles are compared with those of the general population.
Growth Charts Growth charts use a series of percentile curves to demonstrate the distribution of body measurements in children. The Centers for Disease Control and Prevention recommend that the World Health Organization growth standards be used to monitor growth for infants and children between the ages of 0 and 2 years old. Because breastfeeding is the recommended standard for infant feeding, the World Health Organization growth charts are used; they reflect growth patterns among children who were predominately breastfed for at least 4 months and are still breastfeeding at 12 months old. The Centers for Disease Control and Prevention growth charts (www.cdc.gov/growthcharts) are used for children 2 years old and older.
Children whose growth may be questionable include: • Children whose height and weight percentiles are widely disparate (e.g., height in the 10th
percentile and weight in the 90th percentile, especially with above-average skinfold thickness) • Children who fail to follow the expected growth velocity in height and weight, especially during
the rapid growth periods of infancy and adolescence • Children who show a sudden increase (except during normal puberty) or decrease in a previously
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steady growth pattern (i.e., crossing two major percentile lines after 3 years old) • Children who are short in the absence of short parents
Because growth is a continuous but uneven process, the most reliable evaluation lies in comparing growth measurements over time because they reflect change. It is important to remember that normal growth patterns vary among children the same age (Fig. 4-8).
FIG 4-8 These children of identical age (8 years) are markedly different in size. The child on the left, of Asian descent, is at the 5th percentile for height and weight. The child on the right is above 95th percentile
for height and weight. However, both children demonstrate normal growth patterns.
Length The term length refers to measurements taken when children are supine (also referred to as recumbent length). Until children are 2 years old and able to stand alone (or 36 months old if using a chart for birth to 36 months), measure recumbent length using a length board and two measurers (Fig. 4-9, A; see the Evidence-Based Practice box). Because of the normally flexed position during infancy, fully extend the body by (1) holding the head in midline, (2) grasping the knees together gently, and (3) pushing down on the knees until the legs are fully extended and flat against the table. Place the head touching the headboard and the footboard firmly against the heels of the feet. A tape measure should not be used to measure the length of infants and children due to inaccuracy and unreliability (Foote, Brady, Burke, et al, 2014).
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Linear Growth Measurement in Pediatrics
Ask the Question PICOT Question In children, what are the best instruments and techniques to measure linear growth (length and height)?
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Search for the Evidence Search Strategies
Search selection criteria: English language, research-based and review articles and expert opinion from databases, anthropometric and endocrinology textbooks, contact with experts in the field, and informal discovery
Key terms: Length, height, stature, infant, child, adolescent, measurement, instrument, length board, stadiometer, calibration, technique, accuracy, reliability, diurnal variation
Exclusion criteria: Other types of anthropometric measurements, adults
Databases Used MEDLINE, CINAHL, COCHRANE, EMBASE, OCLC, ERIC, National Guideline Clearinghouse (AHRQ)
Critical Appraisal of the Evidence An interdisciplinary team systematically and critically appraised the evidence to develop these clinical practice recommendations using an evidence-based practice rating scheme (US Preventive Services Task Force, 1996).
Measure recumbent length in children younger than 24 to 36 months old and children who cannot stand alone (Foote, Brady, Burke, et al, 2011, 2014) (see Fig. 4-9, A).
• Use a length board with these components: Flat, horizontal surface with stationary headboard and smoothly movable footboard, both at 90-degree angles to the horizontal surface, and attached ruler marked in millimeter and/or -inch increments. Tape measures should never be used.
• Cover length board with soft, thin cloth or paper.
• Remove all clothing and shoes. Remove or loosen diaper. Remove hair ornaments on crown of head.
• Two measurers are required to accomplish correct positioning; one measurer (assistant) can be a parent or other caregiver when procedures are explained and understood.
• Place child supine on length board. Never leave unattended.
• Assistant holds head in midline with crown of head against headboard, compressing the hair.
• Position head in the Frankfort vertical plane (imaginary line from the lower border of the orbit through the highest point of the auditory meatus; the line is parallel to the headboard and perpendicular to the length board).
• Lead measurer positions the body on length board with one hand placed on both legs to fully extend the body.
• Ensure that head remains against headboard, shoulders and hips are not rotated, back is not arched, and legs are not bent. Reposition as necessary.
• Using the other hand, lead measurer moves footboard against heels of both feet with toes pointing upward.
• Read measurement to the nearest millimeter or inch.
• Reposition the child and repeat procedure. Measure at least twice (ideally three times). Average the measurements for the final value. Record immediately.
Measure height in children 24 to 36 months old and older who can stand alone well (Foote, Brady, Burke, et al, 2011, 2014) (see Fig. 4-9, B).
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• Use a stadiometer with these components: Vertical surface to stand against, footboard or firm surface to stand on, movable horizontal headboard at 90-degree angle to the vertical surface, and attached ruler marked in millimeter and/or -inch increments. Wall charts and flip-up horizontal bars (floppy-arm devices) mounted to weighing scales should never be used.
• Remove shoes and heavy outer clothing. Remove hair ornaments on crown of head.
• Stand child on flat surface with back against vertical surface of stadiometer.
• Weight is evenly distributed on both feet with heels together.
• Occiput, scapulae, buttocks, and heels are in contact with vertical surface.
• Encourage child to maintain fully erect position with positional lordosis minimized, knees fully extended, and heels flat. Reposition as necessary.
• Child continues normal breathing with shoulders relaxed and arms hanging down freely.
• Position head in the horizontal Frankfort plane (imaginary line from the lower border of the orbit through the highest point of the auditory meatus; the line is parallel to the headboard and perpendicular to the vertical surface).
• Move headboard down to crown of head, compressing the hair.
• Read measurement at eye level to the nearest millimeter or inch to avoid a parallax error.
• Reposition the child and repeat procedure. Measure at least twice (ideally three times). Average the measurements for the final value. Record immediately.
Special considerations (Foote, Brady, Burke, et al, 2014; Lohman, Roche, and Martorell, 1988).
• Some children, such as those who are obese, may not be able to place their occiput, scapulae, buttocks, and heels all in one vertical plane while maintaining their balance, so use at least two of the four contact points.
• If a child has a leg length discrepancy, place a block or wedge of suitable height under the shortest leg until the pelvis is level and both knees are fully extended before measuring height. To measure length, keep the legs together and measure to the heel of the longest leg.
• Children with special health care needs may require alternative measurements, such as arm span, crown-rump length, sitting height, knee height, or other segmental lengths. In general, when recumbent length is measured in a child with spasticity or contractures, measure the side of the body that is unaffected or less affected.
• Always document the presence of any condition that may interfere with accurate and reliable linear growth measurement.
Quality control measures (Brady, Burke, et al, 2014; Foote, 2014).
• Personnel who measure the growth of infants, children, and adolescents need proper education. Competency should be demonstrated. Refresher sessions should occur when a lack of standardization occurs.
• Length boards and stadiometers must be assembled and installed properly and calibrated at regular intervals (ideally daily, at least monthly, and every time they are moved) due to frequent inaccuracy and the variability between different instruments. Calibration can be performed by measuring a rod of known length and adjusting the instrument accordingly.
• All children should be measured at least twice (ideally three times) during each encounter. The measurements should agree within 0.5 cm (ideally 0.3 cm). Use the mean value. If the variation
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exceeds the limit of agreement, measure again and use the mean of the measures in closest agreement. If none of the measures are within the limit of agreement, then (1) have another measurer assist, (2) check technique, and (3) consider another education session.
• Children between 24 and 36 months of age may have length and/or height measured. Standing height is less than recumbent length due to gravity and compression of the spine. Plot length measurements on a length curve and height measurements on a height curve to avoid misinterpreting the growth pattern.
Apply the Evidence: Nursing Implications Growth is well established as an important and sensitive indicator of health in children. Abnormal growth is a common consequence of many conditions; therefore, its measurement can be a useful warning of possible pathology. In a study of 55 primary care practices within 8 geographical areas in the United States, only 30% of children were measured accurately due to faulty instruments and casual techniques; an educational intervention increased measurement accuracy to 70% (Lipman, Hench, Benyi, et al, 2004). Measurement error influences growth assessment and can result in delayed evaluation and treatment of some children, as well as apparent growth deviation in others who are actually growing normally (Foote, Brady, Burke, et al, 2011). There is good evidence with strong recommendations for using length boards and stadiometers, the described measurement techniques, and the quality control measures. There is fair evidence to recommend procedures for children with special needs (Foote, Brady, Burke, et al, 2014; Lohman, Roche, and Martorell, 1988).
Quality and Safety Competencies: Evidence-Based Practice* Knowledge
Differentiate clinical opinion from research and evidence-based summaries.
Describe the appropriate instruments and techniques to obtain accurate and reliable linear growth measurement of children.
Skills
Base individualized care plan on patient values, clinical expertise, and evidence.
Integrate evidence into practice by using the instruments and techniques for linear growth measurement in clinical care.
Attitudes
Value the concept of evidence-based practice as integral to determining best clinical practice.
Appreciate strengths and weaknesses of evidence for measuring the linear growth of children.
References Foote JM. Optimizing linear growth measurement in children. J Pediatr Health Care.
2014;28(5):413–419. Foote JM, Brady LH, Burke AL, et al. Development of an evidence-based clinical practice
guideline on linear growth measurement of children. J Pediatr Nurs. 2011;26(4):312–324. Foote JM, Brady LH, Burke AL, et al. Evidence-based clinical practice guideline on linear growth
measurement of children. https://www.pedsendo.org/assets/education_training/PENSpositionstatement_linear_growth_measurement2014.pdf 2014 [(to access full-text guideline and implementation tools)].
Lipman TH, Hench KD, Benyi T, et al. A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement. Arch Dis Child. 2004;89:342–346.
Lohman TJ, Roche AF, Martorell R. Anthropometric standardization reference manual. Human Kinetics Books: Champaign, IL; 1988.
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US Preventive Services Task Force. Guide to clinical preventive services: report of the US Preventive Services Task Force. ed 2. Lippincott, Williams, & Wilkins: Philadelphia; 1996.
*Adapted from the Quality and Safety Education for Nurses (QSEN) Institute.
FIG 4-9 Measurement of linear growth. A, Infant. B, Child. (Courtesy of Jan M. Foote.)
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Height The term height (or stature) refers to the measurement taken when a child is standing upright. Wall charts and flip-up horizontal bars (floppy-arm devices) mounted to weighing scales should not be used to measure the height of children (Foote, Brady, Burke, et al, 2014). These devices are not steady and do not maintain a right angle to the vertical ruler, preventing an accurate and reliable height. Measure height by having the child, with the shoes removed, stand as tall and straight as possible with the head in midline and the line of vision parallel to the ceiling and floor. Be certain the child's back is to the wall or other vertical flat surface, with the head, shoulder blades, buttocks, and heels touching the vertical surface (see Fig. 4-9, B). Check for and correct slumping of the shoulders, positional lordosis, bending of the knees, or raising of the heels.
N u r s i n g T i p Normally height is less if measured in the afternoon than in the morning. The time of day should be recorded when measurements are taken (Foote, Brady, Burke, et al, 2014). For children in whom there are concerns about growth, serial measurements should be taken at the same time of day, when possible, to establish an accurate growth velocity (see Evidence-Based Practice Box).
For the most accurate measurement, use a wall-mounted unit (stadiometer; see Fig. 4-9). To improvise a flat, vertical surface for measuring height, attach a paper or metal tape or yardstick to the wall, position the child adjacent to the tape, and place a three-dimensional object, such as a thick book or box, on top of the head. Rest the side of the object firmly against the wall to form a right angle. Measure length or stature to the nearest 1 mm or inch.
Weight Weight is measured with an electronic or appropriately sized balance beam scale, which measures weight to the nearest 10 g (0.35 oz) for infants and 100 g (0.22 lb) for children. Before weighing the child, balance the scale by setting it at 0 and noting if the scale registers at exactly 0 or in the middle of the mark. If the end of the balance beam rises to the top or bottom of the mark, more or less weight, respectively, is needed. Some scales are designed to self-correct, but others need to be recalibrated by the manufacturer. Scales vary in their accuracy; infant scales tend to be more accurate than adult platform scales, and newer scales tend to be more accurate than older ones, especially at the upper levels of weight measurement. When precise measurements are necessary, two nurses should take the weight independently; if there is a discrepancy, take a third reading and use the mean of the measurements in closest agreement.
Take measurements in a comfortably warm room. When the birth-to-2-year or birth-to-36-month growth charts are used, children should be weighed nude. Older children are usually weighed while wearing their underpants, a gown, or light clothing, depending on the setting. However, always respect the privacy of all children. If the child must be weighed wearing some type of special device, such as a prosthesis or an armboard for an intravenous device, note this when recording the weight. Children who are measured for recumbent length are usually weighed on an infant platform scale and placed in a lying or sitting position. When weighing a child, place your hand slightly above the infant to prevent him or her from accidentally falling off the scale (Fig. 4-10, A) or stand close to the toddler, ready to prevent a fall (see Fig. 4-10, B). For maximum asepsis, cover the scale with a clean sheet of paper between each child's weight measurement.
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FIG 4-10 A, Infant on scale. B, Toddler on scale. Note the presence of the nurse to prevent falls. (B, Courtesy of Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Nurses need to become familiar with determining body mass index (BMI), which requires accurate information about the child's weight and height.
or
With the increasing number of overweight children in the United States, the BMI charts are a critical component of children's physical assessment.
N u r s i n g A l e r t BMI for sex and age may be used to identify children and adolescents who are either underweight (<5th percentile), healthy weight (5th percentile to <85th percentile), overweight (≥85th percentile and <95th percentile), or obese (≥95th percentile).
Skinfold Thickness and Arm Circumference Measures of relative weight and stature cannot distinguish between adipose (fat) tissue and muscle. One convenient measure of body fat is skinfold thickness, which is increasingly recommended as a routine measurement. Measure skinfold thickness with special calipers, such as the Lange calipers.
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The most common sites for measuring skinfold thickness are the triceps (most practical for routine clinical use), subscapular, suprailiac, abdomen, and upper thigh. For greatest reliability, follow the exact procedure for measurement and record the average of at least two measurements of one site.
Arm circumference is an indirect measure of muscle mass. Measurement of arm circumference follows the same procedure as for skinfold thickness except the midpoint is measured with a paper or steel tape. Place the tape vertically along the posterior aspect of the upper arm from the acromial process and to the olecranon process; half of the measured length is the midpoint. World Health Organization growth curves are available for triceps skinfold and arm circumference measurements.
Head Circumference Head circumference is a reflection of brain growth. Measure head circumference in children up to 36 months old and in any child whose head size is questionable. Measure the head at its greatest frontooccipital circumference, usually slightly above the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull (Fig. 4-11). Use a paper or non-stretchable tape because a cloth tape can stretch and give a falsely small measurement. Because head shape can affect the location of the maximum circumference, more than one measurement is necessary to obtain the most accurate measure. Measure head circumference to the nearest 1 mm or inch.
FIG 4-11 Measurement of head circumference. (From Seidel HM, Ball JW, Dains JE, et al: Mosby's guide to physical examination, ed 4, St Louis, 1999, Mosby.)
Plot the head size on the appropriate growth chart under head circumference. Generally, head and chest circumferences are equal at about 1 to 2 years old. During childhood, chest circumference exceeds head size by about 5 to 7 cm (2 to 2.75 inches). For newborns, see Physical Assessment, Chapter 7.
Physiologic Measurements Physiologic measurements, key elements in evaluating physical status of vital functions, include temperature, pulse, respiration, and blood pressure. Compare each physiologic recording with normal values for that age group. In addition, compare the values taken on preceding health visits with present recordings. For example, a falsely elevated blood pressure (BP) reading may not indicate hypertension if previous recent readings have been within normal limits. The isolated recording may indicate some stressful event in the child's life.
As in most procedures carried out with children, treat older children and adolescents much the same as adults. However, give special consideration to preschool children (see Atraumatic Care box). For best results in taking vital signs of infants, count respirations first (before the infant is disturbed), take the pulse next, and measure temperature last. If vital signs cannot be taken without disturbing the child, record the child's behavior (e.g., crying) along with the measurement.
At r a u m a t i c C a r e Reducing Young Children's Fears
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Young children, especially preschoolers, fear intrusive procedures because of their poorly defined body boundaries. Therefore avoid invasive procedures, such as measuring rectal temperature, whenever possible. Also, avoid using the word “take” when measuring vital signs, because young children interpret words literally and may think that their temperature or other function will be taken away. Instead, say, “I want to know how warm you are.”
Temperature Temperature is the measure of heat content within an individual's body. The core temperature most closely reflects the temperature of the blood flow through the carotid arteries to the hypothalamus. Core temperature is relatively constant despite wide fluctuations in the external environment. When a child's temperature is altered, receptors in the skin, spinal cord, and brain respond in an attempt to achieve normothermia, a normal temperature state. In pediatrics, there is a lack of consensus regarding what temperature constitutes normothermia for every child. For rectal temperatures in children, a value of 37° to 37.5° C (98.6° to 99.5° F) is an acceptable range, where heat loss and heat production are balanced. For neonates, a core body temperature between 36.5° and 37.6° C (97.7° to 99.7° F) is a desirable range. In the neonate, obtain temperature measurements for monitoring adequacy of thermoregulation, not just for fever; therefore, temperature measurements in each infant should be carefully considered in the context of the purpose and the environment.
The nurse can measure temperature in healthy children at several body sites via oral, rectal, axillary, ear canal, tympanic membrane, temporal artery, or skin route (Box 4-9). For the ill child, other sites for temperature measurement have been investigated. The pulmonary artery is the closest to the hypothalamus and best reflects the core temperature (Batra, Saha, and Faridi, 2012). Other sites used are the distal esophagus, urinary bladder, and nasopharynx (Box 4-10). All of these methods are invasive and difficult to use in clinical practice. One of the most important influences on the accuracy of temperature is improper temperature-taking technique. Detailed discussion of temperature-taking methods and visual examples of proper techniques are given in Table 4-3. For a critical review of the evidence on temperature taking methods, see the Evidence-Based Practice box.
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Temperature Measurement in Pediatrics
Ask the Question PICOT Question In infants and children, what is the most accurate method for measuring temperature in febrile children?
Search for the Evidence Search Strategies Clinical research studies related to this issue were identified by searching for English publications within the past 15 years for infant and child populations; comparisons with gold standard: rectal thermometry.
Databases Used PubMed, Cochrane Collaboration, MD Consult, Joanna Briggs Institute, National Guideline Clearinghouse (AHRQ), TRIP Database Plus, PedsCCM, BestBETs
Critical Appraisal of the Evidence
• Rectal temperature: Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods (Fortuna, Carney, Macy, et al, 2010; Holzhauer, Reith, Sawin, et al, 2009). However, this procedure is more invasive and is contraindicated for infants younger than 1 month old due to risk of rectal perforation (Batra, Saha, and Faridi, 2012). Children with recent rectal surgery, diarrhea, or anorectal lesions, or who are receiving chemotherapy (cancer treatment usually affects the mucosa and causes neutropenia)
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should not undergo rectal thermometry.
• Oral temperature (OT): OT indicates rapid changes in core body temperature, but accuracy may be an issue compared with the rectal site (Batra, Saha, and Faridi, 2012). OTs are considered the standard for temperature measurement (Gilbert, Barton, and Counsell, 2002) but they are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are younger than 5 years old (El-Radhi and Barry, 2006). Limitations of OTs include the effects of ambient room temperature and recent oral intake (Martin and Kline, 2004).
• Axillary temperature: This is inconsistent and insensitive in infants and children older than 1 month old (Falzon, Grech, Caruana, et al, 2003; Jean-Mary, Dicanzio, Shaw, et al, 2002; Stine, Flook, and Vincze, 2012). A systematic review of 20 studies concluded that axillary thermometers showed variation in findings and are not a good method for accurate temperature assessment (Craig, Lancaster, Williamson, et al, 2005). In neonates with fever, the axillary temperature should not be used interchangeably with rectal measurement (Hissink Muller, van Berkel, and de Beaufort, 2008). It can be used as a screening tool for fever in young infants (Batra, Saha, and Faridi, 2012).
• Ear (aural) temperature: This is not a precise measurement of body temperature. A meta-analysis of 101 studies comparing tympanic membrane temperatures with rectal temperatures in children concluded that the tympanic method demonstrated a wide range of variability, limiting its application in a pediatric setting (Craig, Lancaster, Taylor, et al, 2002). Other published reviews continue to find poor sensitivity using infrared ear thermometry (Devrim, Kara, Ceyhan, et al, 2007; Dodd, Lancaster, Craig, et al, 2006). Diagnosis of fever without a focus should not be made based on tympanic thermometry, because it is not an accurate measure of core temperature (Batra, Saha, and Faridi, 2012; Devrim, Kara, Ceyhan, et al, 2007; Dodd, Lancaster, Craig, et al, 2006).
• Temporal artery temperature (TAT): TAT is not predictable for fever in young children but can be used as a screening tool for detecting fever less than 38° C (100.4° F) in children 3 months to 4 years old (Al-Mukhaizeem, Allen, Komar, et al, 2004; Callanan, 2003; Fortuna, Carney, Macy, et al, 2010; Hebbar, Fortenberry, Rogers, et al, 2005; Holzhauer, Reith, Sawin, et al, 2009; Schuh, Komar, Stephens, et al, 2004; Siberry, Diener-West, Schappell, et al, 2002; Titus, Hulsey, Heckman, et al, 2009). However, a study by Batra and Goyal (2013) found that temporal artery temperature correlated better with rectal temperature than axillary and tympanic measures in a group of 50 afebrile children between the ages of 2 and 12 years old.
Apply the Evidence: Nursing Implications
• No single site used for temperature assessment provides unequivocal estimates of core body temperature.
• Studies show that the axillary and tympanic measures demonstrate poor agreement when these modes are compared with more accurate core temperature methods. The differences are more evident as temperature increases, regardless of age.
• TAT is not predictable for fever and should be only used as a screening tool in young children.
• When an accurate method for obtaining a correct reflection of core temperature is needed, the rectal temperature is recommended in younger children and the oral route in older children.
For infants younger than 1 month old, axillary temperatures are recommended for screening.
Quality and Safety Competencies: Evidence-Based Practice* Knowledge
Differentiate clinical opinion from research and evidence-based summaries.
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Demonstrate understanding of thermometry selection based on the developmental age of the child.
Skills
Base individualized care plan on patient values, clinical expertise, and evidence.
Integrate evidence into practice by using the correct type of thermometry to screen for fever compared with measures used for accurate determination of the degree of fever.
Attitudes
Value the concept of evidence-based practice as integral to determining best clinical practice.
Recognize strengths and weaknesses of evidence for the most accurate method for measuring temperature and fever in infants and children.
References Al-Mukhaizeem F, Allen U, Komar L, et al. Comparison of temporal artery, rectal and
esophageal core temperatures in children: results of a pilot study. Paediatr Child Health. 2004;9(7):461–465.
Batra P, Goyal S. Comparison of rectal, axillary, tympanic, and temporal artery thermometry in the pediatric emergency room. Pedatr Emerg Care. 2013;29(7):877.
Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012;5(3):246– 249.
Callanan D. Detecting fever in young infants: reliability of perceived, pacifier, and temporal artery temperatures in infants younger than 3 months of age. Pediatr Emerg Care. 2003;19(4):240–243.
Craig JV, Lancaster GA, Taylor S, et al. Infrared ear thermometry compared with rectal thermometry in children: a systemic review. Lancet. 2002;360:603–609.
Craig JV, Lancaster GA, Williamson PR, et al. Temperature measured at the axilla compared with rectum in children and young people: systematic review. BMJ. 2005;320(7243):1174– 1178.
Devrim I, Kara A, Ceyhan M, et al. Measurement accuracy of fever by tympanic and axillary thermometry. Pediatr Emerg Care. 2007;23(1):16–19.
Dodd SR, Lancaster GA, Craig JV, et al. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. J Clin Epidemiol. 2006;59:354–357.
El-Radhi AS, Barry W. Thermometry in paediatric practice. Arch Dis Child. 2006;91(4):351–356. Falzon A, Grech V, Caruana B, et al. How reliable is axillary temperature measurement? Acta
Paediatr. 2003;92(3):309–313. Fortuna EL, Carney MM, Macy M, et al. Accuracy of non-contact infrared thermometry versus
rectal thermometry in young children evaluated in the emergency department for fever. J Emerg Nurs. 2010;36(2):101–104.
Gilbert M, Barton AJ, Counsell CM. Comparison of oral and tympanic temperatures in adult surgical patients. Appl Nurs Res. 2002;15(1):42–47.
Hebbar K, Fortenberry JD, Rogers K, et al. Comparison of temporal artery thermometer to standard temperature measurement in pediatric intensive care unit patients. Pediatr Crit Care Med. 2005;6(5):557–561.
Hissink Muller PCE, van Berkel LH, de Beaufort AJ. Axillary and rectal temperature measurements poorly agree in newborn infants. Neonatology. 2008;94(1):31–34.
Holzhauer JK, Reith V, Sawin K, et al. Evaluation of temporal artery thermometry in children 3–36 months old. J Spec Pediatr Nurs. 2009;14(4):239–244.
Jean-Mary MB, Dicanzio J, Shaw J, et al. Limited accuracy and reliability of infrared axillary and aural thermometers in a pediatric outpatient population. J Pediatr. 2002;141(5):671–676.
Martin SA, Kline AM. Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clin Issues. 2004;15(2):254–266.
Schuh S, Komar L, Stephens D, et al. Comparison of the temporal artery and rectal thermometry in children in the emergency department. Pediatr Emerg Care. 2004;20(11):736–
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741. Siberry GK, Diener-West M, Schappell E, et al. Comparison of temple temperatures with rectal
temperatures in children under 2 years of age. Clin Pediatr. 2002;41(6):405–414. Stine CA, Flook DM, Vincze DL. Rectal versus axillary temperatures: is there a significant
difference in infants less than 1 years of age? J Pediatr Nurs. 2012;3:265–270. Titus MO, Hulsey T, Heckman J, et al. Temporal artery thermometry utilization in pediatric
emergency care. Clin Pediatr. 2009;48(2):190–193.
*Adapted from the Quality and Safety Education for Nurses (QSEN) Institute.
Box 4-9 R e c o m m e n d e d Te m p e r a t u r e S c r e e n i n g R o u t e s i n I n f a n t s a n d C h i l d r e n Birth to 2 Years Old
Axillary
Rectal—if definitive temperature reading is needed for infants older than 1 month of age
2 to 5 Years Old
Axillary
Tympanic
Oral—when child can hold thermometer under tongue
Rectal—if definitive temperature reading is needed
Older Than 5 Years Old
Oral
Axillary
Tympanic
Box 4-10 A l t e r n a t i ve Te m p e r a t u r e M e a s u r e m e n t S i t e s f o r I l l C h i l d r e n Skin
A probe is placed on the skin to determine heat output in response to changes in the patient's skin temperature.
Skin temperature sensors are most often used for neonates and infants placed in radiant heat warmers or isolettes (using servo control feature of the apparatus). In turn, the heater unit warms to a set point to maintain the infant's temperature within a specified range.
ThermoSpot is an example of a device allowing continuous thermal monitoring in neonates.
Urinary Bladder
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A thermistor or thermocouple is placed within the indwelling bladder catheter. The catheter tip immersed in the bladder provides a continuous temperature read-out on the bedside monitor.
This is not a true measure of core temperature but responds better than rectal and skin temperatures to core body changes.
Because of thermistor sizes, this method is unusable with neonates and small infants.
Pulmonary Artery
A catheter is placed into the heart to obtain a reading in the pulmonary artery.
It is used in critical care settings or operating rooms only in patients requiring aggressive monitoring.
Catheters are not available in sizes for neonates or small infants.
Esophageal Site
A probe is inserted into the lower third of the esophagus at the level of the heart.
This is used in critical care settings or operating rooms.
Several companies have esophageal stethoscopes with temperature probe monitors for patients in the operating room that show a continuous temperature reading.
Nasopharyngeal Site
A probe is inserted into the nasopharynx, posterior to the soft palate, and provides an estimate of hypothalamic temperature.
This is used in critical care settings or operating rooms.
Data from Kumar PR, Nisarga R, Gowda B: Temperature monitoring in newborns using ThermoSpot, Indian J Pediatr 71(9):795– 796, 2004; Martin SA, Kline AM: Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clin Issues 15(2):254–266, 2004; Maxton FJC, Justin L, Gilles D: Estimating core temperature in infants and children after cardiac surgery: a comparison of six methods, J Adv Nurs 45(2):214–222, 2004.
TABLE 4-3 Temperature Measurement Locations for Infants and Children
Temperature Site Oral Place tip under tongue in right or left posterior sublingual pocket, not in front of tongue. Have child
keep mouth closed without biting on thermometer. Pacifier thermometers measure intraoral or supralingual temperature and are available but lack support
in the literature. Several factors affect mouth temperature: Eating and mastication, hot or cold beverages, open-mouth
breathing, and ambient temperature.
Axillary Place tip under arm in center of axilla and keep close to skin, not clothing. Hold child's arm firmly
against side. Temperature may be affected by poor peripheral perfusion (results in lower value), clothing or swaddling, use of radiant warmer, or amount of brown fat in cold-stressed neonate (results in higher value).
Advantage: Avoids intrusive procedure and eliminates risk of rectal perforation.
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Ear Based (Aural) Insert small infrared probe deeply into canal to allow sensor to obtain measurement. Size of probe (most are 8 mm) may influence accuracy of result. In young children, this may be a
problem because of small diameter of canal. Proper placement of ear is controversial related to whether the pinna should be pulled in manner similar
to that used during otoscopy.
Rectal Place well-lubricated tip at maximum 2.5 cm (1 inch) into rectum for children and 1.5 cm (0.6 inch) for
infants; securely hold thermometer close to anus. Child may be placed in side-lying, supine, or prone position (i.e., supine with knees flexed toward
abdomen); cover penis because procedure may stimulate urination. A small child may be placed prone across parent's lap.
Temporal Artery An infrared sensor probe scans across forehead, capturing heat from arterial blood flow. Temporal artery is only artery close enough to skin's surface to provide access for accurate temperature
measurement.
Data from Martin SA, Kline AM: Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clin Issues 15(2):254–266, 2004; Falzon A, Grech V, Caruana B, et al: How reliable is axillary temperature measurement? Acta Paediatr 92(3):309–313, 2003. Oral, axillary, rectal, and temporal artery images courtesy of Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.
The most frequently used temperature measurement devices in infants and children include:
Electronic intermittent thermometers—measure the patient's temperature at oral, rectal, and axillary sites and are used as primary diagnostic indicators
Infrared thermometers—measure the patient's temperature by collecting emitted thermal radiation from a particular site (e.g., ear canal)
Electronic continuous thermometers—measure the patient's temperature during the
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administration of general anesthesia, treatment of hypothermia or hyperthermia, and other situations that require continuous monitoring
Box 4-11 provides a detailed description of these devices.
N u r s i n g A l e r t The belief that core temperature can be estimated by adding 1° C to the temperature taken in the axilla is incorrect. Do not add a degree to the finding obtained by taking a temperature by the axillary route.
Box 4-11 T y p e s o f T h e r m o m e t e r s U s e d t o M e a s u r e Te m p e r a t u r e i n I n f a n t s a n d C h i l d r e n Electronic Thermometer
Temperature is sensed with an electronic component called thermistor mounted at the tip of a plastic and stainless steel probe, which is connected to an electronic recorder. A disposable plastic cover is used for infection control.
Temperature measurement appears on digital display within 60 seconds.
The probe can be placed in the mouth, axilla, or rectum.
Infrared Thermometer
Thermal radiation is measured from the axilla, ear canal, or tympanic membrane.
Temperature measurement appears on the digital display in approximately 1 second.
Three types are available for ear-based use: Tympanic, ear canal, and arterial heat balance via the ear canal (AHBE).
Often these devices are all inappropriately referred to as tympanic thermometers.
Temperatures measured in this way reflect arterial (bloodstream) temperature.
Ear-Based Temperature Sensor
Although this is frequently used in pediatric settings (especially ambulatory clinics), debate continues on the reliability of ear-based thermometry in screening febrile children.
Most models use “offsets” for internal calculations that transform ear temperature into supposedly equivalent oral or rectal temperatures.
Ear Sensor (LighTouch LTX)
This measures the infrared heat energy radiating from canal opening, scans canal for highest temperature reading, and then calculates arterial temperature (correlates highly with core or internal body temperature).
It is available in two sizes; the smaller size of LighTouch Pedi-Q is for infants and toddlers.
Axillary Sensor (LighTouch LTN)
This measures the infrared heat energy radiating from the axilla.
It can be used on wet skin; in incubators; or under radiant heaters, warming pads, or other heat
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sources.
Digital Thermometer
A probe is connected to a microprocessor chip, which translates signals into degrees and sends temperature measurement to digital display.
It is used like an oral electronic thermometer and can be used for measuring oral, rectal, and axillary temperature.
It is more accurate and easier to read but somewhat more expensive than a plastic strip thermometer.
Liquid Crystal Skin Contact Thermometer (Chemical Dot Thermometer)
This single-use, disposable, flexible thermometer has a specific chemical mixture in each circle that changes color to measure temperature increments of of a degree.
There are two types:
1. Kept in mouth (1 minute), axilla (3 minutes), or rectum (3 minutes); color change is read 10 to 15 seconds after removing the thermometer
2. Wearable, continuous-use thermometer, which is placed under axilla; may be read within 2 to 3 minutes after placement and continuously thereafter; discard and replace every 48 hours
Pulse A satisfactory pulse can be taken radially in children older than 2 years of age. However, in infants and young children, the apical impulse (AI) (heard through a stethoscope held to the chest at the apex of the heart) is more reliable (see Fig. 4-33 for location of pulses). Count the pulse for 1 full minute in infants and young children because of possible irregularities in rhythm. However, when frequent apical rates are necessary, use shorter counting times (e.g., 15- or 30-second intervals). For greater accuracy, measure the apical rate while the child is asleep; record the child's behavior along with the rate. Grade pulses according to the criteria in Table 4-4. Compare radial and femoral pulses at least once during infancy to detect the presence of circulatory impairment, such as coarctation of the aorta. (See inside back cover for normal rates for pediatric age groups.)
TABLE 4-4 Grading of Pulses
Grade Description 0 Not palpable +1 Difficult to palpate, thready, weak, easily obliterated with pressure +2 Difficult to palpate, may be obliterated with pressure +3 Easy to palpate, not easily obliterated with pressure (normal) +4 Strong, bounding, not obliterated with pressure
Respiration Count the respiratory rate in children in the same manner as for adult patients. However, in infants, observe abdominal movements, because respirations are primarily diaphragmatic. Because the movements are irregular, count them for 1 full minute for accuracy (see also the Chest section later in this chapter).
Blood Pressure
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BP should be measured annually in children 3 years old through adolescence and in children with symptoms of hypertension, children in emergency departments and intensive care units, and high- risk infants (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, 2004). Auscultation remains the gold standard method of BP measurement in children, under most circumstances. Use of the automated devices is acceptable for BP measurement in newborns and young infants, in whom auscultation is difficult, and in the intensive care setting where frequent BP measurement is needed.
Oscillometric devices measure mean arterial BP and then calculate systolic and diastolic values. The algorithms used by companies are proprietary and differ from company to company and device to device. These devices can yield results that vary widely when one is compared with another, and they do not always closely match BP values obtained by auscultation. An elevated BP reading obtained with an automated or oscillometric device should be repeated using auscultation.
BP readings using oscillometry, such as Dinamap, are generally higher (10 mm Hg higher) than measurements using auscultation (Park, Menard, and Schoolfield, 2005). Differences between Dinamap and auscultatory readings prevent the interchange of the readings by the two methods.
Selection of Cuff No matter what type of noninvasive technique is used, the most important factor in accurately measuring BP is the use of an appropriately sized cuff (cuff size refers only to the inner inflatable bladder, not the cloth covering). A technique to establish an appropriate cuff size is to choose a cuff with a bladder width that is at least 40% of the arm circumference midway between the olecranon and the acromion (see Research Focus box). This will usually be a cuff bladder that covers 80% to 100% of the circumference of the arm (Fig. 4-12). Cuffs that are either too narrow or too wide affect the accuracy of BP measurements. If the cuff size is too small, the reading on the device is falsely high. If the cuff size is too large, the reading is falsely low.
R e s e a r c h F o c u s Selection of a Blood Pressure Cuff
Researchers have found that selection of a cuff with a bladder width equal to 40% of the upper arm circumference most accurately reflects directly measured radial arterial pressure (Clark, Kieh-Lai, Sarnaik, et al, 2002).
Using limb circumference for selecting cuff width more accurately reflects direct arterial blood pressure (BP) than using limb length because this method takes into account variations in arm thickness and the amount of pressure required to compress the artery. For measurement on sites other than the upper arms, use the limb circumference, although the shape of the limb (e.g., conical shape of the thigh) may prevent appropriate placement of the cuff and inaccurately reflect intraarterial BP (Table 4-5).
When using a site other than the arm, BP measurements using noninvasive techniques may differ. Generally, systolic pressure in the lower extremities (thigh or calf) is greater than pressure in the upper extremities, and systolic BP in the calf is higher than that in the thigh (Schell, Briening, Lebet, et al, 2011) (Fig. 4-13).
N u r s i n g A l e r t When taking blood pressure (BP), use an appropriately sized cuff. When the correct size is not available, use an oversized cuff rather than an undersized one or use another site that more appropriately fits the cuff size. Do not choose a cuff based on the name of the cuff (e.g., an “infant” cuff may be too small for some infants).
N u r s i n g A l e r t Compare blood pressure (BP) in the upper and lower extremities to detect abnormalities, such as coarctation of the aorta, in which the lower extremity pressure is less than the upper extremity pressure.
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FIG 4-12 Determination of proper cuff size. A, Cuff bladder width should be approximately 40% of circumference of arm measured at a point midway between olecranon and acromion. B, Cuff bladder
length should cover 80% to 100% of arm circumference. C, Blood pressure (BP) should be measured with the cubital fossa at the heart level. The arm should be supported. The stethoscope bell is placed over the brachial artery pulse proximal and medial to the cubital fossa and below the bottom edge of the cuff. (From National Institutes of Health, National Heart, Lung, and Blood Institute: Update on the Task Force Report [1987] on high blood pressure in
children and adolescents: a working group report from the National High Blood Pressure Education Program, NIH Pub No 96-3790, Bethesda, MD, 1996, Author.)
TABLE 4-5 Recommended Dimensions for Blood Pressure Cuff Bladders
Age Width (cm) Length (cm) Maximum Arm Circumference (cm)* Newborn 4 8 10 Infant 6 12 15 Child 9 18 22 Small adult 10 24 26 Adult 13 30 34 Large adult 16 38 44 Thigh 20 42 52
*Calculated so that largest arm would still allow bladder to encircle arm by at least 80%. From National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, Pediatrics 114(2 Suppl 4th Report):555–576, 2004.
FIG 4-13 Sites for measuring blood pressure. A, Upper arm. B, Lower arm or forearm. C, Thigh. D, Calf or ankle.
Measurement and Interpretation Measuring and interpreting BP in infants and children requires attention to correct procedure because (1) limb sizes vary and cuff selection must accommodate the circumference; (2) excessive pressure on the antecubital fossa affects the Korotkoff sounds; (3) children easily become anxious, which can elevate BP; and (4) BP values change with age and growth. In children and adolescents,
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determine the normal range of BP by body size and age. BP standards that are based on gender, age, and height provide a more precise classification of BP according to body size. This approach avoids misclassifying children who are very tall or very short. The revised BP tables include the 50th, 90th, 95th, and 99th percentiles (with standard deviations) by gender, age, and height.
To use the tables in a clinical setting, determine the height percentile by using the Centers for Disease Control and Prevention growth charts (www.cdc.gov/growthcharts). The child's measured systolic BP and diastolic BP are compared with the numbers provided in the table (boys or girls) according to the child's age and height percentile. The child is normotensive if the BP is below the 90th percentile. If the BP is at or above the 90th percentile, repeat the BP measurement at that visit to verify an elevated BP. BP measurements between the 90th and 95th percentiles indicate prehypertension and necessitate reassessment and consideration of other risk factors. In addition, if an adolescent's BP is more than 120/80 mm Hg, consider the patient prehypertensive, even if this value is below the 90th percentile. This BP level typically occurs for systolic BP at 12 years old and for diastolic BP at 16 years old. If the child's BP (systolic or diastolic) is at or above the 95th percentile, the child may be hypertensive, and the measurement must be repeated on at least two occasions to confirm diagnosis (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, 2004) (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Using the Blood Pressure Tables
1. Use the standard height charts to determine the height percentile.
2. Measure and record the child's systolic BP and diastolic BP.
3. Use the correct gender table for systolic BP and diastolic BP.
4. Find the child's age on the left side of the table. Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column).
5. Then, find the 50th, 90th, 95th, and 99th percentiles for systolic BP in the left columns and for diastolic BP in the right columns.
• BP less than 90th percentile is normal.
• BP between the 90th and 95th percentiles is prehypertension. In adolescents, BP of 120/80 mm Hg or greater is prehypertension even if this figure is less than the 90th percentile.
• BP over the 95th percentile may be hypertension.
6. If the BP is over the 90th percentile, the BP should be repeated twice at the same office visit, and an average systolic BP and diastolic BP should be used.
7. If the BP is over the 95th percentile, BP should be staged. If BP is stage 1 (95th to 99th percentile plus 5 mm Hg), BP measurements should be repeated on two more occasions. If hypertension is confirmed, evaluation should proceed. If BP is stage 2 (>99th percentile plus 5 mm Hg), prompt referral should be made for evaluation and therapy. If the patient is symptomatic, immediate referral and treatment are indicated.
BP, Blood pressure.
From National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, Pediatrics 114(2 Suppl 4th Report):555–576, 2004.
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Orthostatic Hypotension Orthostatic hypotension (OH), also called postural hypotension or orthostatic intolerance, often manifests as syncope (fainting), vertigo (dizziness), or lightheadedness and is caused by decreased blood flow to the brain (cerebral hypoperfusion). Normally blood flow to the brain is maintained at a constant level by a number of compensating mechanisms that regulate systemic BP. When one assumes a sitting or standing position from a supine or recumbent position, peripheral capillary vasoconstriction occurs, and blood that was pooling in the lower vasculature is returned to the heart for redistribution to the head and remainder of the body. When this mechanism fails or is slow to respond, the person may experience vertigo or syncope. One of the most common causes of OH is hypovolemia, which may be induced by medications, such as diuretics, vasodilator medications, and prolonged immobility or bed rest. Other causes of OH include dehydration, diarrhea, emesis, fluid loss from sweating and exertion, alcohol intake, dysrhythmias, diabetes mellitus, sepsis, and hemorrhage.
BP measurements taken with the child first supine and then standing (at least 2 minutes in each position) may demonstrate variability and assist in the diagnosis of OH. The child with a sustained drop in systolic pressure of more than 20 mm Hg or in diastolic pressure of more than 10 mm Hg after standing for 2 minutes without an increase in heart rate of more than 15 beats/min most likely has an autonomic deficit. Nonneurogenic causes of OH have a compensatory increase in pulse of more than 15 beats/min, as well as a drop in BP, as noted previously. For children and adolescents with vertigo, lightheadedness, nausea, syncope, diaphoresis, and pallor, it is important to monitor BP and heart rate to determine the original cause. BP is an important diagnostic measurement in children and adolescents and must be a part of the routine monitoring of vital signs.
N u r s i n g A l e r t Published norms for blood pressure (BP) are valid only if you use the same method of measurement (auscultation and cuff size determination) in clinical practice.
General Appearance The child's general appearance is a cumulative, subjective impression of the child's physical appearance, state of nutrition, behavior, personality, interactions with parents and nurse (also siblings if present), posture, development, and speech. Although the nurse records general appearance at the beginning of the physical examination, it encompasses all the observations of the child during the interview and physical assessment.
Note the facies, the child's facial expression and appearance. For example, the facies may give clues to children who are in pain; have difficulty breathing; feel frightened, discontented, or unhappy; are mentally delayed; or are acutely ill.
Observe the posture, position, and types of body movement. A child with hearing or vision loss may characteristically tilt the head in an awkward position to hear or see better. A child in pain may favor a body part. The child with low self-esteem or a feeling of rejection may assume a slumped, careless, and apathetic pose. Likewise, a child with confidence, a feeling of self-worth, and a sense of security usually demonstrates a tall, straight, well-balanced posture. While observing such body language, do not interpret too freely but rather record objectively.
Note the child's hygiene in terms of cleanliness; unusual body odor; the condition of the hair, neck, nails, teeth, and feet; and the condition of the clothing. Such observations are excellent clues to possible instances of neglect, inadequate financial resources, housing difficulties (e.g., no running water), or lack of knowledge concerning children's needs.
Behavior includes the child's personality, activity level, reaction to stress, requests, frustration, interactions with others (primarily the parent and nurse), degree of alertness, and response to stimuli. Some mental questions that serve as reminders for observing behavior include the following: • What is the child's overall personality? • Does the child have a long attention span, or is he or she easily distracted? • Can the child follow two or three commands in succession without the need for repetition? • What is the youngster's response to delayed gratification or frustration?
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• Does the child use eye contact during conversation? • What is the child's reaction to the nurse and family members? • Is the child quick or slow to grasp explanations?
Skin Assess skin for color, texture, temperature, moisture, turgor, lesions, acne, and rashes. Examination of the skin and its accessory organs primarily involves inspection and palpation. Touch allows the nurse to assess the texture, turgor, and temperature of the skin. The normal color in light-skinned children varies from a milky white and rose to a deeply hued pink. Dark-skinned children, such as those of Native American, Hispanic, or African descent, have inherited various brown, red, yellow, olive green, and bluish tones in their skin. Asian persons have skin that is normally of a yellow tone. Several variations in skin color can occur, some of which warrant further investigation. The types of color change and their appearance in children with light or dark skin are summarized in Table 4-6.
TABLE 4-6 Differences in Color Changes of Racial Groups
Description Appearance in Light Skin Appearance in Dark Skin Cyanosis—bluish tone through skin; reflects reduced (deoxygenated) hemoglobin Bluish tinge, especially in palpebral
conjunctiva (lower eyelid), nail beds, earlobes, lips, oral membranes, soles, and palms
Ashen gray lips and tongue
Pallor—paleness; may be sign of anemia, chronic disease, edema, or shock Loss of rosy glow in skin, especially face Ashen gray appearance in black skin More yellowish brown color in brown skin
Erythema—redness; may be result of increased blood flow from climatic conditions, local inflammation, infection, skin irritation, allergy, or other dermatoses or may be caused by increased numbers of red blood cells as compensatory response to chronic hypoxia
Redness easily seen anywhere on body Much more difficult to assess; rely on palpation for warmth or edema
Ecchymosis—large, diffuse areas, usually black and blue, caused by hemorrhage of blood into skin; typically result of injuries
Purplish to yellow-green areas; may be seen anywhere on skin
Very difficult to see unless in mouth or conjunctiva
Petechiae—same as ecchymosis except for size: small, distinct, pinpoint hemorrhages ≤2 mm in size; can denote some type of blood disorder, such as leukemia
Purplish pinpoints most easily seen on buttocks, abdomen, and inner surfaces of arms or legs
Usually invisible except in oral mucosa, conjunctiva of eyelids, and conjunctiva covering eyeball
Jaundice—yellow staining of skin usually caused by bile pigments Yellow staining seen in sclerae of eyes, skin, fingernails, soles, palms, and oral mucosa
Most reliably assessed in sclerae, hard palate, palms, and soles
Normally, the skin texture of young children is smooth, slightly dry, and not oily or clammy. Evaluate skin temperature by symmetrically feeling each part of the body and comparing upper areas with lower ones. Note any difference in temperature.
Determine tissue turgor, or elasticity in the skin, by grasping the skin on the abdomen between the thumb and index finger, pulling it taut, and quickly releasing it. Elastic tissue immediately resumes its normal position without residual marks or creases. In children with poor skin turgor, the skin remains suspended or tented for a few seconds before slowly falling back on the abdomen. Skin turgor is one of the best estimates of adequate hydration and nutrition.
Accessory Structures Inspection of the accessory structures of the skin may be performed while examining the skin, scalp, or extremities. Inspect the hair for color, texture, quality, distribution, and elasticity. Children's scalp hair is usually lustrous, silky, strong, and elastic. Genetic factors affect the appearance of hair. For example, the hair of African-American children is usually curlier and coarser than that of Caucasian children. Hair that is stringy, dull, brittle, dry, friable, and depigmented may suggest poor nutrition. Record any bald or thinning spots. Loss of hair in infants may indicate lying in the same position and may be a cue to counsel parents concerning the child's stimulation needs.
Inspect the hair and scalp for general cleanliness. Persons in some ethnic groups condition their hair with oils or lubricants that, if not thoroughly washed from the scalp, clog the sebaceous glands, causing scalp infections. Also examine the area for lesions, scaliness, evidence of infestation (such as lice or ticks), and signs of trauma (such as ecchymosis, masses, or scars).
In children who are approaching puberty, look for growth of secondary hair as a sign of normally progressing pubertal changes. Note precocious or delayed appearance of hair growth because, although not always suggestive of hormonal dysfunction, it may be of great concern to the early- or late-maturing adolescent.
Inspect the nails for color, shape, texture, and quality. Normally, the nails are pink, convex, smooth, and hard but flexible (not brittle). The edges, which are usually white, should extend over
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the fingers. Dark-skinned individuals may have more deeply pigmented nail beds. Short, ragged nails are typical of habitual biting. Uncut, dirty nails are a sign of poor hygiene.
The palm normally shows three flexion creases (Fig. 4-14, A). In some conditions such as Down syndrome, the two distal horizontal creases may be fused to form a single horizontal crease (the single palmar crease, or transpalmar crease) (see Fig. 4-14, B). If grossly abnormal lines or folds are observed, sketch a picture to describe them and refer the finding to a specialist for further investigation.
FIG 4-14 Examples of flexion creases on palm. A, Normal. B, Transpalmar crease.
Lymph Nodes Lymph nodes are usually assessed during examination of the part of the body in which they are located. The body's lymphatic drainage system is extensive. Fig. 4-15 shows the usual sites for palpating accessible lymph nodes.
FIG 4-15 Location of superficial lymph nodes. Arrows indicate directional flow of lymph.
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Palpate nodes using the distal portion of the fingers and gently but firmly pressing in a circular motion along the regions where nodes are normally present. During assessment of the nodes in the head and neck, tilt the child's head upward slightly but without tensing the sternocleidomastoid or trapezius muscles. This position facilitates palpation of the submental, submandibular, tonsillar, and cervical nodes. Palpate the axillary nodes with the child's arms relaxed at the sides but slightly abducted. Assess the inguinal nodes with the child in the supine position. Note size, mobility, temperature, and tenderness, as well as reports by the parents regarding any visible change of enlarged nodes. In children, small, nontender, movable nodes are usually normal. Tender, enlarged, warm, erythematous lymph nodes generally indicate infection or inflammation close to their location. Report such findings for further investigation.
Head and Neck Observe the head for general shape and symmetry. A flattening of one part of the head, such as the occiput, may indicate that the child continually lies in this position. Marked asymmetry is usually abnormal and may indicate premature closure of the sutures (craniosynostosis).
N u r s i n g A l e r t After 6 months old, significant head lag strongly indicates cerebral injury and is referred for further evaluation.
Note head control in infants and head posture in older children. By 4 months old, most infants should be able to hold the head erect and in midline when in a vertical position.
Evaluate range of motion by asking the older child to look in each direction (to either side, up and down) or by manually putting the younger child through each position. Limited range of motion may indicate wry neck, or torticollis, in which the child holds the head to one side with the chin pointing toward the opposite side as a result of injury to the sternocleidomastoid muscle.
N u r s i n g A l e r t Hyperextension of the head (opisthotonos) with pain on flexion is a serious indication of meningeal irritation and is referred for immediate medical evaluation.
Palpate the skull for patent sutures, fontanels, fractures, and swellings. Normally, the posterior fontanel closes by 2 months old, and the anterior fontanel fuses between 12 and 18 months old. Early or late closure is noted, because either may be a sign of a pathologic condition.
While examining the head, observe the face for symmetry, movement, and general appearance. Ask the child to “make a face” to assess symmetric movement and disclose any degree of paralysis. Note any unusual facial proportion, such as an unusually high or low forehead; wide- or close-set eyes; or a small, receding chin.
In addition to assessment of the head and neck for movement, inspect the neck for size and palpate its associated structures. The neck is normally short, with skinfolds between the head and shoulders during infancy; however, it lengthens during the next 3 to 4 years.
N u r s i n g A l e r t If any masses are detected in the neck, report them for further investigation. Large masses can block the airway.
Eyes Inspection of External Structures Inspect the lids for proper placement on the eye. When the eye is open, the upper lid should fall near the upper iris. When the eyes are closed, the lids should completely cover the cornea and sclera (Fig. 4-16).
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FIG 4-16 External structures of the eye.
Determine the general slant of the palpebral fissures or lids by drawing an imaginary line through the two points of the medial canthus and across the outer orbit of the eyes and aligning each eye on the line. Usually the palpebral fissures lie horizontally. However, in Asians, the slant is normally upward.
Also inspect the inside lining of the lids, the palpebral conjunctivae. To examine the lower conjunctival sac, pull the lid down while the child looks up. To evert the upper lid, hold the upper lashes and gently pull down and forward as the child looks down. Normally the conjunctiva appears pink and glossy. Vertical yellow striations along the edge are the meibomian glands, or sebaceous glands, near the hair follicle. Located in the inner or medial canthus and situated on the inner edge of the upper and lower lids is a tiny opening, the lacrimal punctum. Note any excessive tearing, discharge, or inflammation of the lacrimal apparatus.
The bulbar conjunctiva, which covers the eye up to the limbus, or junction of the cornea and sclera, should be transparent. The sclera, or white covering of the eyeball, should be clear. Tiny black marks in the sclera of heavily pigmented individuals are normal.
The cornea, or covering of the iris and pupil, should be clear and transparent. Record opacities, because they can be signs of scarring or ulceration, which can interfere with vision. The best way to test for opacities is to illuminate the eyeball by shining a light at an angle (obliquely) toward the cornea.
Compare the pupils for size, shape, and movement. They should be round, clear, and equal. Test their reaction to light by quickly shining a light toward the eye and removing it. As the light approaches, the pupils should constrict; as the light fades, the pupils should dilate. Test the pupil for any response of accommodation by having the child look at a bright, shiny object at a distance and quickly moving the object toward the face. The pupils should constrict as the object is brought near the eye. Record normal findings on examination of the pupils as PERRLA, which stands for “Pupils Equal, Round, React to Light, and Accommodation.”
Inspect the iris and pupil for color, size, shape, and clarity. Permanent eye color is usually established by 6 to 12 months old. While inspecting the iris and pupil, look for the lens. Normally, the lens is not visible through the pupil.
Inspection of Internal Structures The ophthalmoscope permits visualization of the interior of the eyeball with a system of lenses and a high-intensity light. The lenses permit clear visualization of eye structures at different distances from the nurse's eye and correct visual acuity differences in the examiner and child. Use of the ophthalmoscope requires practice to know which lens setting produces the clearest image.
The ophthalmic and otic heads are usually interchangeable on one “body” or handle, which encloses the power source—either disposable or rechargeable batteries. The nurse should practice changing the heads, which snap on and are secured with a quarter turn, and replacing the batteries and light bulbs. Nurses who are not directly involved in physical assessment are often responsible for ensuring that the equipment functions properly.
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Preparing the Child The nurse can prepare the child for the ophthalmoscopic examination by showing the child the instrument, demonstrating the light source and how it shines in the eye, and explaining the reason for darkening the room. For infants and young children who do not respond to such explanations, it is best to use distraction to encourage them to keep their eyes open. Forcibly parting the eyelids results in an uncooperative, watery-eyed child and a frustrated nurse. Usually, with some practice, the nurse can elicit a red reflex almost instantly while approaching the child and may also gain a momentary inspection of the blood vessels, macula, or optic disc.
Funduscopic Examination Fig. 4-17 shows the structures of the back of the eyeball, or the fundus. The fundus is immediately apparent as the red reflex. The intensity of the color increases in darkly pigmented individuals.
N u r s i n g A l e r t A brilliant, uniform red reflex is an important sign because it rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. Any dark shadows or opacities are recorded because they indicate some abnormality in any of these structures.
FIG 4-17 Structures of fundus. (From Ball JW, Dains JE, Flynn JA, et al: Seidel's guide to physical examination, ed 8, St Louis, 2014, Elsevier.)
As the ophthalmoscope is brought closer to the eye, the most conspicuous feature of the fundus is the optic disc, the area where the blood vessels and optic nerve fibers enter and exit the eye. The disc is orange to creamy pink with a pale center and lighter in color than the surrounding fundus. Normally, it is round or vertically oval.
After locating the optic disc, inspect the area for blood vessels. The central retinal artery and vein appear in the depths of the disc and emanate outward with visible branching. The veins are darker and about one fourth larger than the arteries. Normally, the branches of the arteries and veins cross each other.
Other structures that are common are the macula, the area of the fundus with the greatest concentration of visual receptors, and in the center of the macula, a minute glistening spot of reflected light called the fovea centralis; this is the area of most perfect vision.
Vision Testing The US Preventive Services Task Force (2011) recommends vision screening for the presence of amblyopia and its risk factors for all children 3 to 5 years old. Several tests are available for assessing vision. This discussion focuses on ocular alignment, visual acuity, peripheral vision, and color vision. Chapter 18 discusses behavioral and physical signs of visual impairment. Nurses can provide accurate vision screening with appropriate training (Mathers, Keyes, and Wright, 2010).
Ocular Alignment Normally, by 3 to 4 months old, children are able to fixate on one visual field with both eyes
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simultaneously (binocularity). In strabismus, or cross-eye, one eye deviates from the point of fixation. If the misalignment is constant, the weak eye becomes “lazy,” and the brain eventually suppresses the image produced by that eye. If strabismus is not detected and corrected by 4 to 6 years old, blindness from disuse, known as amblyopia, may result.
Tests commonly used to detect misalignment are the corneal light reflex and the cover tests. To perform the corneal light reflex test, or Hirschberg test, shine a flashlight or the light of the ophthalmoscope directly into the patient's eyes from a distance of about 40.5 cm (16 inches). If the eyes are orthophoric, or normal, the light falls symmetrically within each pupil (Fig. 4-18, A). If the light falls off-center in one eye, the eyes are misaligned. Epicanthal folds, excess folds of skin that extend from the roof of the nose to the inner termination of the eyebrow and that partially or completely overlap the inner canthus of the eye, may give a false impression of misalignment (pseudostrabismus) (see Fig. 4-18, B). Epicanthal folds are often found in Asian children.
FIG 4-18 A, Corneal light reflex test demonstrating orthophoric eyes. B, Pseudostrabismus. Inner epicanthal folds cause the eyes to appear misaligned; however, the corneal light reflexes fall perfectly
symmetrically.
In the cover test, one eye is covered, and the movement of the uncovered eye is observed while the child looks at a near (33 cm [13 inches]) or distant (6 m [20 feet]) object. If the uncovered eye does not move, it is aligned. If the uncovered eye moves, a misalignment is present because when the stronger eye is temporarily covered, the misaligned eye attempts to fixate on the object.
In the alternate cover test, occlusion shifts back and forth from one eye to the other, and movement of the eye that was covered is observed as soon as the occluder is removed while the child focuses on a point in front of him or her (Fig. 4-19). If normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move. If misalignment is present, eye movement will occur when the cover is moved. This test takes more practice than the other cover test because the occluder must be moved back and forth quickly and accurately to see the eye move. Because deviations can occur at different ranges, it is important to perform the cover tests at both close and far distances.
N u r s i n g A l e r t The cover test is usually easier to perform if the examiner uses his or her hand rather than a card- type occluder (see Fig. 4-19). Attractive occluders fashioned like an ice cream cone or happy-face lollipop cut from cardboard are also well received by young children.
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FIG 4-19 Alternate cover test to detect amblyopia in a patient with strabismus. A, The eye is occluded, and the child is fixating on light source. B, If the eye does not move when uncovered, the eyes are
aligned.
Visual Acuity Testing in Children The most common test for measuring visual acuity is the Snellen letter chart, which consists of lines of letters of decreasing size. The child stands with his or her heels at a line 10 feet away from the chart. When screening for visual acuity in children, the nurse tests the child's right eye first by covering the left. Children who wear glasses should be screened with them on. Tell the child to keep both eyes open during the examination. If the child fails to read the current line, move up the chart to the next larger line. Continue up the chart until the child is able to read the line. Then begin moving down the chart again until the child fails to read the line. To pass each line, the child must correctly identify four of six symbols on the line. Repeat the procedure, covering the right eye. Table 4-7 provides a list of visual screening tests for children and guidelines for referral.
TABLE 4-7 Eye Examination Guidelines*
Function RecommendedTests Referral Criteria Comments
3 to 5 Years Old Distance visual acuity
Snellen letters Snellen
numbers Tumbling E HOTV Picture test: • Allen figures • LEA symbols
1. Less than four of six correct on 20-foot (6-m) line with either eye tested at 10 feet (3 m) monocularly (i.e., <10/20 or 20/40) or
2. Two-line difference between eyes, even within passing range (i.e., 10/12.5 and 10/20 or 20/25 and 20/40)
1. Tests are listed in decreasing order of cognitive difficulty; highest test that child is capable of performing should be used; in general, tumbling E or HOTV test should be used for children 3 to 5 years old and Snellen letters or numbers for children 6 years old and older.
2. Testing distance of 10 feet (3 m) is recommended for all visual acuity tests. 3. Line of figures is preferred over single figures. 4. Non-tested eye should be covered by occluder held by examiner or by adhesive occluder patch
applied to eye; examiner must ensure that it is not possible to peek with non-tested eye.
Ocular alignment Cross cover test at 10 feet (3 m)
Random dot E stereo test at 18 inches (40 cm)
Simultaneous red reflex test (Bruckner test)
Any eye movement Less than four of six correct Any asymmetry of pupil color, size,
brightness
Child must be fixing on a target while cross cover test is performed. Use direct ophthalmoscope to view both red reflexes simultaneously in a darkened room from 2 to 3
feet (0.6 to 0.9 m) away; detects asymmetric refractive errors as well.
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Ocular media clarity (cataracts, tumors, and so on)
Red reflex White pupil, dark spots, absent reflex Use direct ophthalmoscope in a darkened room. View eyes separately at 12 to 18 inches (30 to 45 cm); white reflex indicates possible retinoblastoma.
6 Years Old and Older Distance visual acuity
Snellen letters Snellen
numbers Tumbling E HOTV Picture test: • Allen figures • LEA symbols
1. Less than four of six correct on 15-foot (4.5- m) line with either eye tested at 10 feet (3 m) monocularly (i.e., <10/15 or 20/30) or
2. Two-line difference between eyes, even within the passing range (i.e., 10/10 and 10/15 or 20/20 and 20/30)
1. Tests are listed in decreasing order of cognitive difficulty; highest test that child is capable of performing should be used; in general, tumbling E or HOTV test should be used for children 3 to 5 years old and Snellen letters or numbers for children 6 years old and older.
2. Testing distance of 10 feet (3 m) is recommended for all visual acuity tests. 3. Line of figures is preferred over single figures. 4. Non-tested eye should be covered by occluder held by examiner or by adhesive occluder patch
applied to eye; examiner must ensure that it is not possible to peek with non-tested eye.
Ocular alignment Cross cover test at 10 feet (3 m)
Random dot E stereo test at 18 inches (40 cm)
Simultaneous red reflex test (Bruckner test)
Any eye movement Less than four of six correct Any asymmetry of pupil color, size,
brightness
Child must be fixing on target while cross cover test is performed. Use direct ophthalmoscope to view both red reflexes simultaneously in a darkened room from 2 to 3
feet (0.6 to 0.9 m) away; detects asymmetric refractive errors as well.
Ocular media clarity (e.g., cataracts, tumors)
Red reflex White pupil, dark spots, absent reflex Use direct ophthalmoscope in a darkened room. View eyes separately at 12 to 18 inches (30 to 45 cm); white reflex indicates possible retinoblastoma.
*Assessing visual acuity (vision screening) is one of the most sensitive techniques for detection of eye abnormalities in children. The American Academy of Pediatrics Section on Ophthalmology, in cooperation with American Association for Pediatric Ophthalmology and Strabismus and American Academy of Ophthalmology, has developed these guidelines to be used by physicians, nurses, educational institutions, public health departments, and other professionals who perform vision evaluation services. From American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Section on Ophthalmology: Eye examination in infants, children, and young adults by pediatricians, Pediatrics 111(4):902–907, 2003.
For children unable to read letters and numbers, the tumbling E or HOTV test is useful. The tumbling E test uses the capital letter E pointing in four different directions. The child is asked to point in the direction the E is facing. The HOTV test consists of a wall chart composed of the letters H, O, T, and V. The child is given a board containing a large H, O, T, and V. The examiner points to a letter on the wall chart, and the child matches the correct letter on the board held in his or her hand. The tumbling E and HOTV are excellent tests for preschool-age children.
Visual Acuity Testing in Infants and Difficult-to-Test Children In newborns, vision is tested mainly by checking for light perception by shining a light into the eyes and noting responses, such as pupillary constriction, blinking, following the light to midline, increased alertness, or refusal to open the eyes after exposure to the light. Although the simple maneuver of checking light perception and eliciting the pupillary light reflex indicates that the anterior half of the visual apparatus is intact, it does not confirm that the infant can see. In other words, this test does not assess whether the brain receives the visual message and interprets the signals.
Another test of visual acuity is the infant's ability to fix on and follow a target. Although any brightly colored or patterned object can be used, the human face is excellent. Hold the infant upright while moving your face slowly from side to side. Other signs that may indicate visual loss or other serious eye problems include fixed pupils, strabismus, constant nystagmus, the setting-sun sign, and slow lateral movements. Unfortunately, it is difficult to test each eye separately; the presence of such signs in one eye could indicate unilateral blindness.
Special tests are available for testing infants and other difficult-to-test children to assess acuity or confirm blindness. For example, in visually evoked potentials, the eyes are stimulated with a bright light or pattern, and electrical activity to the visual cortex is recorded through scalp electrodes (see Research Focus box).
R e s e a r c h F o c u s Instrument-Based Vision Screening
Evidence supports the use of elective instrument-based vision screening, primarily photo screening and autorefraction, in children 6 months old to 3 years old, and as an alternative for children from 3 through 5 years old, particularly in those who are unable or unwilling to cooperate with routine vision charts (American Academy of Pediatrics Section on Ophthalmology and Committee on Practice and Ambulatory Medicine, 2012). Photo screening uses optical images of the eye's red reflex to estimate refractive error, media opacity, ocular alignment, and other factors putting a
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child at risk for amblyopia. Handheld autorefraction is used to evaluate the refractive error of each eye.
N u r s i n g A l e r t If visual fixation and following are not present by 3 to 4 months old, further ophthalmologic evaluation is necessary.
Peripheral Vision In children who are old enough to cooperate, estimate peripheral vision, or the visual field of each eye, by having the children fixate on a specific point directly in front of them while an object, such as a finger or a pencil, is moved from beyond the field of vision into the range of peripheral vision. As soon as children see the object, have them say “Stop.” At that point, measure the angle from the anteroposterior axis of the eye (straight line of vision) to the peripheral axis (point at which the object is first seen). Check each eye separately and for each quadrant of vision. Normally children see about 50 degrees upward, 70 degrees downward, 60 degrees nasalward, and 90 degrees temporally. Limitations in peripheral vision may indicate blindness from damage to structures within the eye or to any of the visual pathways.
Color Vision The tests available for color vision include the Ishihara test and the Hardy-Rand-Rittler test. Each consists of a series of cards (pseudoisochromatic) containing a color field composed of spots of a certain “confusion” color. Against the field is a number or symbol similarly printed in dots but of a color likely to be confused with the field color by a person with a color vision deficit. As a result, the figure or letter is invisible to an affected individual but is clearly seen by a person with normal vision.
Ears Inspection of External Structures The entire external ear is called the pinna, or auricle; one is located on each side of the head. Measure the height alignment of the pinna by drawing an imaginary line from the outer orbit of the eye to the occiput, or most prominent protuberance of the skull. The top of the pinna should meet or cross this line. Low-set ears are commonly associated with renal anomalies or cognitive impairment. Measure the angle of the pinna by drawing a perpendicular line from the imaginary horizontal line and aligning the pinna next to this mark. Normally the pinna lies within a 10-degree angle of the vertical line (Fig. 4-20). If it falls outside this area, record the deviation and look for other anomalies.
FIG 4-20 Ear alignment.
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Normally the pinna extends slightly outward from the skull. Except in newborn infants, ears that are flat against the head or protruding away from the scalp may indicate problems. Flattened ears in an infant may suggest a frequent side-lying position and, just as with isolated areas of hair loss, may be a clue to investigate parents' understanding of the child's stimulation needs.
Inspect the skin surface around the ear for small openings, extra tags of skin, sinuses, or earlobe creases. If a sinus is found, note this because it may represent a fistula that drains into some area of the neck or ear. Note if an earlobe crease is found, because it may be associated with a rare, inherited syndrome. However, having one small abnormality is not uncommon and is often not associated with a serious condition. Cutaneous tags represent no pathologic process but may cause parents concern in terms of the child's appearance.
Also assess the ears for hygiene. An otoscope is not necessary for looking into the external canal to note the presence of cerumen, a waxy substance produced by the ceruminous glands in the outer portion of the canal. Cerumen is usually yellow-brown and soft. If an otoscope is used and any discharge is visible, note its color and odor. Avoid transmitting potentially infectious material to the other ear or to another child through hand washing and using disposable specula or sterilizing reusable specula between each examination.
Inspection of Internal Structures The head of the otoscope permits visualization of the tympanic membrane by use of a bright light, a magnifying glass, and a speculum. Some otoscopes have an attachment for a pneumonic device to insert air into the canal to determine membrane compliance (movement). The speculum, which is inserted into the external canal, comes in a variety of sizes to accommodate different canal widths. The largest speculum that fits comfortably into the ear is used to achieve the greatest area of visualization. The lens, or magnifying glass, is movable, allowing the examiner to insert an object, such as a curette, into the ear canal through the speculum while still viewing the structures through the lens.
Positioning the Child Before beginning the otoscopic examination, position the child properly and gently restrain (sit on parent's lap and hold parent's hands) if necessary. Older children usually cooperate and do not need restraint. However, prepare them for the procedure by allowing them to play with the instrument, demonstrating how it works, and stressing the importance of remaining still. A helpful suggestion is to let them observe you examining the parent's ear. Restraint is needed for younger children, because the ear examination upsets them (see Atraumatic Care box).
At r a u m a t i c C a r e Reducing Distress from Otoscopy in Young Children
Make examining the ear a game by explaining that you are looking for a “big elephant” in the ear. This kind of make-believe is an absorbing distraction and usually elicits cooperation. After examining the ear, clarify that “looking for elephants” was only pretend and thank the child for letting you look in his or her ear. Another great distraction technique is asking the child to put a finger on the opposite ear to keep the light from getting out.
As you insert the speculum into the meatus, move it around the outer rim to accustom the child to the feel of something entering the ear. If examining a painful ear, examine the unaffected ear first, then return to the painful ear, and touch a nonpainful part of the affected ear first. By this time, the child is usually less fearful of anything causing discomfort to the ear and will cooperate more.
For their protection and safety, restrain infants and toddlers for the otoscopic examination. There are two general positions of restraint. In one, the child is seated sideways in the parent's lap with one arm hugging the parent and the other arm at the side. The ear to be examined is toward the nurse. With one hand the parent holds the child's head firmly against his or her chest and hugs the child with the other arm, thereby securing the child's free arm (Fig. 4-21, A). Examine the ear using the same procedure for holding the otoscope as described later.
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FIG 4-21 Position for restraining a child (A) and an infant (B) during otoscopic examination.
The other position involves placing the child on the side, back, or abdomen with the arms at the side and the head turned so that the ear to be examined points toward the ceiling. Lean over the child, use the upper part of the body to restrain the arms and upper trunk movements, and use the examining hand to stabilize the head. This position is practical for young infants and for older children who need minimum restraint, but it may not be feasible for other children who protest vigorously. For safety, enlist the parent's or an assistant's help in immobilizing the head by firmly placing one hand above the ear and the other on the child's side, abdomen, or back (see Fig. 4-21, B).
With cooperative children, examine the ear with the child in a side-lying, sitting, or standing position. One disadvantage to standing is that the child may “walk away” as the otoscope enters the canal. If the child is standing or sitting, tilt the head slightly toward the child's opposite shoulder to achieve a better view of the eardrum (Fig. 4-22).
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FIG 4-22 Positioning the head by tilting it toward opposite shoulder for full view of the tympanic membrane.
With the thumb and forefinger of the free (usually nondominant) hand, grasp the auricle. For the two positions of restraint, hold the otoscope upside down at the junction of its head and handle with the thumb and index finger. Place the other fingers against the skull to allow the otoscope to move with the child in case of sudden movement. In examining a cooperative child, hold the handle with the otic head upright or upside down. Use the dominant hand to examine both ears or reverse hands for each ear, whichever is more comfortable.
Before using the otoscope, visualize the external ear and the tympanic membrane as being superimposed on a clock (Fig. 4-23). The numbers are important geographic landmarks. Introduce the speculum into the meatus between the 3 and 9 o'clock positions in a downward and forward position. Because the canal is curved, the speculum does not permit a panoramic view of the tympanic membrane unless the canal is straightened. In infants, the canal curves upward. Therefore, pull the pinna down and back to the 6 to 9 o'clock range to straighten the canal (Fig. 4-24, A). With older children, usually those older than 3 years old, the canal curves downward and forward. Therefore, pull the pinna up and back toward a 10 o'clock position (see Fig. 4-24, B). If you have difficulty visualizing the membrane, try repositioning the head, introducing the speculum at a different angle, and pulling the pinna in a slightly different direction. Do not insert the speculum past the cartilaginous (outermost) portion of the canal, usually a distance of 0.60 to 1.25 cm (0.23 to 0.5 inch) in older children. Insertion of the speculum into the posterior or bony portion of the canal causes pain.
FIG 4-23 Landmarks of the tympanic membrane. (From Ignatavicius DD, Workman ML: Medical-surgical nursing: patient- centered collaborative care, ed 7, St Louis, 2013, Saunders.)
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FIG 4-24 Positioning for visualizing the eardrum in an infant (A) and in a child older than 3 years old (B).
In neonates and young infants the walls of the canal are pliable and floppy because of the underdeveloped cartilaginous and bony structures. Therefore the very small 2-mm speculum usually needs to be inserted deeper into the canal than in older children. Exercise great care not to damage the walls or eardrum. For this reason, only an experienced examiner should insert an otoscope into the ears of very young infants.
Otoscopic Examination As you introduce the speculum into the external canal, inspect the walls of the canal, the color of the tympanic membrane, the light reflex, and the usual landmarks of the bony prominences of the middle ear. The walls of the external auditory canal are pink, although they are more pigmented in dark-skinned children. Minute hairs are evident in the outermost portion, where cerumen is produced. Note signs of irritation, foreign bodies, or infection.
Foreign bodies in the ear are common in children and range from erasers to beans. Symptoms may include pain, discharge, and affected hearing. Remove soft objects, such as paper or insects, with forceps. Remove small, hard objects, such as pebbles, with a suction tip, a hook, or irrigation. However, irrigation is contraindicated if the object is vegetative matter, such as beans or pasta, which swells when in contact with fluid.
N u r s i n g A l e r t If there is any doubt about the type of object in the ear and the appropriate method to remove it, refer the child to the appropriate practitioner.
The tympanic membrane is a translucent, light pearly pink or gray. Note marked erythema (which may indicate suppurative otitis media); a dull, nontransparent grayish color (sometimes suggestive of serous otitis media); or ashen gray areas (signs of scarring from a previous perforation). A black area usually suggests a perforation of the membrane that has not healed.
The characteristic tenseness and slope of the tympanic membrane cause the light of the otoscope to reflect at about the 5 or 7 o'clock position. The light reflex is a fairly well-defined, cone-shaped reflection, which normally points away from the face.
The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. At the upper end of the long process near the 1 o'clock position (in the right ear) is a sharp, knoblike protuberance, representing the short process of the malleus. Note the absence or distortion of the light reflex or loss or abnormal prominence of any of these landmarks.
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Auditory Testing Several types of hearing tests are available and recommended for screening in infants and children (Table 4-8). The American Academy of Pediatrics recommends pure tone audiometry testing at 500, 1000, 2000, and 4000 Hz, with children failing if they cannot hear the tones at 20 dB (Harlor, Bower, and Committee on Practice and Ambulatory Medicine, Section on Otolaryngology Head and Neck Surgery, 2009). Universal newborn hearing screening is available in most US states. The nurse must operate under a high index of suspicion for those children who may have conditions associated with hearing loss, whose parents are concerned about hearing loss, and who may have developed behaviors that indicate auditory impairment. Chapter 18 discusses types of hearing loss, causes, clinical manifestations, and appropriate treatment. (See the Research Focus box for further discussion).
R e s e a r c h F o c u s Hearing Loss Frequency
The prevalence of hearing loss has increased among American children, and failure to identify children even with mild high-frequency hearing loss may have long-term consequences (Sekhar, Zalewsi, and Paul, 2013). Unilateral or bilateral hearing impairment within the speech frequencies is found in 3.1% of children and youth (Mehra, Eavey, and Keamy, 2009). The importance of asking children and their parents about the presence of hearing problems should be a part of every clinical visit.
TABLE 4-8 Auditory Tests for Infants and Children
Age Auditory Test and AverageTime Type of Measurement Procedure
Newborns Auditory brainstem response (ABR)
Electrophysiologic measurement of activity in auditory nerve and brainstem pathways
Placement of electrodes on child's head detects auditory stimuli presented though earphones one ear at a time.
Infants Behavioral audiometry Used to observe their behavior in response to certain sounds heard through speakers or earphones
The child's responses are observed to the sounds heard.
Toddlers Play audiometry Uses an audiometer to transmit sounds at different volumes and pitches
The toddler is asked to do something with a toy (i.e., touch a toy, move a toy) every time the sound is heard.
Children and adolescents
Pure tone audiometry Uses an audiometer that produces sounds at different volumes and pitches in the child's ears
The child is asked to respond in some way when the tone is heard in the earphone.
Tympanometry (also called impedance or admittance)
Determines how the middle ear is functioning and detects any changes in pressure in the middle ear
A soft plastic tip is placed over the ear canal and the tympanometer measures eardrum movement when the pressure changes.
All ages Evoked optoacoustic emissions (EOAE)
Physiologic test specifically measuring cochlear (outer hair cell) response to presentation of stimulus
Small probe containing sensitive microphone is placed in ear canal for stimulus delivery and response detection.
Nose Inspection of External Structures The nose is located in the middle of the face just below the eyes and above the lips. Compare its placement and alignment by drawing an imaginary vertical line from the center point between the eyes down to the notch of the upper lip. The nose should lie exactly vertical to this line, with each side exactly symmetric. Note its location, any deviation to one side, and asymmetry in overall size and in diameter of the nares (nostrils). The bridge of the nose is sometimes flat in Asian and African-American children. Observe the alae nasi for any sign of flaring, which indicates respiratory difficulty. Always report any flaring of the alae nasi. Fig. 4-25 illustrates the landmarks used in describing the external structures of the nose.
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FIG 4-25 External landmarks and internal structures of the nose.
Inspection of Internal Structures Inspect the anterior vestibule of the nose by pushing the tip upward, tilting the head backward, and illuminating the cavity with a flashlight or otoscope without the attached ear speculum. Note the color of the mucosal lining, which is normally redder than the oral membranes, as well as any swelling, discharge, dryness, or bleeding. There should be no discharge from the nose.
On looking deeper into the nose, inspect the turbinates, or concha, plates of bone that jut into the nasal cavity and are enveloped by the mucous membranes. The turbinates greatly increase the surface area of the nasal cavity as air is inhaled. The spaces or channels between the turbinates are called the meatus and correspond to each of the three turbinates. Normally, the front end of the inferior and middle turbinate and the middle meatus are seen. They should be the same color as the lining of the vestibule.
Inspect the septum, which should divide the vestibules equally. Note any deviation, especially if it causes an occlusion of one side of the nose. A perforation may be evident within the septum. If this is suspected, shine the light of the otoscope into one naris and look for admittance of light to the other. Because olfaction is an important function of the nose, testing for smell may be done at this point or as part of cranial nerve assessment (see Table 4-11).
Mouth and Throat With a cooperative child, the nurse can accomplish almost the entire examination of the mouth and throat without the use of a tongue blade. Ask the child to open the mouth wide; to move the tongue in different directions for full visualization; and to say “ahh,” which depresses the tongue for full view of the back of the mouth (tonsils, uvula, and oropharynx). For a closer look at the buccal mucosa, or lining of the cheeks, ask children to use their fingers to move the outer lip and cheek to one side (see Atraumatic Care box).
At r a u m a t i c C a r e Encouraging Opening the Mouth for Examination
• Perform the examination in front of a mirror.
• Let the child first examine someone else's mouth, such as the parent, the nurse or a puppet (Fig. 4- 26, A), and then examine child's mouth.
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FIG 4-26 A, Encouraging a child to cooperate. B, Positioning a child for examination of the mouth.
• Instruct child to tilt the head back slightly, breathe deeply through the mouth, and hold the breath; this action lowers the tongue to the floor of the mouth without the use of a tongue blade.
• Lightly brushing the palate with a cotton swab also may open the mouth for assessment.
Infants and toddlers usually resist attempts to keep the mouth open. Because inspecting the mouth is upsetting, leave it for the end of the physical examination (along with examination of the ears) or do it during episodes of crying. However, the use of a tongue blade (preferably flavored) to depress the tongue may be needed. Place the tongue blade along the side of the tongue, not in the center back area where the gag reflex is elicited. Fig. 4-26, B, illustrates proper positioning of the child for the oral examination.
The major structure of the exterior of the mouth is the lips. The lips should be moist, soft, smooth, and pink, or a deeper hue than the surrounding skin. The lips should be symmetric when relaxed or tensed. Assess symmetry when the child talks or cries.
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Inspection of Internal Structures The major structures that are visible within the oral cavity and oropharynx are the mucosal lining of the lips and cheeks, gums (or gingiva), teeth, tongue, palate, uvula, tonsils, and posterior oropharynx (Fig. 4-27). Inspect all areas lined with mucous membranes (inside the lips and cheeks, gingiva, underside of the tongue, palate, and back of the pharynx) for color, any areas of white patches or ulceration, bleeding, sensitivity, and moisture. The membranes should be bright pink, smooth, glistening, uniform, and moist.
FIG 4-27 Interior structures of the mouth.
Inspect the teeth for number (deciduous, permanent, or mixed dentition) in each dental arch, for hygiene, and for occlusion or bite (see also Teething, Chapter 9). Discoloration of tooth enamel with obvious plaque (whitish coating on the surface of the teeth) is a sign of poor dental hygiene and indicates a need for counseling. Brown spots in the crevices of the crown of the tooth or between the teeth may be caries (cavities). Chalky white to yellow or brown areas on the enamel may indicate fluorosis (excessive fluoride ingestion). Teeth that appear greenish black may be stained temporarily from ingestion of supplemental iron.
Examine the gums (gingiva) surrounding the teeth. The color is normally coral pink, and the surface texture is stippled, similar to the appearance of an orange peel. In dark-skinned children, the gums are more deeply colored, and a brownish area is often observed along the gum line.
Inspect the tongue for papillae, small projections that contain several taste buds and give the tongue its characteristic rough appearance. Note the size and mobility of the tongue. Normally the tip of the tongue should extend to the lips or beyond.
The roof of the mouth consists of the hard palate, which is located near the front of the oral cavity, and the soft palate, which is located toward the back of the pharynx and has a small midline protrusion called the uvula. Carefully inspect the palates to ensure they are intact. The arch of the palate should be dome shaped. A narrow, flat roof or a high, arched palate affects the placement of the tongue and can cause feeding and speech problems. Test movement of the uvula by eliciting a gag reflex. It should move upward to close off the nasopharynx from the oropharynx.
Examine the oropharynx and note the size and color of the palatine tonsils. They are normally the same color as the surrounding mucosa; glandular, rather than smooth in appearance; and barely visible over the edge of the palatoglossal arches. The size of the tonsils varies considerably during childhood. However, report any swelling, redness, or white areas on the tonsils.
Chest Inspect the chest for size, shape, symmetry, movement, breast development, and the bony landmarks formed by the ribs and sternum. The rib cage consists of 12 ribs on each side and the
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sternum, or breast bone, located in the midline of the trunk (Fig. 4-28). The sternum is composed of three main parts. The manubrium, the uppermost portion, can be felt at the base of the neck at the suprasternal notch. The largest segment of the sternum is the body, which forms the sternal angle (angle of Louis) as it articulates with the manubrium. At the end of the body is a small, movable process called the xiphoid. The angle of the costal margin as it attaches to the sternum is called the costal angle and is normally about 45 to 50 degrees. These bony structures are important landmarks in the location of ribs and intercostal spaces (ICSs), which are the spaces between the ribs. They are numbered according to the rib directly above the space. For example, the space immediately below the second rib is the second ICS.
FIG 4-28 The rib cage.
The thoracic cavity is also divided into segments by drawing imaginary lines on the chest and back. Fig. 4-29 illustrates the anterior, lateral, and posterior divisions.
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FIG 4-29 Imaginary landmarks of the chest. A, Anterior. B, Right lateral. C, Posterior.
Measure the size of the chest by placing the measuring tape around the rib cage at the nipple line. For greatest accuracy, take two measurements—one during inspiration and the other during expiration—and record the average. Chest size is important mainly in relation to head circumference (see Head Circumference earlier in this chapter). Always report marked disproportions because most are caused by abnormal head growth, although some may be a result of altered chest shape, such as barrel chest (chest is round), pectus excavatum (sternum is depressed), or pectus carinatum (sternum protrudes outward).
During infancy the chest's shape is almost circular, with the anteroposterior (front-to-back) diameter equaling the transverse, or lateral (side-to-side), diameter. As the child grows, the chest normally increases in the transverse direction, causing the anteroposterior diameter to be less than the lateral diameter. Note the angle made by the lower costal margin and the sternum, and palpate the junction of the ribs with the costal cartilage (costochondral junction) and sternum, which should be fairly smooth.
Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. During inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases. During expiration the chest falls and decreases in size, the diaphragm rises, and the costal angle narrows (Fig. 4-30). In children younger than 6 or 7 years old, respiratory movement is principally abdominal or diaphragmatic. In older children, particularly girls, respirations are chiefly thoracic. In either case, the chest and abdomen should rise and fall together. Always report any asymmetry of movement.
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FIG 4-30 Movement of the chest during respiration.
While inspecting the skin surface of the chest, observe the position of the nipples and any evidence of breast development. Normally the nipples are located slightly lateral to the midclavicular line between the fourth and fifth ribs. Note symmetry of nipple placement and normal configuration of a darker pigmented areola surrounding a flat nipple in prepubertal children.
Pubertal breast development usually begins in girls between 8 and 12 years old (see Chapter 15). Record early (precocious) or delayed breast development, as well as evidence of any other secondary sexual characteristics. In males, breast enlargement (gynecomastia) may be caused by hormonal or systemic disorders, but more commonly is a result of adipose tissue from obesity or a transitory body change during early puberty. In either situation, investigate the child's feelings regarding breast enlargement.
In adolescent girls who have achieved sexual maturity, palpate the breasts for evidence of any masses or hard nodules. Use this opportunity to discuss the importance of routine breast self- examination. Emphasize that most palpable masses are benign to decrease any fear or concern that results when a mass is felt.
Lungs The lungs are situated inside the thoracic cavity, with one lung on each side of the sternum. Each lung is divided into an apex, which is slightly pointed and rises above the first rib; a base, which is wide and concave and rides on the dome-shaped diaphragm; and a body, which is divided into lobes. The right lung has three lobes: the upper, middle, and lower. The left lung has only two lobes, the upper and lower, because of the space occupied by the heart (Fig. 4-31).
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FIG 4-31 Location of the lobes of the lungs within the thoracic cavity. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 8, St Louis, 2013, Mosby.)
Inspection of the lungs primarily involves observation of respiratory movements. Evaluate respirations for (1) rate (number per minute), (2) rhythm (regular, irregular, or periodic), (3) depth (deep or shallow), and (4) quality (effortless, automatic, difficult, or labored). Note the character of breath sounds, such as noisy, grunting, snoring, or heavy.
Evaluate respiratory movements by placing each hand flat against the back or chest with the thumbs in midline along the lower costal margin of the lungs. The child should be sitting during this procedure and, if cooperative, should take several deep breaths. During respiration your hands will move with the chest wall. Assess the amount and speed of respiratory excursion and note any asymmetry of movement.
Experienced examiners may percuss the lungs. Percuss the anterior lung from apex to base, usually with the child in the supine or sitting position. Percuss each side of the chest in sequence to compare the sounds. When percussing the posterior lung, the procedure and sequence are the same, although the child should be sitting. Resonance is heard over all the lobes of the lungs that are not adjacent to other organs. Record and report any deviation from the expected sound.
Auscultation Auscultation involves using the stethoscope to evaluate breath sounds (see Nursing Care Guidelines box). Breath sounds are best heard if the child inspires deeply (see Atraumatic Care box). In the lungs, breath sounds are classified as vesicular, bronchovesicular, or bronchial (Box 4- 12).
N u r s i n g C a r e G u i d e l i n e s Effective Auscultation
• Make certain child is relaxed and not crying, talking, or laughing. Record if child is crying.
• Check that room is comfortable and quiet.
• Warm stethoscope before placing it against skin.
• Apply firm pressure on chest piece but not enough to prevent vibrations and transmission of
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sound.
• Avoid placing stethoscope over hair or clothing, moving it against the skin, breathing on tubing, or sliding fingers over chest piece, which may cause sounds that falsely resemble pathologic findings.
• Use a symmetric and orderly approach to compare sounds.
At r a u m a t i c C a r e Encouraging Deep Breaths
• Ask the child to “blow out” the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful.
• Place a cotton ball in child's palm; ask child to blow the ball into the air and have parent catch it.
• Place a small tissue on the top of a pencil and ask the child to blow the tissue off.
• Have child blow a pinwheel, a party horn, or bubbles.
Box 4-12 C l a s s i f i c a t i o n o f N o r m a l B r e a t h S o u n d s Vesicular Breath Sounds
Heard over the entire surface of the lungs with the exception of the upper intrascapular area and area beneath the manubrium.
Inspiration is louder, longer, and higher pitched than expiration.
The sound is a soft, swishing noise.
Bronchovesicular Breath Sounds
Heard over the manubrium and in the upper intrascapular regions where the trachea and bronchi bifurcate.
Inspiration is louder and higher pitched than in vesicular breathing.
Bronchial Breath Sounds
Heard only over trachea near suprasternal notch.
The inspiratory phase is short, and the expiratory phase is long.
Absent or diminished breath sounds are always an abnormal finding warranting investigation. Fluid, air, or solid masses in the pleural space interfere with the conduction of breath sounds. Diminished breath sounds in certain segments of the lung can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Increased breath sounds after pulmonary therapy indicate improved passage of air through the respiratory tract. Box 4-13 lists terms used to describe various respiration patterns.
Box 4-13 Va r i o u s Pa t t e r n s o f R e s p i r a t i o n
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Tachypnea: Increased rate
Bradypnea: Decreased rate
Dyspnea: Distress during breathing
Apnea: Cessation of breathing
Hyperpnea: Increased depth
Hypoventilation: Decreased depth (shallow) and irregular rhythm
Hyperventilation: Increased rate and depth
Kussmaul respiration: Hyperventilation, gasping and labored respiration; usually seen in diabetic coma or other states of respiratory acidosis
Cheyne-Stokes respiration: Gradually increasing rate and depth with periods of apnea
Biot respiration: Periods of hyperpnea alternating with apnea (similar to Cheyne-Stokes except that depth remains constant)
Seesaw (paradoxic) respirations: Chest falls on inspiration and rises on expiration
Agonal: Last gasping breaths before death
Various pulmonary abnormalities produce adventitious sounds that are not normally heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. They are classified into two main groups: (1) crackles, which result from the passage of air through fluid or moisture, and (2) wheezes, which are produced as air passes through narrowed passageways, regardless of the cause, such as exudate, inflammation, spasm, or tumor. Considerable practice with an experienced tutor is necessary to differentiate the various types of lung sounds. Often it is best to describe the type of sound heard in the lungs rather than trying to label it. Always report any abnormal sounds for further medical evaluation.
Heart The heart is situated in the thoracic cavity between the lungs in the mediastinum and above the diaphragm (Fig. 4-32). About two thirds of the heart lies within the left side of the rib cage, with the other third on the right side as it crosses the sternum. The heart is positioned in the thorax like a trapezoid:
Vertically along the right sternal border (RSB) from the second to the fifth rib
Horizontally (long side) from the lower right sternum to the fifth rib at the left midclavicular line (LMCL)
Diagonally from the left sternal border (LSB) at the second rib to the LMCL at the fifth rib
Horizontally (short side) from the RSB and LSB at the second ICS—base of the heart
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FIG 4-32 Position of the heart within the thorax. (From Ball JW, Dains JE, Flynn JA, et al: Seidel's guide to physical examination, ed 8, St Louis, 2014, Elsevier.)
Inspection is easiest when the child is sitting in a semi-Fowler position. Look at the anterior chest wall from an angle, comparing both sides of the rib cage with each other. Normally they should be symmetric. In children with thin chest walls, a pulsation may be visible. Because comprehensive evaluation of cardiac function is not limited to the heart, also consider other findings, such as the presence of all pulses (especially the femoral pulses) (Fig. 4-33), distended neck veins, clubbing of the fingers, peripheral cyanosis, edema, blood pressure, and respiratory status.
FIG 4-33 Location of pulses.
Use palpation to determine the location of the AI, the most lateral cardiac impulse that may correspond to the apex. The AI is found:
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• At the fifth ICS and LMCL in children older than 7 years old • At the fourth ICS and just lateral to the LMCL in children younger than 7 years old
Although the AI gives a general idea of the size of the heart (with enlargement, the apex is lower and more lateral), its normal location is variable, making it an unreliable indicator of heart size.
The point of maximum intensity (PMI), as the name implies, is the area of most intense pulsation. Usually the PMI is located at the same site as the AI, but it can occur elsewhere. For this reason, the two terms should not be used synonymously.
Assess the capillary refill time, an important test for circulation and hydration, by pressing the skin lightly on a central site, such as the forehead, or a peripheral site, such as the top of the hand, to produce a slight blanching. The time it takes for the blanched area to return to its original color is the capillary refill time.
N u r s i n g A l e r t Capillary refill should be brisk—less than 2 seconds. Prolonged refill may be associated with poor systemic perfusion or a cool ambient temperature.
Auscultation
Origin of Heart Sounds The heart sounds are produced by the opening and closing of the valves and the vibration of blood against the walls of the heart and vessels. Normally, two sounds—S1 and S2—are heard, which correspond, respectively, to the familiar “lub dub” often used to describe the sounds. S1 is caused by closure of the tricuspid and mitral valves (sometimes called the atrioventricular valves). S2 is the result of closure of the pulmonic and aortic valves (sometimes called semilunar valves). Normally the split of the two sounds in S2 is distinguishable and widens during inspiration. Physiologic splitting is a significant normal finding.
N u r s i n g A l e r t Fixed splitting, in which the split in S2 does not change during inspiration, is an important diagnostic sign of atrial septal defect.
Two other heart sounds, S3 and S4, may be produced. S3 is normally heard in some children; S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation.
Differentiating Normal Heart Sounds Fig. 4-34 illustrates the approximate anatomic position of the valves within the heart chambers. Note that the anatomic location of valves does not correspond to the area where the sounds are heard best. The auscultatory sites are located in the direction of the blood flow through the valves.
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FIG 4-34 Direction of heart sounds for anatomic valve sites and areas (circled) for auscultation.
Normally S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area (Table 4-9). Listen to each sound by inching down the chest. Auscultate the following areas for sounds, such as murmurs, which may radiate to these sites: sternoclavicular area above the clavicles and manubrium, area along the sternal border, area along the left midaxillary line, and area below the scapulae.
N u r s i n g T i p To distinguish between S1 and S2 heart sounds, simultaneously palpate the carotid pulse with the index and middle fingers and listen to the heart sounds; S1 is synchronous with the carotid pulse.
TABLE 4-9 Sequence of Auscultating Heart Sounds*
Auscultatory Site Chest Location Characteristics of Heart Sounds
Aortic area Second right ICS close to sternum S2 heard louder than S1; aortic closure heard loudest Pulmonic area
Second left ICS close to sternum Splitting of S2 heard best, normally widens on inspiration; pulmonic closure heard best
Erb point Second and third left ICSs close to sternum Frequent site of innocent murmurs and those of aortic or pulmonic origin Tricuspid area
Fifth right and left ICSs close to sternum S1 heard as louder sound preceding S2 (S1 synchronous with carotid pulse)
Mitral or apical area
Fifth ICS, LMCL (third to fourth ICS and lateral to LMCL in infants)
S1 heard loudest; splitting of S1 may be audible because mitral closure is louder than tricuspid closure S1 heard best at beginning of expiration with child in recumbent or left side-lying position; occurs immediately after S2;
sounds like word S1 S2 S3: “Ken-tuck-y” S4 heard best during expiration with child in recumbent position (left side-lying position decreases sound); occurs
immediately before S1; sounds like word S4 S1 S2: “Ten-nes-see”
*Use both diaphragm and bell chest pieces when auscultating heart sounds. Bell chest piece is necessary for low-pitched sounds of murmurs, S3, and S4.
ICS, Intercostal space; LMCL, left midclavicular line.
Auscultate the heart with the child in at least two positions: sitting and reclining. If adventitious sounds are detected, further evaluate them with the child standing, sitting and leaning forward, and lying on the left side. For example, atrial sounds (such as, S4) are heard best with the person in a recumbent position and usually fade if the person sits or stands.
Evaluate heart sounds for (1) quality (they should be clear and distinct, not muffled, diffuse, or distant); (2) intensity, especially in relation to the location or auscultatory site (they should not be weak or pounding); (3) rate (they should have the same rate as the radial pulse); and (4) rhythm (they should be regular and even). A particular arrhythmia that occurs normally in many children is sinus arrhythmia, in which the heart rate increases with inspiration and decreases with expiration. Differentiate this rhythm from a truly abnormal arrhythmia by having children hold their breath. In sinus arrhythmia, cessation of breathing causes the heart rate to remain steady.
Heart Murmurs
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Another important category of the heart sounds is murmurs, which are produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood. (For a more detailed discussion, see Cardiovascular Dysfunction, Chapter 23). Murmurs are classified as:
Innocent: No anatomic or physiologic abnormality exists.
Functional: No anatomic cardiac defect exists, but a physiologic abnormality (such as, anemia) is present.
Organic: A cardiac defect with or without a physiologic abnormality exists.
The description and classification of murmurs are skills that require considerable practice and training. In general, recognize murmurs as distinct swishing sounds that occur in addition to the normal heart sounds and record the (1) location, or the area of the heart in which the murmur is heard best; (2) time of the occurrence of the murmur within the S1–S2 cycle; (3) intensity (evaluate in relationship to the child's position); and (4) loudness. Table 4-10 lists the usual subjective method of grading the loudness or intensity of a murmur.
TABLE 4-10 Grading the Intensity of Heart Murmurs
Grade Description I Very faint; often not heard if child sits up II Usually readily heard; slightly louder than grade I; audible in all positions III Loud, but not accompanied by a thrill IV Loud, accompanied by a thrill V Loud enough to be heard with a stethoscope barely touching the chest; accompanied by a thrill VI Loud enough to be heard with the stethoscope not touching the chest; often heard with the human ear close to the chest; accompanied by a thrill
Abdomen Examination of the abdomen involves inspection followed by auscultation and then palpation. Experienced examiners may also percuss the abdomen to assess for organomegaly, masses, fluid, and flatus. Perform palpation last because it may distort the normal abdominal sounds. Knowledge of the anatomic placement of the abdominal organs is essential to differentiate normal, expected findings from abnormal ones (Fig. 4-35).
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FIG 4-35 Location of structures in the abdomen. (From Drake RL, Vogl W, Mitchell AWM: Gray's anatomy for students, ed 3, New York, 2015, Churchill Livingstone.)
For descriptive purposes, the abdominal cavity is divided into four quadrants by drawing a vertical line midway from the sternum to the symphysis pubis and a horizontal line across the abdomen through the umbilicus. The sections are named: • Left upper quadrant • Left lower quadrant • Right upper quadrant • Right lower quadrant
Inspection Inspect the contour of the abdomen with the child erect and supine. Normally the abdomen of infants and young children is cylindric and, in the erect position, fairly prominent because of the physiologic lordosis of the spine. In the supine position, the abdomen appears flat. A midline protrusion from the xiphoid to the umbilicus or symphysis pubis is usually diastasis recti, or failure of the rectus abdominis muscles to join in utero. In a healthy child a midline protrusion is usually a variation of normal muscular development.
N u r s i n g A l e r t A tense, board-like abdomen is a serious sign of paralytic ileus and intestinal obstruction.
The skin covering the abdomen should be uniformly taut, without wrinkles or creases. Sometimes silvery, whitish striae (“stretch marks”) are seen, especially if the skin has been stretched as in obesity. Superficial veins are usually visible in light-skinned, thin infants, but distended veins are an abnormal finding.
Observe movement of the abdomen. Normally chest and abdominal movements are
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synchronous. In infants and thin children, peristaltic waves may be visible through the abdominal wall; they are best observed by standing at eye level to and across from the abdomen. Always report this finding.
Examine the umbilicus for size, hygiene, and evidence of any abnormalities, such as hernias. The umbilicus should be flat or only slightly protruding. If a herniation is present, palpate the sac for abdominal contents and estimate the approximate size of the opening. Umbilical hernias are common in infants, especially in African-American children.
Hernias may exist elsewhere on the abdominal wall (Fig. 4-36). An inguinal hernia is a protrusion of peritoneum through the abdominal wall in the inguinal canal. It occurs mostly in boys, is frequently bilateral, and may be visible as a mass in the scrotum. To locate a hernia, slide the little finger into the external inguinal ring at the base of the scrotum and ask the child to cough. If a hernia is present, it will hit the tip of the finger.
N u r s i n g T i p If the child is too young to cough, have the child blow a pinwheel or bubbles or laugh to raise the intraabdominal pressure sufficiently to demonstrate the presence of an inguinal hernia.
FIG 4-36 Location of hernias.
A femoral hernia, which occurs more frequently in girls, is felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal (a potential space medial to the femoral artery). Feel for a hernia by placing the index finger of your right hand on the child's right femoral pulse (left hand for left pulse) and the middle finger flat against the skin toward the midline. The ring finger lies over the femoral canal, where the herniation occurs. Palpation of hernias in the pelvic region is often part of the genital examination.
Auscultation The most important finding to listen for is peristalsis, or bowel sounds, which sound like short metallic clicks and gurgles. Record their frequency per minute (e.g., 5 sounds/min). Listen for up to 5 minutes before determining that bowel sounds are absent. Stimulate bowel sounds by stroking the abdominal surface with a fingernail. Report absence of bowel sounds or hyperperistalsis, because either usually denotes an abdominal disorder.
Palpation There are two types of palpation: superficial and deep. For superficial palpation, lightly place your hand against the skin and feel each quadrant, noting any areas of tenderness, muscle tone, and
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superficial lesions, such as cysts. Because superficial palpation is often perceived as tickling, use several techniques to minimize this sensation and relax the child (see Atraumatic Care box). Admonishing the child to stop laughing only draws attention to the sensation and decreases cooperation.
At r a u m a t i c C a r e Promoting Relaxation during Abdominal Palpation
• Position child comfortably, such as in a semireclining position in the parent's lap, with knees flexed.
• Warm your hands before touching the skin.
• Use distraction, such as telling stories or talking to child.
• Teach child to use deep breathing and to concentrate on an object.
• Give infant a bottle or pacifier.
• Begin with light, superficial palpation and gradually progress to deeper palpation.
• Palpate any tender or painful areas last.
• Have child hold the parent's hand and squeeze it if palpation is uncomfortable.
• Use the nonpalpating hand to comfort the child, such as placing the free hand on child's shoulder while palpating abdomen.
• To minimize sensation of tickling during palpation:
• Have children “help” with palpation by placing a hand over the palpating hand.
• Have them place a hand on the abdomen with the fingers spread wide apart, and palpate between their fingers.
Deep palpation is for palpating organs and large blood vessels and for detecting masses and tenderness that were not discovered during superficial palpation. Palpation usually begins in the lower quadrants and proceeds upward to avoid missing the edge of an enlarged liver or spleen. Except for palpating the liver, successful identification of other organs (such as the spleen, kidney, and part of the colon) requires considerable practice with tutored supervision. Report any questionable mass. The lower edge of the liver is sometimes felt in infants and young children as a superficial mass 1 to 2 cm (0.4 to 0.8 inch) below the right costal margin (the distance is sometimes measured in fingerbreadths). Normally the liver descends during inspiration as the diaphragm moves downward. Do not mistake this downward displacement as a sign of liver enlargement.
N u r s i n g A l e r t If the liver is palpable 3 cm (1.2 inch) below the right costal margin or the spleen is palpable more than 2 cm (0.8 inch) below the left costal margin, these organs are enlarged—a finding that is always reported for further medical investigation.
Palpate the femoral pulses by placing the tips of two or three fingers (index, middle, or ring) along the inguinal ligament about midway between the iliac crest and symphysis pubis. Feel both pulses simultaneously to make certain that they are equal and strong (Fig. 4-37).
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N u r s i n g A l e r t Absence of femoral pulses is a significant sign of coarctation of the aorta and is referred for medical evaluation.
FIG 4-37 Palpating for femoral pulses.
Genitalia Examination of genitalia conveniently follows assessment of the abdomen while the child is still supine. In adolescents, inspection of the genitalia may be left to the end of the examination. The best approach is to examine the genitalia matter-of-factly, placing no more emphasis on this part of the assessment than on any other segment. It helps to relieve children's and parents' anxiety by telling them the results of the findings; for example, the nurse might say, “Everything looks fine here.”
If it is necessary to ask questions, such as about discharge or difficulty urinating, respect the child's privacy by covering the lower abdomen with the gown or underpants. To prevent embarrassing interruptions, keep the door or curtain closed and post a “do not disturb” sign. Have a drape ready to cover the genitalia if someone enters the room.
In examining the genitalia, wear gloves when touching the child. It might be helpful for the adolescent to know that wearing gloves also prevents skin-to-skin contact.
The genital examination is an excellent time for eliciting questions or concern about body function or sexual activity. Also use this opportunity to increase or reinforce the child's knowledge of reproductive anatomy by naming each body part and explaining its function. This part of the health assessment is an opportune time to teach testicular self-examination to boys.
Male Genitalia Note the external appearance of the glans and shaft of the penis, the prepuce, the urethral meatus, and the scrotum (Fig. 4-38). The penis is generally small in infants and young boys until puberty, when it begins to increase in both length and width. In an obese child, the penis often looks abnormally small because of the folds of skin partially covering it at the base. Be familiar with normal pubertal growth of the external male genitalia to compare the findings with the expected sequence of maturation (see Chapter 15).
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FIG 4-38 Major structures of genitalia in an uncircumcised postpubertal male. (From Douglas G, Nicol F, Robertson C: Mackleod's clinical examination, ed 13, Philadelphia, 2013, Elsevier.)
Examine the glans (head of the penis) and shaft (portion between the perineum and prepuce) for signs of swelling, skin lesions, inflammation, or other irregularities. Any of these signs may indicate underlying disorders, especially sexually transmitted infections.
Carefully inspect the urethral meatus for location and evidence of discharge. Normally it is centered at the tip of the glans. Also note hair distribution. Normally, before puberty, no pubic hair is present. Soft, downy hair at the base of the penis is an early sign of pubertal maturation. In older adolescents, hair distribution is diamond-shaped from the umbilicus to the anus.
Note the location and size of the scrotum. The scrota hang freely from the perineum behind the penis, and the left scrotum normally hangs lower than the right. In infants, the scrota appear large in relation to the rest of the genitalia. The skin of the scrotum is loose and highly rugated (wrinkled). During early adolescence the skin normally becomes redder and coarser. In dark- skinned boys, the scrota are usually more deeply pigmented.
Palpation of the scrotum includes identification of the testes, epididymis, and, if present, inguinal hernias. The two testes are felt as small, ovoid bodies about 1.5 to 2 cm (0.6 to 0.8 inch) long—one in each scrotal sac. They do not enlarge until puberty (see Chapter 15). Pubertal testicular development usually begins in boys between 9 and 13 years old. Record early (precocious) or delayed pubertal development, as well as evidence of any other secondary sexual characteristics.
When palpating for the presence of the testes, avoid stimulating the cremasteric reflex, which is stimulated by cold, touch, emotional excitement, or exercise. This reflex pulls the testes higher into the pelvic cavity. Several measures are useful in preventing the cremasteric reflex during palpation of the scrotum. First, warm the hands. Second, if the child is old enough, examine him in a tailor or “Indian” position, which stretches the muscle, preventing its contraction (Fig. 4-39, A). Third, block the normal pathway of ascent of the testes by placing the thumb and index finger over the upper part of the scrotal sac along the inguinal canal (see Fig. 4-39, B). If there is any question concerning the existence of two testes, place the index and middle fingers in a scissors fashion to separate the right and left scrota. If, after using these techniques, you have not palpated the testes, feel along the inguinal canal and perineum to locate masses that may be undescended testes. Although undescended testes may descend at any time during childhood and are checked at each visit, report any failure to palpate the testes.
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FIG 4-39 A, Preventing the cremasteric reflex by having the child sit in the tailor position. B, Blocking the inguinal canal during palpation of the scrotum for descended testes.
Female Genitalia The examination of female genitalia is limited to inspection and palpation of external structures. If a vaginal examination is required, the nurse should make an appropriate referral unless he or she is qualified to perform the procedure.
A convenient position for examination of the genitalia involves placing the young girl supine on the examining table or in a semireclining position on the parent's lap with the feet supported on your knees as you sit facing the child. Divert the child's attention from the examination by instructing her to try to keep the soles of her feet pressed against each other. Separate the labia majora with the thumb and index finger and retract outward to expose the labia minora, urethral meatus, and vaginal orifice.
Examine the female genitalia for size and location of the structures of the vulva, or pudendum (Fig. 4-40). The mons pubis is a pad of adipose tissue over the symphysis pubis. At puberty, the mons is covered with hair, which extends along the labia. The usual pattern of female hair distribution is an inverted triangle. The appearance of soft, downy hair along the labia majora is an early sign of sexual maturation. Note the size and location of the clitoris, a small, erectile organ located at the anterior end of the labia minora. It is covered by a small flap of skin, the prepuce.
FIG 4-40 External structures of the genitalia in a postpubertal female. The labia are spread to reveal deeper structures. (From Paulsen F, Waschke J: Sobotta atlas of human anatomy, vol 2, ed 15, Munich, 2013, Elsevier.)
The labia majora are two thick folds of skin running posteriorly from the mons to the posterior commissure of the vagina. Internal to the labia majora are two folds of skin called the labia minora. Although the labia minora are usually prominent in newborns, they gradually atrophy, which makes them almost invisible until their enlargement during puberty. The inner surface of the labia
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should be pink and moist. Note the size of the labia and any evidence of fusion, which may suggest male scrota. Normally, no masses are palpable within the labia.
The urethral meatus is located posterior to the clitoris and is surrounded by the Skene glands and ducts. Although not a prominent structure, the meatus appears as a small V-shaped slit. Note its location, especially if it opens from the clitoris or inside the vagina. Gently palpate the glands, which are common sites of cysts and sexually transmitted lesions.
The vaginal orifice is located posterior to the urethral meatus. Its appearance varies depending on individual anatomy and sexual activity. Ordinarily, examination of the vagina is limited to inspection. In virgins, a thin crescent-shaped or circular membrane, called the hymen, may cover part of the vaginal opening. In some instances, it completely occludes the orifice. After rupture, small rounded pieces of tissue called caruncles remain. Although an imperforate hymen denotes lack of penile intercourse, a perforate one does not necessarily indicate sexual activity (see also Sexual Abuse, Chapter 16).
N u r s i n g A l e r t In girls who have been circumcised, the genitalia will appear different. Do not show surprise or disgust but note the appearance and discuss the procedure with the young woman (see also Chapter 2, Cultural Considerations “Circumcision”).
Surrounding the vaginal opening are Bartholin glands, which secrete a clear, mucoid fluid into the vagina for lubrication during intercourse. Palpate the ducts for cysts. Also note the discharge from the vagina, which is usually clear or white.
Anus After examination of the genitalia, it is easy to identify the anal area, although the child should be placed on the abdomen. Note the general firmness of the buttocks and symmetry of the gluteal folds. Assess the tone of the anal sphincter by eliciting the anal reflex (anal wink). Gently scratching the anal area results in an obvious quick contraction of the external anal sphincter.
Back and Extremities Spine Note the general curvature of the spine. Normally, the back of a newborn is rounded or C shaped from the thoracic and pelvic curves. The development of the cervical and lumbar curves approximates development of various motor skills, such as cervical curvature with head control, and gives older children the typical double S curve.
Marked curvatures in posture are abnormal. Scoliosis, lateral curvature of the spine, is an important childhood problem, especially in girls. Although scoliosis may be identified by observing and palpating the spine and noting a sideways displacement, more objective tests include: • With the child standing erect, clothed only in underpants (and bra if an older girl), observe from
behind, noting asymmetry of the shoulders and hips. • With the child bending forward so the back is parallel to the floor, observe from the front and
side, noting asymmetry or prominence of the rib cage. A slight limp, a crooked hemline, or complaints of a sore back are other signs and symptoms of
scoliosis. Inspect the back, especially along the spine, for any tufts of hair, dimples, or discoloration.
Mobility of the vertebral column is easy to assess in most children because of their tendency to be in constant motion during the examination. However, you can test mobility by asking the child to sit up from a prone position or to do a modified sit-up exercise.
Movement of the cervical spine is an important diagnostic sign of neurologic problems, such as meningitis. Normally movement of the head in all directions is effortless.
N u r s i n g A l e r t
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Hyperextension of the neck and spine, or opisthotonos, which is accompanied by pain when the head is flexed, is always referred for immediate medical evaluation.
Extremities Inspect each extremity for symmetry of length and size; refer any deviation for orthopedic evaluation. Count the fingers and toes to be certain of the normal number. This is so often taken for granted that an extra digit (polydactyly) or fusion of digits (syndactyly) may go unnoticed.
Inspect the arms and legs for temperature and color, which should be equal in each extremity, although the feet may normally be colder than the hands.
Assess the shape of bones. There are several variations of bone shape in children. Although many of them cause parents concern, most are benign and require no treatment. Bowleg, or genu varum, is lateral bowing of the tibia. It is clinically present when the child stands with an outward bowing of the legs, giving the appearance of a bow. Usually, there is an outward curvature of both femur and tibia (Fig. 4-41, A). Toddlers are usually bowlegged after beginning to walk until all of their lower back and leg muscles are well developed. Unilateral or asymmetric bowlegs that are present beyond 2 to 3 years old, particularly in African-American children, may represent pathologic conditions requiring further investigation.
FIG 4-41 A, Genu varum. B, Genu valgum.
Knock knee, or genu valgum, appears as the opposite of bowleg, in that the knees are close together but the feet are spread apart. It is determined clinically by using the same method as for genu varum but by measuring the distance between the malleoli, which normally should be less than 7.5 cm (3 inches) (see Fig. 4-41, B). Knock knee is normally present in children from about 2 to 7 years old. Knock knee that is excessive, asymmetric, accompanied by short stature, or evident in a child nearing puberty requires further evaluation.
Next inspect the feet. Infants' and toddlers' feet appear flat because the foot is normally wide and the arch is covered by a fat pad. Development of the arch occurs naturally from the action of walking. Normally at birth the feet are held in a valgus (outward) or varus (inward) position. To determine whether a foot deformity at birth is a result of intrauterine position or development, scratch the outer, then inner, side of the sole. If the foot position is self-correctable, it will assume a right angle to the leg. As the child begins to walk, the feet turn outward less than 30 degrees and inward less than 10 degrees.
Toddlers have a “toddling” or broad-based gait, which facilitates walking by lowering the center of gravity. As the child reaches preschool age, the legs are brought closer together. By school age, the walking posture is much more graceful and balanced.
The most common gait problem in young children is pigeon toe, or toeing in, which usually results from torsional deformities, such as internal tibial torsion (abnormal rotation or bowing of the tibia). Tests for tibial torsion include measuring the thigh–foot angle, which requires considerable practice for accuracy.
Elicit the plantar or grasp reflex by exerting firm but gentle pressure with the tip of the thumb
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against the lateral sole of the foot from the heel upward to the little toe and then across to the big toe. The normal response in children who are walking is flexion of the toes. Babinski sign, dorsiflexion of the big toe and fanning of the other toes, is normal during infancy but abnormal after about 1 year old or when locomotion begins.
Joints Evaluate the joints for range of motion. Normally this requires no specific testing if you have observed the child's movements during the examination. However, routinely investigate the hips in infants for congenital dislocation by checking for subluxation of the hip. Report any evidence of joint immobility or hyperflexibility. Palpate the joints for heat, tenderness, and swelling. These signs, as well as redness over the joint, warrant further investigation.
Muscles Note symmetry and quality of muscle development, tone, and strength. Observe development by looking at the shape and contour of the body in both a relaxed and a tensed state. Estimate tone by grasping the muscle and feeling its firmness when it is relaxed and contracted. A common site for testing tone is the biceps muscle of the arm. Children are usually willing to “make a muscle” by clenching their fists.
Estimate strength by having the child use an extremity to push or pull against resistance, as in the following examples:
Arm strength: Child holds the arms outstretched in front of the body and tries to raise the arms while downward pressure is applied.
Hand strength: Child shakes hands with nurse and squeezes one or two fingers of the nurse's hand.
Leg strength: Child sits on a table or chair with the legs dangling and tries to raise the legs while downward pressure is applied.
Note symmetry of strength in the extremities, hands, and fingers, and report evidence of paresis, or weakness.
Neurologic Assessment The assessment of the nervous system is the broadest and most diverse part of the examination process, because every human function, both physical and emotional, is controlled by neurologic impulses. Much of the neurologic examination has already been discussed, such as assessment of behavior, sensory testing, and motor function. The following focuses on a general appraisal of cerebellar function, deep tendon reflexes, and the cranial nerves.
Cerebellar Function The cerebellum controls balance and coordination. Much of the assessment of cerebellar function is included in observing the child's posture, body movements, gait, and development of fine and gross motor skills. Tests (such as, balancing on one foot and the heel-to-toe walk) assess balance. Test coordination by asking the child to reach for a toy, button clothes, tie shoes, or draw a straight line on a piece of paper (provided the child is old enough to do these activities). Coordination can also be tested by any sequence of rapid, successive movements, such as quickly touching each finger with the thumb of the same hand.
Several tests for cerebellar function can be performed as games (Box 4-14). When a Romberg test is done, stay beside the child if there is a possibility that he or she might fall. School-age children should be able to perform these tests, although in the finger-to-nose test, preschoolers normally can only bring the finger within 5 to 7.5 cm (2 to 3 inches) of the nose. Difficulty in performing these exercises indicates a poor sense of position (especially with the eyes closed) and incoordination (especially with the eyes open).
Box 4-14
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Te s t s f o r C e r e b e l l a r F u n c t i o n Finger-to-nose test: With the child's arm extended, ask the child to touch the nose with the index
finger with the eyes open and then closed.
Heel-to-shin test: Have the child stand and run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened and then closed.
Romberg test: Have the child stand with the eyes closed and heels together; falling or leaning to one side is abnormal and is called the Romberg sign.
Reflexes Testing reflexes is an important part of the neurologic examination. Persistence of primitive reflexes (see Chapter 7), loss of reflexes, or hyperactivity of deep tendon reflexes is usually a result of a cerebral insult.
Elicit reflexes by using the rubber head of the reflex hammer, flat of the finger, or side of the hand. If the child is easily frightened by equipment, use your hand or finger. Although testing reflexes is a simple procedure, the child may inhibit the reflex by unconsciously tensing the muscle. To avoid tensing, distract younger children with toys or talk to them. Older children can concentrate on the exercise of grasping their two hands in front of them and trying to pull them apart. This diverts their attention from the testing and causes involuntary relaxation of the muscles.
Deep tendon reflexes are stretch reflexes of a muscle. The most common deep tendon reflex is the knee jerk reflex, or patellar reflex (sometimes called the quadriceps reflex). Figs. 4-42 to 4-45 illustrate the reflexes normally elicited. Report any diminished or hyper-reflexive response for further evaluation.
FIG 4-42 Testing for the triceps reflex. The child is placed supine, with the forearm resting over the chest, and the triceps tendon is struck. Alternate procedure: The child's arm is abducted with the upper arm supported and the forearm allowed to hang freely. The triceps tendon is struck. Normal response is
partial extension of the forearm.
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FIG 4-43 Testing for the biceps reflex. The child's arm is held by placing the partially flexed elbow in the examiner's hand with the thumb over the antecubital space. The examiner's thumbnail is struck with a
hammer. Normal response is partial flexion of the forearm.
FIG 4-44 Testing for the patellar, or knee-jerk, reflex, using distraction. The child sits on the edge of the examining table (or on the parent's lap) with the lower legs flexed at the knee and dangling freely. The
patellar tendon is tapped just below the kneecap. Normal response is partial extension of the lower leg.
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FIG 4-45 Testing for the Achilles reflex. The child should be in the same position as for the knee-jerk reflex. The foot is supported lightly in the examiner's hand, and the Achilles tendon is struck. Normal
response is plantar flexion of the foot (the foot pointing downward).
Cranial Nerves Assessment of the cranial nerves is an important area of neurologic assessment (Fig. 4-46; Table 4- 11). With young children, present the tests as games to foster trust and security at the beginning of the examination. Also include the cranial nerve test when examining each system, such as tongue movement and strength, gag reflex, swallowing, cardinal positions of gaze (Fig. 4-47), and position of the uvula during examination of the mouth.
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FIG 4-46 Cranial nerves. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 8, St Louis, 2013, Mosby.)
TABLE 4-11 Assessment of Cranial Nerves
Description and Function Tests I—Olfactory Nerve Olfactory mucosa of nasal cavity Smell
With eyes closed, have child identify odors, such as coffee, alcohol from a swab, or other smells; test each nostril separately.
II—Optic Nerve Rods and cones of retina, optic nerve Vision
Check for perception of light, visual acuity, peripheral vision, color vision, and normal optic disc.
III—Oculomotor Nerve Extraocular muscles of eye: • Superior rectus—moves eyeball up and in • Inferior rectus—moves eyeball down and in • Medial rectus—moves eyeball nasally • Inferior oblique—moves eyeball up and out
Have child follow an object (toy) or light in six cardinal positions of gaze (see Fig. 4-47).
Pupil constriction and accommodation Perform PERRLA (Pupils Equal, Round, React to Light, and Accommodation). Eyelid closing Check for proper placement of eyelid. IV—Trochlear Nerve Superior oblique (SO) muscle—moves eye down and out Have child look down and in (see Fig. 4-47). V—Trigeminal Nerve Muscles of mastication Have child bite down hard and open jaw; test symmetry and strength. Sensory—face, scalp, nasal and buccal mucosa With child's eyes closed, see if child can detect light touch in mandibular and maxillary regions.
Test corneal and blink reflex by touching cornea lightly with a whisk of cotton ball twisted into a point (approach from side so the child does not blink before cornea is touched).
VI—Abducens Nerve Lateral rectus (LR) muscle—moves eye temporally Have child look toward temporal side (see Fig. 4-47). VII—Facial Nerve Muscles for facial expression Have child smile, make funny face, or show teeth to see symmetry of expression. Anterior two thirds of tongue (sensory) Have child identify sweet or salty solution; place each taste on anterior section and sides of protruding tongue; if child
retracts tongue, solution will dissolve toward posterior part of tongue. VIII—Auditory, Acoustic, or Vestibulocochlear Nerve Internal ear Hearing and balance
Test hearing; note any loss of equilibrium or presence of vertigo.
IX—Glossopharyngeal Nerve Pharynx, tongue Stimulate posterior pharynx with a tongue blade; child should gag. Posterior third of tongue Sensory
Test sense of sour or bitter taste on posterior segment of tongue.
X—Vagus Nerve Muscles of larynx, pharynx, some organs of gastrointestinal system, sensory fibers of root of tongue, heart, and lung
Note hoarseness of voice, gag reflex, and ability to swallow. Check that uvula is in midline; when stimulated with tongue blade, it should deviate upward and to stimulated side.
XI—Accessory Nerve Sternocleidomastoid and trapezius muscles of shoulder Have child shrug shoulders while applying mild pressure; with examiner's palms placed laterally on child's cheeks,
have child turn head against opposing pressure on either side; note symmetry and strength. XII—Hypoglossal Nerve Muscles of tongue Have child move tongue in all directions; have child protrude tongue as far as possible; note any midline deviation.
Test strength by placing tongue blade on one side of tongue and having child move it away.
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FIG 4-47 Checking extraocular movements in the six cardinal positions indicates the functioning of cranial nerves III, IV, and VI. (From Ignatavicius DD, Workman LM: Medical-surgical nursing: patient-centered collaborative care,
ed 8, St Louis, 2016, Elsevier.)
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Review Questions 1. While interviewing parents who have just arrived in the health care clinic, the nurse begins the
interview. Which statement below involves therapeutic communication techniques? Select all that apply. a. Allow the parents to direct the conversation so that they feel comfortable and in control. b. Use broad, open-ended questions so that parents can feel open to discuss issues. c. Redirect by asking guided questions to keep the parents on task. d. Use careful listening, which relies on the use of clues and verbal leads to help move the
conversation along. e. Ask carefully worded, detailed questions to get accurate information.
2. A nurse looks over her assignment for the day that includes an infant, a preschool-age child, a third-grader, and a sophomore in high school. Which techniques take into consideration developmental stages when working with pediatric patients? a. Being aware that infants will become agitated due to stranger anxiety around 4 months old b. When a preschooler is getting blood drawn, giving a detailed explanation will be helpful c. Explaining and demonstrating what the BP machine does to the third-grader before taking her
blood pressure d. Using a single consistent approach with the adolescent will help allay anger and hostility
3. These general approaches can be helpful when performing a physical exam. Select all that apply. a. With toddlers, restraint may be necessary, and requesting a parent's assistance is appropriate. b. When examining a preschooler, giving a choice of which parts to examine may be helpful in
gaining the child's cooperation. c. With a school-age child, it is always best to have the parents present when examining. d. Giving explanations about body systems can make adolescents nervous due to their
egocentricities. e. An infant physical exam is done head to toe, similarly to the adult.
4. When assessing BP in a child: a. Knowledge of normal mean is important: newborn, 65/41; 1 month to 2 years old, 95/58; and 2
to 5 years old, 101/57. b. Cuff size is the most important variable and should be measured using limb length. c. The child is considered normotensive if the BP is below the 95th percentile. d. Check upper- and lower-extremity BP to look for abnormalities, such as aortic stenosis, which
causes lower-extremity BP to be higher than upper-extremity BP.
5. Growth measurement is a key element in children of their health status. One measurement for height is linear growth measurement. What should the nurse do to perfect this technique? Select all that apply. a. Understand the difference in measurement for children who can stand alone and for those who
must lie recumbent. b. Use a length board and footboard or a stadiometer, which is the best technique, or use a tape
measure. c. Two measurers are usually required for a recumbent child, although one measurer may be
sufficient for a cooperative child. d. Reposition the child and repeat the procedure. Measure at least twice (ideally three times).
Average the measurements for the final value. e. Demonstrate competency when measuring the growth of infants, children, and adolescents.
Refresher sessions should be taken when a lack of standardization occurs.
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Correct Answers 1. b, c, d; 2. c;
3. a, b; 4. a;
5. a, d, e
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Ball JW, Dains JE, Flynn JA, et al. Seidel's guide to physical examination. ed 8. Elsevier: St Louis; 2014.
Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012;5(3):246– 249.
Blank L, Coster J, O'Cathain A, et al. The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis. J Adv Nurs. 2012;68(12):2610– 2621.
Broner N, Embry VV, Gremminger MG, et al. Mandatory reporting and keeping youth safe. Administration on Children, Youth and Families, Family and Youth Services Bureau: Washington, DC; 2013.
Clark JA, Kieh-Lai MW, Sarnaik A, et al. Discrepancies between direct and indirect blood pressure measurements using various recommendations for arm cuff selection. Pediatrics. 2002;110(5):920–923.
Dosman C, Andrews D. Anticipatory guidance for cognitive and social-emotional development: birth to five years. Paediatr Child Health. 2012;17(2):75–80.
Foote JM, Brady LH, Burke AL, et al. Evidence-based clinical practice guideline on linear growth measurement of children. https://www.pedsendo.org/assets/education_training/PENSpositionstatement_linear_growth_measurement2014.pdf 2014.
Harlor AD Jr, Bower C, Committee on Practice and Ambulatory Medicine, Section on Otolaryngology—Head and Neck Surgery. Hearing assessment in infants and children: recommendations beyond neonatal screening. Pediatrics. 2009;124(4):1252–1263.
Mathers M, Keyes M, Wright M. A review of the evidence on the effectiveness of children's vision screening. Child Care Health Dev. 2010;36(6):754–780.
Mehra S, Eavey RD, Keamy DG. The epidemiology of hearing impairment in the United States: newborns, children, and adolescents. Otolaryngol Head Neck Surg. 2009;140(4):461– 472.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl 4th Report):555–576.
Park MK, Menard SW, Schoolfield J. Oscillometric blood pressure standards for children. Pediatr Cardiol. 2005;26(5):601–607.
Purc-Stephenson RJ, Thrasher C. Patient compliance with telephone triage recommendations: a meta-analytic review. Patient Educ Couns. 2012;87(2):135–142.
Purc-Stephenson RJ, Thrasher C. Nurses' experiences with telephone triage and advice: a meta-ethnography. J Adv Nurs. 2010;66(3):482–494.
Schell K, Briening E, Lebet R, et al. Comparison of arm and calf automatic noninvasive blood pressures in pediatric intensive care patients. J Pediatr Nurs. 2011;26(1):3–12.
Sekhar DL, Zalewski TR, Paul IM. Variability of state school-based hearing screening protocols in the United States. J Community Health. 2013;38(3):569–574.
Stacey D, Macartney G, Carley M, et al. Development and evaluation of evidence-informed clinical nursing protocols for remote assessment, triage and support of cancer treatment- induced symptoms. Nurs Res Pract. 2013;2013:171872 [Epub].
US Department of Agriculture, National Agricultural Library. Food and nutrition information center: interactive DRI for healthcare professionals. http://fnic.nal.usda.gov/fnic/interactiveDRI/; 2014.
US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US
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Preventive Task Force Recommendation statement. Pediatrics. 2011;127(2):340–346. *The term illness is used in its broadest sense to denote any problem of a physical, emotional, or psychosocial nature. It is actually a history of the chief complaint.
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Pain Assessment and Management in Children Marilyn J. Hockenberry
The evidence-based literature on pediatric pain assessment and management grows considerably each year. Treatment options for pediatric acute and chronic pain are continually being evaluated, and new technologies and administration options become available every day (Tobias, 2014a). Unfortunately, despite advances in acute and chronic pediatric pain management, many children and adolescents continue to suffer from inadequately treated pain of all types. Pain is a frequent occurrence in children with more than 25% of children experiencing pain during hospitalization (Kozlowski, Kost-Byerly, Colantuoni, et al, 2014). Effective management of pain in children requires a comprehensive approach of assessment, pain intervention, and reassessment (Habich, Wilson, Thielk, et al, 2012).
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Pain Assessment The purpose of a pediatric pain assessment is to determine how much pain the child is feeling. The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) recommends specific core domains to assess pain in children that include pain intensity, global judgment of satisfaction with treatment, symptoms and adverse events, physical recovery, and emotional response (McGrath, Walco, Turk, et al, 2008). Although pain assessment includes more than a number rating, understanding the intensity of the pain experienced by the child is essential for effective pain management. Numerous pediatric pain scales exist and are most commonly identified as behavioral pain measures, self-report pain rating scales, and multidimensional pain assessment tools.
Behavioral Pain Measures Behavioral or observational measures of pain are generally used for children from infancy to 4 years old (Table 5-1). Behavioral pain assessment may provide a more complete picture of the total pain experience when administered in conjunction with a subjective self-report measure. Behavioral pain measurement tools may be more time consuming than self-reports because they depend on a trained observer to watch and record children's behaviors, such as vocalization, facial expression, and body movements that suggest discomfort. Distress behaviors, such as vocalization of sounds associated with pain, changes in facial expression, and unexpected or unusual body movements, have been associated with pain (Figs. 5-1 and 5-2). Understanding that these behaviors are associated with pain makes assessing pain in infants and small children with no or limited communication skills a little easier. However, discriminating between pain behaviors and reactions to other sources of distress, such as hunger, anxiety, or other types of discomfort, is not always easy. Behavioral pain measures are most reliable when used to measure short, sharp procedural pain, such as during injections or lumbar punctures, or when assessing pain in infants and young children. They are less reliable when measuring recurrent or chronic pain and when assessing pain in older children, where pain scores on behavioral measures do not always correlate with the children's own reports of pain intensity. Box 5-1 describes pain responses by infants and children of various ages.
TABLE 5-1 Summary of Selected Behavioral Pain Assessment Scales for Young Children
Ages of Use Reliability and Validity Variables Scoring Range FLACC Postoperative Pain Tool 2 months old to 7 years old
Validity using analysis of variance for repeated measures to compare FLACC scores before and after analgesia; preanalgesia FLACC scores significantly higher than postanalgesia scores at 10, 30, and 60 minutes (p < 0.001 for each time) Correlation coefficients used to compare FLACC pain scores and OPS; significant positive correlation between FLACC and OPS (r = 0.80; p < 0.001); positive correlation also found between FLACC scores and nurses' global ratings of pain (r[47] = 0.41; p < 0.005)
Face (0-2) Legs (0-2) Activity (0-2) Cry (0-2) Consolability (0-2)
0 = no pain; 10 = worst pain
FLACC SCALE FLACC 0 1 2 Face No particular expression or smile Occasional grimace or frown,
withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense
Arched, rigid, or jerking
Cry No cry (awake or asleep) Moans or whimpers, occasional complaint
Crying steadily, screams or sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible
Difficult to console or comfort
OPS, Observational pain scores. From Merkel SI, Voepel-Lewis T, Shayevitz JR, et al: The FLACC: a behavioral scale for scoring postoperative pain in young children, Pediatr Nurs 23(3):293–297, 1997. Used with permission of Jannetti Publications, Inc., and the University of Michigan Health System. Can be reproduced for clinical and research use.
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FIG 5-1 Full, robust crying of preterm infant after heel stick. (Courtesy of Halbouty Premature Nursery, Texas Children's Hospital, Houston, TX; photo by Paul Vincent Kuntz.)
FIG 5-2 The face of pain after heel stick. Note eye squeeze, brow bulge, nasolabial furrow, and wide- spread mouth. (Courtesy of Halbouty Premature Nursery, Texas Children's Hospital, Houston, TX; photo by Paul Vincent Kuntz.)
Box 5-1 C h i l d r e n ' s R e s p o n s e s t o Pa i n a t Va r i o u s A g e s Newborn and Young Infant
• Uses crying
• Reveals facial appearance of pain (brows lowered and drawn together, eyes tightly closed, and mouth open and squarish)
• Exhibits generalized body response of rigidity or thrashing, possibly with local reflex withdrawal from what is causing the pain
• Shows no relationship between what is causing the pain and subsequent response
Older Infant
• Uses crying
• Shows a localized body response with deliberate withdrawal from what is causing the pain
• Reveals expression of pain or anger
• Demonstrates a physical struggle, especially pushing away from what is causing the pain
Young Child
• Uses crying and screaming
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• Uses verbal expressions, such as “Ow,” “Ouch,” or “It hurts”
• Uses thrashing of arms and legs to combat pain
• Attempts to push what is causing the pain away before it is applied
• Displays lack of cooperation; need for physical restraint
• Begs for the procedure to end
• Clings to parent, nurse, or other significant person
• Requests physical comfort, such as hugs or other forms of emotional support
• Becomes restless and irritable with ongoing pain
• Worries about the anticipation of the actual painful procedure
School-Age Child
• Demonstrates behaviors of the young child, especially during actual painful procedure, but less before the procedure
• Exhibits time-wasting behavior, such as “Wait a minute” or “I'm not ready”
• Displays muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead
Adolescent
• Less vocal with less physical resistance
• More verbal in expressions, such as “It hurts” or “You're hurting me”
• Displays increased muscle tension and body control
The FLACC Pain Assessment Tool is an interval scale that includes the five categories of behavior: Facial expression, Leg movement, Activity, Cry, and Consolability (Babl, Crellin, Cheng, et al, 2012; Merkel, Voepel-Lewis, Shayevitz, et al, 1997). It measures each behavior on a 0 to 10 scale, with total scores ranging from 0 (no pain behaviors) to 10 (most possible pain behaviors).
The only behavior pain measurement tool recommended for use with children in critical care settings is the COMFORT scale (Ambuel, Hamlett, Marx, et al, 1992). The COMFORT scale is a behavioral, unobtrusive method of measuring distress in unconscious and ventilated infants, children, and adolescents. This scale has eight indicators: alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each indicator is scored between 1 and 5 based on the behaviors exhibited by the patient. The provider observes the patient unobtrusively for 2 minutes and derives the total score by adding the scores of each indicator. The total scores can range between 8 and 40. A score of 17 to 26 generally indicates adequate sedation and pain control. The COMFORT behavior (COMFORT-B) scale is able to detect specific changes in pain or distress intensity in critically-ill children and in young children with burns (Boerlage, Ista, Duivenvoorden, et al, 2015; de Jong, Tuinebreijer, Bremer, et al, 2012). The COMFORT scale performed best when compared to the CHIPPS, CRIESS, and PIPP in assessing behavioral and physiologic components of pain in newborns following cardiac surgery (Franck, Ridout, Howard, et al, 2011).
Self-Report Pain Rating Scales Self-report measures are most often used for children older than 4 years old (Table 5-2). There are many different “faces” scales for the measurement of pain intensity. Although children at 4 or 5 years old are able to use self-report measures, cognitive characteristics of the preoperational stage
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influence their ability to separate feelings of pain and mood. Smiling faces on pain assessment scales can result in inadequacies of the pain rating (Quinn, Sheldon, and Cooley, 2014). Simple, concrete anchor words, such as “no hurt” to “biggest hurt,” are more appropriate than “least pain sensation to worst intense pain imaginable.” The ability to discriminate degrees of pain in facial expressions appears to be reasonably established by 3 years old (see Table 5-2). Faces scales provide a series of facial expressions depicting gradations of pain. The faces are appealing because children can simply point to the face that represents how they feel.
TABLE 5-2 Pain Rating Scales for Children
Pain Scale, Description Instructions Recommended Age, Comments Wong-Baker FACES Pain Rating Scale* Consists of six cartoon faces ranging from smiling face for “no pain” to tearful face for “worst pain”
Original instructions: Explain to child that each face is for a person who feels happy because there is no pain (hurt) or sad because there is some or a lot of pain. FACE 0 is very happy because there is no hurt. FACE 1 hurts just a little bit. FACE 2 hurts a little more. FACE 3 hurts even more. FACE 4 hurts a whole lot, but FACE 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask child to choose face that best describes own pain. Record number under chosen face on pain assessment record. Brief word instructions: Point to each face using the words to describe the pain intensity. Ask child to choose face that best describes own pain, and record appropriate number.
For children as young as 3 years old. Using original instructions without affect words, such as happy or sad, or brief words resulted in same range of pain rating, probably reflecting child's rating of pain intensity. For coding purposes, numbers 0, 2, 4, 6, 8, and 10 can be substituted for 0 to 5 system to accommodate 0 to 10 system. The Wong-Baker FACES Pain Rating Scale provides three scales in one: facial expressions, numbers, and words. Research supports cultural sensitivity of FACES for Caucasian, African- American, Hispanic, Thai, Chinese, and Japanese children.
Word-Graphic Rating Scale† (Tesler, Savedra, Holzemer, et al, 1991) Uses descriptive words (may vary in other scales) to denote varying intensities of pain
Explain to child, “This is a line with words to describe how much pain you may have. This side of the line means no pain, and over here the line means worst possible pain.” (Point with your finger where “no pain” is, and run your finger along the line to “worst possible pain,” as you say it.) “If you have no pain, you would mark like this.” (Show example.) “If you have some pain, you would mark somewhere along the line, depending on how much pain you have.” (Show example.) “The more pain you have, the closer to worst pain you would mark. The worst pain possible is marked like this.” (Show example.) “Show me how much pain you have right now by marking with a straight, up-and-down line anywhere along the line to show how much pain you have right now.” With millimeter rule, measure from the “no pain” end to mark and record this measurement as pain score.
For children from 4 to 17 years old.
Numeric Scale Uses straight line with end points identified as “no pain” and “worst pain” and sometimes “medium pain” in the middle; divisions along line marked in units from 0 to 10 (high number may vary)
Explain to child that at one end of line is 0, which means that person feels no pain (hurt). At the other end is usually a 5 or 10, which means the person feels worst pain imaginable. The numbers 1 to 5 or 1 to 10 are for very little pain to a whole lot of pain. Ask child to choose number that best describes own pain.
For children as young as 5 years old, as long as they can count and have some concept of numbers and their values in relation to other numbers. Scale may be used horizontally or vertically. Number coding should be same as other scales used in facility.
Visual Analog Scale (VAS) (Cline, Herman, Shaw, et al, 1992) Defined as vertical or horizontal line that is drawn to certain length, such as 10 cm (4 inches), and anchored by items that represent extremes of the subjective phenomenon being measured, such as pain
Ask child to place mark on line that best describes amount of own pain. With centimeter ruler, measure from “no pain” end to the mark, and record this measurement as the pain score. For children as young as years
old, preferably 7 years old. Vertical or horizontal scale may be used. Research shows that children from ages 3 to18 years old least prefer VAS compared with other scales (Luffy and Grove, 2003; Wong and Baker, 1988).
Oucher (Villarruel and Denyes, 1991) Consists of six photographs Numeric scale: Point to each section of scale to explain variations in pain intensity: For children from 3 to 13 years old.
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of a white child's face representing “no hurt” to “biggest hurt you could ever have;” also includes vertical scale with numbers from 0 to 100; scales for African- American and Hispanic children have been developed
“0 means no hurt.” “This means little hurts” (pointing to lower part of scale, 1 to 29). “This means middle hurts” (pointing to middle part of scale, 30 to 69). “This means big hurts” (pointing to upper part of scale, 70 to 99). “100 means the biggest hurt you could ever have.” Score is actual number stated by child. Photographic scale: Point to each photograph and explain variations in pain intensity using following language:
First picture from the bottom is “no hurt,” second is “a little hurt,” third is “a little more hurt,” fourth is “even more hurt than that,” fifth is “pretty much or a lot of hurt,” and sixth is “biggest hurt you could ever have.”
Score pictures from 0 to 5, with bottom picture scored as 0. General: Practice using Oucher by recalling and rating previous pain experiences (e.g., falling off bike). Child
points to number or photograph that describes pain intensity associated with experience. Obtain current pain score from child by asking, “How much hurt do you have right now?”
Use numeric scale if child can count off any two numbers or by tens (Jordan- Marsh, Yoder, Hall, et al, 1994). Determine whether child has cognitive ability to use photographic scale; child should be able to rate six geometric shapes from largest to smallest. Determine which ethnic version of Oucher to use; allow child to select version of Oucher or use version that most closely matches physical characteristics of child. Note: Ethnically similar scale may not be preferred by child when given choice of ethnically neutral cartoon scale (Luffy and Grove, 2003).
*Copyright 1983, Wong-Baker FACES Foundation, www.WongBakerFACES.org. Used with permission. Originally published in Whaley & Wong's Nursing Care of Infants and Children. ©Elsevier Inc. †Instructions for Word-Graphic Rating Scale from Acute Pain Management Guideline Panel: Acute pain management in infants, children, and adolescents: operative and medical procedures; quick reference guide for clinicians, ACHPR Pub. No. 92-0020, Rockville, MD, 1992, Agency for Health Care Research and Quality, US Department of Health and Human Services. Word-Graphic Rating Scale is part of the Adolescent Pediatric Pain Tool and is available from Pediatric Pain Study, University of California, School of Nursing, Department of Family Health Care Nursing, San Francisco, CA 94143-0606; 415-476-4040.
The Faces Pain Scale–Revised (FPS-R; Hicks, von Baeyer, Spafford, et al, 2001) and the Wong- Baker FACES Pain Rating Scale (Wong and Baker, 1988) are the most widely used faces pain measurement tools. The FPS-R scale consists of six faces depicting increasing gradation of pain severity from 0 = “no pain” on the left face to 5 = “most pain possible” on the right face. In developing this scale, the authors did not include a smiling face at the “no pain” end or tears at the “most pain” end and validated it so that it is equivalent to a 0 to 10 metric system. The Wong-Baker FACES Pain Rating Scale consists of six cartoon faces ranging from a smiling face for “no pain” to a tearful face for “worst pain.” The child is asked to choose a face that describes his or her pain. The Wong-Baker FACES Pain Rating Scale is able to differentiate pain from fear in school-aged children (Garra, Singer, Domingo, et al, 2013). The Wong-Baker FACES Pain Rating Scale is the most preferred and widely used in children's hospitals across the United States and has been translated into many languages (Oakes, 2011).
For children 8 years old and older, the Numeric Rating Scale (NRS), specifically the 0 to 10 scale, is most widely used in clinical practice because it is easy to use. The Visual Analogue Scale (VAS) uses descriptors along a line that provides a highly subjective evaluation of a pain or other symptom. VASs are often used with older children and adults. Although the VAS requires a higher degree of abstraction than the NRS, the PedIMMPACT group recommends the VAS because of the lack of supportive evidence through psychometric studies with the NRS in children and adolescents.
The number of pain measures available for use in infants, young children, and adolescents has increased dramatically and adds a layer of complexity to the assessment of pain in children. The current trend supports a common metric for measurement of pain in children. Most instruments consist of 0 for no pain to a range of 4 to 160 for the top anchors in pain measures. A pain score of 5 may mean a lot of pain (if a 0 to 5 scale is used) or very little (if a 0 to 100 scale is used), and it may not be clearly specified which score corresponds to which scale. Other health care providers who do not specialize in pediatric pain may be confused by the available instruments and scoring methods and may not be able to determine the effectiveness of interventions by the pain score documented. An advantage to using a common metric is that a certain score may be considered as the point at which an intervention is required, or a point at which relief may be considered effective. The 0 to 10 system as the common metric was reported to be preferred by health care providers and would make pain scores easier to read, interpret, and integrate into research and practice.
Multidimensional Measures Several cognitive skills, such as measurement, classification, and seriation (the ability to accurately place in ascending or descending order), become apparent between 7 and 10 years old. Older children are able to use a 0 to 10 NRS used by adolescents and adults. Other dimensions (such as pain quality, pain location, and spatial distribution of pain) may change without a change in pain intensity.
Pain charts or pain drawings are used to obtain information regarding the location of pain and have been well validated for children 8 years old and older (von Baeyer, Lin, Seidman, et al, 2011). The Adolescent Pediatric Pain Tool (APPT), modeled after the McGill Pain Questionnaire (Melzack, 1975), is a multidimensional pain measurement instrument used with children and adolescents to
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assess pain location, intensity, and quality (Fernandes, De Campos, Batalha, et al, 2014) (Fig. 5-3). The APPT is an instrument with an anterior and posterior body outline on one side and a 100-mm word-graphing rating scale with a pain descriptor on the other side (Savedra, Holzemer, Tesler, et al, 1993; Savedra, Tesler, Holzemer, et al, 1989; Tesler, Savedra, Holzemer, et al, 1991). Each of the three components of the APPT is scored separately. The body outline is scored by placing a clear plastic template overlay with 43 body areas on the body outline diagram. An estimate of the pervasiveness of the pain is made by counting the number of body areas marked. A ruler or micrometer preprinted on the APPT is used to score the word-graphic rating scale. The number of millimeters from the left side of the scale to the point marked by the child is measured; and the numeric value provides an overall evaluation of the amount of pain the child is experiencing. The total number of words on the descriptor list is counted, and scores range from 0 to 56. The clinician then counts the number of words selected in each of three categories—evaluative (0-8), sensory (0- 37), and affective (0-11)—and calculates a percentage score for each one (Savedra, Holzemer, Tesler, et al, 1993). A systematic review of the APPT found that it can be helpful in customizing pain management interventions for adolescents (Fernandes, De Campos, Batalha, et al, 2014).
FIG 5-3 Adolescent Pediatric Pain Tool (APPT): Body outlines for pain assessment. Instructions: “Color in the areas on these drawings to show where you have pain. Make the marks as big or as small as the place where the pain is.” Tool has been completed by a child with sickle cell disease. (Redrawn from Savedra MC, Tesler MD, Holzemer WL, Ward JA. Adolescent pediatric pain tool (APPT): preliminary user's manual. San Francisco: University of
California, 1989.)
The Pediatric Pain Questionnaire (PPQ) is a multidimensional pain instrument to assess patient and parental perceptions of the pain experience in a manner appropriate for the cognitive- developmental level of children and adolescents (Lootens and Rapoff, 2011). The PPQ consists of eight areas of inquiry: pain history, pain language, the colors children associate with pain, emotions children experience, the worst pain experiences, the ways children cope with pain, the positive aspects of pain, and the location of their current pain. The three components of the PPQ include (1) VASs; (2) color-coded rating scales; and (3) verbal descriptors to provide information about the sensory, affective, and evaluative dimensions of chronic pain. There is also information about the child and family's pain history, symptoms, pain relief interventions, and socioenvironmental situations that may influence pain. The child, parent, and physician each complete the form separately.
Chronic and Recurrent Pain Assessment Pain that persists for 3 months or more or beyond the expected period of healing is defined as
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chronic pain. Complex regional pain syndrome and chronic daily headache are the most common types of chronic pain conditions in children. Pain that is episodic and recurs is defined as recurrent pain—the time frame within which episodes of pain recurs every 3 months or more frequently. Recurrent pain syndromes in children include migraine headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain (see Research Focus box).
R e s e a r c h F o c u s Pain in School-Age Children
Van Dijk, McGrath, Pickett, et al (2006) reported that 57% of school-age children have at least one recurrent pain (headaches, stomach pains, growing pains) and at least 6% have one or more chronic pain episodes (disease related, back pain).
Chronic or recurrent pain adversely affects the psychosocial and physical well-being of children. The domains for the assessment of chronic or recurrent pain are the same for acute pain (pain intensity, global judgment of satisfaction with treatment, symptoms and adverse events, physical functioning, emotional functioning, economic factors), plus two additional domains: role functioning and sleep. Because the time course of chronic or recurrent pain is different from that of acute pain, measures used to assess chronic pain often evaluate the symptom over time.
A systematic review of treatment for functional abdominal pain disorders found no evidence to support pharmacologic therapy (Korterink, Rutten, Venmans, et al, 2015).
For children and adolescents with chronic pain, a measure such as the Functional Disability Inventory (FDI) (Walker and Greene, 1991) provides a more comprehensive evaluation of the influence of pain on physical functioning. The FDI assesses the child's ability to perform everyday physical activities and has established psychometric properties with different populations (Claar and Walker, 2006; Kashikar-Zuck, Flowers, Claar et al, 2011). For children younger than 7 years old, the Pediatric Quality of Life Scale (PedsQL), developed by Varni, Seid, and Rode (1999), is a multidimensional scale with both parent and child versions that is recommended for assessing physical, emotional, social, and academic functioning as they relate to the child's pain. The PedsQL and the PedMIDAS (Gold, Mahrer, Yee, et al, 2009; Hershey, Powers, Vockell, et al, 2001; 2004) have been validated for measurement of role functioning in children with chronic or recurrent pain. The PedMIDAS is specifically designed to evaluate pain caused by migraines in children.
Pain diaries are commonly used to assess pain symptoms and response to treatment in children and adolescents with recurrent or chronic pain (Fortier, Wahi, Bruce, et al, 2014; Stinson, Stevens, Feldman, et al, 2008). Diary studies have included children as young as 6 years old. Conventional paper-and-pencil measures have been associated with several limitations, such as poor compliance, missing data, hoarding of responses, and back and forward filling. An electronic diary to assess pediatric chronic pain is a developing area that holds promise for the future (see Research Focus box).
R e s e a r c h F o c u s Electronic Diaries
An increasing number of studies are converting paper diaries into electronic diaries for use in school-age children and adolescents with recurrent or chronic pain (Stinson, Stevens, Feldman, et al, 2008). Electronic diaries were found to show higher accuracy of children's diary responses and higher compliance rates when compared with the paper format. However, electronic diaries are more expensive and may have a number of logistical issues left to resolve.
Sleep disruption is also common in those with chronic or recurrent pain (Valrie, Bromberg, Palermo, et al, 2013). A sleep diary can be useful in keeping a record of activities surrounding sleep, including bedtime, time to fall asleep, number of night awakenings, waking in the morning, and especially any pain or other circumstance that interfered with sleeping. The sleep diary was validated using sleep actigraphy in healthy 13- to 14-year-old children (Gaina, Sekine, Chen, et al,
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2004). The Sleep Habits Questionnaire, which is useful for assessing sleep behaviors in school-age children with chronic or recurrent pain, has also been evaluated for use in preschool and toddlers using parent proxy (Sneddon, Peacock, and Crowley, 2013).
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Assessment of Pain in Specific Populations Pain in Neonates The impact of early pain exposure greatly affects the developing nervous system, with persistent long-term effects. This makes neonatal assessment extremely important, although difficult, because the most reliable indicator of pain, self-report, is not possible. Evaluation must be based on physiologic changes and behavioral observations with validated instruments (Hatfield and Ely, 2015) (Box 5-2). Although behaviors (such as vocalizations, facial expressions, body movements, and general relaxation state) are common to all infants, they vary with different situations. Crying associated with pain is more intense and sustained (see Fig. 5-1). Facial expression is the most consistent and specific characteristic; scales are available to systematically evaluate facial features, such as eye squeeze, brow bulge, open mouth, and taut tongue. Most infants respond with increased body movements, but the infant may be experiencing pain even when lying quietly with eyes closed. The preterm infant's response to pain may be behaviorally blunted or absent; however, there is ample evidence that such infants are neurologically capable of feeling pain. In addition, infants in awake or alert states demonstrate a more robust reaction to painful stimuli than infants in sleep states. Also, an infant receiving a muscle-paralyzing agent (vecuronium) is incapable of a behavioral or visible pain response.
Box 5-2 M a n i f e s t a t i o n s o f A c u t e Pa i n i n t h e N e o n a t e Physiologic Responses
Vital signs: Observe for variations
• Increased heart rate
• Increased blood pressure
• Rapid, shallow respirations
Oxygenation
• Decreased transcutaneous oxygen saturation (TcPO2)
• Decreased arterial oxygen saturation (SaO2)
Skin: Observe color and character
• Pallor or flushing
• Diaphoresis
• Palmar sweating
Other observations
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• Increased muscle tone
• Dilated pupils
• Decreased vagal nerve tone
• Increased intracranial pressure
• Laboratory evidence of metabolic or endocrine changes: Hyperglycemia, lowered pH, elevated corticosteroids
Behavioral Responses
Vocalizations: Observe quality, timing, and duration
• Crying
• Whimpering
• Groaning
Facial expression: Observe characteristics, timing, orientation of eyes and mouth
• Grimaces
• Brow furrowed
• Chin quivering
• Eyes tightly closed
• Mouth open and squarish
Body movements and posture: Observe type, quality, and amount of movement or lack of movement; relationship to other factors
• Limb withdrawal
• Thrashing
• Rigidity
• Flaccidity
• Fist clenching
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Changes in state: Observe sleep, appetite, activity level
• Changes in sleep-wake cycles
• Changes in feeding behavior
• Changes in activity level
• Fussiness, irritability
• Listlessness
SaO2, Arterial oxygen saturation; TcPO2, transcutaneous oxygen pressure.
Although regular use of pain assessment tools can assist caregivers in determining whether the infant is in pain, caregivers must consider the infant's maturity, behavioral state, energy resources available to respond, and risk factors for pain. In infants with diminished ability to respond robustly to pain, it is imperative to presume that pain exists in all situations that are usually considered painful for adults and children, even in the absence of behavioral or physiologic signs.
Several pain assessment tools for neonates have been developed (Table 5-3). One tool used by nurses who work with premature and full-term infants in the neonatal intensive care setting is called CRIES, which is an acronym for the tool's physiologic and behavioral indicators of pain: Crying, Requiring increased oxygen, Increased vital signs, Expression, and Sleeplessness. Each indicator is scored from 0 to 2, with a total possible pain score, representing the worst pain, of 10. A pain score greater than 4 is considered significant. This tool has been tested for reliability and validity for postoperative pain in infants between the ages of 32 weeks of gestation up to 20 weeks postterm (60 weeks) (Sweet and McGrath, 1998).
TABLE 5-3 Summary of Pain Assessment Scales for Infants
Ages of Use Reliability and Validity Variables ScoringRange Neonatal Infant Pain Scale (NIPS) (Lawrence, Alcock, McGrath, et al, 1993) Average gestational age: 33.5 weeks
Interrater reliability: 0.92 and 0.97 Construct validity using analysis of variance between scores before, during, and after procedure: F = 18.97, df = 2.42, p < 0.001 Concurrent validity between NIPS and visual analog scale (VAS) using Pearson correlations: 0.53-0.84 Internal consistency using Cronbach alpha: 0.95, 0.87, and 0.88 for before, during, and after procedure scores
Facial expression (0-1) Arms (0-1) Cry (0-2) Legs (0-1) Breathing patterns (0-1) State of arousal (0-1)
0 = no pain; 7 = worst pain
CRIES (Krechel and Bildner, 1995) 32-60 weeks of gestational age
Concurrent validity between CRIES and POPS: 0.73 (p < 0.0001, n = 1382); Spearman correlation between subjective report and POPS and CRIES: 0.49 (p < 0.0001, n > 1300) Discriminant validity using before and after analgesia scores: Wilcoxon sign rank test; mean decline of 3.0 units (p < 0.0001, n = 74) Interrater reliability using Spearman correlation coefficient: r = 0.72 (p < 0.0001, n = 680)
Crying (0-2) Requires increased oxygen (0-2) Increased vital signs (0-2) Expression (0-2) Sleepless (0-2)
0 = no pain; 10 = worst pain
Premature Infant Pain Profile (PIPP) (Stevens, Johnston, Petryshen, et al, 1996) 28-40 weeks of gestational age
Internal consistency using Cronbach alpha: 0.75-0.59; standardized item alpha for six items: 0.71 Construct validity using handling versus painful situations: Statistically significant differences (paired t = 12.24, two-tailed p < 0.0001, and Mann-Whitney U = 765.5, p < 0.00001) and using real versus sham heel stick procedures with infants ages 28-30 weeks of gestational age (t = 2.4, two-tailed p < 0.02, and Mann-Whitney U = 132, p < 0.016) and with full-term boys undergoing circumcision with topical anesthetic versus placebo (t = 2.6, two-tailed p < 0.02, or nonparametric equivalent Mann-Whitney U test, U = 145.7, two- tailed p < 0.02)
Gestational age (0-3) Eye squeeze (0- 3) Behavioral state (0-3) Nasolabial furrow (0-3) Heart rate (0-3) Oxygen saturation (0-3) Brow bulge (0- 3)
0 = no pain; 21 = worst pain
Neonatal Pain, Agitation, and Sedation Scale (NPASS) (Puchalski and Hummel, 2002) Birth (23 weeks of gestational age) and full- term newborns up to 100 days
Interrater reliability using ICC: 0.95 CI for preintervention and postintervention pain scale; 0.95 CI for preintervention and postintervention sedation scale
Internal consistency (Cronbach alpha): Preintervention pain scale, 0.75 and 0.71 raters 1 and 2 Postintervention pain scale, 0.25 and 0.27 raters 1 and 2 Preintervention sedation scale, 0.88 and 0.81 raters 1 and 2 Postintervention sedation scale, 0.86 and 0.89 raters 1 and 2
Cry/irritability (0-2) Behavior/state (0-2) Facial expression (0-2) Extremities/tone (0-2)
Pain score: 0 = no pain; 10 = intense pain Sedation score: 0 = no sedation; 10 = deep sedation
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Vital signs— heart rate, respiratory rate, blood pressure, SaO2 (0-2)
CRIES NEONATAL POSTOPERATIVE PAIN SCALE CRIES 0 1 2 Crying No High pitched Inconsolable Requires oxygen for saturation >95%
No <30% >30%
Increased vital signs
Heart rate and blood pressure ≤preoperative state Heart rate and blood pressure increase <20% of preoperative state
Heart rate and blood pressure increase >20% of preoperative state
Expression None Grimace Grimace, grunt
Sleepless No Wakes at frequent intervals
Constantly awake
CI, Confidence intervals; ICC, interclass correlations; SaO2, arterial oxygen saturation.
The Premature Infant Pain Profile (PIPP) was developed specifically for preterm infants (Sweet and McGrath, 1998; Gibbons, Stevens, Yamada, et al, 2014). The category “gestational age at time of observation” gives a higher pain score to infants with lower gestational age. Infants who are asleep 15 seconds before the painful procedure also receive additional points for their blunted behavioral responses to painful stimuli.
The Neonatal Pain, Agitation, and Sedation Scale (NPASS) was originally developed to measure pain or sedation in preterm infants after surgery (Hillman, Tabrizi, Gauda, et al, 2015). It measures five criteria (see Table 5-3) in two dimensions (pain and sedation) and is used in neonates as young as 23 weeks of gestation up to infants 100 days old. Extra points are added in the pain scale dimension for preterm infants based on gestational age.
Children with Communication and Cognitive Impairment The assessment of pain in children with communication and cognitive impairment can be challenging (Crosta, Ward, Walker, et al, 2014). Children who have significant difficulties in communicating with others about their pain include those who have significant neurologic impairments (e.g., cerebral palsy), cognitive impairment, metabolic disorders, autism, severe brain injury, and communication barriers (e.g., critically ill children who are on ventilators or heavily sedated or have neuromuscular disorders, loss of hearing, or loss of vision) and consequently are at greater risk for undertreatment of pain. Children with communication and cognitive deficits often experience spasticity, contractures, injury, infection, and orthopedic surgical treatment that may be painful. Behaviors include moaning, inconsistent patterns of play and sleep, changes in facial expression, and other physical problems that may mask expression of pain and be difficult to interpret (see Research Focus box).
R e s e a r c h F o c u s Pain Reporting in Cognitively Impaired Children
Parents of children with severe cognitive impairment reported that their child experienced pain or severe discomfort that was not being effectively managed (Crosta, Ward, Walker, et al, 2014; Malviya, Voepel-Lewis, Burke, et al, 2006). The most frequently reported pain behaviors are crying; being less active; seeking comfort; moaning; not cooperating; being irritable; being stiff, spastic, tense, or rigid; sleeping less; being difficult to satisfy or pacify; flinching or moving body part away; and being agitated or fidgety. Parents also reported that some daily living activities were painful, such as assisted stretching and walking, independent standing, toileting, putting on splints, occupational therapy, range of motion, and physical therapy.
The revised FLACC observational pain scale uses a behavioral approach that observes the child's face, legs, activity, cry, and consolability and is supported for use in clinical practice for children with cognitive impairment (Voepel-Lewis, Malviya, Tait, et al, 2008).
The Non-Communicating Children's Pain Checklist-Revised (NCCPC) is a pain measurement tool specifically designed for children with cognitive impairments (Breau, McGrath, Camfield, et al,
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2002). The scale discriminates between periods of pain and calm and can predict behavior during subsequent episodes of pain (Fig. 5-4). The scale consists of six subscales (vocal, social, facial, activity, body and limbs, physiologic signs), which are scored based on the number of times the items are observed over a 10-minute period (0 = not at all; 1 = just a little; 2 = fairly often; 3 = very often). The NCCPC has been used during the postoperative period and was effective in measuring pain in the clinical setting (Massaro, Ronfani, Ferrara, et al, 2014).
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FIG 5-4 Non-communicating Children's Pain Checklist—Postoperative Version (NCCPC- PV). (Copyright 2004, Lynn Breau, Patrick McGrath, Allen Finley, and Carol Camfield. Reprinted with permission.)
Cultural Differences Expression of pain can be greatly affected by communication barriers (Azize, Humphreys, Cattani, 2011). A major challenge in the assessment and management of pain in children is the cultural appropriateness of pain assessment tools that have been validated only in Caucasian and English- speaking children (see Cultural Considerations and Research Focus boxes). Cultural background may influence the validity and reliability of pain assessment tools developed in a single cultural context.
C u l t u r a l C o n s i d e r a t i o n s Pain Scales
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Observational scales and interview questionnaires for pain may not be as reliable for pain assessment as self-report scales in children of Hispanic origin. Children of Asian descent, who may learn to read Chinese characters vertically downward and from right to left, may have difficulty using horizontally-oriented scales.
R e s e a r c h F o c u s Pain Reporting in Non–English-Speaking Children
Jacob, McCarthy, Sambuco, et al (2008) examined the pain experience of Spanish-speaking children with cancer who were asked about their pain during the week before a scheduled oncology clinic appointment. They found that 41% of the patients were experiencing pain. Some were experiencing moderate to severe pain and did not receive medications because they did not report their pain.
Children with Chronic Illness and Complex Pain Questionnaires and pain assessment scales do not always provide the most meaningful means of assessing pain in children, particularly for those with complex pain. Some children cannot relate to a face or a number that describes their pain. Other children, such as those with cancer, are experiencing multiple symptoms and may find it difficult to isolate the pain from other symptoms. Rating the pain is only one aspect of assessment and does not always accurately convey to others how they really feel (Oakes, 2011).
The most important aspect of pain assessment for children with chronic illness, particularly those with complex pain, is the relationship that develops between the child and the family. This relationship offers health care providers a sense of what the pain experience means to the child and family. The pain experience can interfere with the child's ability to eat, sleep, and perform daily activities and routines and may be complicated by side effects of medical treatments, and complications associated with disease management.
Other important components of assessment include the onset of pain; pain duration or pattern; the effectiveness of the current treatment; factors that aggravate or relieve the pain; other symptoms and complications concurrently felt; and interference with the child's mood, function, and interactions with family (Pasero and McCaffrey, 2011). In addition to asking the child or parent when the pain started and how long the pain lasts, the nurse can assess variations and rhythms by asking whether the pain is better or worse at certain times of the day or night. If the child has had pain for a while, the child or parent may know which medications and doses are helpful. They may also have found some nonpharmacologic methods that have helped. The nurse may ask the child or parent to keep a diary of activities, positions, and other events that may increase or decrease the pain. Pain may be accompanied by other symptoms (such as nausea and poor appetite), and it may interfere with sleep and other activities. A diary can help families identify triggers that may cause pain and interventions that work.
Other aspects warranting careful assessment that may pose barriers to effective management include family issues and relationships, fears and concerns about addictions the clinician's and family's lack of knowledge about pain, inappropriate use of pain medications, ineffective management of adverse effects from medications, and the use of different pain management modalities.
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Pain Management Children may experience pain as a result of surgery, injuries, acute and chronic illnesses, and medical or surgical procedures. Unrelieved pain may lead to potential long-term physiologic, psychosocial, and behavioral consequences. Improving pain management requires a multifactorial approach encompassing education, institutional support, attitude shifts, and change leaders (Twycross, 2010). Nonpharmacologic interventions and adequate pain medications are both essential to providing optimal pain management.
Nonpharmacologic Management Pain is often associated with fear, anxiety, and stress. A number of nonpharmacologic techniques, such as distraction, relaxation, guided imagery, and cutaneous stimulation, can help with pain control (see Nursing Care Guidelines box). It is also important to provide coping strategies that help reduce pain perception, make pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics or reduce the dosage required.
N u r s i n g C a r e G u i d e l i n e s Nonpharmacologic Strategies for Pain Management
General Strategies
Consult child-life specialist.
Use nonpharmacologic interventions to supplement, not replace, pharmacologic interventions, and use for mild pain and pain that is reasonably well controlled with analgesics.
Form a trusting relationship with child and family.
Express concern regarding their reports of pain and intervene appropriately.
Take an active role in seeking effective pain management strategies.
Use general guidelines to prepare child for procedure.
Prepare child before potentially painful procedures, but avoid “planting” the idea of pain.
• For example, instead of saying, “This is going to (or may) hurt,” say, “Sometimes this feels like pushing, sticking, or pinching, and sometimes it doesn't bother people. Tell me what it feels like to you.”
• Use “nonpain” descriptors when possible (e.g., “It feels like heat” rather than “It's a burning pain”). This allows for variation in sensory perception, avoids suggesting pain, and gives the child control in describing reactions.
• Avoid evaluative statements or descriptions (e.g., “This is a terrible procedure” or “It really will hurt a lot”).
Stay with child during a painful procedure.
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Allow parents to stay with child if child and parent desire; encourage parent to talk softly to child and to remain near child's head.
Involve parents in learning specific nonpharmacologic strategies and in assisting child with their use.
Educate child about the pain, especially when explanation may lessen anxiety (e.g., that pain may occur after surgery and does not indicate something is wrong); reassure the child that he or she is not responsible for the pain.
For long-term pain control, offer the child a doll, which represents “the patient,” and allow child to do everything to the doll that is done to them; emphasize pain control through the doll by stating, “Dolly feels better after the medicine.”
Teach procedures to child and family for later use.
Specific Strategies Distraction
Involve parent and child in identifying strong distractors.
Involve child in play; use radio, tape recorder, CD player, or computer game; have child sing or use rhythmic breathing.
Have child take a deep breath and blow it out until told to stop.
Have child blow bubbles to “blow the hurt away.”
Have child concentrate on yelling or saying “ouch,” with instructions to “yell as loud or soft as you feel it hurt; that way I know what's happening.”
Have child look through kaleidoscope (type with glitter suspended in fluid-filled tube) and encourage him or her to concentrate by asking, “Do you see the different designs?”
Use humor, such as watching cartoons, telling jokes or funny stories, or acting silly with child.
Have child read, play games, or visit with friends.
Relaxation
With an infant or young child:
• Hold in a comfortable, well-supported position, such as vertically against the chest and shoulder.
• Rock in a wide, rhythmic arc in a rocking chair or sway back and forth, rather than bouncing child.
• Repeat one or two words softly, such as “Mommy's here.”
With a slightly older child:
• Ask child to take a deep breath and “go limp as a rag doll” while exhaling slowly; then ask child to yawn (demonstrate if needed).
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• Help child assume a comfortable position (e.g., pillow under neck and knees).
• Begin progressive relaxation: starting with the toes, systematically instruct child to let each body part “go limp” or “feel heavy.” If child has difficulty relaxing, instruct child to tense or tighten each body part and then relax it.
• Allow child to keep eyes open, since children may respond better if eyes are open rather than closed during relaxation.
Guided Imagery
Have child identify some highly pleasurable real or imaginary experience.
Have child describe details of the event, including as many senses as possible (e.g., “feel the cool breezes,” “see the beautiful colors,” “hear the pleasant music”).
Have child write down or tape record script.
Encourage child to concentrate only on the pleasurable event during the painful time; enhance the image by recalling specific details by reading the script or playing the tape.
Combine with relaxation and rhythmic breathing.
Positive Self-Talk
Teach child positive statements to say when in pain (e.g., “I will be feeling better soon,” or “When I go home, I will feel better, and we will eat ice cream”).
Thought Stopping
Identify positive facts about the painful event (e.g., “It does not last long”).
Identify reassuring information (e.g., “If I think about something else, it does not hurt as much”).
Condense positive and reassuring facts into a set of brief statements and have child memorize them (e.g., “Short procedure, good veins, little hurt, nice nurse, go home”).
Have child repeat the memorized statements whenever thinking about or experiencing the painful event.
Behavioral Contracting
Informal: May be used with children as young as 4 or 5 years old:
• Use stars, tokens, or cartoon character stickers as rewards.
• Give a child who is uncooperative or procrastinating during a procedure a limited time (measured by a visible timer) to complete the procedure.
• Proceed as needed if child is unable to comply.
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• Reinforce cooperation with a reward if the procedure is accomplished within specified time.
Formal: Use written contract, which includes:
• Realistic (seems possible) goal or desired behavior
• Measurable behavior (e.g., agrees not to hit anyone during procedures)
• Contract written, dated, and signed by all persons involved in any of the agreements
• Identified rewards or consequences that are reinforcing
• Goals that can be evaluated
• Commitment and compromise requirements for both parties (e.g., while timer is used, nurse will not nag or prod child to complete procedure)
There is strong evidence that distraction and hypnosis are effective interventions for needle- related pain and distress in children and adolescents (Uman, Birnie, Noel, et al, 2013). There is less evidence that cognitive-behavioral therapy (CBT), parent coaching plus distraction, suggestion, or virtual reality are effective for needle-related pain. Environmental and psychological factors may exert a powerful influence on children's pain perceptions and may be modified by using psychosocial strategies, education, parental support, and cognitive-behavioral interventions. CBT is an evidence-based psychological approach for managing pediatric pain (Logan, Coakley, and Garcia, 2014). CBT uses strategies that focus on thoughts and behaviors that modify negative beliefs and enhance the child's ability to solve pain-related problems that result in better pain management.
Nonnutritive sucking (pacifier) (Fig. 5-5), kangaroo care, swaddling/facilitated tucking interventions reduce behavioral, physiologic, and hormonal responses to pain from procedures, such as heel punctures, in preterm and newborn infants (Meek and Huertas, 2012; Pillai Riddell, Racine, Turcotte, et al, 2011) (see Research Focus box).
R e s e a r c h F o c u s Nonpharmacologic Methods of Pain Management—Preterm and Newborn Infants
Sucrose is safe and effective in reducing pain during needle sticks in neonates (Stevens, Yamada, Ohlsson, et al, 2004). In a randomized controlled trial of 71 infants comparing oral sucrose, facilitated tucking, and a combination of both interventions, sucrose with and without facilitated tucking had pain-relieving effects (Cignacco, Sellam, Stoffel, 2012). Significant differences were found in pain responses during heel lancing between infants who were kangaroo held and those who were not. Infant responses to pain during heel lance procedures were studied using kangaroo holding (Fig. 5-6), with the neonate held upright at a 60-degree angle between the mother's breasts for maximal skin-to-skin contact (Johnston, Stevens, Pinelli, et al, 2003). A blanket was placed over the neonate's back, and the mother's clothes were wrapped around the neonate for 30 minutes before the lancing procedure, during, and at least 30 minutes after the heel stick. Another group remained in the isolette in a prone position, swaddled with a blanket and the heel accessible, for 30
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minutes before the heel lancing procedure. Pain scores were significantly lower in kangaroo-held infants.
Although there is lack of evidence on the effectiveness of sweet-tasting solutions in reducing injection pain in infants and children 1 to 12 months old, the data is promising (Kassab, Foster, Foureur, et al, 2012). A recent randomized controlled trial found sucrose reduced 16- to 19-month- old infant distress during immunizations (Yilmaz, Ceylan, Oguz, et al, 2014).
FIG 5-5 Sucking following oral sucrose can enhance analgesia before a heel stick in a preterm infant.
FIG 5-6 Mother using kangaroo hold with her newborn infant. Note placement of the infant directly on the mother's skin.
If the child cannot identify a familiar coping technique, the nurse can describe several strategies (e.g., distraction, breathing, guided imagery) and let the child select the most appealing one. Experimentation with several strategies that are suitable to the child's age, pain intensity, and abilities is often necessary to determine the most effective approach. Parents should be involved in the selection process; they may be familiar with the child's usual coping skills and can help identify potentially successful strategies. Involving parents also encourages their participation in learning the skill with the child and acting as coach. If the parent cannot assist the child, other appropriate persons may include a grandparent, older sibling, nurse, or child-life specialist.
Children should learn to use a specific strategy before pain occurs or before it becomes severe. To
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reduce the child's effort, instructions for a strategy, such as distraction or relaxation, can be audiotaped and played during a period of comfort. However, even after they have learned an intervention, children often need help using it during a painful procedure. The intervention can also be used after the procedure. This gives the child a chance to recover, feel mastery, and cope more effectively.
Complementary Pain Medicine Many terms are used to describe approaches to health care that are outside the realm of conventional medicine as practiced in the United States. Complementary and alternative medicine (CAM), as defined by the National Center for Complementary and Alternative Medicine, is a group of diverse medical and health care systems, practices, and products that are not currently considered part of conventional medicine. Although some scientific evidence exists regarding some CAM therapies, for most, key questions are yet to be answered through well-designed scientific studies—questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.
Classification of Complementary and Alternative Medicine CAM therapies are grouped into five classes: • Biologically based—foods, special diets, herbal or plant preparations, vitamins, other supplements • Manipulative treatments—chiropractic, osteopathy, massage • Energy based—Reiki, bioelectric or magnetic treatments, pulsed fields, alternating and direct
currents • Mind-body techniques—mental healing, expressive treatments, spiritual healing, hypnosis,
relaxation • Alternative medical systems—homeopathy; naturopathy; ayurvedic; traditional Chinese
medicine, including acupuncture and moxibustion The therapies that are increasingly used include herbal medicine, massage, megavitamins, self-
help groups, folk remedies, energy healing, and homeopathy (Myers, Stuber, Bonamer-Rheingans, et al, 2005). CAM options are used frequently with children at the end of life and are found by their caregivers to be beneficial (Heath, Oh, Clarke, et al, 2012).
Pharmacologic Management The World Health Organization (2012) states that the principles for pharmacologic pain management should include: • Using a two-step strategy • Dosing at regular intervals • Using the appropriate route of administration • Adapting treatment to the individual child
The traditional World Health Organization stepladder has been replaced with a two-step approach for use with children. This two-step strategy consists of a choice of category of analgesic medications, according to the child's level of pain severity. For children older than 3 months old with mild pain, the first step is to administer a nonopioid; nonsteroidal antiinflammatory drugs (NSAIDs) are frequently used for mild pain. A strong opioid is usually administered to children with moderate or severe pain. Morphine is the medicine of choice for the second step, although other opioids may be considered (World Health Organization, 2012). The following sections discuss the most common pain medications used in children in the nonopioid and opioid categories.
Nonopioids Nonopioids, including acetaminophen (Tylenol, paracetamol) and NSAIDs are suitable for mild to moderate pain (Table 5-4). These agents are known for the antipyretic, antiinflammatory, and/or analgesic actions (Tobias, 2014a). Nonopioids are usually the first analgesics for pain related to tissue injury, also known as nociceptive pain. NSAIDs can provide safe and effective pain relief when dosed at appropriate levels with adequate frequency. Most NSAIDs take about 1 hour for effect, so
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timing is crucial.
TABLE 5-4 Nonsteroidal Antiinflammatory Drugs for Children
Drug Dosage Comments Acetaminophen (Tylenol) 10-15 mg/kg/dose q 4-6 h PO not to exceed five doses in 24 h or 75 mg/kg/day,
or 4000 mg/day Available in numerous preparations Nonprescription Higher dosage range may provide increased analgesia
Choline magnesium trisalicylate (Trilisate)
10-15 mg/kg q 8-12 h PO Maximum dose 3000 mg/day
Available in suspension, 500 mg/5 ml Prescription
Ibuprofen (children's Motrin, children's Advil)
Children >6 months old: 5-10 mg/kg/dose q 6-8 h Maximum dose 30 mg/kg/day or 3200 mg/day
Available in numerous preparations Available in suspension, 100 mg/5 ml, and drops, 100 mg/2.5 ml Nonprescription
Naproxen (Naprosyn) Children >2 years old: 5-7 mg/kg/dose every 12 h Maximum 20 mg/kg/day or 1250 mg/day
Available in suspension, 125 mg/5 ml, and several different dosages for tablets Prescription
Indomethacin 1-2 mg/kg q 6-12 h Maximum 4g/kg/day or 200 mg/day
Available in 25-mg and 50-mg capsules and suspension 25 mg/5 ml Prescription
Diclofenac 0.5-0.75 mg/kg q 6-12 h PO Maximum 3 mg/kg day or 200 mg/day
Available in 50-mg tablet and extended release 100-mg tablets Prescription
PO, By mouth. Data from McAuley DF: GlobalRPh: NSAID's, 2013, http:/globalrph.com/nsaids.htm.
Opioids Opioids are needed for moderate to severe pain (Tables 5-5 to 5-7). Morphine remains the standard agent used for comparison to other opioid agents. When morphine is not a suitable opioid, drugs such as hydromorphone hydrochloride (Dilaudid) and fentanyl citrate (Sublimaze) are used. Codeine, a once commonly used oral opiate analgesic, is a weak opioid and has well-known safety and efficacy problems related to genetic variability in biotransformation (Yellon, Kenna, Cladis, et al, 2014; Racoosin, Roberson, Pacanowski, et al, 2013; World Health Organization, 2012). For this reason, codeine is excluded as a recommendation for treatment of moderate pain in the WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Dilaudid has a longer duration of action than morphine (4 to 6 hours) and is less associated with nausea and pruritus than morphine. Sublimaze is a synthetic product that is 100 times more potent than morphine (Tobias, 2014b).
S a f e t y A l e r t The optimum dosage of an analgesic is one that controls pain without causing undesirable side effects. This usually requires titration, the gradual adjustment of drug dosage (usually by increasing the dose) until optimum pain relief without excessive sedation is achieved. Dosage recommendations are only safe initial dosages (see Tables 5-5 to 5-7), not optimum dosages.
TABLE 5-5 Starting Dosages for Opioid Analgesics in Opioid-Naive Children (1 to 12 Years Old)
Medicine Route of Administration Starting Dosage Morphine Oral (immediate release) 1 to 2 years old: 200-400 mcg/kg every 4 h
2 to 12 years old: 200-500 mcg/kg every 4 h (maximum: 5 mg) Oral (prolonged release) 200-800 mcg/kg every 12 h IV injection* 1 to 2 years old: 100 mcg/kg every 4 h
2 to 12 years old: 100-200 mcg/kg every 4 h (maximum: 2.5 mg)SC injection IV infusion Initial IV dose: 100-200 mcg/kga, then 20-30 mcg/kg/h SC infusion 20 mcg/kg/h
Fentanyl IV injection 1-2 mcg/kg,† repeated every 30 to 60 min IV infusion Initial IV dose 1-2 mcg/kg,† then 1 mcg/kg/h
Hydromorphone‡ Oral (immediate release) 30-80 mcg/kg every 3-4 h (maximum: 2 mg/dose) IV injection§ or SC injection 15 mcg/kg every 3-6 h
Methadone‖ Oral (immediate release) 100-200 mcg/kg Every 4 h for the first two to three doses, then every 6-12 h (maximum: 5 mg/dose initially)¶IV injectiona and SC injection
Oxycodone Oral (immediate release) 125-200 mcg/kg every 4 h (maximum: 5 mg/dose) Oral (prolonged release) 5 mg every 12 h
*Administer IV morphine slowly over at least 5 minutes. †Administer IV fentanyl slowly over 3 to 5 minutes. ‡Hydromorphone is a potent opioid, and significant differences exist between oral and IV dosing. Use extreme caution when converting from one route to another. In converting from parenteral hydromorphone to oral hydromorphone, doses may need to be titrated up to five times the IV dose. §Administer IV hydromorphone slowly over 2 to 3 minutes.
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ǁDue to the complex nature and wide interindividual variation in the pharmacokinetics of methadone, methadone should only be commenced by practitioners experienced with its use. ¶Methadone should initially be titrated like other strong opioids. The dosage may need to be reduced by 50% 2 to 3 days after the effective dose has been found to prevent adverse effects due to methadone accumulation. From then on, dosage increases should be performed at intervals of 1 week or over and with a maximum increase of 50%. aAdminister IV methadone slowly over 3 to 5 minutes. IV, Intravenous; SC, subcutaneous. From World Health Organization: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, Geneva, 2012, World Health Organization.
TABLE 5-6 Starting Dosages for Opioid Analgesics for Opioid-Naive Neonates
Medicine Route of Administration Starting Dosage Morphine IV injection* 25-50 mcg/kg every 6 h
SC injection IV infusion Initial IV dose* 25-50 mcg/kg, then 5-10 mcg/kg/h
100 mcg/kg every 4 or 6 h Fentanyl IV injection† 1-2 mcg/kg every 2-4 h‡
IV infusion† Initial IV dose‡ 1-2 mcg/kg, then 0.5-1 mcg/kg/h
*Administer intravenous (IV) morphine slowly over at least 5 minutes. †The IV doses for neonates are based on acute pain management and sedation dosing information. Lower doses are required for non-ventilated neonates. ‡Administer IV fentanyl slowly over 3 to 5 minutes. IV, Intravenous; SC, subcutaneous. From World Health Organization: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, Geneva, 2012, World Health Organization.
TABLE 5-7 Starting Dosages for Opioid Analgesics in Opioid-Naive Infants (1 Month to 1 Year Old)
Medicine Route of Administration Starting Dosage Morphine Oral (immediate release) 80-200 mcg/kg every 4 h
IV injection* 1 to 6 months old: 100 mcg/kg every 6 h 6 to 12 months old: 100 mcg/kg every 4 h (maximum: 2.5 mg/dose)SC injection
IV infusion* 1 to 6 months old: Initial IV dose: 50 mcg/kg, then 10-30 mcg/kg/h 6 to 12 months old: Initial IV dose: 100-200 mcg/kg, then 20-30 mcg/kg/h
SC infusion 1 to 3 months old: 10 mcg/kg/h 3 to 12 months old: 20 mcg/kg/h
Fentanyl† IV injection 1-2 mcg/kg every 2-4 h‡ IV infusion Initial IV dose 1-2 mcg/kg‡, then 0.5-1 mcg/kg/h
Oxycodone Oral (immediate release) 50-125 mcg/kg every 4 h
*Administer intravenous (IV) morphine slowly over at least 5 minutes. †The IV doses of fentanyl for infants are based on acute pain management and sedation dosing information. ‡Administer IV fentanyl slowly over 3 to 5 minutes. IV, Intravenous; SC, subcutaneous. From World Health Organization: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, Geneva, 2012, World Health Organization.
Coanalgesic Drugs Several drugs, known as coanalgesic drugs or adjuvant analgesics, may be used alone or with opioids to control pain symptoms and opioid side effects (Table 5-8). Drugs frequently used to relieve anxiety, cause sedation, and provide amnesia are diazepam (Valium) and midazolam (Versed); however, these drugs are not analgesics and should be used to enhance the effects of analgesics, not as a substitute for analgesics. Other adjuvants include tricyclic antidepressants (e.g., amitriptyline, imipramine) and antiepileptics (e.g., gabapentin, carbamazepine, clonazepam) for neuropathic pain (Rastogi and Campbell, 2014). Other medications commonly prescribed include stool softeners and laxatives for constipation, antiemetics for nausea and vomiting, diphenhydramine for itching, steroids for inflammation and bone pain, and dextroamphetamine and caffeine for possible increased pain and sedation (Table 5-9).
S a f e t y A l e r t
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The use of placebos to determine whether the patient is having pain is unjustified and unethical; a positive response to a placebo, such as a saline injection, is common in patients who have a documented organic basis for pain. Therefore the deceptive use of placebos does not provide useful information about the presence or severity of pain. The use of placebos can cause side effects similar to those of opioids, can destroy the patient's trust in the health care staff, and raises serious ethical and legal questions. The American Society of Pain Management Nursing has issued a position statement against the use of placebos to treat pain (Amstein, Broglio, Wuhrman, et al, 2011).
TABLE 5-8 Coanalgesic Adjuvant Drugs
Drug Dosage Indications Comments Antidepressants Amitriptyline 0.2-0.5 mg/kg PO hs
Titrate upward by 0.25 mg/kg q 5-7 days prn Available in 10- and 25-mg tablets Usual starting dose: 10-25 mg
Continuous neuropathic pain with burning, aching, dysesthesia with insomnia
Provides analgesia by blocking reuptake of serotonin and norepinephrine, possibly slowing transmission of pain signals Helps with pain related to insomnia and depression (use nortriptyline if patient is oversedated) Analgesic effects seen earlier than antidepressant effects
Nortriptyline 0.2-1.0 mg/kg PO AM or bid Titrate up by 0.5 mg q 5-7 days Maximum: 25 mg/dose
Neuropathic pain as above without insomnia
Side effects include dry mouth, constipation, urinary retention
Anticonvulsants Gabapentin 5 mg/kg PO hs
Increase to bid on day 2, tid on day 3 Maximum: 300 mg/day
Neuropathic pain Mechanism of action unknown Side effects include sedation, ataxia, nystagmus, dizziness
Carbamazepine <6 years old: 2.5-5 mg/kg PO bid initially Increase 20 mg/kg/24 h, divide bid every week prn Maximum: 100 mg bid 6-12 years old: 5 mg/kg PO bid initially Increase 10 mg/kg/24 h; divide bid every week prn to usual Maximum: 100 mg/dose bid >12 years old: 200 mg PO bid initially Increase 200 mg/24 h, divide bid every week prn to maximum: 1.6-2.4 g/24 h
Sharp, lancinating neuropathic pain Peripheral neuropathies Phantom limb pain
Similar analgesic effect to amitriptyline Monitor blood levels for toxicity only Side effects include decreased blood counts, ataxia, gastrointestinal irritation
Anxiolytics Lorazepam 0.03-0.1 mg/kg q 4-6 h PO or IV
Maximum: 2 mg/dose Muscle spasm Anxiety
May increase sedation in combination with opioids Can cause depression with prolonged use
Diazepam 0.1-0.3 mg/kg q 4-6 h PO or IV Maximum: 10 mg/dose
Corticosteroids Dexamethasone Dose dependent on clinical situation; higher
bolus doses in cord compression, then lower daily dose Try to wean to NSAIDs if pain allows Cerebral edema: 1-2 mg/kg load, then 1-1.5 mg/kg/day divided q 6 h Maximum: 4 mg/dose Antiinflammatory: 0.08-0.3 mg/kg/day divided q 6-12 h
Pain from increased intracranial pressure Bony metastasis Spinal or nerve compression
Side effects include edema, gastrointestinal irritation, increased weight, acne Use gastro protectants such as H2-blockers (ranitidine) or proton pump inhibitors, such as omeprazole for long-term administration of steroids or NSAIDs in end-stage cancer with bony pain
Others Clonidine 2-4 mcg/kg PO q 4-6 h
May also use a 100 mcg transdermal patch q 7 days for patients >40 kg (88 lbs.)
Neuropathic pain Lancinating, sharp, electrical, shooting pain Phantom limb pain
α2-adenoreceptor agonist modulates ascending pain sensations Routes of administration: oral, transdermal, and spinal Management of withdrawal symptoms Monitor for orthostatic hypertension, decreased heart rate Sedation common
Mexiletine 2-3 mg/kg/dose PO tid, may titrate 0.5 mg/kg q 2-3 wk prn Maximum: 300 mg/dose
Similar to lidocaine, longer acting Stabilizes sodium conduction in nerve cells, reduces neuronal firing Can enhance action of opioids, antidepressants, anticonvulsants Side effects include dizziness, ataxia, nausea, vomiting May measure blood levels for toxicity
bid, Twice a day; hs, at bedtime; IV, intravenous; NSAID, nonsteroidal antiinflammatory drug; PO, by mouth; prn, as needed; q, every; tid, three times a day.
TABLE 5-9 Management of Opioid Side Effects
Side Effect Adjuvant Drugs Nonpharmacologic Techniques Constipation Senna and docusate sodium
Tablet:
2 to 6 years old: Start with tablet once a day; maximum: 1 tablet twice a day 6 to 12 years old: Start with 1 tablet once a day; maximum: 2 tablets twice a day >12 years old: Start with 2 tablets once a day; maximum: 4 tablets twice a day Liquid:
1 month old to 1 year old: 1.25-5 ml q hs 1 to 5 years old: 2.5-5 ml q hs 5 to 15 years old: 5-10 ml q hs >15 years old: 10-25 ml q hs Casanthranol and docusate sodium Liquid: 5-15 ml q hs Capsules: 1 cap PO q hs Bisacodyl: PO or PR
3 to 12 years old: 5 mg/dose/day >12 years old: 10-15 mg/dose/day Lactulose
7.5 ml/day after breakfast Adult: 15-30 ml/day PO Mineral oil: 1-2 tsp/day PO Magnesium citrate
Increase water intake Prune juice, bran cereal, vegetables Exercise
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<6 years old: 2-4 ml/kg PO once 6 to 12 years old: 100-150 ml PO once >12 years old: 150-300 ml PO once Milk of magnesia
<2 years old: 0.5 ml/kg/dose PO once 2 to 5 years old: 5-15 ml/day PO 6 to 12 years old: 15-30 ml PO once >12 years old: 30-60 ml PO once
Sedation Caffeine: Single dose of 1-1.5 mg PO Dextroamphetamine: 2.5-5 mg PO in AM and early afternoon Methylphenidate: 2.5-5 mg PO in AM and early afternoon Consider opioid switch if sedation persists
Caffeinated drinks (e.g., Mountain Dew, cola drinks)
Nausea, vomiting Promethazine: 0.5 mg/kg q 4-6 h; maximum: 25 mg/dose Ondansetron: 0.1-0.15 mg/kg IV or PO q 4 h; maximum: 8 mg/dose Granisetron: 10-40 mcg/kg q 2-4 h; maximum: 1 mg/dose Droperidol: 0.05-0.06 mg/kg IV q 4-6 h; can be very sedating
Imagery, relaxation Deep, slow breathing
Pruritus Diphenhydramine: 1 mg/kg IV or PO q 4-6 h prn; maximum: 25 mg/dose Hydroxyzine: 0.6 mg/kg/dose PO q 6 h; maximum: 50 mg/dose Naloxone: 0.5 mcg/kg q 2 min until pruritus improves (diluted in solution of 0.1 mg of naloxone per 10 ml of saline) Butorphanol: 0.3-0.5 mg/kg IV (use cautiously in opioid-tolerant children; may cause withdrawal symptoms); maximum: 2 mg/dose because mixed agonist-antagonist
Oatmeal baths, good hygiene Exclude other causes of itching Change opioids
Respiratory depression— mild to moderate
Hold dose of opioid Reduce subsequent doses by 25%
Arouse gently, give oxygen, encourage to deep breathe
Respiratory depression— severe
Naloxone During disease pain management: 0.5 mcg/kg in 2 min increments until breathing improves (Pasero and McCaffrey, 2011) Reduce opioid dose if possible Consider opioid switch During sedation for procedures: 5-10 mcg/kg until breathing improves Reduce opioid dose if possible Consider opioid switch
Oxygen, bag and mask if indicated
Dysphoria, confusion, hallucinations
Evaluate medications, eliminate adjuvant medications with central nervous system effects as symptoms allow Consider opioid switch if possible Haloperidol (Haldol): 0.05-0.15 mg/kg/day divided in two to three doses; maximum: 2-4 mg/day
Rule out other physiologic causes
Urinary retention Evaluate medications, eliminate adjuvant medications with anticholinergic effects (e.g., antihistamines, tricyclic antidepressants)
Occurs more frequently with spinal analgesia than with systemic opioid use Oxybutynin
1 year old: 1 mg tid 1 to 2 years old: 2 mg tid 2 to 3 years old: 3 mg tid 4 to 5 years old: 4 mg tid >5 years old: 5 mg tid
Rule out other physiologic causes In/out or indwelling urinary catheter
hs, At bedtime; IV, intravenous; PO, by mouth; PR, by rectum; prn, as needed; q, every; tid, three times a day.
Choosing the Pain Medication Dose Children (except infants younger than 3 to 6 months old) metabolize drugs more rapidly than adults and show great variability in drug elimination and side effects (Oakes, 2011). Younger children may require higher doses of opioids to achieve the same analgesic effect. Therefore the therapeutic effect and duration of analgesia vary. Children's dosages are usually calculated according to body weight, except in children with a weight greater than 50 kg (110 pounds), where the weight formula may exceed the average adult dose. In this case, the adult dose is used.
A reasonable starting dose of an opioid for infants younger than 6 months old who are not mechanically ventilated is one fourth to one third of the recommended starting dose for older children. The infant is monitored closely for signs of pain relief and respiratory depression. The dose is titrated to effect. Because tolerance can develop rapidly, large doses may be needed for continued severe pain. If pain relief is inadequate, the initial dose is increased (usually by 25% to 50% if pain is moderate, or by 50% to 100% if pain is severe) to provide greater analgesic effectiveness. Decreasing the interval between doses may also provide more continuous pain relief.
A major difference between opioids and nonopioids is that nonopioids have a ceiling effect, which means that doses higher than the recommended dose will not produce greater pain relief. Opioids do not have a ceiling effect other than that imposed by side effects; therefore, larger dosages can be safely given for increasing severity of pain.
Parenteral and oral dosages of opioids are not the same. Because of the first-pass effect, an oral opioid is rapidly absorbed from the gastrointestinal tract and is partially metabolized in the liver before reaching the central circulation. Therefore oral dosages must be larger to compensate for the partial loss of analgesic potency to achieve an equal analgesic effect. Conversion factors (Table 5-10) for selected opioids must be used when a change is made from intravenous (IV) (preferred) or intramuscular (IM) to oral. Immediate conversion from IM or IV to the suggested equianalgesic oral dose may result in a substantial error. For example, the dose may be significantly more or less than what the child requires. Small changes ensure small errors.
TABLE 5-10 Approximate Dose Ratios for Switching between Parenteral and Oral Dosage Forms
Medicine Dosage Ratio (Parenteral : Oral) Morphine 1 : 2 to 1 : 3 Hydromorphone 1 : 2 to 1 : 5* Methadone 1 : 1 to 1 : 2
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*Hydromorphone is a potent opioid and significant differences exist between oral and intravenous (IV) dosing. Use extreme caution when converting from one route to another. In converting from parenteral hydromorphone to oral hydromorphone, doses may need to be titrated up to 5 times the IV dose. World Health Organization: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, Geneva, 2012, World Health Organization.
Choosing the Timing of Analgesia The right timing for administering analgesics depends on the type of pain. For continuous pain control, such as for postoperative or cancer pain, a preventive schedule of medication around the clock (ATC) is effective. The ATC schedule avoids the low plasma concentrations that permit breakthrough pain. If analgesics are administered only when pain returns (a typical use of the prn, or “as needed,” order), pain relief may take several hours. This may require higher doses, leading to a cycle of undermedication of pain alternating with periods of overmedication and drug toxicity. This cycle of erratic pain control also promotes “clock watching,” which may be erroneously equated with addiction. Nurses can effectively use prn orders by giving the drug at regular intervals, because “as needed” should be interpreted as “as needed to prevent pain,” not “as little as possible.”
Choosing the Method of Administration Several routes of analgesic administration can be used (Box 5-3), and the most effective and least traumatic route of administration should be selected. Continuous analgesia is not always appropriate, because not all pain is continuous. Frequently, temporary pain control or conscious sedation is needed to provide analgesia before a scheduled procedure. When pain can be predicted, the drug's peak effect should be timed to coincide with the painful event. For example, with opioids the peak effect is approximately a half hour for the IV route; with nonopioids the peak effect occurs about 2 hours after oral administration. For rapid onset and peak of action, opioids that quickly penetrate the blood-brain barrier (e.g., IV fentanyl) provide excellent pain control.
Box 5-3 R o u t e s a n d M e t h o d s o f A n a l g e s i c D r u g A d m i n i s t r a t i o n Oral
Oral route preferred because of convenience, cost, and relatively steady blood levels
Higher dosages of oral form of opioids required for equivalent parenteral analgesia
Peak drug effect occurring after 1 to 2 hours for most analgesics
Delay in onset a disadvantage when rapid control of severe or fluctuating pain is desired
Sublingual, Buccal, or Transmucosal
Tablet or liquid placed between cheek and gum (buccal) or under tongue (sublingual)
Highly desirable because more rapid onset than oral route
• Produces less first-pass effect through liver than oral route, which normally reduces analgesia from oral opioids (unless sublingual or buccal form is swallowed, which occurs often in children)
Few drugs commercially available in this form
Many drugs can be compounded into sublingual troche or lozenge.*
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• Actiq: Oral transmucosal fentanyl citrate in hard confection base on a plastic holder; indicated only for management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant to opioid therapy, but can be used for preoperative or preprocedural sedation and analgesia
Intravenous (Bolus)
Preferred for rapid control of severe pain
Provides most rapid onset of effect, usually in about 5 minutes
Advantage for acute pain, procedural pain, and breakthrough pain
Needs to be repeated hourly for continuous pain control
Drugs with short half-life (morphine, fentanyl, hydromorphone) preferable to avoid toxic accumulation of drug
Intravenous (Continuous)
Preferred over bolus and intramuscular (IM) injection for maintaining control of pain
Provides steady blood levels
Easy to titrate dosage
Subcutaneous (Continuous)
Used when oral and intravenous (IV) routes not available
Provides equivalent blood levels to continuous IV infusion
Suggested initial bolus dose to equal 2-hour IV dose; total 24-hour dose usually requires concentrated opioid solution to minimize infused volume; use smallest gauge needle that accommodates infusion rate
Patient-Controlled Analgesia
Generally refers to self-administration of drugs, regardless of route
Typically uses programmable infusion pump (IV, epidural, subcutaneous [SC]) that permits self- administration of boluses of medication at preset dose and time interval (lockout interval is time between doses)
Patient-controlled analgesia (PCA) bolus administration often combined with initial bolus and continuous (basal or background) infusion of opioid
Optimum lockout interval not known but must be at least as long as time needed for onset of drug
• Should effectively control pain during movement or procedures
• Longer lockout provides larger dose
Family-Controlled Analgesia
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One family member (usually a parent) or other caregiver designated as child's primary pain manager with responsibility for pressing PCA button
Guidelines for selecting a primary pain manager for family-controlled analgesia:
• Spends a significant amount of time with the patient
• Is willing to assume responsibility of being primary pain manager
• Is willing to accept and respect patient's reports of pain (if able to provide) as best indicator of how much pain the patient is experiencing; knows how to use and interpret a pain rating scale
• Understands the purpose and goals of patient's pain management plan
• Understands concept of maintaining a steady analgesic blood level
• Recognizes signs of pain and side effects and adverse reactions to opioid
Nurse-Activated Analgesia
Child's primary nurse designated as primary pain manager and is only person who presses PCA button during that nurse's shift
Guidelines for selecting primary pain manager for family-controlled analgesia also applicable to nurse-activated analgesia
May be used in addition to basal rate to treat breakthrough pain with bolus doses; patient assessed every 30 minutes for need for bolus dose
May be used without a basal rate as a means of maintaining analgesia with around-the-clock bolus doses
Intramuscular
Note: Not recommended for pain control; not current standard of care
Painful administration (hated by children)
Tissue and nerve damage caused by some drugs
Wide fluctuation in absorption of drug from muscle
Faster absorption from deltoid than from gluteal sites
Shorter duration and more expensive than oral drugs
Time consuming for staff and unnecessary delay for child
Intranasal
Available commercially as butorphanol (Stadol NS); approved for those older than 18 years old
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Should not be used in patient receiving morphine-like drugs because butorphanol is partial antagonist that will reduce analgesia and may cause withdrawal
Intradermal
Used primarily for skin anesthesia (e.g., before lumbar puncture, bone marrow aspiration, arterial puncture, skin biopsy)
Local anesthetics (e.g., lidocaine) cause stinging, burning sensation
Duration of stinging dependent on type of “caine” used
To avoid stinging sensation associated with lidocaine:
• Buffer the solution by adding 1 part sodium bicarbonate (1 mEq/ml) to 9 to 10 parts 1% or 2% lidocaine with or without epinephrine
Normal saline with preservative, benzyl alcohol, anesthetizes venipuncture site
Same dose used as for buffered lidocaine
Topical or Transdermal
EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% liposomal lidocaine cream)
• Eliminates or reduces pain from most procedures involving skin puncture
• Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure
Lidocaine-tetracaine (Synera, S-Caine)
• Apply for 20 to 30 minutes
• Do not apply to broken skin
LAT (lidocaine-adrenaline-tetracaine), tetracaine-phenylephrine (tetraphen)
• Provides skin anesthesia about 15 minutes after application on nonintact skin
• Gel (preferable) or liquid placed on wounds for suturing
• Adrenaline not for use on end arterioles (fingers, toes, tip of nose, penis, earlobes) because of vasoconstriction
Transdermal fentanyl (Duragesic)
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• Available as patch for continuous pain control
• Safety and efficacy not established in children younger than 12 years old
• Not appropriate for initial relief of acute pain because of long interval to peak effect (12 to 24 hours); for rapid onset of pain relief, give an immediate-release opioid
• Orders for “rescue doses” of an immediate-release opioid recommended for breakthrough pain, a flare of severe pain that breaks through the medication being administered at regular intervals for persistent pain
• Has duration of up to 72 hours for prolonged pain relief
• If respiratory depression occurs, possible need for several doses of naloxone
Vapo-coolant
• Use of prescription spray coolant, such as Fluori-Methane or ethyl chloride (Pain-Ease); applied to the skin for 10 to 15 seconds immediately before the needle puncture; anesthesia lasts about 15 seconds
• Some children dislike cold; may be more comfortable to spray coolant on a cotton ball and then apply this to the skin
• Application of ice to the skin for 30 seconds found to be ineffective
Rectal
Alternative to oral or parenteral routes
Variable absorption rate
Generally disliked by children
Many drugs able to be compounded into rectal suppositories*
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Regional Nerve Block Use of long-acting local anesthetic (bupivacaine or ropivacaine) injected into nerves to block pain at
site
Provides prolonged analgesia postoperatively, such as after inguinal herniorrhaphy
May be used to provide local anesthesia for surgery, such as dorsal penile nerve block for circumcision or for reduction of fractures
Inhalation
Use of anesthetics, such as nitrous oxide, to produce partial or complete analgesia for painful procedures
Side effects (e.g., headache) possible from occupational exposure to high levels of nitrous oxide
Epidural or Intrathecal
Involves catheter placed into epidural, caudal, or intrathecal space for continuous infusion or single or intermittent administration of opioid with or without a long-acting local anesthetic (e.g., bupivacaine, ropivacaine)
Analgesia primarily from drug's direct effect on opioid receptors in spinal cord
Respiratory depression rare but may have slow and delayed onset; can be prevented by checking level of sedation and respiratory rate and depth hourly for initial 24 hours and decreasing dose when excessive sedation is detected
Nausea, itching, and urinary retention common dose-related side effects from the epidural opioid
Mild hypotension, urinary retention, and temporary motor or sensory deficits common unwanted effects of epidural local anesthetic
Catheter for urinary retention inserted during surgery to decrease trauma to child; if inserted when child is awake, anesthetize urethra with lidocaine
*For further information about compounding drugs in troche or suppository form, contact Professional Compounding Centers of America (PCCA), 9901 S. Wilcrest Drive, Houston, TX 77009; 800-331-2498; www.pccarx.com.
Data from Pasero C, McCaffrey M: Pain assessment and pharmacologic management, St Louis, 2011, Elsevier.
Severe pain that is uncontrolled by large variations in plasma concentrations of opioids is best controlled through continuous IV infusion rather than intermittent boluses. If intermittent boluses are given, make certain the intervals between doses do not exceed the drug's expected duration of effectiveness. For extended pain control with fewer administration times, drugs that provide longer duration of action (e.g., some NSAIDs, time-released morphine or oxycodone, methadone) can be used.
Patient-Controlled Analgesia A significant advance in the administration of IV, epidural, or subcutaneous analgesics is the use of patient-controlled analgesia (PCA). As the name implies, the patient controls the amount and frequency of the analgesic, which is typically delivered through a special infusion device. Children who are physically able to “push a button” (i.e., 5 to 6 years old) and who can understand the concept of pushing a button to obtain pain relief can use PCA. Although it is controversial, parents and nurses have used the IV PCA system for the child. Nurses can efficiently use the infusion
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device on a child of any age to administer analgesics to avoid signing for and preparing opioid injections every time one is needed (Fig. 5-7). When PCA is used as “nurse- or parent-controlled” analgesia, the concept of patient control is negated, and the inherent safety of PCA needs to be monitored. Research has reported safe and effective analgesia in children when the patient, parent, or nurse controlled the PCA (Oakes, 2011).
FIG 5-7 Nurse programming a patient-controlled analgesia (PCA) pump to administer analgesia.
PCA infusion devices typically allow for three methods or modes of drug administration to be used alone or in combination:
1. Patient-administered boluses that can be infused only according to the preset amount and lockout interval (time between doses). More frequent attempts at self-administration may mean the patient needs the dose and time adjusted for better pain control.
2. Nurse-administered boluses that are typically used to give an initial loading dose to increase blood levels rapidly and to relieve breakthrough pain (pain not relieved with the usual programmed dose).
3. Continuous basal rate infusion that delivers a constant amount of analgesic and prevents pain from returning during those times, such as sleep, when the patient cannot control the infusion.
As with any type of analgesic management plan, continued assessment of the child's pain relief is essential for the greatest benefit from PCA. Typical uses of PCA are for controlling pain from surgery, sickle cell crisis, trauma, and cancer. Morphine is the drug of choice for PCA and usually comes in a concentration of 1 mg/ml. Other options are hydromorphone (0.2 mg/ml) and fentanyl (0.01 mg/ml). Hydromorphone is often used when patients are not able to tolerate side effects, such as pruritus and nausea from the morphine PCA. Table 5-11 provides initial PCA settings for opioid- naive children.
TABLE 5-11 Initial Patient-Controlled Analgesia Settings for Opioid-Naive Children
Drug Continuous Infusion Dosage Bolus Dosage/Frequency Morphine 0-0.02 mg/kg/h 0.02 mg/kg q 15-30 min Hydromorphone 0-0.004 mg/kg/h 0.004 mg/kg q 15-30 min
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Fentanyl 0-0.5 to 1 mcg/kg/h 0.5-1 mcg/kg q 10-15 min
Epidural Analgesia Epidural analgesia is used to manage pain in selected cases. Although an epidural catheter can be inserted at any vertebral level, it is usually placed into the epidural space of the spinal column at the lumbar or caudal level (Suresh, Birmingham, and Kozlowski, 2012). The thoracic level is usually reserved for older children or adolescents who have had an upper abdominal or thoracic procedure, such as a lung transplant. An opioid (usually fentanyl, hydromorphone, or preservative-free morphine, which is often combined with a long-acting local anesthetic, such as bupivacaine or ropivacaine) is instilled via single or intermittent bolus, continuous infusion, or patient-controlled epidural analgesia. Analgesia results from the drug's effect on opiate receptors in the dorsal horn of the spinal cord, rather than the brain. As a result, respiratory depression is rare, but if it occurs, it develops slowly, typically 6 to 8 hours after administration. Careful monitoring of sedation level and respiratory status is critical to prevent opioid-induced respiratory depression. Assessment of pain and the skin condition around the catheter site are important aspects of nursing care.
Transmucosal and Transdermal Analgesia Oral transmucosal fentanyl (Oralet) and intranasal fentanyl (Mudd, 2011) provides nontraumatic preoperative and preprocedural analgesia and sedation. Fentanyl is also available as a transdermal patch (Duragesic). Duragesic is contraindicated for acute pain management, but it may be used for older children and adolescents who have cancer pain or sickle cell pain or for patients who are opioid tolerant.
One of the most significant improvements in the ability to provide atraumatic care to children undergoing procedures is the anesthetic cream (Zempsky, 2014; Oakes, 2011). LMX4 (a 4% liposomal lidocaine cream) or EMLA (a eutectic mixture of local anesthetics) are the most well- studied topical anesthetics found to be effective in children. The EMLA (lidocaine 2.5% and prilocaine 2.5%), whose melting point is lower than that of the two anesthetics alone, permits effective concentrations of the drug to penetrate intact skin (Fig. 5-8). Transdermal patches, such as Synera (lidocaine and tetracaine), are effective methods to administer topical analgesia before painful procedures.
FIG 5-8 LMX (liposomal lidocaine cream) is an effective analgesic before intravenous (IV) insertion or blood draw.
In emergency situations, there is not enough time for topical preparations like LMX or EMLA to take effect, and refrigerant sprays, such as ethyl chloride and fluoromethane can be used. When sprayed on the skin, these sprays vaporize, rapidly cool the area, and provide superficial anesthesia.
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Hospital formularies may have other products with lidocaine, prilocaine, or amethocaine topical preparations that require less time for application.
The intradermal route is sometimes used to inject a local anesthetic, typically lidocaine, into the skin to reduce the pain from a lumbar puncture, bone marrow aspiration, or venous or arterial access. One problem with the use of lidocaine is the stinging and burning that initially occur. However, the use of buffered lidocaine with sodium bicarbonate reduces the stinging sensation.
Monitoring Side Effects Both NSAIDs and opioids have side effects, although the major concern is with those from opioids (Box 5-4). Respiratory depression is the most serious complication and is most likely to occur in sedated patients. The respiratory rate may decrease gradually, or respirations may cease abruptly; lower limits of normal are not established for children, but any significant change from a previous rate calls for increased vigilance. A slower respiratory rate does not necessarily reflect decreased arterial oxygenation; an increased depth of ventilation may compensate for the altered rate. If respiratory depression or arrest occurs, be prepared to intervene quickly (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Managing Opioid-Induced Respiratory Depression
If Respirations Are Depressed
Assess sedation level.
Reduce infusion by 25% when possible.
Stimulate patient (shake shoulder gently, call by name, ask to breathe).
Administer oxygen.
If Patient Cannot be Aroused or Is Apneic
Initiate resuscitation efforts as appropriate.
Administer naloxone (Narcan):
• For children weighing less than 40 kg (88 lbs.), dilute 0.1 mg naloxone in 10 ml sterile saline to make 10 mcg/ml solution and give 0.5 mcg/kg.
• For children weighing more than 40 kg (88 lbs.), dilute 0.4-mg ampule in 10 ml sterile saline and give 0.5 ml.
Administer bolus by slow intravenous (IV) push every 2 minutes until effect is obtained.
Closely monitor patient. Naloxone's duration of antagonist action may be shorter than that of the opioid, requiring repeated doses of naloxone.
Note: Respiratory depression caused by benzodiazepines (e.g., diazepam [Valium] or midazolam [Versed]) can be reversed with flumazenil (Romazicon). Pediatric dosing experience suggests 0.01 mg/kg (0.1 ml/kg); if no (or inadequate) response after 1 to 2 minutes, administer same dose and repeat as needed at 60-second intervals for maximum dose of 1 mg (10 ml).
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Box 5-4
S i d e E f f e c t s o f O p i o i d s General
Constipation (possibly severe)
Respiratory depression
Sedation
Nausea and vomiting
Agitation, euphoria
Mental clouding
Hallucinations
Orthostatic hypotension
Pruritus
Urticaria
Sweating
Miosis (may be sign of toxicity)
Anaphylaxis (rare)
Signs of Tolerance
Decreasing pain relief
Decreasing duration of pain relief
Signs of Withdrawal Syndrome in Patients with Physical Dependence Initial Signs of Withdrawal
Lacrimation
Rhinorrhea
Yawning
Sweating
Later Signs of Withdrawal
Restlessness
Irritability
Tremors
Anorexia
Dilated pupils
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Gooseflesh
Nausea, vomiting
Although respiratory depression is the most dangerous side effect, constipation is a common, and sometimes serious, side effect of opioids, which decrease peristalsis and increase anal sphincter tone. Prevention with stool softeners and laxatives is more effective than treatment once constipation occurs. Dietary treatment, such as increased fiber, is usually not sufficient to promote regular bowel evacuation. However, dietary measures, such as increased fluid and fruit intake, and physical activity are encouraged. Pruritus from epidural or IV infusion is treated with low doses of IV naloxone, nalbuphine, or diphenhydramine. Nausea, vomiting, and sedation usually subside after 2 days of opioid administration, although oral or rectal antiemetics are sometimes necessary.
Both tolerance and physical dependence can occur with prolonged use of opioids (see Community Focus box). Physical dependence is a normal, natural, physiologic state of “neuroadaptation.” When opioids are abruptly discontinued without weaning, withdrawal symptoms occur 24 hours later and reach a peak within 72 hours. Symptoms of withdrawal include signs of neurologic excitability (irritability, tremors, seizures, increased motor tone, insomnia), gastrointestinal dysfunction (nausea, vomiting, diarrhea, abdominal cramps), and autonomic dysfunction (sweating, fever, chills, tachypnea, nasal congestion, rhinitis). Withdrawal symptoms can be anticipated and prevented by weaning patients from opioids that were administered for more than 5 to 10 days. Adherence to a weaning protocol to prevent or minimize withdrawal symptoms from opioids is required. A weaning flowsheet (Fig. 5-9, A) may be used to assess the efficacy of opioid weaning in neonates (Franck and Vilardi, 1995). In older infants and young children (7 months to 10 years old) the Withdrawal Assessment Tool–1 (see Fig. 5-9, B) may be used to assess and monitor withdrawal symptoms in pediatric critically ill children who are exposed to opioids and benzodiazepines for prolonged periods (Franck, Harris, Soetenga, et al, 2008).
C o m m u n i t y F o c u s Fear of Opioid Addiction
One of the reasons for the unfounded but prevalent fear of addiction from opioids used to relieve pain is a misunderstanding of the differences between physical dependence, tolerance, and addiction. Health care professionals and the community often confuse addiction with the physiologic effects of opioids, when in reality these three events are unrelated.
The American Society of Addiction Medicine defines these three terms as follows:
• Physical dependence on an opioid is a physiologic state in which abrupt cessation of the opioid, or administration of an opioid antagonist, results in a withdrawal syndrome. Physical dependence on opioids is an expected occurrence in all individuals who continuously use opioids for therapeutic or nontherapeutic purposes. It does not, in and of itself, imply addiction.
• Tolerance is a form of neuroadaptation to the effects of chronically administered opioids (or other medications) that is indicated by the need for increasing or more frequent doses of the medication to achieve the initial effects of the drug. A person may develop tolerance both to the analgesic effects of opioids and to some of the unwanted side effects, such as respiratory depression, sedation, or nausea. Tolerance is variable in occurrence, but it does not, in and of itself, imply addiction.
• Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of dysfunctional opioid use that may involve any or all of the following:
• Adverse consequences associated with the use of opioids
• Loss of control over the use of opioids
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• Preoccupation with obtaining opioids, despite the presence of adequate analgesia
Unfortunately, individuals who have severe, unrelieved pain may become intensely focused on finding relief. Sometimes behaviors such as “clock watching” make patients appear to others to be preoccupied with obtaining opioids. However, this preoccupation focuses on finding relief of pain, not on using opioids for reasons other than pain control. This phenomenon has been termed pseudoaddiction and must not be confused with real addiction.
Nurses must educate older children, parents, and health professionals about the extremely low risk of real addiction (>1%) from the use of opioids to treat pain. Infants, young children, and comatose or terminally ill children simply cannot become addicted because they are incapable of a consistent pattern of drug-seeking behavior, such as stealing, drug dealing, prostitution, and use of family income, to obtain opioids for nonanalgesic reasons.
Data from American Society of Addiction Medicine: Public policy statement on definitions related to the use of opioids for pain treatment, 2001, www.asam.org/Pain.html.
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FIG 5-9 A, Weaning flowsheet to monitor opioid weaning in neonates. B, Withdrawal assessment tool for infants and children. SBS, State behavioral scale. (A, Modified from Franck L, Vilardi J: Assessment and management of opioid withdrawal in ill neonates, Neonatal Netw 14[2]:39–48, 1995; B, ©2007 LS Franck and MAQ Curley. All rights reserved. Reprinted
in Franck LS, Harris SK, Soetenga DJ, et al: The Withdrawal Assessment Tool–1 [WAT–1]: an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients, Pediatr Crit Care Med 9[6]:577, 2008. *From Curley MQ, Harris SK,
Fraser KA, et al: State behavioral scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation, Pediatr Crit Care Med 7(2):107–114, 2008.
Tolerance occurs when the dose of an opioid needs to be increased to achieve the same analgesic effects that was previously achieved at a lower dose (see Community Focus box). Tolerance may develop after 10 to 21 days of morphine administration. Treatment of tolerance involves increasing the dose or decreasing the duration between doses.
Parents and older children may fear addiction when opioids are prescribed. The nurse should address these concerns with assurance that any such risk is extremely low. It may be helpful to ask the question, “If you did not have this pain, would you want to take this medicine?” The answer is invariably no, which reinforces the solely therapeutic nature of the drug. It is also important to avoid making statements to the family, such as “We don't want you to get used to this medicine,” or “By now you shouldn't need this medicine,” which may reinforce the fear of becoming addicted. Whereas both physical dependence and tolerance are physiologic states, addiction or psychologic
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dependence is a psychologic state and implies a “cause-effect” mode of thinking, such as “I need the drug because it makes me feel better.” Infants and children do not have the cognitive ability to make the cause-effect association and therefore cannot become addicted. The use of opioid analgesics early in life has not been demonstrated to increase the risk for addiction later in life. Nurses need to explain to parents the differences among physical dependence, tolerance, and addiction and allow them to express concerns about the use and duration of use of opioids. Infants and children, when treated appropriately with opioids, may be at risk for physical tolerance and physical dependence but not psychological dependence or addiction.
Decreasing opioid in children requires a systematic approach. For children on opioids for less than 5 days, decrease the opioid dose by 20% to 30% every 1 to 2 days (Oakes, 2011). For children who have been on opioids for longer than 5 to 7 days, a slower weaning is recommended: Wean by a 20% reduction on the first day, follow with opioid reductions of 5% to 10% each day as tolerated until a total daily dose of morphine (or its equivalent) of 30 mg for an adolescent or a dose of 0.6 mg/kg/day is reached (Oakes, 2011).
Consequences of Untreated Pain in Infants Despite current research on the neonate's experience of pain, infant pain often remains inadequately managed. The mismanagement of infant pain is partially the result of misconceptions regarding the effects of pain on the neonate and the lack of knowledge of immediate and long-term consequences of untreated pain. Infants respond to noxious stimuli through physiologic indicators (increased heart rate and blood pressure, variability in heart rate and intracranial pressure, and decreases in arterial oxygen saturation [SaO2] and skin blood flow) and behavioral indicators (muscle rigidity, facial expression, crying, withdrawal, and sleeplessness) (Clark, 2011; Oakes, 2011). The physiologic and behavioral changes, as well as a variety of neurophysiologic responses to noxious stimulation, are responsible for acute and long-term consequences of pain.
Several harmful effects occur with unrelieved pain, particularly when pain is prolonged. Pain triggers a number of physiologic stress responses in the body, and they lead to negative consequences that involve multiple systems. Unrelieved pain may prolong the stress response and adversely affect an infant or child's recovery, whether it is from trauma, surgery, or disease (see the Research Focus box).
R e s e a r c h F o c u s Deep Intraoperative Anesthesia: Landmark Study
In the landmark study by Anand and Hickey (1992), 30 neonates received deep intraoperative anesthesia with high doses of the opioid sufentanil, followed postoperatively by an infusion of opioids for 24 hours; and 15 neonates received lighter anesthesia with halothane and morphine, followed postoperatively by intermittent morphine and diazepam. The 15 neonates who received the lighter anesthesia and intermittent postoperative opioids had more severe hyperglycemia and lactic acidemia, and four postoperative deaths occurred in the group. The 30 neonates who received deep anesthesia had a lower incidence of complications (sepsis, metabolic acidosis, disseminated intravascular coagulation) and no deaths.
Poorly-controlled acute pain can predispose patients to chronic pain syndromes. Box 5-5 provides a list of numerous complications of untreated pain in infants. A guiding principle in pain management is that prevention of pain is always better than treatment. Pain that is established and severe is often more difficult to control. When pain is unrelieved, sensory input from injured tissues reaches spinal cord neurons and may enhance subsequent responses. Long-lasting changes in cells within spinal cord pain pathways may occur after a brief painful stimulus and may lead to the development of chronic pain conditions.
Box 5-5 C o n s e q u e n c e s o f U n t r e a t e d Pa i n i n I n f a n t s
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Acute Consequences
Periventricular-intraventricular hemorrhage
Increased chemical and hormone release
Breakdown of fat and carbohydrate stores
Prolonged hyperglycemia
Higher morbidity for neonatal intensive care unit patients
Memory of painful events
Hypersensitivity to pain
Prolonged response to pain
Inappropriate innervation of the spinal cord
Inappropriate response to nonnoxious stimuli
Lower pain threshold
Potential Long-Term Consequences
Higher somatic complaints of unknown origin
Greater physiologic and behavioral responses to pain
Increased prevalence of neurologic deficits
Psychosocial problems
Neurobehavioral disorders
Cognitive deficits
Learning disorders
Poor motor performance
Behavioral problems
Attention deficits
Poor adaptive behavior
Inability to cope with novel situations
Problems with impulsivity and social control
Learning deficits
Emotional temperament changes in infancy or childhood
Accentuated hormonal stress responses in adult life
An experience known as the windup phenomenon has been attributed to a decreased pain threshold and chronic pain. Central and peripheral mechanisms that occur in response to noxious tissue injury have been studied in an attempt to explain a prolonged neonatal response to pain
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characteristic of the windup phenomenon. After exposure to noxious stimuli, multiple levels of the spinal cord experience an altered excitability. This altered excitability may cause nonnoxious stimuli, such as routine nursing care and handling, to be perceived as noxious stimuli. Nurses who care for infants and children should consider the potential acute and long-term effects of pain on their young patients and be advocates in treating and preventing pain.
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Common Pain States in Children Painful and Invasive Procedures Procedures that infants and children must experience as part of routine medical care often cause pain and distress. For example, infants and children experience a substantial amount of pain due to routine immunizations. The Evidence-Based Practice Box—Reducing Injection Pain During Childhood Immunizations provides interventions that can minimize pain during these procedures.
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Reducing Injection Pain during Childhood Immunizations
By Rebecca Njord
Introduction Infants and children experience a substantial amount of pain due to routine immunizations. Recent evidence shows that infant and childhood pain is not only immediately distressing to both the infant and the caregiver, but it can have lifelong consequences. Recent evidence has shown that infants who exhibit vaccine-related pain early on in life are more likely to do so at subsequent injections (Campbell, Pillai Riddell, Garfield, et al, 2013). There exist many simple, scientifically grounded strategies that reduce injection pain in infants (Taddio, Chambers, Halperin, et al, 2009; Taddio, Ilersich, Ipp, et al, 2009). This section examines the current evidence supporting strategies to reduce vaccine-related pain among healthy infants and children (birth to 18 months old) receiving routine immunizations.
Ask the Question What measures are effective in reducing pain experienced during routine childhood immunizations for infants and children 0 to 18 months old?
Search for the Evidence Search Strategies Search selection criteria included English publications within past 10 years, research-based articles (level 1 or lower) on infants and children (0 to 18 months old) receiving routine childhood immunizations.
Databases Used PubMed, Cochrane Collaboration, MD Consult, Joanna Briggs Institute, National Guideline Clearinghouse (AHQR), TRIP Database Plus, PedsCCM, BestBETs
Critically Analyze the Evidence Injection Techniques
• Needle length (longer versus shorter needle)
• A systematic review conducted by Davenport (2004) identified two small classic studies that demonstrated that a 25-mm-long needle produced less redness and swelling compared to a 16-mm-long needle when used during routine childhood immunizations. Study A (Ipp, Gol, Goldbach, et al, 1989) and Study B (Diggle and Deeks, 2000) both examined the effect of needle length on local reaction (redness and swelling) in infants and children, 0 to 24 months old,
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receiving routine DTP-polio immunizations. The 25-mm needle produced less redness and swelling compared to the 16-mm needle but was not associated with lower pain scores.
• Does tactile stimulation help reduce injection pain in infants?
• A randomized-controlled trial conducted by Hogan, Probst, Wong, et al (2014) evaluated whether parent-led tactile stimulation would reduce injection pain in 4- to 6-month-old infants. One hundred twenty infants scheduled to receive a routine diphtheria, tetanus, acellular pertussis, inactivated poliovirus, and Haemophilus influenzae type B (DTaP-IPV-Hib) vaccine and pneumococcal conjugate vaccine (PCV) were randomized to receive parent-led tactile stimulation for 15 seconds before, during, and after immunization administration at a site immediately distal to the injection point, or act as a control. All infants received the standard of care for pain reduction in the clinic (skin-to-skin, 2 ml 24% sucrose prior to injection, upright positioning, and rapid injection without aspiration). The trial demonstrated no reduction in modified behavioral pain score (MBPS) for infants receiving tactile stimulation in the presence of other pain-reducing strategies, compared to infants receiving no tactile stimulation.
• Does aspiration increase injection pain?
• Rapid intramuscular (IM) injection without aspiration reduces injection pain by shortening the time of the procedure and avoiding displacement of the needle (Taddio, Ilersich, Ipp, et al, 2009).
• One hundred thirteen 4- to 6-month-old infants were randomized to either the slow injection–aspiration–slow withdrawal (standard) immunization technique or rapid immunization without aspiration (intervention) in a randomized-controlled trial conducted by Ipp, Taddio, Sam, et al (2007). Infants in the intervention group (n = 56) had lower MBPSs, were less likely to cry, cried for a shorter time, and had lower pain scores when scored by both parents and physicians using a Visual Analogue Scale (VAS).
• Vaccine choice and vaccine order
• A randomized-controlled trial by Ipp, Cohen, Goldbach, et al (2004) compared the immediate pain response to two different measles, mumps, and rubella (MMR) vaccine products. Forty-nine 12-month-
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old children were randomized to receive either Priorix or MMR-II for their initial MMR vaccine. Pain response was measured using both VAS and MBPS and scored independently by a physician, a parent, and a third observer. Children receiving Priorix had substantially lower pain scores (VAS: 15 versus 33, p = 0.003; MBPS: 3 versus 5, p = 0.03).
• In a similar trial, Ipp, Parkin, Lear, et al (2009) randomized 120 2- to 6-month-old infants to receive either DTaP-Hib vaccine followed by PCV, or PCV followed by DTaP-Hib. Infants who received DTaP- Hib prior to PCV had lower MBPS and VAS scores compared to infants who received PCV first (MBPS: 7.6 versus 8.2, p = 0.037; VAS: 4.2 versus 5.6, p = 0.003). When administered first, infants who received DTaP-Hib also cried for a shorter time compared to infants who received PCV first.
• Knutsson, Jansson, and Alm (2006) randomized 295 18- to 24-month- old children (average age 19 months old) to receive either Priorix or MMR-II in a double-blind study. Pain was assessed using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS) and VAS. Children receiving Priorix had substantially lower pain scores compared to MMR-II (mean CHEOPS = 1.9 versus 6.1, p < 0.001; mean VAS = 2.3 versus 5.2, p < 0.001, respectively). MMR-II was much more likely to produce a scream in children (n = 78 versus n = 12, p < 0.001), and all children had settled to no cry by 3 minutes after injection.
• Simultaneous versus sequential vaccines
• McGowan, Cottrell, Roberts, et al (2013) randomized 72 infants between 2 and 6 months old to receive either simultaneous or sequential vaccines. Half of the participants (n = 36) received DTaP- IPV-Hib and PCV, and half received DTaP-IPV-Hib and meningococcal-C (MEN-C). Pain was measured using nurse-scored MBPS and parent-scored VAS. There was no difference in VAS between the sequential and simultaneous groups. There is some evidence (p = 0.7) that infants in the sequential group experienced more discomfort for a longer period of time compared to the simultaneous group.
Positioning
• Vertical versus lying down
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• Supine positioning is associated with increased fear in children who experience a greater feeling of lost control, confusion, anxiety, and anger (Gaskell, Binns, and Heyhoe, 2005).
• One hundred eighteen 9-month-old to 4-year-old children were randomized to either upright or supine positioning for IV insertion in a trial conducted by Sparks, Setlik, and Luhman (2007). The upright group had lower PBRS-R (procedural behavior rating scale– revised) scores, indicating less anxiety, fear, and pain compared to the supine group.
• In a trial of 106 2- to 6-month-old infants, there was no difference in pain score or duration of cry between infants placed supine and upright (Ipp, Taddio, Goldbach, et al, 2004). However, parents of the supine group could pick up their infant at any time during the procedure. Results from the study were not adjusted for changes in cry that occurred after the infant was picked up. Results from this study suggest that contact between the infant and parent (e.g., soothing the infant) provides analgesic effects for the infant and may have masked the negative effect of supine positioning.
Breastfeeding
• In a systematic review of 11 randomized- and quasi-randomized-controlled trials examining the use of breastfeeding to reduce vaccine-related pain, the breastfed infants cried for shorter periods of time and had less increased heart rates than swaddled infants or infants offered a pacifier (Shah, Aliwalis, and Shah, 2007). Infants who breastfed during the procedure cried for the shortest amount of time, followed by swaddled infants held by their mothers. Infants who were held by research assistants cried the most. Breastfeeding does not appear to impact blood pressure or oxygen saturation, but the breastfed infants' heart rates did not increase as much as non-breastfed infants. There was no difference in crying time or pain scores for infants offered high doses of sucrose (2 ml of 12% sucrose in sterile water) compared to the breastfeeding infants. Breastfeeding, where feasible and appropriate, is recommended over sucrose because breastfeeding is a no-cost intervention, promotes mother-infant bonding, provides comfort to the infant, and may encourage mothers to breastfeed.
• Sixty-six infants between 2 and 4 months old were randomized to receive a routine DTaP vaccine while breastfeeding or standard care (swaddled and placed in bassinet) (Efe and Ozer, 2007). Pain was measured using change in heart rates, oxygen saturation levels, and duration of cry. Crying time was shorter in the breastfed group compared to the control group, but heart rate and oxygen saturation were unaffected by breastfeeding.
• One hundred twenty infants younger than 1 year old were randomized to either standard care or breastfeeding during administration of a routine pediatric immunization (Abdel Razek and Az El-Dein, 2009). Pain was measured using the Wong-Baker FACES Pain Rating Scale, Neonatal Infant Pain Scale (NIPS), duration of cry, and changes in heart rate. The breastfeeding group experienced lower pain by all measures used, including change in heart rate. Care was taken in this study to ensure the infant had a secure latch prior to injection and was encouraged to continue breastfeeding if there was a pause. Further, all breastfeeding infants were positioned skin-to-skin during the procedure. It is possible that the added benefit of skin-to-skin positioning
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further relaxed the breastfed infants in this study compared to other, similar studies.
• One hundred fifty-eight infants between 0 and 6 months old were randomized to either no intervention or breastfeeding during routine vaccine administration (Dilli, Küçük, and Dallar, 2009). Pain was measured using duration of cry and NIPS. Breastfed infants cried on average for 20 seconds, and non-breastfed infants cried on average for 150 seconds (p < 0.001). NIPS scores were significantly lower for breastfed infants (NIPS average = 3) compared to non-breastfed infants (NIPS average = 6, p < 0.001).
Skin-to-Skin or Kangaroo Care
• Kostandy, Anderson, and Good (2013) conducted an in-hospital randomized-controlled trial among healthy, full-term newborns examining the impact of skin-to-skin infant cry time and consolability among infants receiving a hepatitis B vaccine within the first hour of life. Thirty-six mother-infant dyads were randomized to either routine (infant placed supine in bassinet) or skin- to-skin (prone on mother's chest) vaccine administration. Skin-to-skin infants had shorter cry times and calmed more quickly after vaccine administration.
• Saeidi, Asnaashari, Amirnejad, et al (2011) conducted a randomized-controlled trial of 60 healthy, full-term newborns randomized to either swaddling and placed next to mother, or skin-to-skin positioning for in-hospital hepatitis B vaccine administration. Infants placed skin-to-skin had lower pain intensity scores, cried for a shorter time, and returned to preprocedure behavior more quickly compared to the swaddled infants.
• Chermont, Falcao, de Souza Silva, et al (2009) conducted a trial where 640 infants between 12 and 72 hours old were randomized to either standard care (no analgesia), skin-to-skin initiated 2 minutes prior to injection, 25% sucrose administered 2 minutes prior to injection, or a combination of skin-to-skin and 25% sucrose for routine hepatitis B vaccination. Infants in the skin-to-skin branch of the trial had lower pain scores (NIPS, Premature Infant Pain Profile [PIPP], and Neonatal Facial Coding System [NFCS]) and experienced procedural pain for a shorter time than the other infants. Infants receiving 25% dextrose had decreased pain duration but not decreased pain scores compared to the skin-to-skin group. The combination of 25% dextrose and skin-to-skin had stronger analgesic effects than either intervention alone.
Patient and Patient-Parent Interaction
• Caregiver or nurse-led distraction and coaching
• In a study conducted by Cohen, MacLaren, Fortson, et al (2006), 136 infants between 1 and 21 months old were randomized to either typical care (comfort, reassurance, and so on) or parent-led distraction (watching a DVD and redirected to the DVD by the parents) while receiving routine infant immunizations. Infants in the parent-led distraction group had lower observer-rated distress scores, particularly postinjection.
• In 2005, Cramer-Berness and Friedman (2005) conducted a randomized-controlled trial where 123 infants were randomized to routine care, comfort care (parents encouraged to employ their “usual” comfort measures), or distraction (verbal distraction, toys and/or videos, coaching “look at me” or “you are so brave”). Infants in the distraction/coaching group recovered more quickly compared
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to infants in the other two groups and scored lower on parent-rated VASs during the recovery phase.
• Cohen, Bernard, McClellan, et al (2006) conducted a second randomized-controlled trial where 84 12-month-old children were randomized to routine care, topical anesthetic, or nurse-led distraction (movie and a toy with redirection to the distraction). Children in the distraction group had lower observer-rated distress scores (MBPS), particularly in the period immediately following the injection (the “recovery phase” 10 seconds after needle is withdrawn for an additional 10 seconds).
• Verbal reassurance and soothing
• Racine, Pillai Riddell, Flora, et al (2012) conducted a cross-sectional analysis of infant distress and parent soothing (combination of verbal reassurance and rocking or picking up the infant) among 606 infants between 2 and 12 months old. At 2 months old, caregiver soothing did not impact infant distress. However, among infants 4, 6, and 12 months old, infant distress increased caregiver soothing and produced further increases in infant distress.
• Campbell, Pillai Riddell, Garfield, et al (2013) conducted a cross- sectional study examining the relationship between caregiver soothing and infant distress among 760 infants between 2 and 12 months old. Infants who were soothed did not have lower observer- rated distress scores compared to infants who were not soothed. Caregiver soothing did not impact infant distress, but physical soothing (e.g., picking up the infant or rocking) is encouraged because it promotes infant-caregiver bonding and trust elements that have long-term implications for infant development.
• In a naturalistic observation study of 49 infants conducted by Blount, Devine, Cheng, et al (2008), verbal reassurance, empathy, and apology were shown to increase anxiety and crying in participating infants (Child–Adult Medical Procedure Interaction Scale-Infant Version IV [CAMPIS-IV]). This same study showed that skin-to-skin contact between caregiver and infant decreased CAMPIS-IV scores, as did rocking or physically soothing the infant.
Pharmacologic and Additional Techniques
• Should I ice the site prior to injection?
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• No trials examining the effect of icing the site prior to injection have been conducted among infants.
• Topical numbing agents
• O'Brien, Taddio, Ipp, et al (2004) conducted a randomized-controlled trial examining the effect of topical 4% amethocaine gel in reducing pain associated with routine, subcutaneous MMR administration among 120 12-month-old children. Change from baseline MBPS postinjection was used to measure pain. Children in the nonintervention branch (n = 59) had a much greater increase in MBPS score compared to the intervention group (change in MBPS = 2.3 versus 1.5, respectively, p = 0.029).
• In a double-blind, placebo-controlled, randomized trial, 110 full- term newborns received 1 g of amethocaine gel 4% or placebo 30 minutes prior to IM injection of 0.5 ml of vitamin K (Shah, Taddio, Hancock, et al, 2008). Pain was measured using VAS to assess for percent facial grimacing score, percent cry duration, and time to cry. There was no statistically significant difference for percent facial grimacing or cry duration between the two groups (p = 0.41 and p = 0.34, respectively). Time to cry was longer for the amethocaine group (4.7 seconds versus 2.7, p = 0.01) compared to the placebo group.
• Twenty-seven 6- to 12-month-old infants were randomized to either topical lidocaine-prilocaine (n = 7), 12% oral sucrose (n = 7), or no intervention (n = 13) for routine immunization administration (Dilli, Küçük, Dallar, 2009). Pain was measured using NIPS and duration of cry. Both intervention groups cried for an average of 35 seconds compared to the nonintervention group cry time average of 150 seconds (p < 0.001). NIPS scores were similarly reduced for the intervention infants (average of 3.5 compared to 6, p < 0.001). There was no measurable difference in pain reduction between the sucrose and lidocaine-prilocaine group, and both interventions were effective in reducing vaccine-associated pain in this study.
• Does oral sucrose diminish vaccine-pain in infants?
• Hatfield, Gusic, Dyer, et al (2008) conducted a randomized- controlled trial comparing 24% oral sucrose to placebo for pain control in infants receiving 2- or 4-month routine immunizations.
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Eighty-three infants received either sucrose (n = 38) or placebo (n = 45) 2 minutes prior to injection of combined DTaP, IPV, and hepatitis B (HepB) vaccines, followed 1 minute later by a Hib vaccine and 3 minutes later by a PCV. The University of Wisconsin Children's Hospital Pain scale was used to measure pain response at baseline and 2, 5, 7, and 9 minutes after administration of sucrose/placebo. The oral sucrose infants had lowered pain scores at minutes 5, 7, and 9. Pain scores peaked in both groups of infants at 7 minutes, with an average pain score of 3.8 for sucrose infants and 4.8 for placebo infants. By minute 9, pain scores for infants in the sucrose group had returned to baseline, whereas infants in the placebo group had an average pain score of 2.91.
• A double-blind randomized-controlled trial was conducted by Kassab, Sheehy, King, et al (2012) to examine the effectiveness of 25% oral glucose in relieving pain for 120 infants receiving 2-month routine vaccinations. Infants received either 2 ml of glucose (n = 60) or sterile water (n = 60) 2 minutes prior to consecutive administration of DTaP-HepB-IPV (right thigh) or Hib (left thigh) vaccines. Pain was measured with the MBPS, crying time, and duration of full-lung cry. Infants in the intervention group spent an average of 38 seconds crying compared to 77.9 seconds in the placebo group. MBPS during immunization and postimmunization was statistically lower in the intervention group (p = 0.005 and p < 0.001, respectively). Average full-lung crying time was 7.38 seconds in the sucrose infants compared to 13.84 seconds in the placebo infants (p < 0.001).
• One hundred ten 3-month-old infants were randomized to receive either 2 ml 30% glucose (n = 55) or water (n = 55) prior to routine immunization (Thyr, Sundholm, Teeland, et al, 2007). Infants were enrolled in the study and remained in their respective study branch for 3-, 5-, and 12-month vaccines. Pain was evaluated by measuring crying time in both groups. At 3 months old, infants in the glucose group cried for an average of 18 seconds compared to 23 seconds in the placebo group (p = 0.664). At 5 and 12 months old, the intervention infants cried for an average of 6 seconds and 14 seconds compared to 16 (p = 0.017) and 29 seconds (p = 0.031), respectively. In the water group, there was a significant correlation between infants who cried at 3 months old and subsequently cried at 5 and 12 months old (r = 0.515, p < 0.001, and r = 0.332, p = 0.199,
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respectively). However, this correlation was not repeated in the glucose group, suggesting that glucose is an effective intervention for reducing vaccine-related pain in very young infants.
• One hundred thirteen infants were randomized to receive 2 ml 50% sucrose, 75% sucrose, or water by mouth prior to administration of 2-, 4-, and 6-month vaccines (Curry, Brown, and Wrona, 2012). Pain was measured by the FLACC Pain Assessment Tool (Facial expression, Leg movement, Activity, Cry, and Consolability) score and crying time. There was no significant difference between the intervention groups and control group in terms of FLACC scores or crying time (p = 0.646 and p = 0.24, respectively). Parents were not instructed to withhold comfort measures, and infants who were rocked, held, or patted had significantly lower FLACC scores (p = 0.029).
Apply the Evidence: Nursing Implications There is moderate evidence with strong recommendations using the GRADE criteria (Balshem, Helfand, Schunemann, et al, 2011) that the following interventions reduce pain during routine immunizations for infants and children between 0 and 18 months old:
• Skin-to-skin or breastfeeding where appropriate and agreeable to the caregiver and infant
• Upright positioning of child (sitting or held by caregiver)
• Sucrose administration prior to injection
• Use of topical anesthetics prior to injection
• Use the proper vaccine site and needle length for age and size of child
• Rapid injection without aspiration
There is low evidence and strong recommendation for implementation supporting the following interventions to reduce pain during routine immunizations for infants and children between 0 and 18 months old:
• Administering the least painful vaccine first when administering multiple vaccines in one visit
• Parent-led or clinician-led distraction, or redirection
• Caregivers and nurses should avoid verbal reassurance, empathy, and apology
Quality and Safety Competencies: Evidence-Based Practice* Knowledge Differentiate clinical opinion from research and evidence-based summaries. Describe the most reliable methods to reduce pain during routine immunizations for infants and children between 0 and 18 months old.
Skills Base the individualized care plan on patient values, clinical expertise, and evidence. Integrate evidence into practice by using the most reliable methods to reduce pain when administering routine vaccinations to infants and children between 0 and 18 months old.
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Attitudes Value the concept of evidence-based practice as integral in determining the best clinical practice. Appreciate strengths and weakness of the evidence for the interventions listed in this section.
References Abdel Razek A, Az El-Dein N. Effect of breast-feeding on pain relief during infant
immunization injections. Int J Nurs Pract. 2009;15(2):99–104. Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating the quality of
evidence. J Clin Epidemiol. 2011;64(4):401–406. Blount RL, Devine KA, Cheng PS, et al. The impact of adult behaviors and vocalizations on
infant distress during immunizations. J Pediatr Psychol. 2008;33(10):1163–1174. Campbell L, Pillai Riddell R, Garfield H, et al. A cross-sectional examination of the
relationship between caregiver proximal soothing and infant pain over the first year of life. Pain. 2013;154(6):813–823.
Chermont AG, Falcão LF, de Souza Silva EH. Skin-to-skin contact and/or oral 25% dextrose for procedural pain relief for term newborn infants. Pediatrics. 2009;124(6):e1101–e1107.
Cohen LL, Bernard RS, McClellan C, et al. Topical anesthesia versus distraction for infants' immunization distress: evaluation with a 6-month follow-up. Children's Health Care. 2006;35(2):103–121.
Cohen LL, MacLaren JE, Fortson BL, et al. Randomized clinical trial of distraction for infant immunization pain. Pain. 2006;125(1-2):165–171.
Cramer-Berness LJ, Friedman AG. Behavioral interventions for infant immunizations. Children's Health Care. 2005;34(2):95–111.
Curry DM, Brown C, Wrona S. Effectiveness of oral sucrose for pain management in infants during immunizations. Pain Manag Nurs. 2012;13(3):139–149.
Davenport JM. A systematic review ascertain whether the standard needle is more effective than a longer or wider needle in reducing the incidence of local reaction in children receiving primary immunization. J Adv Nurs. 2004;46(1):66–77.
Diggle L, Deeks J. Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial. BMJ. 2000;321(7266):931–933.
Dilli D, Küçük IG, Dallar Y. Interventions to reduce pain during vaccination in infancy. J Pediatr. 2009;154(3):385–390.
Efe E, Ozer ZC. The use of breast-feeding for pain relief during neonatal immunization injections. Appl Nurs Res. 2007;20(1):10–16.
Gaskell S, Binns F, Heyhoe MB, et al. Taking the sting out of needles: education for staff in primary care. Paediatr Nurs. 2005;17(4):24–28.
Hatfield LA, Gusic ME, Dyer AM, et al. Analgesic properties of oral sucrose during routine immunizations at 2 and 4 months of age. Pediatrics. 2008;121(2):e327–e334.
Hogan ME, Probst J, Wong K, et al. A randomized-controlled trial of parent-led tactile stimulation to reduce pain during infant immunization injections. Clin J Pain. 2014;30(3):259–265.
Ipp M, Cohen E, Goldbach M, et al. Effect of choice of measles-mumps-rubella vaccine on immediate vaccination pain in infants. Arch Pediatr Adolesc Med. 2004;158(4):323–326.
Ipp MM, Gol R, Goldbach M, et al. Adverse reactions to diphtheria, tetanus, pertussis-polio vaccination at 18 months of age: effect of injection site and needle length. Pediatrics. 1989;83(5):679–682.
Ipp M, Parkin PC, Lear N, et al. Order of vaccine injection and infant pain response. Arch Pediatr Adolesc Med. 2009;163(5):469–472.
Ipp M, Taddio A, Goldbach M, et al. Effects of age, gender and holding on pain response during infant immunization. Can J Clin Pharmacol. 2004;11(1):e2–e7.
Ipp M, Taddio A, Sam J, et al. Vaccine-related pain: randomised controlled trial of two injection techniques. Arch Dis Child. 2007;92(12):1105–1108.
Kassab M, Sheehy A, King M, et al. A double-blind randomised controlled trial 25% oral glucose for pain relief in 2-month old infants undergoing immunisation. Int J Nurs Stud.
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2012;49(3):249–256. Kostandy R, Anderson GC, Good M. Skin-to-skin contact diminishes pain from hepatitis B
vaccine injection in healthy full-term neonates. Neonatal Netw. 2013;32(4):274–280. McGowan A, Cottrell S, Roberts R. Minimizing pain response during routine infant
immunisation. Community Practitioner. 2013 http://www.readperiodicals.com/201306/3006230571.html.
O'Brien L, Taddio A, Ipp M, et al. Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination. Pediatrics. 2004;114(6):e720–e724.
Racine NM, Pillai Riddell RR, Flora D, et al. A longitudinal examination of verbal reassurance during infant immunization: occurrence and examination of emotional availability as a potential moderator. J Pediatr Psychol. 2012;37(8):935–944.
Saeidi R, Asnaashari Z, Amirnejad M, et al. Use of “kangaroo care” to alleviate the intensity of vaccination pain in newborns. Iran J Pediatr. 2011;21(1):99–102.
Shah PS, Aliwalas L, Shah V. Breastfeeding or breastmilk to alleviate procedural pain in neonates: a systematic review. Breastfeed Med. 2007;2(2):74–84.
Shah VS, Taddio A, Hancock R, et al. Topical amethocaine gel 4% for intramuscular injection in term neonates: a double-blind, placebo-controlled, randomized trial. Clin Ther. 2008;30(1):166–174.
Sparks LA, Setlik J, Luhman J. Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial. J Pediatr Nurs. 2007;22(6):440–447.
Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management during routine childhood immunizations: the nerve of it. Clin Ther. 2009;31(Suppl 2):S152–S167.
Taddio A, Ilersich AL, Ipp M, et al. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31(Suppl 2):S48–S76.
Thyr M, Sundholm A, Teeland L, et al. Oral glucose as an analgesic to reduce infant distress following immunization at the age of 3, 5 and 12 months. Acta Paediatr. 2007;96(2):233–236.
*Adapted from the Quality and Safety Education for Nurses (QSEN) Institute.
Combining pharmacologic and nonpharmacologic interventions provides the best approach for reducing pain. Local anesthetic administration is crucial to minimize pain from the procedure and is discussed in the Transmucosal and Transdermal Analgesia section earlier in the chapter. Common systems that do not require needles for providing local analgesics are found in Table 5-12.
TABLE 5-12 Local Anesthetics Given by Systems Without Needles
Agents Time for EffectiveAnalgesia Concerns
EMLA (eutectic mixture of local anesthetics) (2.5% lidocaine and 2.5% prilocaine)
60-90 min Use with caution for young infants (<3 months old) because of possible methemoglobinemia related to metabolism of prilocaine Not effective for heel lancing or finger sticks Vasoconstriction decreases vein visibility May be applied by parent
LMX4 (4% liposomal lidocaine cream)
30 min Available over the counter May be applied by parent
Synera (lidocaine [70 mg] and tetracaine [70 mg])
20-30 min Not approved for parent application
Needle-free lidocaine injection device (J-tip) (1% buffered lidocaine)
1 min Creates a disconcerting “pop” when activated Local hyperemia and minor bleeding Not approved for parent application
Adapted from Oakes LL: Infant and child pain management, New York, 2011, Springer Publishing; Pasero C, McCaffrey M: Pain assessment and pharmacologic management, St Louis, 2011, Elsevier.
Procedural Sedation and Analgesia Severe pain associated with invasive procedures and anxiety associated with diagnostic imaging can be managed with sedation and analgesia. Sedation involves a wide range of levels of consciousness (Box 5-6). A thorough patient assessment including the child's history is essential before procedural sedation.
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Box 5-6 L e ve l s o f S e d a t i o n Minimal Sedation (Anxiolysis)
Patient responds to verbal commands.
Cognitive function may be impaired.
Respiratory and cardiovascular systems are unaffected.
Moderate Sedation (Previously Conscious Sedation)
Patient responds to verbal commands but may not respond to light tactile stimulation.
Cognitive function is impaired.
Respiratory function is adequate; cardiovascular system is unaffected.
Deep Sedation
Patient cannot be easily aroused except with repeated or painful stimuli.
Ability to maintain airway may be impaired.
Spontaneous ventilation may be impaired; cardiovascular function is maintained.
General Anesthesia
Loss of consciousness, patient cannot be aroused with painful stimuli.
Airway cannot be maintained adequately and ventilation is impaired.
Cardiovascular function may be impaired.
From Meredith JR, O'Keefe KP, Galwankar S: Pediatric procedural sedation and analgesia, J Emerg Trauma Shock 1(2):88–96, 2008.
Key components to include in the patient history include: • Past medical history: Major illnesses, such as asthma, psychiatric disorders, cardiac disease,
hepatic or renal impairment; previous hospitalizations or surgeries; history of previous anesthesia or sedation
• Allergies: Opiates, benzodiazepines, barbiturates, local anesthetics, or others • Current medications: Cardiovascular medications, central nervous system depressants; use
caution with chronic benzodiazepine and opiate users; administration of reversal agents may induce withdrawal or seizures
• Drug use: Narcotics, benzodiazepines, barbiturates, cocaine, and alcohol • Last oral intake: For nonemergent cases, some guidelines recommend more than 6 hours for solid
food and more than 2 hours for clear liquid • Volume status: Vomiting, diarrhea, fluid restriction, urinary output, making tears
A physical status evaluation using the American Society of Anesthesiologists Physical Status Classification (Meredith, O'Keefe, and Galwankar, 2008) is documented before administering analgesia and sedation: • Class I: A normally healthy patient • Class II: A patient with mild systemic disease • Class III: A patient with severe systemic disease • Class IV: A patient with severe systemic disease that is a constant threat to life
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• Class V: A moribund patient who is not expected to survive without the operation To provide a safe environment for procedural sedation and analgesia (PSA), equipment should
be readily available to prevent or manage adverse events and complications (Box 5-7). The patient should have an IV access for titration of sedation and analgesic medications and for administration of possible antagonists and fluids. Trained personnel (physician, registered nurse, respiratory therapist) whose sole responsibility is to monitor the patient (rather than performing or assisting with the procedure) should be present to monitor for adverse events and complications.
Box 5-7 P r o c e d u r a l S e d a t i o n a n d A n a l g e s i a E q u i p m e n t N e e d s • High-flow oxygen and delivery method
• Airway management materials: endotracheal tubes, bag valve masks, and laryngoscopes
• Pulse oximetry, blood pressure monitor, electrocardiography,* capnography*
• Suction and large-bore catheters
• Vascular access supplies
• Resuscitation drugs, intravenous (IV) fluids
• Reversal agents, including flumazenil and naloxone
*May be optional devices.
Postoperative Pain Surgery and traumatic injuries (fractures, dislocations, strains, sprains, lacerations, burns) generate a catabolic state as a result of increased secretion of catabolic hormones and lead to alterations in blood flow, coagulation, fibrinolysis, substrate metabolism, and water and electrolyte balance and increase the demands on the cardiovascular and respiratory systems. The major endocrine and metabolic changes occur during the first 48 hours after surgery or trauma. Local anesthetics and opioid neural blockade may effectively mitigate the physiologic responses to surgical injury.
Pain associated with surgery to the chest (e.g., repair of congenital heart defects, chest trauma) or abdominal regions (e.g., appendectomy, cholecystectomy, splenectomy) may result in pulmonary complications. Pain leads to decreased muscle movement in the thorax and abdominal area and leads to decreased tidal volume, vital capacity, functional residual capacity, and alveolar ventilation. The patient is unable to cough and clear secretions, and the risk for complications (such as, pneumonia and atelectasis) is high. Severe postoperative pain also results in sympathetic overactivity that leads to increases in heart rate, peripheral resistance, blood pressure, and cardiac output. The patient eventually experiences an increase in cardiac demand and myocardial oxygen consumption and a decrease in oxygen delivery to the tissues.
The basis for good postoperative pain control in children is preemptive analgesia (Michelet, Andreu-Gallien, Bensalah, et al, 2012). Preemptive analgesia involves administration of medications (e.g., local and regional anesthetics, analgesics) before the child experiences the pain or before surgery is performed so that the sensory activation and changes in the pain pathways of the peripheral and central nervous system can be controlled. Preemptive analgesia lowers postoperative pain, lowers analgesic requirement, lowers hospital stay, lowers complications after surgery, and minimizes the risks for peripheral and central nervous system sensitization that can lead to persistent pain.
A combination of medications (multimodal or balanced analgesia) is used for postoperative pain and may include NSAIDs, local anesthetics, nonopioids, and opioid analgesics to achieve optimum relief and minimize side effects. Opioids (see Tables 5-5 to 5-7) administered ATC during the first 48 hours or administered via PCA are commonly prescribed (see Table 5-8). Perioperative NSAID
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administration is shown to reduce opioid consumption and postoperative nausea and vomiting in children (Michelet, Andreu-Gallien, Bensala, et al, 2012). Scheduled acetaminophen is supported as the preferred medication in children after tonsillectomy; codeine is not recommended due to the risk of children who may experience ultra-rapid metabolizers caused by abnormal function of the CYP2D6 enzyme (Yellon, Kenna, Cladis, et al, 2014).
The combination of the IV NSAID ketorolac and morphine using a PCA device is frequently prescribed after thoracic surgery. Morphine delivered by PCA leads to a lower total dosage of opioid analgesia when compared with the administration of intermittent doses of analgesic as required. After bowel surgery, a mixture of a local anesthetic (bupivacaine) and a low-dose opioid (fentanyl) delivered by epidural route improves the rate of recovery and minimizes the gastrointestinal effects (e.g., bowel stasis, nausea, vomiting). Once bowel function has been restored, oral opioids (such as immediate release and controlled release preparations) are preferred in older children. Controlled-release opioids facilitate ATC dosing and improve sleep. They are also associated with a lower incidence of nausea, sedation, and breakthrough pain.
Burn Pain Because burn pain has multiple components, involves repeated manipulations over the injured painful sites, and has changing patterns over time, it is difficult and challenging to control. Burn pain includes a constant background pain that is felt at the wound sites and surrounding areas. Burn pain is exacerbated (breakthrough pain) by movements, such as changing position, turning in bed, walking, or even breathing. Areas of normal skin that have been harvested for skin grafts (donor sites) also are painful. Pain is commonly experienced with intense tingling or itching sensations when skin grafting is required. During the healing process, when the tissue and nerve regenerate, the necrotic tissue (eschar) is excised until viable tissue is reached. The healing process may last for months to years. Pain or paresthetic sensations (itching, tingling, cold sensations, and so on) may persist. In addition, discomfort may be associated with immobilization of limbs in splints or garments, as well as multiple surgical interventions such as skin grafting and reconstructive surgery.
Multiple therapeutic procedures are carried out during the course of treatment. These procedures (dressing changes, wound débridement and cleansing, physical therapy sessions) occur daily or even several times a day (see Chapter 13). Providing proper analgesia without interfering with the patient's awareness during and after the procedure is the biggest challenge in the management of burn pain. Fentanyl or alfentanil has a major advantage over morphine because of the short duration. Fentanyl can prevent over sedation after the procedure. For less painful procedures, premedication with oral morphine, oral ketamine, or milder opioids 15 minutes before the procedure may be sufficient. Depending on the patient's anxiety level, a benzodiazepine (e.g., lorazepam) before the procedure may be beneficial. For longer procedures, morphine is the mainstay of treatment. Some patients may require moderate to deep sedation and analgesia. Oral oxycodone with midazolam and acetaminophen, in addition to nitrous oxide, may be needed. IV ketamine administered at subtherapeutic doses has been one of the most extensively used anesthetics for burn patients. The dysphoria and unpleasant reactions associated with ketamine administration may be minimized with premedication with a benzodiazepine. If ketamine is used with either morphine or fentanyl, the regimen could have opioid-sparing actions and reduce the opioid-related side effects.
Psychological interventions are helpful in the treatment of burn pain. These interventions include hypnosis, relaxation training (breathing exercises, progressive muscle relaxation), biofeedback, stress inoculation training, cognitive-behavioral strategies (guided imagery, distraction, coping skills), and group and individual psychotherapy. They can be used alone or in combination. All these techniques can help the patient relax and maintain a sense of control. A major disadvantage of these interventions is they require time and discipline and often patients are too stressed, fatigued, disoriented, or sick to engage in them.
Recurrent Headaches in Children Recurrent headaches in children can be caused by several factors, including tension, dental braces, imbalance or weakness of eye muscles causing deviation in alignment and refractive errors, sequelae to accidents, sinusitis and other cranial infection or inflammation, increased intracranial
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pressure, epileptic attacks, drugs, obstructive sleep apnea, and, rarely, hypertension (see Chapter 27). Other causes may include arteriovenous malformations, disturbances in cerebrospinal fluid flow or absorption, intracranial hemorrhages, ocular and dental diseases, bacterial infections, and brain tumors.
Severe pain is the most disturbing symptom in migraine. Tension-type headache is usually mild or moderate, often producing a pressing feeling in the temples, like a “tight band around the head.” Continuous, daily, or near-daily headache with no specific cause occurs in a small subgroup of children. In epilepsy, headaches commonly occur immediately before, during, or after a seizure attack.
Treatment of recurrent headaches requires an understanding of the antecedents and consequences of headache pain. A headache diary can allow the child to record the time of onset, activities before the onset, any worries or concerns as far back as 24 hours before the onset, severity and duration of pain, pain medications taken, and activity pattern during headache episodes. The headache diary allows ongoing monitoring of headache activity, indicates the effects of interventions, and guides treatment planning.
Headache management involves two main behavioral approaches: (1) teaching patients self- control skills to prevent headache (biofeedback techniques and relaxation training), and (2) modifying behavior patterns that increase the risk of headache occurrence or reinforce headache activity (cognitive-behavioral stress management techniques). Families may be able to identify factors that trigger the headache and avoid the triggers in the future. Biofeedback is a technology- based form of relaxation therapy and can be useful in assessing and reinforcing learning of relaxation skills, such as progressive muscle relaxation, deep breathing, and imagery. Children as young as 7 years old are able to learn these skills and with 2 to 3 weeks of practice are able to decrease the time needed to achieve relaxation.
To modify behavior patterns that increase the risk of headache or reinforce headache activity, the nurse instructs parents to avoid giving excessive attention to their child's headache and to respond matter-of-factly to pain behavior and requests for special attention. Parents learn to assess whether the child is avoiding school or social performance demands because of headache. Parents are taught to focus attention on adaptive coping, such as the use of relaxation techniques and maintenance of normal activity patterns. When using cognitive-behavioral stress management techniques, the parents identify negative thoughts and situations that may be associated with increased risk for headache. The parent teaches the child to activate positive thoughts and engage in adaptive behavior appropriate to the situation.
Recurrent Abdominal Pain in Children RAP or functional abdominal pain is defined as pain that occurs at least once per month for 3 consecutive months, accompanied by pain-free periods, and is severe enough that it interferes with a child's normal activities (see Chapter 16). Management of RAP is highly individualized to reflect the causes of the pain and the psychosocial needs of the child and family. A clear understanding of the child's characteristics (anxiety, physical health, temperament, coping skills, experience, learned response, depression), child's disability (school attendance, activities with family, social interactions, pain behaviors), environmental factors (family attitudes and behavioral patterns, school environment, community, friendships), and the pain stimulus (disease, injury, stress) is important in planning management strategies (Oakes, 2011).
Before any workup of the pain, the nurse informs the family that RAP is common in children and only 10% of children with RAP have an identifiable organic cause for their pain symptom. Medical workup is dictated by the child's symptoms and signs in combination with knowledge about common organic causes of RAP. If an organic cause is found, it will be treated appropriately. Even if no organic cause is found, the nurse needs to communicate to the child and family a belief that the pain is real. Usually the abdominal pain goes away, but even if problems are identified, they may not be the actual cause, and pain may persist, may be replaced by another symptom, or may go away on its own. The management plan includes regular follow-up at 3- to 4-month intervals, a list of symptoms that call for earlier contact, and biobehavioral pain management techniques. The goal is to minimize the impact of the pain on the child's activities and the family's life.
The use of CBT has been documented to reduce or eliminate pain in children with RAP and highlights the involvement of parents in supporting their child's self-management behavior. Case reports have demonstrated the effectiveness of implementing a time-out procedure, token systems,
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and positive reinforcement based on operant theory treatment modalities. Stress management and cognitive-behavioral strategies have also been successful. Parent training in how to avoid positive reinforcement of sick behaviors and focus on rewarding healthy behaviors is important. Over the course of several sessions, parents are educated about RAP, how to distinguish between sick and well behaviors, a reward system for well behaviors, and the importance of reinforcing relaxation and coping skills taught to children for pain management. Treatment may consist of a varying number of sessions over 1 to 6 months and may include various components, such as monitoring symptoms, limiting parent attention, relaxation training, increasing dietary fiber, and requiring school attendance. No negative side effects of symptom substitution occurred with the interventions.
Pain in Children with Sickle Cell Disease A painful episode is the most frequent cause for emergency department visits and hospital admissions among children with sickle cell disease (see Chapter 24). The acute painful episode in sickle cell disease is the only pain syndrome in which opioids are considered the major therapy and are started in early childhood and continued throughout adult life. A source of frustration for patients and clinicians is that most current analgesic regimens are inadequate in controlling some of the most severe painful episodes. A multidisciplinary approach that involves both pharmacologic and nonpharmacologic modalities (cognitive-behavioral intervention, heat, massage, physical therapy) is needed but not often implemented. The goals of treatment of the acute episode may not be to take all the pain away, which is usually impossible, but to make the pain tolerable to the patient until the episode resolves and to increase function and patient participation in activities of daily living (Oakes, 2011).
Patients coming to an emergency department for acute painful episodes usually have exhausted all home care options or outpatient therapy. The nurse should ask patients what the usual medication, dosage, and side effects were in the past; the usual medication taken at home; and medication taken since the onset of present pain. The patient may be on long-term opioid therapy at home and therefore may have developed some degree of tolerance. A different potent opioid or a larger dose of the same medication may be indicated. Because mixed opioid-agonist-antagonists may precipitate withdrawal syndromes, avoid these if patients were taking long-term opioids at home. A “passport” card with patient information about the diagnosis, previous complications, suggested pain management regimen, and name and contact information of the primary hematologist is helpful for parents and facilitates management of pain in the emergency department.
The patient is admitted for inpatient management of severe pain if adequate relief is not achieved in the emergency department. For severe pain, IV administration with bolus dosing and continuous infusion using a PCA device may be necessary. Patients requiring more than 5 to 7 days of opioids should have tapering doses to avoid the physiologic symptoms of withdrawal (dysphoria, nasal congestion, diarrhea, nausea and vomiting, sweating, and seizures). Appropriate weaning of the PCA schedules start with reduction of the continuous infusion rate before discontinuation while the patient continues to use demand doses for analgesia. Morphine-equivalent equianalgesic conversions may be used to convert continuous infusion rates to equivalent oral analgesics (see Table 5-10). Doses of long-acting oral analgesics, such as sustained release oral morphine, may also be used to replace continuous infusion dosing. The demand doses can be subsequently reduced if analgesia remains adequate.
Patients, who are administered doses of opioids that are inadequate to relieve their pain, or whose doses are not tapered after a course of treatment, may develop iatrogenic pseudoaddiction, which resembles addiction. Pseudoaddiction or clock-watching behavior may be resolved by communicating with patients to ensure accurate assessment, involving them in decisions about their pain management, and administering adequate opioid doses.
Cancer Pain in Children Pain in children with cancer is present before diagnosis and treatment and may resolve after initiation of anticancer therapy. However, treatment-related pain is common (Table 5-13). Pain may be related to an operation, mucositis, a phantom limb, or infection. Pain can also be related to chemotherapy and procedures, such as bone marrow aspiration, needle puncture, and lumbar
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puncture. Tumor-related pain frequently occurs when the child relapses or when tumors become resistant to treatment. Intractable pain may occur in patients with solid tumors that metastasize to the central or peripheral nervous system. In young adult survivors of childhood cancer, chronic pain conditions may develop, including complex regional pain syndrome of the lower extremity, phantom limb pain, avascular necrosis, mechanical pain related to bone that failed to unite after tumor resection, and postherpetic neuralgia.
TABLE 5-13 Cancer Pain in Children
Type Clinical Presentation Causes Bone Skull Vertebrae Pelvis and femur
Aching to sharp, severe pain generally more pronounced with movement; point tenderness common Skull—headaches, blurred vision Spine—tenderness over spinous process Extremities—pain associated with movement or lifting Pelvis and femur—pain associated with movement; pain with weight bearing and walking
Infiltration of bone Skeletal metastases—irritation and stretching of pain receptors in periosteum and endosteum Prostaglandins released from bone destruction
Neuropathic Peripheral Plexus Epidural Cord compression
Complaints of pain without any detectable tissue damage Abnormal or unpleasant sensations, generally described as tingling, burning, or stabbing Often a delay in onset Brief, shooting pain Increased intensity of pain with receptive stimuli
Nerve injury caused by tumor infiltration; can also be caused by injury from treatment (e.g., vincristine toxicity) Infiltration or compression of peripheral nerves Surgical interruption of nerves (phantom pain after amputation)
Visceral Soft tissue Tumors of bowel Retroperitoneum
Poorly localized Varies in intensity Pressure, deep or aching
Obstruction—bowel, urinary tract, biliary tract Mucosal ulceration Metabolic alteration Nociceptor activation, generally from distention or inflammation of visceral organs
Treatment Related Mucositis Infection Post-lumbar puncture headaches Radiation dermatitis Postsurgical
Difficulty swallowing, pain from lesions in oropharynx; may extend throughout entire gastrointestinal tract Infection may be localized pain from focused infection or generalized (i.e., tissue infection versus septicemia) Severe headache after lumbar puncture Skin inflammation causing redness and breakdown Pain related to tissue trauma secondary to surgery
Direct side effects of treatment for cancer: Chemotherapy Radiation Surgery
Oral mucositis (ulceration of the oral cavity and throat) may occur in patients undergoing chemotherapy or radiotherapy and in patients undergoing bone marrow transplant. No present therapy adequately relieves the pain of these lesions. Antihistamines, local anesthetics, and opioids provide only temporary relief, may block taste perception, or may produce additional side effects, such as lethargy and constipation. Initial treatment includes single agents (saline, opioids, sodium bicarbonate, hydrogen peroxide, sucralfate suspension, clotrimazole, nystatin, viscous lidocaine, amphotericin B, dyclonine) or mouthwash mixtures using a combination of agents (lidocaine, diphenhydramine, Maalox or Mylanta, nystatin). The mucositis after bone marrow transplantation may be prolonged, continuously intense, exacerbated by mouth care and swallowing, or worse during waking hours. The patient may be unable to eat or swallow. Morphine administered as a continuous infusion or delivered by PCA device may be required until mucositis is resolved (Hickman, Varadarajan, and Weisman, 2014).
Other treatment-related pain includes (1) abdominal pain after allogeneic bone marrow transplantation, which may be associated with acute graft-versus-host disease; (2) abdominal pain associated with typhlitis (infection of the cecum), which occurs when the patient is immunocompromised; (3) phantom sensations and phantom limb pain after an amputation; (4) peripheral neuropathy after administration of vincristine; and (5) medullary bone pain, which may be associated with administration of granulocyte colony–stimulating factor.
Survivors of childhood cancer describe vivid memories of their experience with repeated painful procedures during treatment. These procedures include needle puncture for IM chemotherapy (L- asparaginase), IV lines, port access and blood draws, lumbar puncture, bone marrow aspiration and biopsy, removal of central venous catheters, and other invasive diagnostic procedures. Fear and anxiety related to these procedures may be minimized with parent and child preparation. The preparation starts with obtaining information from the parent about the child's coping styles, explaining the procedure, and enlisting their support, followed by an age-appropriate explanation to the child. CBT (guided imagery, relaxation, music therapy, hypnosis), conscious sedation, and general anesthesia have been effective in decreasing pain and distress during the procedure. Topical analgesics (cold sprays, EMLA, amethocaine gels), as discussed previously, are effective in providing analgesia before needle procedures.
Lumbar puncture for administration of chemotherapy (e.g., cytarabine, methotrexate) and collection of cerebrospinal fluid may lead to a leak at the puncture site and low intracranial
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pressure. Some children may experience post-dural puncture headache, which may be treated by administering nonopioid analgesics and placing the patient in the supine position for 1 hour after the procedure. The pain related to bone marrow aspiration is due to the insertion of a large needle into the posterior iliac space and the unpleasant sensation experienced at the time of marrow aspiration.
If the patient is neutropenic (absolute neutrophil count <500/mm3), the antipyretic action of acetaminophen may mask a fever. In patients with thrombocytopenia (platelet count <50,000/mm3), who may be at risk for bleeding, NSAIDs are contraindicated. Morphine is the most widely used opioid for moderate to severe pain and may be administered via the oral (including sustained release formulations, such as MS Contin), IV, subcutaneous, epidural, and intrathecal routes.
The most common clinical syndrome of neuropathic pain is painful peripheral neuropathy caused by chemotherapeutic agents, particularly vincristine and cisplatin, and rarely cytarabine (Hickman, Varadarajan, and Weisman, 2014). After withdrawal of the chemotherapy, the neuropathy may resolve over weeks to months, or it may persist even after withdrawal. Neuropathic pain is associated with at least one of the following: (1) pain that is described as electric or shocklike, stabbing, or burning; (2) signs of neurologic involvement (paralysis, neuralgia, pain hypersensitivity) other than those associated with the progression of the tumor; and (3) the location of the solid organ cancer consistent with neurologic damage that could give rise to neuropathic pain. An epidural or subarachnoid infusion may be initiated if the patient experiences dose-limiting side effects of opioids or if pain is resistant to opioids. Tricyclic antidepressants (amitriptyline, desipramine) and anticonvulsants (gabapentin, carbamazepine) have demonstrated effectiveness in neuropathic cancer pain (see Research Focus box).
R e s e a r c h F o c u s Tricyclic Antidepressants to Treat Neuropathic Pain
Although there is limited evidence for the use of antidepressants for the management of pain in children, there is clinical experience on the use of amitriptyline for pain management in children (World Health Organization, 2012). A study of 90 children with irritable bowel syndrome, functional abdominal pain, or functional dyspepsia randomized participants to 4 weeks of placebo or amitriptyline (Saps, Youssef, Miranda, et al, 2009). Both amitriptyline and placebo were associated with excellent therapeutic response. There was no significant difference between amitriptyline and placebo after 4 weeks of treatment. Patients with mild to moderate intensity of pain responded better to treatment.
Pain and Sedation in End-of-Life Care Many patients at the end of life require doses of opioids that make them sedated but arousable as their disease progresses (cancer, human immunodeficiency virus, cystic fibrosis, neurodegenerative disease). Patients achieve comfort with a combination of opioids and adjuvant analgesics in most situations. Parents need reassurance that the opioids are treating pain but not causing the child's death and that the child's advancing disease is the cause of death.
A small group of patients have intolerable side effects or inadequate analgesia despite extremely aggressive use of medications to relieve pain and side effects. Continuous sedation may be a means of relieving suffering when there is no feasible or acceptable means of providing analgesia that preserves alertness. A continuing high-dose infusion of opioids along with sedation is prescribed to reduce the possibility that a child might experience unrelieved pain but be too sedated to report it. Sedation in these situations is widely regarded as providing comfort, not euthanasia. Clinicians and ethicists have a range of views regarding assisted suicide and euthanasia, but they all agree that no child or parent should choose death because of inadequate efforts to relieve pain and suffering.
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Review Questions 1. When caring for their infant, a parent asks you, “Is Emily in a lot of pain? How would you know
since she can't really tell you?” The best answer to this question is a. “Infants don't feel pain as we do because their pain receptors are not fully developed yet.” b. “The nurses give pain medication before she really feels the pain.” c. “We assess her pain using an infant pain assessment tool and give the medicine as needed.” d. “Although we try to give her medicine before she feels pain, we watch her very closely and use
different techniques to help relieve the pain.” 2. Pain scales for infants and their uses include but are not limited to
a. CRIES: Crying, Requiring increased oxygen, Inability to console, Expression, and Sleeplessness b. FLACC Pain Assessment Tool: Facial expression, Leg movement, Activity, Cry, and
Consolability c. Non-Communicating Children's Pain Checklist (NCCPC): Parent and health care giver
questionnaire assessing acute and chronic pain d. Neonatal Pain, Agitation, and Sedation Scale (NPASS): For infants from 3 to 6 months old
3. As the nurse is getting Nathan ready for surgery, his doctor asked you to explain preemptive analgesic to Nathan's mother. Which response leads you to believe his mother needs more teaching? a. “I understand that preemptive analgesia is giving Nathan pain medication before he has pain
and could be given before surgery.” b. “This medication will control Nathan's pain so he doesn't feel anything.” c. “Giving this medicine early may help prevent complications after surgery.” d. “By controlling Nathan's pain, he will be more comfortable and may be able to go home
sooner.” 4. When teaching a 6-year-old child with sickle cell disease and his family about pain management,
which of the following should the nurse discuss? Select all that apply. a. When pain medications are used, all pain will be eliminated. b. Nonpharmacologic methods of pain relief, including heat, massage, physical therapy, humor,
and distraction. c. It is helpful to use a “passport card” that includes information about the diagnosis, any
previous complications, and the pain regimen. d. Only the physician can decide the best course of treatment, and the other health care providers
follow that plan. e. Long-term medication use considers many factors.
5. How can the nurse prepare a child for a painful procedure? Select all that apply. a. Be honest and use correct terms so that the child trusts the nurse. b. Involve the child in the use of distraction, such as using bubbles, music, or playing a game. c. Kindly ask parents to leave the room so that they don't have to watch the painful procedure. d. Teach positive self-talk such as, “When you go home, you will feel better and be able to see
your friends.” e. Use guided imagery that involves recalling a previous pleasurable event.
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Correct Answers 1. d; 2. b;
3. b; 4. b, c, d;
5. b, d, e
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assessment tools for children with cognitive impairment. Anesth Analg. 2008;106(1):72–78. von Baeyer CL, Lin V, Seidman LC, et al. Pain charts (body maps or manikins) in assessment
of the location of pediatric pain. Pain Manag. 2011;1(1):61–68. Walker LS, Greene JW. The functional disability inventory: measuring a neglected dimension
of child health status. J Pediatr Psychol. 1991;16(1):39–58. Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs.
1988;14(1):9–17. World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in
children with medical illnesses. World Health Organization: Geneva; 2012. Yellon RF, Kenna MA, Cladis FP, et al. What is the best non-codeine post adenotonsilectomy
pain management for children? Laryngoscope. 2014;124(8):1737–1738. Yilmaz G, Cavlan N, Oguz M, et al. Oral sucrose administration to reduce pain response
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Zempsky WT. Topical anesthetics and analgesics. McGrath PC, Stevens BJ, Walker SM, et al. Oxford textbook of paediatric pain. Oxford University Press: Oxford UK; 2014.
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Childhood Communicable and Infectious Diseases Marilyn J. Hockenberry
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Infection Control According to the Centers for Disease Control and Prevention, approximately 2 million patients each year develop hospital-acquired infections (HAIs). A Centers for Disease Control and Prevention report in 2009 estimated the overall cost of HAIs to hospitals in the United States at $35 billion to $45 billion (Scott, 2009). These infections occur when there is interaction among patients, health care personnel, equipment, and bacteria. HAIs are preventable if caregivers practice meticulous cleaning and disposal techniques.
Standard Precautions synthesize the major features of universal (blood and body fluid) precautions (designed to reduce the risk of transmission of blood-borne pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body substances). Standard Precautions involve the use of barrier protection (personal protective equipment [PPE]), such as gloves, goggles, gowns, and masks, to prevent contamination from blood; all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood; nonintact skin; and mucous membranes. Standard Precautions are designed for the care of all patients to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection.
In 2007, the Centers for Disease Control and Prevention recommended adding Respiratory Hygiene/Cough Etiquette and safe injection practices to Standard Precautions. Respiratory Hygiene/Cough Etiquette stresses the importance of source control measures to contain respiratory secretions to prevent droplet and fomite transmission of viral respiratory tract infections, such as respiratory syncytial virus (RSV), influenza, and adenovirus (Siegel, Rhinehart, Jackson, et al, 2007). Safe injection practices involve the use of safety-engineered sharp devices to prevent sharps injury as a component of Standard Precautions.
Hand hygiene continues to be the single most important practice to reduce the transmission of infectious diseases in health care settings (Siegel, Rhinehart, Jackson, et al, 2007). Hand hygiene includes hand washing with soap and water, as well as the use of alcohol-based products for hand disinfection.
Transmission-Based Precautions are designed for patients with documented or suspected infection or colonization (presence of microorganisms in or on patient but without clinical signs and symptoms of infection) with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in hospitals. The three types of Transmission-Based Precautions are (1) Airborne Precautions, (2) Droplet Precautions, and (3) Contact Precautions. They may be combined for diseases that have multiple routes of transmission (Box 6-1). They are to be used in addition to Standard Precautions.
Box 6-1 T y p e s o f P r e c a u t i o n s a n d Pa t i e n t s R e q u i r i n g T h e m Standard Precautions for Prevention of Transmission of Pathogens Use Standard Precautions for the care of all patients. Hand hygiene should be emphasized as part of Standard Precautions.
Respiratory Hygiene/Cough Etiquette In addition to Standard Precautions the Centers for Disease Control and Prevention suggests a combination of measures designed to minimize the transmission of respiratory pathogens via droplet or airborne routes in the health care environment. Measures include covering the mouth and nose during coughing and sneezing; offering a surgical mask to persons who are coughing; using tissues to contain respiratory secretions; turning the head away from others; and keeping a space of 3 feet or more when coughing. These measures should be used for patients and visitors or family members who have symptoms of respiratory infection upon entry to the health care institution (Siegel, Rhinehart, Jackson, et al, 2007).
Airborne Precautions In addition to Standard Precautions, use Airborne Precautions and airborne infection isolation
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room (AIIR) for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and tuberculosis.
Droplet Precautions In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include:
• Invasive Haemophilus influenzae type b (Hib) disease, including meningitis, pneumonia, epiglottitis, and sepsis
• Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
• Other serious bacterial respiratory tract infections spread by droplet transmission, including diphtheria (pharyngeal), mycoplasmal pneumonia, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children
• Serious viral infections spread by droplet transmission, including adenovirus, influenza, mumps, human parvovirus B19, and rubella
Contact Precautions In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include:
• Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance
• Enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile; for diapered or incontinent patients: enterohemorrhagic Escherichia coli O157 : H7, Shigella organisms, hepatitis A, or rotavirus
• Respiratory syncytial virus (RSV), parainfluenza virus, or enteroviral infections in infants and young children.
• Skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (HSV; neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis or decubitus, pediculosis, scabies, staphylococcal furunculosis in infants and young children, zoster (disseminated or in the immunocompromised host)
• Viral or hemorrhagic conjunctivitis
• Viral hemorrhagic infections (Ebola, Lassa, or Marburg)
Modified from Siegel JD, Rhinehart E, Jackson M, et al: 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, 2007, http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.
Airborne Precautions reduce the risk of airborne transmission of infectious agents. Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue [≤5 mm] of evaporated droplets that may remain suspended in the air for long periods) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors. Special air handling and ventilation are required to prevent airborne transmission. The term airborne infection isolation room (AIIR) has replaced negative pressure isolation room; this room is used to isolate persons with a suspected or confirmed airborne infectious disease transmitted by the airborne route, such as measles, varicella, and tuberculosis.
Droplet Precautions reduce the risk of droplet transmission of infectious agents. Droplet
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transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during procedures, such as suctioning and bronchoscopy. Transmission requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances, usually 3 feet or less, through the air. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Droplet Precautions apply to any patient with known or suspected infection with pathogens that can be transmitted by infectious droplets (see Box 6-1).
Contact Precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when turning or bathing patients. Direct-contact transmission also can occur between two patients (e.g., by hand contact). Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment. Contact Precautions apply to specified patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect contact.
N u r s i n g A l e r t The most common piece of medical equipment, the stethoscope, can be a potent source of harmful microorganisms and nosocomial infections. Consider also the keyboard and desktop as potential sources.
Nurses caring for young children are frequently in contact with body substances, especially urine, feces, and vomitus. Nurses need to exercise judgment concerning those situations when gloves, gowns, or masks are necessary. For example, wear gloves and possibly gowns for changing diapers when there are loose or explosive stools. Otherwise, the plastic lining of disposable diapers provides a sufficient barrier between the hands and body substances.
Antimicrobial-resistant organisms are causing increasing numbers of HAIs. In hospitals, patients are the most significant sources of methicillin-resistant Staphylococcus aureus (MRSA), and the main mode of transmission is patient-to-patient via the hands of a health care provider. Hand washing is the most critical infection control practice.
During feedings, wear gowns if the child is likely to vomit or spit up, which often occurs during burping. When wearing gloves, wash hands thoroughly after removing the gloves, because gloves fail to provide complete protection. The absence of visible leaks does not indicate that gloves are intact.
Another essential practice of infection control is that all needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers are installed in patients' rooms. Because children are naturally curious, extra attention is needed in selecting a suitable type of container and a location that prevents access to the discarded needles (Fig. 6-1). The use of needleless systems allows secure syringe or intravenous (IV) tubing attachment to vascular access devices without the risk of needle stick injury to the child or nurse.
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FIG 6-1 To prevent needlestick injuries, used needles (and other sharp instruments) are not capped or broken and are disposed of in a rigid, puncture-resistant container located near site of use. Note
placement of container to prevent children's access to contents.
Immunizations* One of the most dramatic advances in pediatrics has been the decline of infectious diseases during the twentieth century because of the widespread use of immunization for preventable diseases. This trend has continued into the twenty-first century with the development of newer vaccines. Although many of the immunizations can be given to individuals of any age, the recommended primary schedule begins during infancy and, with the exception of boosters, is completed during early childhood. Therefore, health promotion during infancy includes a discussion of childhood immunizations for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles, mumps, and rubella (MMR); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); hepatitis A virus (HAV); meningococcal; pneumococcal conjugate vaccine (PCV); influenza (and H1N1); and varicella-zoster virus (VZV; chickenpox). Selected vaccines generally reserved for children considered at high risk for the disease are discussed here and as appropriate throughout this chapter.
To facilitate an understanding of immunizations, key terms are listed in Box 6-2. Although in this discussion, the terms vaccination and immunization are used interchangeably in reference to active immunization; they are not synonymous because the administration of an immunobiologic such as a vaccine cannot automatically be equated with the development of adequate immunity.
Box 6-2 K e y I m m u n i z a t i o n Te r m s Acquired immunity: Immunity from exposure to the invading agent, either bacteria, virus, or toxin
Active immunity: A state where immune bodies are actively formed against specific antigens, either naturally by having had the disease clinically or subclinically or artificially by introducing the antigen into the individual
Antibody: A protein, found mostly in serum, that is formed in response to exposure to a specific antigen
Antigen: A variety of foreign substances, including bacteria, viruses, toxins, and foreign proteins, that stimulate the formation of antibodies
Antitoxin: A solution of antibodies (e.g., diphtheria antitoxin, botulinum antitoxin) derived from the serum of animals immunized with specific antigens and used to confer passive immunity and for treatment
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Attenuate: Reduce the virulence (infectiousness) of a pathogenic microorganism by such measures as treating it with heat or chemicals or cultivating it on a certain medium
Combination vaccine: Combination of multiple vaccines into one parenteral form
Conjugate vaccine: A carrier protein with proven immunologic potential combined with a less antigenic polysaccharide antigen to enhance the type and magnitude of the immune response (e.g., Haemophilus influenza type b [Hib])
Herd immunity: A condition in which the majority of the population community is vaccinated and the spread of certain diseases is stopped, because the population that has been vaccinated protects those in the same population who are unvaccinated
Immunity: An inherited or acquired state in which an individual is resistant to the occurrence or the effects of a specific disease, particularly an infectious agent
Immunization: Inclusive term denoting the process of inducing or providing active or passive immunity artificially by administering an immunobiologic
Immunobiologic: Antigenic substances (e.g., vaccines and toxoids) or antibody-containing preparations (e.g., globulins and antitoxins) from human or animal donors, used for active or passive immunization or therapy
Immunoglobulin (Ig) or intravenous immunoglobulin (IVIG): A sterile solution containing antibodies from large pools of human blood plasma; primarily indicated for routine maintenance of immunity of certain immunodeficient persons and for passive immunization against measles and hepatitis A
Monovalent vaccine: Vaccine designed to vaccinate against a single antigen or organism
Natural immunity: Innate immunity or resistance to infection or toxicity
Passive immunity: Temporary immunity obtained by transfusing immunoglobulins or antitoxins either artificially from another human or an animal that has been actively immunized against an antigen or naturally from the mother to the fetus via the placenta
Polyvalent vaccine: Vaccine designed to vaccinate against multiple antigens or organisms (e.g., meningococcal polysaccharide vaccine [MCV4])
Specific immunoglobulins: Special preparations obtained from blood plasma from donor pools preselected for a high antibody content against a specific antigen (e.g., hepatitis B immune globulin [HBIG], varicella zoster immunoglobulin, rabies immunoglobulin, tetanus immunoglobulin [TIG], and cytomegalovirus immunoglobulin); as with Ig and IVIG, do not transmit hepatitis B virus (HBV), human immunodeficiency virus (HIV), or other infectious diseases
Toxoid: A modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxin
Vaccination: Originally referred to inoculation with vaccinia smallpox virus to make a person immune to smallpox; currently denotes physical act of administering any vaccine or toxoid
Vaccine: A suspension of live (usually attenuated) or inactivated microorganisms (e.g., bacteria, viruses, or rickettsiae) or fractions of the microorganism administered to induce immunity and prevent infectious disease or its sequelae
Schedule for Immunizations In the United States, two organizations, the Committee on Infectious Diseases of the American Academy of Pediatrics and the Advisory Committee on Immunization Practices of the Centers for
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Disease Control and Prevention, govern the recommendations for immunization policies and procedures. In Canada, recommendations are from the National Advisory Committee on Immunization under the authority of the Minister of Health and Public Health Agency of Canada. The policies of each committee are recommendations, not rules, and they change as a result of advances in the field of immunology. Nurses need to be knowledgeable about the purpose of each organization, view immunization practices in light of the needs of each individual child and the community, and keep informed of the latest advances and changes in policy.
The recommended age for beginning primary immunizations of infants is at birth or within 2 weeks of birth. Children born preterm should receive the full dose of each vaccine at the appropriate chronologic age. A recommended catch-up schedule for children not immunized during infancy is available at the Centers for Disease Control and Prevention website (http://www.cdc.gov/vaccines/schedules/index.html). Immunization recommendation schedules for Canadian children are available at http://www.phac-aspc.gc.ca/im/is-cv/index-eng.php.
Children who began primary immunization at the recommended age but fail to receive all the doses do not need to begin the series again but instead receive only the missed doses. For situations in which there is doubt that the child will return for immunization according to the optimum schedule, HBV vaccine (HepB), DTaP, IPV (poliovirus vaccine), MMR, varicella, and Hib vaccines can be administered simultaneously at separate injection sites. Parenteral vaccines are given in separate syringes in different injection sites (American Academy of Pediatrics, 2015).
Recommendations for Routine Immunizations*
Hepatitis B Virus HBV is a significant pediatric disease because HBV infections that occur during childhood and adolescence can lead to fatal consequences from cirrhosis or liver cancer during adulthood. Up to 90% of infants infected perinatally and 25% to 50% of children infected before 5 years old become HBV carriers. In addition, the incidence of HBV infection increases rapidly during adolescence (American Academy of Pediatrics, 2015). It is recommended that newborns receive HepB before hospital discharge if the mother is hepatitis B surface antigen (HBsAg) negative. Monovalent HepB should be given as the birth dose, whereas combination vaccine containing HepB may be given for subsequent doses in the series. Both full-term and preterm infants born to mothers whose HBsAg status is positive or unknown should receive HepB and hepatitis B immune globulin (HBIG), 0.5 ml, within 12 hours of birth at two different injection sites. Because the immune response to HepB is not optimum in newborns weighing less than 2000 g (4.4 lbs.), the first HepB dose should be given to such infants at a chronological age of 1 month old, as long as the mother's HBsAg status is negative (American Academy of Pediatrics, 2015). In the event that the preterm infant is given a dose at birth, the current recommendation is that the infant be given the full series (three additional doses) at 1, 2, and 6 months of age. The American Academy of Pediatrics (2015) also encourages immunization of all children by 11 years old.
The vaccine is given intramuscularly in the vastus lateralis in newborns or in the deltoid for older infants and children. Regardless of age, avoid the dorsogluteal site because it has been associated with low antibody seroconversion rates, indicating a reduced immune response. No data exist regarding the seroconversion when the ventrogluteal site is used. The vaccine can be safely administered simultaneously at a separate site with DTaP, MMR, and Hib vaccines.
Hepatitis A Virus Hepatitis A has been recognized as a significant child health problem, particularly in communities with unusually high infection rates. HAV is spread by the fecal-oral route and from person-to- person contact, by ingestion of contaminated food or water, and, rarely, by blood transfusion. The illness has an abrupt onset, with fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, and jaundice being the most common clinical signs of infection. In children younger than 6 years old, who represent approximately one third of all cases of hepatitis A, the disease may be asymptomatic, and jaundice is rarely evident.
HepA vaccine is now recommended for all children beginning at 1 year old (i.e., 12 months old to 23 months old). The second dose in the two-dose series may be administered no sooner than 6 months after the first dose. Since the implementation of widespread childhood HepA vaccination, infection rates among children from 5 to 14 years old have declined significantly.
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Diphtheria Although cases of diphtheria are rare in the United States, the disease can result in significant morbidity. Respiratory manifestations include respiratory nasopharyngitis or obstructive laryngotracheitis with upper airway obstruction. The cutaneous manifestations of the disease include vaginal, otic, conjunctival, or cutaneous lesions, which are primarily seen in urban homeless persons and in the tropics (American Academy of Pediatrics, 2015). Administer a single dose of equine antitoxin intravenously to the child with clinical symptoms because of the often fulminant progression of the disease (American Academy of Pediatrics, 2015). Diphtheria vaccine is commonly administered (1) in combination with tetanus and pertussis vaccines (DTaP) or DTaP and Hib vaccines for children younger than 7 years old, (2) in combination with a conjugate Hib vaccine, (3) in a combined vaccine with tetanus (DT) for children younger than 7 years old who have some contraindication to receiving pertussis vaccine, (4) in combination with tetanus and acellular pertussis (Tdap) for children 11 years old and older, or (5) as a single antigen when combined antigen preparations are not indicated. Although the diphtheria vaccine does not produce absolute immunity, protective antitoxin persists for 10 years or more when given according to the recommended schedule, and boosters are given every 10 years for life (see later discussion for adolescent diphtheria and acellular pertussis and tetanus toxoid recommendation). Several vaccines contain diphtheria toxoid (Hib, meningococcal, pneumococcal), but this does not confer immunity to the disease.
Tetanus Three forms of tetanus vaccine—tetanus toxoid, tetanus immunoglobulin (TIG) (human), and tetanus antitoxin (equine antitoxin)—are available; however, tetanus antitoxin is no longer available in the United States. Tetanus toxoid is used for routine primary immunization, usually in one of the combinations listed for diphtheria, and provides protective antitoxin levels for approximately 10 years.
Tetanus and diphtheria toxoids along with acellular pertussis vaccine (Tdap, adolescent formulation) are now recommended for children 11 to 12 years old who have completed the recommended DTaP/DTP vaccine series but have not received the tetanus (Td) booster dose. Adolescents 13 to 18 years old who have not received the Td/Tdap booster should receive a single Tdap booster, provided the routine DTaP/DTP childhood immunization series has been previously received. In response to the increase in cases of pertussis in children, adolescents, and adults, the Centers for Disease Control and Prevention (Advisory Committee on Immunization Practices) now recommend that a Tdap booster be administered regardless of the time interval from the last tetanus- or diphtheria-toxoid containing vaccine (DTaP, DTP, Td, or Tdap). In addition, children 7 to 10 years old who are not fully vaccinated for pertussis (i.e., did not receive five doses of DTaP or four doses of DTaP with the fourth dose being administered on or after the fourth birthday), should receive a dose of Tdap (Centers for Disease Control and Prevention, 2011c). It is recommended that children receive subsequent Td boosters every 10 years (American Academy of Pediatrics, 2015). Boostrix (Tdap) is currently licensed for children 10 to 18 years old, whereas Adacel (Tdap) is licensed for individuals 11 to 64 years old.
For wound management, passive immunity is available with TIG. Persons with a history of two previous doses of tetanus toxoid can receive a booster dose of the toxoid. Separate syringes and different sites are used when tetanus toxoid and TIG are given concurrently.
For children older than 7 years old who require wound prophylaxis, tetanus immunization may be accomplished by administering Td (adult-type diphtheria and tetanus toxoids). If TIG is not available, the equine antitoxin (not available in the United States) may be administered after appropriate testing for sensitivity. The antitoxin is administered in a separate syringe and at a separate intramuscular site if given concurrently with tetanus toxoid.
Pertussis Pertussis vaccine is recommended for all children 6 weeks old through 6 years old (up to the seventh birthday) who have no neurologic contraindications to its use. Concerns over outbreaks of the disease in the past decade have prompted discussion about vaccinating infants and adults. Many cases of pertussis have occurred in children younger than 6 months old or persons older than 7 years old, both groups falling in the category for which pertussis immunization previously was not recommended. The tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) is
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now recommended at 11 to 12 years old for children who have completed the DTaP/DTP childhood series. The Tdap is also recommended for adolescents 13 to 18 years old who have not received a tetanus booster (Td) or Tdap dose and have completed the childhood DTaP/DTP series. When the Tdap is used as a booster dose, it may be administered regardless of the interval from the previous tetanus, diphtheria, and pertussis-containing vaccine. In addition, children 7 to 10 years old who are not fully vaccinated for pertussis (i.e., did not receive five doses of DTaP or four doses of DTaP, with the fourth dose being administered on or after the fourth birthday) should receive a dose of Tdap (Centers for Disease Control and Prevention, 2011c) (see discussion in Tetanus).
The Advisory Committee on Immunization Practices (Centers for Disease Control and Prevention) and American College of Obstetricians and Gynecologists has recommended that pregnant adolescents and women who are not protected against pertussis receive the Tdap vaccine optimally between 27 and 36 weeks gestation or postpartum prior to discharge from the hospital; breastfeeding is not a contraindication to Tdap vaccination (Centers for Disease Control and Prevention, 2013b).
Currently, two forms of pertussis vaccine are available in the United States. The whole-cell pertussis vaccine is prepared from inactivated cells of Bordetella pertussis and contains multiple antigens. In contrast, the acellular pertussis vaccine contains one or more immunogens derived from the B. pertussis organism. The highly purified acellular vaccine is associated with fewer local and systemic reactions than those occurring with the whole-cell vaccine in children of similar age. The acellular pertussis vaccine is recommended by the American Academy of Pediatrics (2015) for the first three immunizations and is usually given at 2, 4, and 6 months old with diphtheria and tetanus (DTaP). Several forms of acellular pertussis vaccine are currently licensed for use in infants: Daptacel, Pediarix, Kinrix (DTaP and IPV), and Infanrix (diphtheria, tetanus toxoid, and acellular pertussis conjugate). Pentacel is licensed for use in infants 4 weeks old and older; in addition to acellular pertussis, diphtheria, and tetanus, this vaccine also contains inactivated poliovirus (IPV) and Hib conjugate. Either the acellular or whole-cell vaccine may be given for the fourth and fifth doses, but the acellular is preferred. It is also recommended that the first three DTaP vaccinations be from the same manufacturer. The fourth dose may be from a different manufacturer. The child who has received one or more whole-cell vaccines may complete the series of five with the acellular vaccine.
Health care workers who may be susceptible to pertussis as a result of waning immunity and who have potential exposure to children or adults with pertussis should receive a single dose of Tdap (if not previously vaccinated with same) and take the necessary protective precautions against droplet contamination (wear procedural or surgical masks and practice hand washing). The diagnosis of pertussis may be missed or delayed in unvaccinated infants, who often are seen with respiratory distress and apnea without the typical cough.
Additional guidelines for prevention and treatment of pertussis among health care workers and close contacts can be found on the Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/.
Polio An all-IPV (inactivated poliovirus vaccine) schedule for routine childhood polio vaccination is now recommended for children in the United States. All children should receive four doses of IPV at 2 months old, 4 months old, 6 to 18 months old, and 4 to 6 years old (American Academy of Pediatrics, 2015).
The change from the exclusive use of oral polio vaccine (OPV) to the exclusive use of IPV is related to the rare risk of vaccine-associated polio paralysis (VAPP) from OPV. The exclusive use of IPV eliminates the risk of VAPP but is associated with an increased number of injections and increased cost. Since IPV usage was instituted in the United States in 2000, no new indigenously acquired cases of VAPP have occurred. PEDIARIX is a combination vaccine containing DTaP, hepatitis B, and IPV; this may be used as the primary immunization beginning at 2 months old (American Academy of Pediatrics, 2015). KINRIX contains DTaP and IPV and it may be used as the fifth dose in the DTaP series and the fourth dose in the IPV series in children 4 to 6 years old whose previous vaccine doses have been with INFANRIX and/or PEDIARIX for the first three doses and INFANRIX for the fourth dose. As noted earlier, PENTACEL is also licensed for use in infants 4 weeks old and older and contains DTaP, Hib, and IPV. PEDIARIX has been licensed for use in children as young as 6 weeks old and contains DTaP, Hep B, and IPV.
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Measles The measles (rubeola) vaccine is given at 12 to 15 months old. During the course of measles outbreaks, the vaccine can be given at 6 to 11 months old, followed by a second inoculation after 12 months old. The second measles immunization is recommended at 4 to 6 years old (at school entry) but may be given earlier provided that 4 weeks have elapsed since the administration of the previous dose. Revaccination should occur by 11 to 12 years old if the measles vaccine was not administered at school entry (4 to 6 years old). Any child who is vaccinated before 12 months old should receive two additional doses beginning at 12 to 15 months old and separated by at least 4 weeks (American Academy of Pediatrics, 2015). Revaccination should include all individuals born after 1956 who have not received two doses of measles vaccine after 12 months old. Individuals born before this date are thought to be immune from exposure to natural measles virus. Because of the continuing occurrence of measles in older children and young adults, identify potentially susceptible adolescents and young adults and immunize them if two doses of measles vaccine have not been administered previously or the person had a confirmed case of the illness.
The measles, mumps, rubella, and varicella (MMRV) vaccine is an attenuated live virus vaccine and may be given to children 12 months to 15 months old and before or at 4 through 6 years old concurrent with other vaccines. Children with HIV should not receive the MMRV vaccine because of a lack of evidence of its safety in this population. The risks and benefits of administering the MMRV vaccine should be fully explained to the parent or caregiver; the risk for a febrile seizure at 5 to 12 days in children 12 to 23 months old remains relatively low and should be weighed with the benefit of one fewer intramuscular injection (American Academy of Pediatrics, 2015). The American Academy of Pediatrics (2015) recommends that either the MMR or MMRV vaccine be given as the first dose of MMRV vaccine at 12 through 47 months old; for children 48 months old and older, the first dose with MMRV is recommended to decrease the number of injections; for the second dose at any age (15 months through 12 years old), MMRV is also recommended for the same reason.
Vitamin A supplementation has been effective in decreasing the morbidity and mortality associated with measles in developing countries (see also Table 6-1).
Mumps Mumps virus vaccine is recommended for children at 12 to 15 months old and is typically given in combination with measles and rubella. It should not be administered to infants younger than 12 months old because persisting maternal antibodies can interfere with the immune response. Because of continued occurrence of the disease, especially in children 10 to 19 years old, mumps immunization is recommended for all individuals born after 1957 who may be susceptible to mumps (i.e., those who have no history of having had the disease or vaccine and who have no laboratory evidence of immunity).
Rubella Rubella is a relatively mild infection in children, but in a pregnant woman the actual infection presents serious risks to the developing fetus. Therefore, the aim of rubella immunization is actually protection of the unborn child rather than the recipient of the immunization.
Rubella immunization is recommended for all children at 12 to 15 months old and at the age of school entry or 4 to 6 years old or sooner, according to the routine recommendations for the MMRV vaccine (American Academy of Pediatrics, 2015). Increased emphasis should also be placed on vaccinating all unimmunized prepubertal children and susceptible adolescents and adult women in the childbearing age group. Because the live attenuated virus may cross the placenta and theoretically present a risk to the developing fetus, rubella vaccine is currently not given to any pregnant woman. Although this is standard practice, current evidence from women who received the vaccine while pregnant and delivered unaffected offspring indicates that the risk to the fetus is negligible. In addition, there is no reported danger of administering rubella vaccine to a child if the mother is pregnant. Postpubertal females without evidence of rubella immunity should be immunized unless they are pregnant; they should be counseled not to become pregnant for 28 days after receiving the rubella-containing vaccine (American Academy of Pediatrics, 2015).
Haemophilus influenzae Type B Hib conjugate vaccines protect against a number of serious infections caused by H. influenza type b,
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especially bacterial meningitis, epiglottitis, bacterial pneumonia, septic arthritis, and sepsis (Hib is not associated with the viruses that cause influenza, or “flu”). Hib vaccines that are currently available include PedvaxHIB, Pentacel, and Comvax, which are combination vaccines, and Hiberix and ActHIB. Pentacel is described in the previous section on Pertussis. MenHibrix has been licensed for administration to children 6 weeks old to 18 months old and provides protection against meningococcal (groups A, C, Y, and W-135), as well as Hib. MenHibrix is administered in a four- dose series at 2, 4, 6, and 12 to 15 months old. These conjugate vaccines connect Hib to a nontoxic form of another organism, such as meningococcal protein, tetanus toxoid, or diphtheria protein. There is no antibody response to these nontoxic proteins, but they significantly improve the antibody response to Hib, especially in infants. The use of combination vaccines provides equivalent immunogenicity and decreases the number of injections an infant receives. However, it is important that they be given to the appropriate-age child. Hiberix is a conjugate vaccine licensed for use as the booster (final) dose of the Hib vaccine series for children 15 months old to 4 years old (Briere EC, Rubin L, Moro PL, et al, 2014a). In 2013, the American Academy of Pediatrics clarified that only one dose of Hib should be given to children 15 months old or older who have not been previously vaccinated (American Academy of Pediatrics, 2013).
When possible, the Hib conjugate vaccine used at the first vaccination should be used for all subsequent vaccinations in the primary series. All Hib vaccines are administered by intramuscular injection using a separate syringe and at a site separate from any concurrent vaccinations.
N u r s i n g A l e r t The use of meningococcal and diphtheria proteins in combination vaccines does not mean the child has received adequate immunization for meningococcal or diphtheria illnesses; the child must be given the appropriate vaccine for that specific disease.
Varicella Administration of the cell-free live-attenuated varicella vaccine is recommended for any susceptible child (one who lacks proof of varicella vaccination or has a reliable history of varicella infection). A single dose of 0.5 ml should be given by subcutaneous injection. The first dose of varicella vaccine is recommended for children 12 to 15 months old, and to ensure adequate protection, a second varicella vaccine is recommended for children 4 to 6 years old. The second varicella vaccine may be administered before 4 years old as long as a period of 3 months occurs between the first and second doses. Children 13 years old or older who are susceptible should receive two doses administered at least 4 weeks apart. Children in the same age-group (13 to 18 years old) who have received only one previous varicella vaccine should receive a second varicella vaccine. The two-dose regimen was adopted to protect children who did not have adequate protection with one dose, not because of waning immunity to the vaccine (American Academy of Pediatrics, 2015). The combination vaccine MMRV (ProQuad) is licensed for use in children 12 months old to 12 years old (see discussion under Measles).
According to the American Academy of Pediatrics (2015), children who have received two doses of the varicella vaccine are one third less likely to have breakthrough illness in the first 10 years of immunization in comparison with those who have received one dose. Children who do contract varicella after immunization reportedly have milder cases with fewer vesicles, lower degree of fever, and faster recovery. Antibodies persist for at least 8 years.
Keep the vaccine frozen in the lyophilic form (stable particles that readily go into solution), and use it within 30 minutes of being reconstituted to ensure viral potency.
Varicella vaccine may be administered simultaneously with MMR. However, separate syringes and injection sites should be used. If they are not administered simultaneously, the interval between administration of varicella vaccine and MMR should be at least 1 month. Varicella vaccine may also be given simultaneously with DTaP, IPV, HepB, or Hib (American Academy of Pediatrics, 2015). The vaccine is administered subcutaneously.
Pneumococcal Disease Streptococcal pneumococci are responsible for a number of bacterial infections in children younger than 2 years old, which may cause serious morbidity and mortality. Among these are generalized infections (such as, septicemia and meningitis) or localized infections (such as otitis media, sinusitis,
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and pneumonia). These illnesses are particularly problematic in children who attend day care facilities (the incidence in day care children is two or three times higher than in children not attending out-of-home day care) and in those who are immunocompromised. A 13-valent pneumococcal vaccine (PCV13 [Prevnar13]) has been licensed for use and is currently recommended as the standard pneumococcal vaccine for children 6 weeks old to 24 months old. Children who have started the PCV series with PCV7 may complete the vaccine series with PCV13 (American Academy of Pediatrics, 2015; Centers for Disease Control and Prevention, 2013a).
The PCV13 vaccine is administered at 2, 4, and 6 months old, with a fourth dose at 12 to 15 months old. A single supplemental dose of PCV13 is recommended for children 14 through 59 months old who have received an age-appropriate series of PCV7. PCV13 is also recommended for all children younger than 24 months old and in older children (24 to 71 months old) with sickle cell disease; functional or anatomic asplenia; nephrotic syndrome or chronic renal failure; conditions associated with immunosuppression, such as solid organ transplantation, drug therapy, or cytoreduction therapy (including long-term systemic corticosteroid therapy); diabetes mellitus; cochlear implants; congenital immunodeficiency; human immunodeficiency virus (HIV) infection; cerebrospinal fluid leaks; chronic cardiovascular disease (e.g., congestive heart failure or cardiomyopathy); chronic pulmonary disease (e.g., emphysema or cystic fibrosis, but not asthma); chronic liver disease (e.g., cirrhosis); or exposure to living environments or social settings in which the risk of invasive pneumococcal disease or its complications is very high (e.g., Alaskan Native, African-American, and certain Native American populations). The PCV13 vaccine may be administered in conjunction with all other immunizations in a separate syringe and at a separate intramuscular site.
The PPSV23 (pneumococcal polysaccharide [23-valent] vaccine) is not recommended for children younger than 24 months old who do not have one of the high-risk conditions described previously. One dose of PPSV23 is recommended in children older than 23 months old who have one of the high-risk conditions after primary immunization with PCV13.
Influenza The influenza vaccine is recommended annually for children 6 months old to 18 years old. Influenza vaccine (inactivated influenza vaccine [IIV])* may be given to any healthy children 6 months old and older. The vaccine is administered in early fall before the flu season begins and is repeated yearly for ongoing protection. The intramuscular vaccine is administered as two separate doses 4 weeks apart in first-time recipients younger than 9 years old. The dose is 0.25 ml for children 6 to 35 months old and 0.5 ml for children 3 years old and older. An intradermal form of IIV has been licensed for persons 18 to 64 years old. The vaccine may be given simultaneously with other vaccines but in a separate syringe and at a separate site. The vaccine is administered yearly because different strains of influenza are used each year in the manufacture of the vaccine. The Advisory Committee on Immunization Practices (Grohskopf LA, Olsen SL, Sokolow LZ, et al, 2014b) recommends an assessment of the egg allergenic reaction—mild versus severe—prior to making a decision about the vaccine administration to children who have a history of egg allergy. Several options for administering the influenza vaccine are described in the literature, and individuals should discuss the risks and benefits with a knowledgeable health care practitioner.
The live attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent vaccine in specific age-groups. The vaccine is given nasally as two doses at least 28 days apart in healthy persons 2 to 49 years old. The LAIV form is not recommended for children 2 to 4 years old with wheezing in the previous 12 months; those with diagnosed asthma; or for children with underlying medical conditions that predispose them to influenza complications (Grohskopf LA, Olsen SL, Sokolow LZ, et al, 2014b; American Academy of Pediatrics, 2013). Although the LAIV is an alternative to the injection, it costs more and may not be covered by insurance companies. Either IIV or LAIV may be given to healthy, nonpregnant persons 2 to 49 years old (American Academy of Pediatrics, 2015). Yearly influenza vaccine should be administered to health care workers and to children 6 to 59 months old with medical conditions (including asthma, cardiac disease, HIV, diabetes, and sickle cell disease) that place them at risk for influenza-related complications.
The H1N1 virus (swine flu) is a subtype of influenza type A. Previous outbreaks of H1N1 influenza occurred in 1918, and the mortality rates were significant both in the United States and worldwide (American Academy of Pediatrics, 2015). The pandemic of H1N1 in 2009 to 2010 caused
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significant morbidity and mortality worldwide, but particularly in Mexico and the United States. Antigenic shift occurs when influenza A viruses undergo significant changes that result in new infection subtypes; such is the case in the current pandemic. The signs and symptoms of H1N1 flu are the same as those mentioned later for influenza. The most updated information on the status of this disease may be found at the websites for the Centers for Disease Control and Prevention (http://www.cdc.gov/flu/about/season/index.htm).
Meningococcal Disease Invasive meningococcal disease continues to be the cause of high morbidity in children in the United States. Infants younger than 1 year old are particularly susceptible, yet the highest fatalities occur in adolescents (approximately 20%). There is also evidence that the risk of meningococcal infections is high in college freshmen living in dormitories. Meningococcal infections are also responsible for significant morbidities, including limb or digit amputation, skin scarring, hearing loss, and neurologic disabilities.
Neisseria meningitidis is the leading cause of bacterial meningitis in the United States. It is not recommended that children 9 months old to 10 years old routinely receive the meningococcal conjugate vaccines, because the infection rate is low in this age group. Children at increased risk for meningococcal infection should receive a two-dose series of either MenACY-D (Menactra) or MenACY-CRM (Menveo), both of which are MCV4 vaccines, or the infant series of MenHibrix (Hib- MenCY) given at least 2 months apart. These include children with terminal complement component deficiency, anatomic or functional asplenia, or HIV. Children 2 years to 18 years old who travel to or reside in countries where N. meningitidis is hyperendemic or epidemic or who are at risk during a community outbreak should receive one dose of MCV4 (either Menveo or Menactra). Menactra is licensed for administration in children as young as 9 months of age, whereas Menveo is only licensed for children 2 years old and older.
Children and adolescents 11 to 12 years old should receive a single immunization of MCV4 (either Menactra or Menveo) and a booster of the same at 16 to 18 years old. Others at high risk who should receive MCV4 include college freshmen living in dormitories and military recruits. MenHibrix has been licensed for administration to children 6 weeks old to 18 months old and provides protection against meningococcal (groups A, C, Y, and W-135), as well as Hib. MenHibrix is administered in a four-dose series at 2, 4, 6, and 12 to 15 months old.
Persons who are at high risk for the disease and previously received MCV4-3 or more years previously should be re-immunized with MCV4. MCV4 (Menveo or Menactra) is administered as an intramuscular injection (0.5 ml) and may be administered in conjunction with other vaccines in a separate syringe and at a separate site. Immunization with MCV4 is contraindicated in persons with hypersensitivity to any components of the vaccine, including diphtheria toxoid, and to rubber latex (part of vial stopper).
In 2014, the US Food and Drug Administration approved the first meningococcal serogroup B (MenB) vaccine, which Advisory Committee on Immunization Practices recommends for use in children older than 10 years old and at increased risk for exposure (Folaranmi T, Rubin L, Martin SW, et al, 2015).
Recommendations for Selected Immunizations Two additional vaccines are recommended for children and adolescents at high risk for particular diseases. Two rotavirus vaccines, RotaTeq (RV5) and Rotarix (RV1), have received a license from the US Food and Drug Administration for distribution in the United States. Rotavirus is one of the leading causes of severe diarrhea in infants and young children. RotaTeq is licensed for administration to infants at 6 to 12 weeks of age, with two additional doses administered at 4- to 10- week intervals but not after 32 weeks old; the dose is 2 ml, and the product must be protected from light until administration (American Academy of Pediatrics, 2015). Rotarix (1 ml) may be administered beginning at 6 weeks of age, with a second dose at least 4 weeks after the first dose but before 24 weeks old. Both vaccines are administered orally.
Three human papillomavirus (HPV) vaccines have been licensed for use in adolescents; a nine- valent HPV (9vHPV or HPV9) vaccine was approved by the US Food and Drug Administration in December 2014, making three vaccines available (2vHPV, 4vHPV, and 9vHPV) for female children and adolescents to prevent HPV-related cervical cancer. The vaccine is administered intramuscularly in three separate doses; the first dose in the series may be given at 11 to 12 years
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old (minimum age, 9 years old), and the second dose is administered 2 months after the first, with the third dose being given 6 months after the first dose. The HPV4 or HPV9 vaccine may also be administered to boys and men 9 to 26 years old in a three-dose series to reduce the likelihood of genital warts (Petrosky, Bocchini, Hariri, et al, 2015; American Academy of Pediatrics, 2015). The bivalent vaccine (HPV2), Cervarix, is licensed for use in girls and women 10 to 25 years old for the prevention of HPV-related cervical cancer; this vaccine is given in a three-dose series.
Immunizations that may be used in older children and adolescents in the future and that are being evaluated include vaccines for preventing diseases, such as herpes simplex virus (HSV), human cytomegalovirus, and Epstein-Barr virus.
Reactions Vaccines for routine immunizations are among the safest and most reliable drugs available. However, minor side effects do occur after many of the immunizations, and, rarely, a serious reaction may result from the vaccine. A number of inactive components are incorporated in vaccines to enhance their effectiveness and safety. Some of these components include preservatives, stabilizers, adjuvants, antibiotics (e.g., neomycin), and purified culture medium proteins (e.g., egg) to enhance effectiveness. A child may react to the preservative in the vaccine rather than the vaccine component; an example of this is the hepatitis B vaccine, which is prepared from yeast cultures. Yeast hypersensitivity therefore would preclude one from receiving that particular vaccine without consulting an allergist. Trace amounts of neomycin are used to decrease bacterial growth within certain vaccine preparations, and persons with documented anaphylactic reactions to neomycin should avoid those vaccines.
Most vaccine preparations now contain vial stoppers with a synthetic rubber to prevent latex allergy reactions, but health care personnel administering vaccines should make sure that the package insert specifies that there is no latex in the stopper. In the event that an individual has a severe reaction to a vaccine and subsequent immunizations are required, an allergist should be consulted to determine the best course of action. The influenza vaccine contains small amounts of egg protein, so children who have severe allergy to egg should seek the advice of an allergist regarding this vaccine. Most children with an egg allergy are reported to be likely to develop a tolerance to small amounts over time (Settipane, Siri, and Bellanti, 2009).
Some vaccines contain a preservative, thimerosal, that contains ethyl mercury. Concerns regarding possible mercury poisoning in the 1990s prompted many to put off vaccination of infants and small children for fear of childhood developmental problems, such as autism. A number of manufacturers have since stopped producing vaccines containing thimerosal. No local hypersensitivity reactions to thimerosal have been recorded, and studies on thimerosal and the potential link to autism or any other pervasive developmental disorder failed to establish a causal relationship between the two (Hviid, Stellfeld, Wohlfahrt, et al, 2003; Parker, Schwartz, Todd, et al, 2004; Price, Thompson, Goodson, et al, 2010; Schultz, 2010). The Institute of Medicine (2004), following an in-depth 3-year study, concluded that there was no link between autism and the MMR vaccine or vaccines containing the preservative thimerosal. The influenza vaccine does not contain any additives such as thimerosal.
With inactivated antigens, such as DTaP, side effects are most likely to occur within a few hours or days of administration and are usually limited to local tenderness, erythema, and swelling at the injection site; low-grade fever; and behavioral changes (drowsiness, fretfulness, eating less, prolonged or unusual cry). Local reactions tend to be less severe when a needle of sufficient length to deposit the vaccine in the muscle is used (see Atraumatic Care box). Rarely, more severe reactions may occur, especially with pertussis and varicella. Reactions to DTaP tend to be more severe if they occurred with a previous immunization.
At r a u m a t i c C a r e Immunizations
Needle length is an important factor and must be considered for each individual child; fewer reactions to immunizations are observed when the vaccine is given deep into the muscle rather than into subcutaneous tissue. Contrary to previous belief, deep intramuscular tissue has a better blood supply and fewer pain receptors than adipose tissue, thus providing an optimum site for
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immunizations with fewer side effects (Zuckerman, 2000).
• Recommended needle length for newborn to 2 months old is 16 mm ( inch).
• Select a needle of adequate length (25 mm [1 inch] in infants) to deposit the antigen deep in the muscle mass.
• Toddlers and older children require a needle length of 16 to 25 mm ( to 1 inch) for deltoid, or 25 to 32 mm (1 to 1 inches) for vastus lateralis (Schechter, Zempsky, Cohen, et al, 2007).
• Adolescents require a needle length of 25 to 51 mm (1 to 2 inches) in deltoid or vastus lateralis (Schechter, Zempsky, Cohen, et al, 2007).
• Inject into the vastus lateralis or ventrogluteal muscle; the deltoid may be used in children 18 months old or older.
• Use an air bubble to clear the needle after injecting the vaccine (theoretically beneficial but unproved).
References Schechter NL, Zempsky WT, Cohen LL, et al. Pain reduction during pediatric immunizations:
evidence-based review and recommendations. Pediatrics. 2007;119(5):e1184–e1198. Zuckerman J. The importance of injecting vaccines into muscle. BMJ. 2000;321(7271):1237–
1238.
S a f e t y A l e r t Emergency Management of Anaphylaxis*
Drug: Epinephrine 0.001 mg/kg up to maximum of 0.3 mg
Dose: EpiPen Jr (0.15 mg) intramuscularly (IM) for child weighing 8 to 25 kg (17.5 to 55 lbs.)
EpiPen (0.3 mg) IM for child weighing 25 kg (55 lbs.) or more
Observe for adverse reactions, such as tachycardia, hypertension, irritability, headaches, nausea, and tremors.
*Keet C: Recognition and management of food-induced anaphylaxis, Pediatr Clin North Am 58(2):377–388, 2011.
Hib vaccine is one of the safest vaccines available but may be associated with low-grade fever and mild local reactions at the site of injection, which resolve rapidly.
Unlike the inactivated antigens, live attenuated virus vaccines such as MMR and MMRV multiply for days or weeks, and unfavorable reactions such as fever and rash and vaccine-associated disorders can occur up to 30 to 60 days later. These reactions are usually mild, although reactions to rubella tend to be more troublesome in older children and adults.
Contraindications and Precautions Nurses need to be aware of the reasons for withholding immunizations—both for the child's safety in terms of avoiding reactions and for the child's maximum benefit from receiving the vaccine. Unfounded fears and lack of knowledge regarding contraindications can needlessly prevent a child from having protection from life-threatening diseases. Issues that have surfaced regarding vaccines include the misconception that administering combination vaccines may overload the child's
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immune system; the combined vaccines have undergone rigorous study in relation to side effects and immunogenicity rates following administration. Others may express concern that vaccines are not a part of the individual's natural immunity and that administering too many vaccines may decrease the child's immunity to such diseases. Parents may also voice concerns that vaccines may cause diseases, such as asthma, multiple sclerosis, or diabetes mellitus (Kimmel, Burns, Wolfe, et al, 2007). Another concern of parents is the number of vaccines or “shots” given to infants at any given time and the pain and discomfort this may cause.
A contraindication is considered as a condition in an individual that increases the risk for a serious adverse reaction (e.g., not administering a live virus vaccine to a severely immune compromised child). Thus one would not administer a vaccine when a contraindication is present. A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity. If conditions are such that the benefit of receiving the vaccine would outweigh the risk of an adverse event or incomplete response, a precaution would not prevent vaccine administration (American Academy of Pediatrics, 2015).
The general contraindication for all immunizations is a severe febrile illness. This precaution avoids adding the risk of adverse side effects from the vaccine to an already ill child or mistakenly identifying a symptom of the disease as having been caused by the vaccine. The presence of minor illnesses, such as the common cold, is not a contraindication. Live virus vaccines are generally not administered to anyone with an altered immune system, because multiplication of the virus may be enhanced, causing a severe vaccine-induced illness.
In general, live virus vaccines such as varicella and MMR should not be administered to persons who are severely immunocompromised (National Center for Immunization and Respiratory Diseases, 2011). Another contraindication to live virus vaccines (e.g., MMR and varicella) is the presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies. Administration of MMR and varicella should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions (except washed red blood cells, which do not interfere with the immune response). Suggested intervals between administration of immunoglobulin preparations and MMR and varicella depend on the type of immune product and dosage. If the vaccine and immunoglobulin are given simultaneously because of imminent exposure to disease, the two preparations are injected at sites far from each other. Vaccination should be repeated after the suggested intervals unless there is serologic evidence of antibody production.
A final contraindication is a known allergic response to a previously administered vaccine or a substance in the vaccine. An anaphylactic reaction to a vaccine or its component is a true contraindication. MMR vaccines contain minute amounts of neomycin; measles and mumps vaccines, which are grown on chick embryo tissue cultures, are not believed to contain significant amounts of egg cross-reacting proteins. Therefore, only a history of anaphylactic reaction to neomycin, gelatin, or the vaccine itself is considered a contraindication to their use.
Pregnancy is a contraindication to MMR vaccines, although the risk of fetal damage is primarily theoretic. Breastfeeding is not a contraindication for any vaccine. The only vaccine virus that has been isolated in human milk is rubella and there is no indication that this is harmful to infants; rubella infection in an infant as a result of exposure to rubella virus in human milk would likely be well tolerated, because the vaccine is attenuated (American Academy of Pediatrics, 2015). See also Family-Centered Care box.
F a m i l y - C e n t e r e d C a r e Communicating with Parents about Immunizations
• Provide accurate and user-friendly information on vaccines (the necessity for each one, the disease each prevents, and potential adverse effects).
• Realize that the parent is expressing concern for the child's health.
• Acknowledge the parent's concerns in a genuine, empathetic manner.
• Tailor the discussion to the needs of the parent.
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• Avoid judgmental or threatening language.
• Be knowledgeable about the benefits of individual vaccines, the common adverse effects, and how to minimize those effects.
• Give the parent the vaccine information statement (VIS) beforehand and be prepared to answer any questions that may arise.
• Help the parent make an informed decision regarding the administration of each vaccine.
• Be flexible and provide parents with options regarding the administration of multiple vaccines, especially in infants, who must receive multiple injections at 2, 4, and 6 months old (i.e., allow parents to space the vaccinations at different visits to decrease the total number of injections at each visit; make provisions for office visits for immunization purposes only [does not incur a practitioner fee except for administration of vaccine], provided that the child is healthy).
• Involve the parent in minimizing the potential adverse effects of the vaccine (e.g., administering an appropriate dose of acetaminophen 45 minutes before administering the vaccine [as warranted]; applying eutectic mixture of local anesthetics [EMLA; lidocaine–prilocaine] or LMX4 [4% lidocaine] to the injection sites before administration; following up to check on the child if untoward reactions have occurred in the past or parent is especially anxious about the child's well-being).
• Respect the parent's ultimate wishes.
Data from Coyer SM: Understanding parental concerns about immunizations, J Pediatr Health Care 16(4):193-196, 2002; Fredrickson DD, Davis TC, Bocchini JA: Explaining the risks and benefits of vaccines to parents, Pediatr Ann 30(7):400-406, 2001; Rosenthal P: Overcoming skepticism toward vaccines: a look at the real benefits and risks, Consult Pediatr 4(suppl):S3-S7, 2004.
To identify the rare child who may not be able to receive the vaccines, take a careful allergy history. If the child has a history of anaphylaxis, report this to the practitioner before administering the vaccine. Contact dermatitis in reaction to neomycin is not considered a contraindication to immunization. Evidence indicates that children who are egg-sensitive are not at increased risk for untoward reactions to MMR vaccine. Furthermore, skin testing of egg-allergic children with vaccine has failed to predict immediate hypersensitivity reactions (American Academy of Pediatrics, 2015).
Nurses are at the forefront in providing parents with appropriate information regarding childhood immunization benefits, contraindications, and side effects and the effects of non- vaccination on the child's health. Some suggestions for communicating with parents about the benefits of immunizations in childhood are provided in Family-Centered Care box (Coyer, 2002; Fredrickson, Davis, and Arnold, 2004; Rosenthal, 2004).
Administration The principal precautions in administering immunizations include proper storage of the vaccine to protect its potency and institution of recommended procedures for injection. The nurse must be familiar with the manufacturer's directions for storage and reconstitution of the vaccine. For example, if the vaccine is to be refrigerated, it should be stored on a center shelf, not in the door, where frequent temperature increases from opening the refrigerator can alter the vaccine's potency. For protection against light, the vial can be wrapped in aluminum foil. Periodic checks are established to ensure that no vaccine is used after its expiration date.
The DTP (or DTaP) vaccines contain an adjuvant to retain the antigen at the injection site and prolong the stimulatory effect. Because subcutaneous or intracutaneous injection of the adjuvant can cause local irritation, inflammation, or abscess formation, excellent intramuscular injection technique must be used
The total series requires several injections, and every attempt is made to rotate the sites and administer the injections as painlessly as possible. (See the discussion about intramuscular injections in Chapter 20.) When two or more injections are given at separate sites, the order of injections is arbitrary. Some practitioners suggest injecting the less painful one first. Some believe this is DTP (or DTaP), whereas others suggest the MMR or Hib vaccine. Still others advocate injecting at two sites simultaneously (requires two operators) (see Research Focus box).
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R e s e a r c h F o c u s Order of Injections
Ipp, Parkin, Lear, and colleagues (2009) evaluated the administration order of the vaccines diphtheria, tetanus, and acellular pertussis–Haemophilus influenzae type b (DTaP-Hib) and pneumococcal conjugate vaccine (PCV) and pain perception in 120 infants 2 to 6 months old. The infants who were given the primary DTaP-Hib vaccine before the PCV vaccine had significantly lower pain scores as measured by the Modified Behavioral Pain Scale than those who received the PCV vaccine first. Both groups of infants were given both vaccines. Additional pain measures included crying as measured by video recording and parent perception of child pain using the visual analog scale. The researchers recommend giving the primary DTaP-Hib vaccine before the PCV to reduce pain in infants receiving routine immunizations.
Because allergic reactions can occur after injection of vaccines, take the appropriate precautions. (See the Safety Alert box earlier in this chapter.)
One of the most important features of injecting vaccines is adequate penetration of the muscle for deposition of the drug intramuscularly and not subcutaneously (depending on the manufacturer's recommendation for administration). The use of appropriate needle length is an essential component of administering vaccines. In two studies, the use of longer needles significantly decreased the incidence of localized edema and tenderness when vaccines were administered to a group of infants (Diggle and Deeks, 2000; Diggle, Deeks, and Pollard, 2006) (see Translating Evidence into Practice box). Similar findings have been recorded for children 4 to 6 years old receiving the fifth DTaP vaccine (Jackson, Yu, Nelson, et al, 2011). In some studies, the site of administration influenced pain perception and localized reactions. Cook and Murtagh (2006) found that administration of the pertussis vaccine in the ventrogluteal muscle in children 2 months old to 18 months old was safe and had few localized reactions in comparison to anterolateral thigh administration. Junqueira, Tavares, Martins, and colleagues (2010) found that administration of the hepatitis B vaccine in the ventrogluteal muscle (versus anterolateral thigh) of 580 infants resulted in a lower incidence of fever and localized reactions.
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Appropriate Site, Technique, Needle Size, and Dosage for Intramuscular Injections in Infants, Toddlers, and Small Children*
Ask the Question In infants, toddlers, and small children what is the best site, technique, needle size and gauge, and dosage for intramuscular (IM) injections?
Search for the Evidence Search Strategies Literature from 1999 to 2015 was reviewed to obtain clinical research studies related to this issue.
Databases Used CINAHL, PubMed
Critically Analyze the Evidence GRADE criteria: Evidence quality low; recommendation strong (Guyatt, Oxman, Vist, et al, 2008)
The searches reviewed were mostly small studies. There were no randomized trials, double- blinded trials, or large clinical studies addressing the subject of IM injections in children.
• Studies in adults indicate that injection pain can be minimized by deep IM administration, because muscle tissue has fewer nerve endings and medications are absorbed faster than those administered subcutaneously (Ogston-Tuck, 2014a; Zuckerman, 2000). Immunizations such as diphtheria, tetanus, and acellular pertussis (DTaP) and hepatitis A and B contain an aluminum adjuvant that, if injected into subcutaneous tissue, increases the incidence of local reactions.
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Inadvertent injection into subcutaneous tissue may be caused by use of a needle too short to reach IM tissue (Zuckerman, 2000).
• One study found that 4-month-old infants experienced fewer local side effects (redness, tenderness, and swelling) when immunizations were administered into the anterior aspect of the thigh with a 25-mm (1-inch) needle as opposed to the shorter 16-mm ( -inch) needle (Diggle and Deeks, 2000).
• Another study comparing needle length and injection method found that a longer needle (25 mm) was preferred for injection when bunching the skin and injecting, whereas a shorter needle (16 mm) was perceived as causing fewer localized reactions when the injection was administered with the skin being held taut (Groswasser, Kahn, Bouche, et al, 1997). However, the study's conclusions fail to address whether needle lengths were applicable to both the deltoid and vastus lateralis muscles.
• Cook and Murtagh (2002) made ultrasound measurements of the subcutaneous and muscle layer thickness in 57 children ages 2, 4, 6, and 18 months old. These researchers concluded that a 16- mm needle was sufficient to penetrate the anterolateral thigh muscle if the needle is inserted at a 90-degree angle without pinching the muscle, whereas thigh measurements demonstrated that a 25-mm needle was necessary to penetrate the muscle when a 45-degree injection technique was employed. This study supports the concept of longer needle length and use of a 90-degree angle to fully deposit the medication into the deep muscle (Ogston-Tuck, 2014b).
• In a study by Davenport (2004), needle length proved to be the most significant variable for local reactions in children after injection with 16-mm and 25-mm needles; the 25-mm needle was associated with fewer localized reactions.
• Diggle, Deeks, and Pollard (2006) likewise found that when long needles (25 mm) were used for infant immunizations, localized vaccine reactions were significantly reduced in comparison to the shorter needles (16 mm).
• In a study of diphtheria-tetanus-pertussis (DTP) immunizations administered to infants 7 months old and younger, only 84.6% of injections were administered at the correct site (anterior thigh); an alarming number were given in the dorsogluteal (5.1%) and deltoid (2.6%) muscles (Daly, Johnston, and Chung, 1992).
• The ventrogluteal site is relatively free of important nerves and vascular structures, the site is easily identified by landmarks, and the subcutaneous tissue is thinner in that area (Ogston-Tuck, 2014a).
• The American Academy of Pediatrics (2015) and Centers for Disease Control (2011) recommend that vaccines containing adjuvants such as aluminum (DTaP, hepatitis A and B, diphtheria- tetanus [DT or Td]) be given deep into the muscle to prevent local reactions. For the majority of infants, a 1-inch, 22- to 25-gauge needle can be used. For neonates and preterm infants a -inch needle is usually sufficient when the needle is inserted at a 90-degree angle. The National Center for Immunization and Respiratory Diseases (2011) recommends that toddlers receive injections with a 1-inch long needle in the anterolateral thigh; the deltoid muscle could be used if the muscle size is adequate. For children 3 to 18 years old, the deltoid muscle is preferred and needle size can range from 22- to 25-gauge and from - to 1-inch long, depending on the technique used.
• The American Academy of Pediatrics (2015) recommends that injections in the anterolateral thigh be given at least 2.5 cm (1 inch) apart so that local reactions are less likely to overlap. The dorsogluteal muscle should be avoided in infants and toddlers, and perhaps even in smaller preschoolers with smaller muscle mass, because of the possibility of damaging the sciatic nerve. The anterolateral aspect of the thigh offers the greatest thickness of muscle (Ogston-Tuck, 2014b). When multiple vaccines are given, two may be given in the thigh (anterior and lateral) because of its larger size.
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No research or supportive data were found regarding the amount of medication to be given at the different sites in infants and toddlers. In general, 1 ml of medication is recommended for infants younger than 12 months old; however, no data can be found to refute or support such a recommendation. Furthermore, small and preterm infants may only tolerate up to 0.5 ml in each muscle to prevent local complications.
In summary, some discrepancy remains in actual clinical practice regarding IM injection sites, amount of drug injected, and needle size in infants and toddlers. Further research is needed to address the following issues:
• What is the appropriate muscle in which an IM injection can be administered with fewest adverse effects in infants and toddlers?
• What is the appropriate needle size based on the infant or toddler's age and weight?
• What is the largest safe amount of medication that can be given to infants and toddlers based on weight and muscle size?
Apply the Evidence: Nursing Implications Based on the evidence in the literature, the recommendation is to continue administering IM injections in the anterolateral aspect of the thigh in the majority of infants. The deltoid can be used in toddlers if the muscle mass is adequate but the anterolateral aspect of the thigh is still preferred. The deltoid is preferred for children 3 to 18 years old.
Needle length is an important factor in decreasing local reactions; the length should be adequate to deposit the medication into the muscle for IM injections. Recommendations are for a 22- to 25- mm ( - to 1-inch) needle in infants. For toddlers and most older children (3 to 18 years old) the needle should be at least 1 inch long (Centers for Disease Control and Prevention, 2011). Preterm and small emaciated infants may require a shorter needle based on weight and muscle mass size.
References American Academy of Pediatrics, Committee on Infectious Diseases, Pickering L. 2015 red
book: report of the Committee on Infectious Diseases. ed 30. The Academy: Elk Grove Village, IL; 2015.
Centers for Disease and Prevention. General recommendations on immunization. MMWR. 2011;60(RR–2):1–20.
Cook IF, Murtagh J. Needle length required for intramuscular vaccination of infants and toddlers: an ultrasonographic study. Aust Fam Physician. 2002;31(3):295–297.
Daly JM, Johnston W, Chung Y. Injection sites utilized for DPT immunizations in infants. J Community Health Nurs. 1992;9(2):87–94.
Davenport JM. A systematic review to ascertain whether the standard needle is more effective than a longer or wider needle in reducing the incidence of local reaction in children receiving primary immunization. J Adv Nurs. 2004;46(1):66–77.
Diggle L, Deeks J. Effect of needle length on incidence of local reactions to routine immunisation in infants aged 4 months: randomised controlled trial. BMJ. 2000;321(7266):931–933.
Diggle L, Deeks JJ, Pollard AJ. Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomized controlled trial. BMJ. 2006;333(7568):571.
Groswasser J, Kahn A, Bouche B, et al. Needle length and injection technique for efficient intramuscular vaccine delivery in infants and children evaluated through an ultrasonographic determination of subcutaneous and muscle layer thickness. Pediatrics. 1997;100(3 Pt 1):400–403.
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926.
National Center for Immunization and Respiratory Diseases. Centers for Disease Control and Prevention. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1– 64.
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Ogston-Tuck S. Intramuscular injection technique: an evidence-based approach. Nurs Stand. 2014;29(4):52–59.
Ogston-Tuck S. Subcutaneous injection technique: an evidence-based approach. Nurs Stand. 2014;29(3):53–58.
Zuckerman J. The importance of injecting vaccines into muscle. BMJ. 2000;321(7271):1237– 1238.
*See also Intramuscular Administration, Chapter 20.
An important nursing responsibility is accurate documentation. Each child should have an immunization record for parents to keep, especially for families who move frequently. Although immunization rates have increased significantly, health professionals should use every opportunity to encourage complete immunization of all children (see Community Focus box). Blank immunization records may be downloaded from a number of websites, including the Immunization Action Coalition (www.immunize.org), which has vaccine information and records in a number of languages.
C o m m u n i t y F o c u s Keeping Current on Vaccine Recommendations
It is much easier to keep current if you know where to look for the official recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. The primary sources are publications and the Internet. You can also contact each organization to request information:
American Academy of Pediatrics
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
847-434-4000
Fax: 847-434-8000
www.aap.org
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
404-639-3311
Information: 800-232-4636
www.cdc.gov
Vaccine and immunization information: www.cdc.gov/vaccines
The American Academy of Pediatrics' Report of the Committee on Infectious Diseases, known as the Red Book, is an authoritative source of information on vaccines and other important pediatric infectious diseases. However, it lacks an in-depth review and reference list of controversial issues. The recommendations in the Red Book first appear in the journal Pediatrics and/or the AAP News. Typically, the most recent immunization schedule appears in the January issue of the journal.
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The Centers for Disease Control and Prevention now offers a valuable online resource tool for parents and clinicians. The tool prints out an individualized vaccination schedule with dates associated with each vaccination based on the child's date of birth. Clinicians can use this tool for children younger than 5 years old to serve as a reminder for parents. Nurses should note that the personalized tool is based on the current immunization schedule and may need to be adjusted with the yearly updates from the American Academy of Pediatrics and the Advisory Committee on Immunization Practices. The tool is available at www2a.cdc.gov/nip/kidstuff/newscheduler_le.
A publication of the Centers for Disease Control, Morbidity and Mortality Weekly Report (MMWR), contains comprehensive reviews of the literature and important background data regarding vaccine efficacy and side effects. To receive an electronic copy, send an email message to [email protected]. The body content should read: SUBscribe mmwr-toc. Electronic copy also is available from the centers' website at www.cdc.gov or from the centers' file transfer protocol server at ftp.cdc.gov.
Vaccine information statements (VISs) are available by calling your state or local health department. They can also be downloaded from the Immunization Action Coalition's website at www.immunize.org/vis or Centers for Disease Control and Prevention's website at www.cdc.gov/vaccines/pubs/vis/default.htm. Some translations are available.
Another resource to keep up to date on the vaccines that are licensed and commercially available is the US Food and Drug Administration's Center for Biologics Evaluation and Research report for each year, www.fda.gov/BiologicsBloodVaccines/Vaccines/default.htm.
Document the following information on the medical record: day, month, and year of administration; manufacturer and lot number of vaccine; and name, address, and title of the person administering the vaccine. Additional data to record are the site and route of administration and evidence that the parent or legal guardian gave informed consent before the immunization was administered. Report any adverse reactions after the administration of a vaccine to the Vaccine Adverse Event Reporting System (www.vaers.hhs.gov; 1-800-822-7967).
An additional source of vaccine information that must be given to parents (as required by the National Childhood Vaccine Injury Act, 1986) before the administration of vaccines is the VIS for the particular vaccine being administered. Practitioners are required by law to fully inform families of the risks and benefits of the vaccines. VISs are designed to provide updated information to the adult vaccinee or parents or legal guardians of children being vaccinated regarding the risks and benefits of each vaccine. The practitioner should answer questions regarding the information in the VIS. VISs are available for the following vaccines: adenovirus, anthrax, tetanus, diphtheria, pertussis, MMR, MMRV, IPV, HPV, varicella, Hib, influenza, meningococcal, pneumococcal (13 and 23), rabies, rotavirus, shingles, smallpox, yellow fever, Japanese encephalitis, typhoid, and hepatitis A and B. An updated VIS should be provided, and documentation in the patient's chart should state that the VIS was given and include the publication date of the VIS; this represents informed consent once the parent or caregiver gives permission to administer the vaccines. VISs are available from state or local health departments or from the Immunization Action Coalition* and Centers for Disease Control and Prevention.†
In response to the concerns of manufacturers, practitioners, and parents of children with serious vaccine-associated injuries, the National Childhood Vaccine Injury Act of 1986 and the Vaccine Compensation Amendments of 1987 were passed. These laws are designed to provide fair compensation for children who are inadvertently injured and provide greater protection from liability for vaccine manufacturers and providers. (See the 2015 Red Book: Report of the Committee on Infectious Diseases [American Academy of Pediatrics, 2015] for further details of this program.)
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Communicable Diseases The incidence of childhood communicable diseases has declined significantly since the advent of immunizations. The use of antibiotics and antitoxins has further reduced serious complications resulting from such infections. However, infectious diseases do occur, and nurses must be familiar with the infectious agent to recognize the disease and to institute appropriate preventive and supportive interventions (Table 6-1).
TABLE 6-1 Communicable Diseases of Childhood
Disease Clinical Manifestations Therapeutic Management and Complications Nursing Care Management Chickenpox (Varicella) (Fig. 6-2) Agents: Varicella-zoster
virus (VZV) Source: Primary secretions
of respiratory tract of infected persons; to a lesser degree, skin lesions (scabs not infectious)
Transmissions: Direct contact, droplet (airborne) spread, and contaminated objects
Incubation period: 2 to 3 weeks, usually 14 to 16 days
Period of communicability: Probably 1 day before eruption of lesions (prodromal period) to 6 days after first crop of vesicles when crusts have formed
Prodromal stage: Slight fever, malaise, and anorexia for first 24 hours; rash highly pruritic; begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time
Distribution: Centripetal, spreading to face and proximal extremities but sparse on distal limbs and less on areas not exposed to heat (i.e., from clothing or sun)
Constitutional signs and symptoms: Elevated temperature from lymphadenopathy, irritability from pruritus
Specific: Antiviral agent acyclovir (Zovirax); varicella-zoster immune globulin or intravenous immune globulin (IVIG) after exposure in high-risk children
Supportive: Diphenhydramine hydrochloride or antihistamines to relieve itching; skin care to prevent secondary bacterial infection
Complications: Secondary bacterial infections (abscesses, cellulitis, necrotizing fasciitis, pneumonia, sepsis)
Encephalitis Varicella pneumonia (rare in normal children) Hemorrhagic varicella (tiny hemorrhages in
vesicles and numerous petechiae in skin) Chronic or transient thrombocytopenia Preventive: Childhood immunization
Maintain Standard, Airborne, and Contact Precautions if hospitalized until all lesions are crusted; for immunized child with mild breakthrough varicella, isolate until no new lesions are seen.
Keep child in home away from susceptible individuals until vesicles have dried (usually 1 week after onset of disease), and isolate high-risk children from infected children.
Administer skin care: Give bath and change clothes and linens daily; administer topical calamine lotion; keep child's fingernails short and clean; apply mittens if child scratches.
Keep child cool (may decrease number of lesions).
Lessen pruritus; keep child occupied. Remove loose crusts that rub and
irritate skin. Teach child to apply pressure to
pruritic area rather than scratching it. Avoid use of aspirin (possible
association with Reye syndrome). Diphtheria Agent: Corynebacterium
diphtheriae Source: Discharges from
mucous membranes of nose and nasopharynx, skin, and other lesions of infected person
Transmission: Direct contact with infected person, a carrier, or contaminated articles
Incubation period: Usually 2 to 5 days, possibly longer
Period of communicability: Variable; until virulent bacilli are no longer present (identified by three negative cultures); usually 2 weeks but as long as 4 weeks
Vary according to anatomic location of pseudomembrane Nasal: Resembles common cold, serosanguineous mucopurulent
nasal discharge without constitutional symptoms; may have frank epistaxis
Tonsillar-pharyngeal: Malaise; anorexia; sore throat; low-grade fever; pulse increased above expected for temperature within 24 hours; smooth, adherent, white or gray membrane; lymphadenitis possibly pronounced (“bull's neck”); in severe cases, toxemia, septic shock, and death within 6 to 10 days
Laryngeal: Fever, hoarseness, cough, with or without previous signs listed; potential airway obstruction; apprehensive; dyspneic retractions; cyanosis
Equine antitoxin (usually intravenously); preceded by skin or conjunctival test to rule out sensitivity to horse serum
Antibiotics (penicillin G procaine or erythromycin) in addition to equine antitoxin
Complete bed rest (prevention of myocarditis) Tracheostomy for airway obstruction Treatment of infected contacts and carriers Complications: Toxic cardiomyopathy (2nd to
3rd week) Toxic neuropathy Preventive: Childhood immunization
Follow Standard and Droplet Precautions until two cultures are negative for C. diphtheriae; use Contact Precautions with cutaneous manifestations.
Administer antibiotics in timely manner.
Participate in sensitivity testing; have epinephrine available.
Administer complete care to maintain bed rest.
Use suctioning as needed. Observe respiration for signs of
obstruction. Administer humidified oxygen as
prescribed.
Erythema Infectiosum (Fifth Disease) (Fig. 6-3) Agent: Human parvovirus
B19 Source: Infected persons,
mainly school-age children Transmission: Respiratory
secretions and blood, blood products
Incubation period: 4 to 14 days; may be as long as 21 days
Period of communicability: Uncertain but before onset of symptoms in children with aplastic crisis
Rash appears in three stages: I: Erythema on face, chiefly on cheeks (“slapped face”
appearance); disappears by 1 to 4 days II: About 1 day after rash appears on face, maculopapular red
spots appear, symmetrically distributed on upper and lower extremities; rash progresses from proximal to distal surfaces and may last ≥1 week
III: Rash subsides but reappears if skin is irritated or traumatized (sun, heat, cold, friction)
In children with aplastic crisis, rash usually absent and prodromal illness includes fever, myalgia, lethargy, nausea, vomiting, and abdominal pain
Child with sickle cell disease may have concurrent vaso- occlusive crisis
Symptomatic and supportive: Antipyretics, analgesics, antiinflammatory drugs
Possible blood transfusion for transient aplastic anemia
Complications: Self-limited arthritis and arthralgia (arthritis may become chronic); more common in adult women
May result in serious complications (anemia, hydrops) or fetal death if mother infected during pregnancy (primarily second trimester)
Aplastic crisis in children with hemolytic disease or immunodeficiency
Myocarditis (rare)
Isolation of child is not necessary, except hospitalized child (immunosuppressed or with aplastic crises) suspected of parvovirus infection is placed on Droplet Precautions and Standard Precautions.
Pregnant women need not be excluded from workplace where parvovirus infection is present; they should not care for patients with aplastic crises. Explain low risk of fetal death to those in contact with affected children; assist with routine fetal ultrasound for detection of fetal hydrops.
Exanthem Subitum (Roseola Infantum) (Fig. 6-4) Agent: Human herpesvirus
type 6 (HHV-6; rarely HHV-7)
Source: Possibly acquired from saliva of healthy adult person; entry via nasal, buccal, or conjunctival mucosa
Transmission: Year round; no reported contact with infected individual in most cases (virtually limited to children <3 years old but peak age is 6 to 15 months old)
Incubation period: Usually 5 to 15 days
Period of communicability: Unknown
Persistent high fever >39.5° C (103° F) for 3-7 days in child who appears well
Precipitous drop in fever to normal with appearance of rash Bulging fontanel Rash: Discrete rose-pink macules or maculopapules appearing
first on trunk, then spreading to neck, face, and extremities; nonpruritic; fades on pressure; lasts 1 to 2 days
Associated signs and symptoms: Cervical and postauricular lymphadenopathy, inflamed pharynx, cough, coryza
Nonspecific Antipyretics to control fever Complications: Recurrent febrile seizures
(possibly from latent infection of central nervous system that is reactivated by fever)
Encephalitis Hepatitis (rare)
Use Standard Precautions. Teach parents measures for lowering
temperature (antipyretic drugs); ensure adequate parental understanding of specific antipyretic dosage to prevent accidental overdose.
If child is prone to seizures, discuss appropriate precautions and possibility of recurrent febrile seizures.
Mumps Agent: Paramyxovirus Source: Saliva of infected
persons
Prodromal stage: Fever, headache, malaise, and anorexia for 24 hours, followed by “earache” that is aggravated by chewing
Parotitis: By third day, parotid gland(s) (either unilateral or
Preventive: Childhood immunization Symptomatic and supportive: Analgesics for
pain and antipyretics for fever
Maintain isolation during period of communicability; institute Droplet
and Contact Precautions during
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with or droplet spread from an infected person
Incubation period: 14 to 21 days
Period of communicability: Most communicable immediately before and after swelling begins
accompanied by pain and tenderness; other exocrine glands (submandibular) may also be swollen
refuses to drink or vomits because of meningoencephalitis
Complications: Sensorineural deafness Postinfectious encephalitis Myocarditis Arthritis Hepatitis Epididymo-orchitis Oophoritis Pancreatitis Sterility (extremely rare in adult men) Meningitis
Encourage rest and decreased activity during prodromal phase until swelling subsides.
Give analgesics for pain; if child is unwilling to swallow pills or tablet medication, use elixir form.
Encourage fluids and soft, bland foods; avoid foods requiring chewing.
Apply hot or cold compresses to neck, whichever is more comforting.
To relieve orchitis, provide warmth and local support with tight-fitting underpants.
Measles (Rubeola) (Fig. 6-5) Agent: Virus Source: Respiratory tract
secretions, blood, and urine of infected person
Transmission: Usually by direct contact with droplets of infected person; primarily in the winter
Incubation period: 10 to 20 days
Period of communicability: From 4 days before to 5 days after rash appears, but mainly during prodromal (catarrhal) stage
Prodromal (catarrhal) stage: Fever and malaise, followed in 24 hours by coryza, cough, conjunctivitis, Koplik spots (small, irregular red spots with a minute, bluish-white center first seen on buccal mucosa opposite molars 2 days before rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside
Rash: Appears 3 to 4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3 to 4 days assumes brownish appearance, and fine desquamation occurs over area of extensive involvement
Constitutional signs and symptoms: Anorexia, abdominal pain, malaise, generalized lymphadenopathy
Preventive: Childhood immunization. Supportive: Bed rest during febrile period;
antipyretics Antibiotics to prevent secondary bacterial
infection in high-risk children Complications: Otitis media Pneumonia (bacterial) Obstructive laryngitis and laryngotracheitis Encephalitis (rare but has high mortality) Vitamin A supplementation Administer Vitamin A (World Heath
Organization recommendation) for children with acute illness: 200,000 International units for children 12 months old and older; 100,000 International units for children 6 through 11 months old; 50,000 International units for infants younger than 6 months old (American Academy of Pediatrics, 2015)
Maintain isolation until fifth day of rash; if child is hospitalized, institute Airborne Precautions.
Encourage rest during prodromal stage; provide quiet activity.
Fever: Instruct parents to administer antipyretics; avoid chilling; if child is prone to seizures, institute appropriate precautions.
Eye care: Dim lights if photophobia present; clean eyelids with warm saline solution to remove secretions or crusts; keep child from rubbing eyes.
Coryza, cough: Use cool-mist vaporizer; protect skin around nares with layer of petrolatum; encourage fluids and soft, bland foods.
Skin care: Keep skin clean; use tepid baths as necessary.
Pertussis (Whooping Cough) Agent: Bordetella pertussis Source: Discharge from
respiratory tract of infected persons
Transmission: Direct contact or droplet spread from infected person; indirect contact with freshly contaminated articles
Incubation period: 6 to 20 days; usually 7 to 10 days
Period of communicability: Greatest during catarrhal stage before onset of paroxysms
Catarrhal stage: Begins with symptoms of upper respiratory tract infection, such as coryza, sneezing, lacrimation, cough, and low-grade fever; symptoms continue for 1 to 2 weeks, when dry, hacking cough becomes more severe
Paroxysmal stage: Cough most common at night, consists of short, rapid coughs followed by sudden inspiration associated with a high-pitched crowing sound or “whoop;” during paroxysms, cheeks become flushed or cyanotic, eyes bulge, and tongue protrudes; paroxysm may continue until thick mucus plug is dislodged; vomiting frequently follows attack; stage generally lasts 4 to 6 weeks, followed by convalescent stage
Infants <6 months old may not have characteristic whoop cough, but have difficulty maintaining adequate oxygenation with amount of secretions, frequent vomiting of mucus and formula or breast milk
Pertussis may occur in adolescents and adults with varying manifestations; cough and whoop may be absent, however, as many as 50% of adolescents may have a cough for up to 10 weeks (American Academy of Pediatrics, 2015)
Additional symptoms in adolescents include difficulty breathing, and posttussive vomiting
(See also Immunizations, for discussion of pertussis immunization schedule.)
Preventive: Immunization; current belief is that childhood immunizations for pertussis do not confer lifelong immunity to adolescents and adults, so a pertussis booster is recommended for adolescents Refer to the CDC Immunization Guidelines
Antimicrobial therapy (e.g., erythromycin, clarithromycin, azithromycin)
Supportive: Hospitalization sometimes required for infants, children who are dehydrated, or those who have complications
Increased oxygen intake and humidity Adequate fluids Intensive care and mechanical ventilation if
needed for infants <6 months old Complications: Pneumonia (usual cause of
death in younger children) Atelectasis Otitis media Seizures Hemorrhage (scleral, conjunctival, epistaxis;
pulmonary hemorrhage in neonate) Weight loss and dehydration Hernias (umbilical and inguinal) Prolapsed rectum Complications reported among adolescents
include syncope, sleep disturbance, rib fractures, incontinence, and pneumonia (American Academy of Pediatrics, 2015)
Maintain isolation during catarrhal stage; if child is hospitalized, institute Standard and Droplet Precautions.
Obtain nasopharyngeal culture for diagnosis.
Encourage oral fluids; offer small amount of fluids frequently.
Ensure adequate oxygenation during paroxysms; position infant on side to decrease chance of aspiration with vomiting.
Provide humidified oxygen; suction as needed to prevent choking on secretions.
Observe for signs of airway obstruction (increased restlessness, apprehension, retractions, cyanosis).
Encourage compliance with antibiotic therapy for household contacts.
Encourage adolescents to obtain pertussis booster (Tdap) Refer to the CDC Immunization Guidelines).
Use Standard Precautions and Droplet in health care workers exposed to children with persistent cough and high suspicion of pertussis.
Poliomyelitis Agent: Enteroviruses, three
types: Type 1, most frequent cause of paralysis, both epidemic and endemic; type 2, least frequently associated with paralysis; type 3, second most frequently associated with paralysis
May be manifested in three different forms: Abortive or inapparent: Fever, uneasiness, sore throat,
headache, anorexia, vomiting, abdominal pain; lasts a few hours to a few days
Nonparalytic: Same manifestations as abortive but more severe, with pain and stiffness in neck, back, and legs
Preventive: Childhood immunization Supportive: Complete bed rest during acute
phase Mechanical or assisted ventilation in case of
respiratory paralysis Physical therapy for muscles after acute stage
Institute Contact Precautions. Administer mild sedatives as necessary
to relieve anxiety and promote rest. Participate in physical therapy
procedures (use of moist hot packs and range-of-motion exercises).
Source: Feces and oropharyngeal secretions of infected persons, especially young children
Transmission: Direct contact with persons with apparent or inapparent active infection; spread via fecal-oral and pharyngeal- oropharyngeal routes
Vaccine-acquired paralytic polio may occur as a result of the live oral polio vaccination (no longer available in the United States)
Incubation period: Usually 7 to 14 days, with range of 5 to 35 days
Period of communicability: Not exactly known; virus present in throat and feces shortly after infection and persists for about 1 week in throat and 4 to 6 weeks in feces
Paralytic: Initial course similar to nonparalytic type, followed by recovery and then signs of central nervous system paralysis
Complications: Permanent paralysis Respiratory arrest Hypertension Kidney stones from demineralization of bone
during prolonged immobility
Position child to maintain body alignment and prevent contractures or skin breakdown; use footboard or appropriate orthoses to prevent footdrop; use pressure mattress for prolonged immobility.
Encourage child to perform activities of daily living to capability; promote early ambulation with assistive devices; administer analgesics for maximum comfort during physical activity; give high-protein diet and bowel management for prolonged immobility.
Observe for respiratory paralysis (difficulty talking, ineffective cough, inability to hold breath, shallow and rapid respirations); report such signs and symptoms to practitioner.
Rubella (German Measles) (Fig. 6-6) Agent: Rubella virus Source: Primarily
nasopharyngeal secretions of person with apparent or inapparent infection; virus also present in blood, stool, and urine
Incubation period: 14 to 21 days
Period of communicability: 7 days before to about 5 days after appearance of rash
Constitutional signs and symptoms: Occasionally low-grade fever, headache,
Prodromal stage: Absent in children, present in adults and adolescents; consists of low-grade fever, headache, malaise, anorexia, mild conjunctivitis, coryza, sore throat, cough, and lymphadenopathy; lasts 1 to 5 days, subsides 1 day after appearance of rash
Rash: First appears on face and rapidly spreads downward to neck, arms, trunk, and legs; by end of first day, body is covered with discrete, pinkish-red maculopapular exanthema; disappears in same order as it began and is usually gone by third day
Preventive: Childhood immunization No treatment necessary other than antipyretics
for low-grade fever and analgesics for discomfort
Complications: Rare (arthritis, encephalitis, or purpura); most benign of all childhood communicable diseases; greatest danger is teratogenic effect on fetus
Institute Droplet Precautions. Reassure parents of benign nature of
illness in affected child. Use comfort measures as necessary. Avoid contact with pregnant woman. Monitor rubella titer in pregnant
adolescent.
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malaise, and lymphadenopathy
Scarlet Fever (Fig. 6-7) Agent: Group A β-hemolytic
streptococci Source: Usually from
nasopharyngeal secretions of infected persons and carriers
Transmission: Direct contact with infected person or droplet spread; indirectly by contact with contaminated articles or ingestion of contaminated milk or other food
Incubation period: 2 to 5 days, with range of 1 to 7 days
Period of communicability: During incubation period and clinical illness, approximately 10 days; during first 2 weeks of carrier phase, although may persist for months
Prodromal stage: Abrupt high fever, pulse increased out of proportion to fever, vomiting, headache, chills, malaise, abdominal pain, halitosis
Enanthema: Tonsils enlarged, edematous, reddened, and covered with patches of exudates; in severe cases appearance resembles membrane seen in diphtheria; pharynx is edematous and beefy red; during first 1 to 2 days tongue is coated and papillae become red and swollen (white strawberry tongue); by fourth or fifth day white coat sloughs off, leaving prominent papillae (red strawberry tongue); palate is covered with erythematous punctate lesions
Exanthema: Rash appears within 12 hours after prodromal signs; red pinhead-sized punctate lesions rapidly become generalized but are absent on face, which becomes flushed with striking circumoral pallor; rash more intense in folds of joints; by end of first week desquamation begins (fine, sandpaper-like on torso; sheetlike sloughing on palms and soles), which may be complete by 3 weeks or longer
Full course of penicillin (or erythromycin in penicillin-sensitive children) or oral cephalosporin
Antibiotic therapy for newly diagnosed carriers (nose or throat cultures positive for streptococci)
Supportive: Rest during febrile phase, analgesics for sore throat; antipruritics for rash if bothersome
Complications: Peritonsillar and retropharyngeal abscess
Sinusitis Otitis media Acute glomerulonephritis Acute rheumatic fever Polyarthritis (uncommon)
Institute Standard and Droplet Precautions until 24 hours after initiation of treatment.
Ensure compliance with oral antibiotic therapy; intramuscular benzathine penicillin G (Bicillin) may be given.
Encourage rest during febrile phase; provide quiet activity during convalescent period.
Relieve discomfort of sore throat with analgesics, gargles, lozenges, antiseptic throat sprays, and inhalation of cool mist.
Encourage fluids during febrile phase; avoid irritating liquids (certain citrus juices) or rough foods (chips); when child is able to eat, begin with soft diet.
Advise parents to consult practitioner if fever persists after beginning therapy.
Discuss procedures for preventing spread of infection—discard toothbrush; avoid sharing drinking and eating utensils.
FIG 6-2 Chickenpox (varicella). A, Progression of disease. B, Simultaneous stages of lesions. C, Clinical view. (C, From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 4, St Louis, 2004, Mosby.)
FIG 6-3 Erythema infectiosum (fifth disease). (From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 4, St Louis, 2004, Mosby.)
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FIG 6-4 Exanthem subitum (roseola infantum). (From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 4, St Louis, 2004, Mosby.)
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FIG 6-5 Measles (rubeola). A, Progression of disease. B, Clinical view. C, Koplik spots. (B, From Paller SA, Mancini AJ: Hurwitz clinical pediatric dermatology, ed 4, St Louis, 2011, Saunders/Elsevier; C, from Habif TP: Clinical dermatology: a color
guide to diagnosis and therapy, ed 5, St Louis, 2010, Mosby/Elsevier.)
FIG 6-6 Rubella (German measles). A, Progression of rash. B, Clinical view. (B, From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 5, St Louis, 2007, Mosby/Elsevier; courtesy of Dr. Michael Sherlock, Lutherville, MD.)
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FIG 6-7 Scarlet fever.
Nursing Care Management Table 6-1 describes the more common communicable diseases of childhood, their therapeutic management, and specific nursing care. The following is a general discussion of nursing care management for communicable diseases.
Identification of the infectious agent is of primary importance to prevent exposure to susceptible individuals. Nurses in ambulatory care settings, child care centers, and schools are often the first persons to see signs of a communicable disease, such as a rash or sore throat. The nurse must operate under a high index of suspicion for common childhood diseases to identify potentially infectious cases and to recognize diseases that require medical intervention. An example is the common complaint of sore throat. Although most often a symptom of a minor viral infection, it can signal diphtheria or a streptococcal infection, such as scarlet fever. Each of these bacterial conditions requires appropriate medical treatment to prevent serious complications.
When the nurse suspects a communicable disease, it is important to assess: • Recent exposure to a known case • Prodromal symptoms (symptoms that occur between early manifestations of the disease and its
overt clinical syndrome) or evidence of constitutional symptoms, such as a fever or rash (see Table 6-1)
• Immunization history • History of having the disease
Immunizations are available for many diseases, and infection usually confers lifelong immunity; therefore, the possibility of many infectious agents can be eliminated based on these two criteria.
Prevent Spread Prevention consists of two components: prevention of the disease and control of its spread to others. Primary prevention rests almost exclusively on immunization.
Control measures to prevent spread of disease should include techniques to reduce risk of cross- transmission of infectious organisms between patients and to protect health care workers from organisms harbored by patients. If the child is hospitalized, follow the facility's policies for infection control. The most important procedure is hand washing. Persons directly caring for the child or handling contaminated articles must wash their hands and practice effective Standard Precautions in care of their patients.
Instruct the child to practice good hand washing technique after toileting and before eating. For those diseases spread by droplets, instruct the parents in measures to reduce airborne transmission. The child who is old enough should use a tissue to cover the face during coughing or sneezing; otherwise, the parent should cover the child's mouth with a tissue and then discard it (see Box 6-1).
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Stress the usual hygiene measures of not sharing eating and drinking utensils to the family.
N u r s i n g A l e r t If a child is admitted to the hospital with an undiagnosed exanthema, institute strict Transmission- Based Precautions (contact, airborne, and droplet) and Standard Precautions until a diagnosis is confirmed. Childhood communicable diseases requiring these precautions include diphtheria, varicella-zoster virus (VZV; chickenpox), measles, tuberculosis, adenovirus, Haemophilus influenzae type b (Hib), influenza, mumps, Neisseria meningitidis, Mycoplasma pneumoniae infection, pertussis, plague, rhinovirus, Group A streptococcal pharyngitis, severe acute respiratory syndrome (SARS), pneumonia, or scarlet fever (American Academy of Pediatrics, 2015).
Prevent Complications Although most children recover without difficulty, certain groups are at risk for serious, even fatal, complications from communicable diseases—especially the viral diseases chickenpox and erythema infectiosum (fifth disease) caused by human parvovirus B19.
Children with immunodeficiency—those receiving steroid or other immunosuppressive therapy, those with a generalized malignancy such as leukemia or lymphoma, or those with an immunologic disorder—are at risk for viremia from replication of the varicella-zoster virus (VZV)* in the blood. VZV is so named because it causes two distinct diseases: varicella (chickenpox) and zoster (herpes zoster or shingles). Varicella occurs primarily in children younger than 15 years old. However, it leaves the threat of herpes zoster, an intensely painful varicella that is localized to a single dermatome (body area innervated by a particular segment of the spinal cord). In children, the dermatomes most likely affected by herpes zoster are the cervical and sacral dermatomes (Leung, Robson, and Leong, 2006). Immunocompromised patients and healthy infants younger than 1 year old (who also have reduced immunity) are at a higher risk for reactivation of VZV causing herpes zoster, probably as a result of a deficiency in cellular immunity (American Academy of Pediatrics, 2015; Galea, Sweet, Beninger, et al, 2008). Complications of herpes zoster virus in children include secondary bacterial infection, depigmentation, and scarring. Postherpetic neuralgia in children is uncommon (Leung, Robson, and Leong, 2006).
The use of varicella-zoster immune globulin or intravenous immune globulin (IVIG) is recommended for children who are immunocompromised, who have no previous history of varicella, and who are likely to contract the disease and have complications as a result (American Academy of Pediatrics, 2015). The antiviral agent acyclovir (Zovirax) or valacyclovir may be used to treat varicella infections in susceptible immunocompromised persons. It is effective in decreasing the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. Consider oral acyclovir or valacyclovir for immunocompromised children without a history of varicella disease, newborns whose mother had varicella within 5 days before delivery or within 48 hours after delivery, and hospitalized preterm infants with significant varicella exposure (American Academy of Pediatrics, 2015).
Children with hemolytic disease, such as sickle cell disease, are at risk for aplastic anemia from erythema infectiosum. Human parvovirus B19 infects and lyses red blood cell precursors, thus interrupting the production of red blood cells. Therefore, the virus may precipitate a severe aplastic crisis in patients who need increased red blood cell production to maintain normal red blood cell volumes. Thrombocytopenia and neutropenia may also occur as a result of human parvovirus B19 infection. The fetus has a relatively high rate of red blood cell production and an immature immune system; it may develop severe anemia and hydrops as a result of maternal human parvovirus infection. Fetal death rates as a result of human parvovirus B19 have been estimated to be between 2% and 6%, with the greatest risk appearing to be in the first 20 weeks (Koch, 2016; American Academy of Pediatrics, 2015).
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N u r s i n g A l e r t Refer children at risk for contracting these communicable diseases to the practitioner immediately in case of known exposure or outbreaks.
In the past decade, incidence of pertussis has increased, particularly in infants younger than 6 months old and in children 10 to 14 years old. Early clinical manifestations of pertussis in infants may include gagging, coughing, emesis, and apnea; the typical “whoop” associated with the disease is absent (Wood and McIntyre, 2008). In older children, the disease may manifest as a common cold, but a prolonged cough (6 to 10 weeks or longer) is common in adolescents (American Academy of Pediatrics, 2015) (see Table 6-1). There is now a recommendation that children 11 to 18 years old receive a booster pertussis vaccine (Tdap) to prevent the disease (see Pertussis earlier in chapter). Because pertussis is contagious, especially among close household members, identify pertussis early and initiate treatment for the child and those who have been exposed. Azithromycin (for infants <1 month) and erythromycin, clarithromycin, or azithromycin are administered to infants and children with pertussis (American Academy of Pediatrics, 2015).
Prevention of complications from diseases such as diphtheria, pertussis, and scarlet fever requires compliance with antibiotic therapy. With oral preparations, stress the need to complete the entire course of therapy (see Compliance in Chapter 20).
Evidence suggests that vitamin A supplementation reduces both morbidity and mortality in measles and that all children with severe measles should receive vitamin A supplements. A single oral dose of 200,000 international units for children at least 1 year old is recommended (use half that dose for children 6 to 12 months old) (see Table 6-1). The higher dose may be associated with vomiting and headache for a few hours. The dose should be repeated the next day and at 4 weeks for children with ophthalmologic evidence of vitamin A deficiency (American Academy of Pediatrics, 2015).
N u r s i n g A l e r t Although the risk of vitamin A toxicity from these doses (they are 100 to 200 times the recommended dietary allowance) is relatively low, nurses should instruct parents on safe storage of the drug. Ideally, vitamin A should be dispensed in the age-appropriate unit dose to prevent excessive administration and possible toxicity.
Provide Comfort Many communicable diseases cause skin manifestations that are bothersome to the child. The chief discomfort from most rashes is itching, and measures such as cool baths (usually without soap) and lotions (e.g., calamine) are helpful.
N u r s i n g A l e r t When lotions with active ingredients such as diphenhydramine in Caladryl are used, they are applied sparingly, especially over open lesions, where excessive absorption can lead to drug toxicity. Use these lotions with caution in children who are simultaneously receiving an oral antihistamine. Cooling the lotion in the refrigerator beforehand often makes it more soothing on the skin than at room temperature.
To avoid overheating, which increases itching, children should wear lightweight, loose, nonirritating clothing and keep out of the sun. If the child persists in scratching, keep the nails short and smooth or use mittens and clothes with long sleeves or legs. For severe itching, antipruritic medication, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), may be required, especially when the child has trouble sleeping because of itching. Loratadine, cetirizine, and fexo- fenadine do not cause drowsiness and may be preferred for urticaria during the day.
An elevated temperature is common, and both antipyretic medicine (acetaminophen or ibuprofen) and environmental manipulation are implemented (see Controlling Elevated Temperatures in Chapter 20). Acetaminophen is effective in lowering the fever but does not
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significantly reduce the symptoms of itching, anorexia, abdominal pain, fussiness, or vomiting. A sore throat, another frequent symptom, is managed with lozenges, saline rinses (if the child is
old enough to cooperate), and analgesics. Because most children are anorectic during an illness, bland foods and increased liquids are usually preferred. During the early stages of the disease, children voluntarily curtail their activity, and although bed rest is beneficial, it should not be imposed unless specifically indicated. During periods of irritability, quiet activity (e.g., reading, music, television, video games, puzzles, or coloring) helps distract children from the discomfort.
Support Child and Family Most communicable diseases are benign but may produce considerable concern and anxiety for parents. Often the occurrence of a disease, such as chickenpox, is the first time the child is acutely uncomfortable. Parents need assistance to cope with manifestations of the illness, such as intense itching. The family and child need reassurance that recovery is generally rapid. However, visible signs of the dermatosis may be present for some time after the child is well enough to resume usual activities.
N u r s i n g A l e r t The occurrence of a communicable disease provides the opportunity to ask parents about the child's immunization status and reinforce the benefits of vaccines for children.
Conjunctivitis Acute conjunctivitis (inflammation of the conjunctiva) occurs from a variety of causes that are typically age related. In newborns, conjunctivitis can occur from infection during birth, most often from Chlamydia trachomatis (inclusion conjunctivitis) or Neisseria gonorrhoeae. These organisms, as well as HSV, cause serious ocular damage. In infants, recurrent conjunctivitis may be a sign of nasolacrimal (tear) duct obstruction. A chemical conjunctivitis may occur within 24 hours of instillation of neonatal ophthalmic prophylaxis; the clinical features include mild lid edema and a sterile, nonpurulent eye discharge (Johnson, 2009). In children, the usual causes of conjunctivitis are viral, bacterial, allergic, or related to a foreign body. Bacterial infection accounts for most instances of acute conjunctivitis in children. Diagnosis is made primarily from the clinical manifestations (Box 6-3), although cultures of purulent drainage may be needed to identify the specific cause.
Box 6-3 C l i n i c a l M a n i f e s t a t i o n s o f C o n j u n c t i v i t i s Bacterial Conjunctivitis (“Pink Eye”)
Purulent drainage
Crusting of eyelids, especially on awakening
Inflamed conjunctiva
Swollen lids
Viral Conjunctivitis
Usually occurs with upper respiratory tract infection
Serous (watery) drainage
Inflamed conjunctiva
Swollen lids
Allergic Conjunctivitis
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Itching
Watery to thick, stringy discharge
Inflamed conjunctiva
Swollen lids
Conjunctivitis Caused by Foreign Body
Tearing
Pain
Inflamed conjunctiva
Usually only one eye affected
Therapeutic Management Treatment of conjunctivitis depends on the cause. Viral conjunctivitis is self-limiting, and treatment is limited to removal of the accumulated secretions. Bacterial conjunctivitis has traditionally been treated with topical antibacterial agents, such as polymyxin and bacitracin (Polysporin), sodium sulfacetamide (Sulamyd), or trimethoprim and polymyxin (Polytrim). However, in one study of children with acute infective conjunctivitis treated by placebo versus topical chloramphenicol, there was little difference in cure rates; the authors concluded that most children will get better without antibiotic treatment (Rose, Harnden, Brueggemann, et al, 2005). Fluoroquinolones, approved for children 1 year old and older, are viewed by ophthalmologists as the best ophthalmic antimicrobial agents available (Lichtenstein, Rinehart, and Levofloxacin Bacterial Conjunctivitis Study Group, 2003). Fourth generation fluoroquinolones (such as, moxifloxacin, gatifloxacin, and besifloxacin) provide broad spectrum coverage, are bactericidal, and are generally well tolerated (Alter, Vidwan, Sobande, et al, 2011). Drops may be used during the day and an ointment at bedtime, because the ointment preparation remains in the eye longer but blurs the vision. Corticosteroids are avoided because they reduce ocular resistance to bacteria.
Nursing Care Management Nursing care includes keeping the eye clean and properly administering ophthalmic medication. Remove accumulated secretions by wiping from the inner canthus downward and outward, away from the opposite eye. Warm, moist compresses, such as a clean washcloth wrung out with hot tap water, are helpful in removing the crusts. Compresses are not kept on the eye because an occlusive covering promotes bacterial growth. Instill medication immediately after the eyes have been cleaned and according to correct procedure (see Chapter 20).
Prevention of infection in other family members is an important consideration with bacterial conjunctivitis. Keep the child's washcloth and towel separate from those used by others. Discard tissues used to clean the eye. Instruct the child to refrain from rubbing the eye and to use good hand washing technique.
N u r s i n g A l e r t Signs of serious conjunctivitis include reduction or loss of vision, ocular pain, photophobia, exophthalmos (bulging eyeball), decreased ocular mobility, corneal ulceration, and unusual patterns of inflammation (e.g., the perilimbal flush associated with iritis or localized inflammation associated with scleritis). If a patient has any of these signs, refer him or her immediately to an ophthalmologist.
Stomatitis Stomatitis is inflammation of the oral mucosa, which may include the buccal (cheek) and labial (lip) mucosa, tongue, gingiva, palate, and floor of the mouth. It may be infectious or noninfectious and
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may be caused by local or systemic factors. In children, aphthous stomatitis and herpetic stomatitis are typically seen. Children with immunosuppression and those receiving chemotherapy or head and neck radiotherapy are at high risk for developing mucosal ulceration and herpetic stomatitis.
Aphthous stomatitis (aphthous ulcer, canker sore) is a benign but painful condition whose cause is unknown. Its onset is usually associated with mild traumatic injury (biting the cheek, hitting the mucosa with a toothbrush, or a mouth appliance rubbing on the mucosa), allergy, or emotional stress. The lesions are painful, small, whitish ulcerations surrounded by a red border. They are distinguished from other types of stomatitis by healthy adjacent tissues, absence of vesicles, and no systemic illness. The ulcers persist for 4 to 12 days and heal uneventfully.
Herpetic gingivostomatitis (HGS) is caused by HSV, most often type 1, and may occur as a primary infection or recur in a less severe form known as recurrent herpes labialis (commonly called cold sores or fever blisters). The primary infection usually begins with a fever; the pharynx becomes edematous and erythematous; and vesicles erupt on the mucosa, causing severe pain (Fig. 6-8). Cervical lymphadenitis often occurs, and the breath has a distinctly foul odor. In the recurrent form, the vesicles appear on the lips, usually singly or in groups. The precipitating factors for the cold sores include emotional stress, trauma (often related to dental procedures), immunosuppression, or exposure to excessive sunlight. The disease can last 5 to 14 days, with varying degrees of severity.
FIG 6-8 Primary gingivostomatitis. (From Thompson JM, McFarland GM, Hirsch JE, et al: Mosby's clinical nursing, ed 5, St Louis, 2002, Mosby.)
Stomatitis may occur as a manifestation of hand-foot-and-mouth disease (HFMD) and herpangina; both manifest with scattered vesicles on the buccal mucosa and are commonly caused by the nonpolio enteroviruses (primarily coxsackieviruses). Children with either HFMD or herpangina often have poor intake as a result of the mouth sores; infants may refuse to nurse or take a bottle or may pull away and cry after a few seconds of nursing.
Therapeutic Management Treatment for all types of stomatitis is aimed at relief of symptoms, primarily pain. Acetaminophen and ibuprofen are usually sufficient for mild cases, but with more severe HGS, stronger analgesics such as codeine may be needed. Topical anesthetics are helpful and include over-the-counter preparations, such as Orabase, Anbesol, and Kank-A. Lidocaine (Xylocaine Viscous) can be prescribed for the child who can keep 1 tsp of the solution in the mouth for 2 to 3 minutes and then expectorate the drug. A mixture of equal parts of diphenhydramine elixir and aluminum and magnesium hydroxide (Maalox) provides mild analgesia, antiinflammatory properties, and a protective coating for the lesions. Sucralfate can also be used as a coating agent for oral mucous membranes. Specific treatment for children with severe cases of HGS is the use of antiviral agents, such as acyclovir (Hudson and Powell, 2009; Phillips, 2008). A systematic review found weak evidence that acyclovir is effective in reducing the number of oral lesions, preventing development of new lesions, and decreasing difficulty with eating and drinking (Nasser, Fedorowicz, Khoshnevisan, et al, 2008).
Nursing Care Management The chief nursing goals for children with stomatitis are relief of pain and prevention of spread of the herpes virus. Analgesics and topical anesthetics are used as needed to provide relief, especially before meals to encourage food and fluid intake. For younger infants and toddlers who cannot swish and swallow, apply the diphenhydramine and Maalox solution with a cotton-tipped
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applicator before feedings to minimize pain. Educating parents regarding the use of these medications is important to maintain adequate hydration in the child whose mouth is too sore to take liquids. Drinking bland fluids through a straw is helpful in avoiding the painful lesions. Encourage mouth care; the use of a very soft bristle toothbrush or disposable foam-tipped toothbrush provides gentle cleaning near ulcerated areas.
Careful hand washing is essential when caring for children with HGS. Because the infection is autoinoculable, children should keep their fingers out of the mouth; contaminated hands can infect other body parts. Very young children may require elbow restraints to ensure compliance. Articles placed in the mouth are cleaned thoroughly. Newborns and individuals with immunosuppression should not be exposed to infected children.
N u r s i n g A l e r t When examining herpetic lesions, wear gloves. The virus easily enters breaks in the skin and can cause herpetic whitlow of the fingers.
Because herpes infection is often associated with sexual transmission, explain to parents and older children that HGS is usually caused by type 1 HSV, the type not associated with sexual activity.
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Intestinal Parasitic Diseases Intestinal parasitic diseases, including helminths (worms) and protozoa, constitute the most frequent infections in the world. In the United States, the incidence of intestinal parasitic disease, especially giardiasis, has increased among young children who attend day care centers. Young children are especially at risk because of typical hand-mouth activity and uncontrolled fecal activity.
Various infecting organisms cause intestinal parasitic diseases in humans. This discussion is limited to the two most common parasitic infections among children in the United States: giardiasis and pinworms. Table 6-2 describes the outstanding features of selected helminths that belong to the family of nematodes.
TABLE 6-2 Selected Intestinal Parasites
Clinical Manifestations Comments Ascariasis—Ascaris lumbricoides (Common Roundworm) Light infections/asymptomatic: Parent may find roundworm in child's diaper with/without stool or
see roundworms in the toilet Heavy infections: Anorexia, irritability, nervousness, enlarged abdomen, weight loss, fever,
intestinal colic Severe infections: Intestinal obstruction, appendicitis, perforation of intestine with peritonitis,
obstructive jaundice, lung involvement (pneumonitis)
Transferred to mouth by way of contaminated food, fingers, or toys (ascaris lays eggs in soil which children play in)
No person-to-person transmission Largest of the intestinal helminths Affects principally young children 1 to 4 years old Prevalent in warm climates Treat with albendazole (single dose); or mebendazole for 3 days; or ivermectin
(children >15 kg) as a single dose; or nitazoxanide for 3 days Reexamine stool specimen in 2 weeks to establish need for further pharmacologic
therapy (American Academy of Pediatrics, 2015) Hookworm Disease—Necator americanus and Ancylostoma duodenale Light infections in well-nourished individuals: No problems Heavier infections: Mild to severe hypochromic, microcytic anemia, malnutrition; hypoproteinemia
and edema May be itching and burning followed by erythema and a papular eruption in areas to which the
organism migrates
Transmitted by discharging eggs on the soil, which are picked up by human host, commonly in the feet, causing infection from direct skin contact with contaminated soil
Recommend wearing shoes, although children playing in contaminated soil expose many skin surfaces
Diagnosis established by presence of hookworm eggs in stool (humans are the only host of hookworms)
Treat with albendazole, mebendazole, and pyrantel pamoate Strongyloidiasis—Strongyloides stercoralis (Threadworm) Light infection: Asymptomatic Heavy infection: Respiratory signs and symptoms; abdominal pain, distention; nausea and
vomiting; diarrhea (large, pale stools, often with mucus) Larva migration manifests as pruritic skin lesions in the perianal area, buttocks, and upper thighs,
creating serpiginous, erythematous tracks called larva currens (American Academy of Pediatrics, 2015)
Life threatening in children with weakened immunologic defenses
Transmission is same as for hookworm except autoinfection common; humans are hosts, but cats, dogs, and other animals may also be hosts for the threadworm
Older children and adults affected more often than young children Severe infections may lead to severe nutritional deficiency Diagnosis: Often difficult; several stool specimens may be required Treat with ivermectin (preferred); or thiabendazole and albendazole (both less
effective than ivermectin) Visceral Larva Migrans—Toxocara canis (Dogs) (Roundworm) Intestinal Toxocariasis—Toxocara cati (Cats) (Roundworm) Depends on reactivity of infected individual May be asymptomatic except for eosinophilia or pulmonary wheezing Specific diagnosis difficult Visceral toxocariasis: Fever, leukocytosis, eosinophilia, hepatomegaly, and
hypogammaglobulinemia, malaise, anemia, cough (American Academy of Pediatrics, 2015) Ocular invasion may occur Rarely pneumonia, myocarditis, encephalitis
Transmitted by direct contamination of hands from contact with soil or contaminated objects; less commonly by direct contact with dog or cat
More common in children or adults with pica Keep dogs and cats away from areas where children play; sandboxes especially
important transmission areas; more common in hot, humid regions Hand washing is imperative in children playing in soil or around domestic animals,
such as cats and dogs Periodic deworming of diagnosed dogs and cats Control of dog and cat population Diagnosis: Hypergammaglobulinemia and hypereosinophilia; increased titers of
anti-A or anti-B blood group antigens; liver biopsy in some cases Treat with albendazole; specific symptoms may require additional treatment
Trichuriasis—Trichuris trichiura (Whipworm or Human Whipworm) Light infections: Asymptomatic Heavy infections: Abdominal pain and distention, diarrhea; failure to thrive, impaired cognitive
development; stools may have mucus, water, and blood
Transmitted from contaminated soil, fruit, vegetables, toys, and other objects Most frequent in warm, moist climates Occurs most often in undernourished children living in unsanitary conditions where
human feces are not disposed of properly Diagnosis by microscopic examination of stool specimen Treat with albendazole, mebendazole, or ivermectin
General Nursing Care Management Nursing responsibilities related to intestinal parasitic infections involve assistance with identification of the parasite, treatment of the infection, and prevention of initial infection or reinfection. Laboratory examination of substances containing the worm, its larvae, or ova can identify the organism. Most are identified by examining fecal smears from the stools of persons suspected of harboring the parasite. Fresh specimens are best for revealing parasites or larvae; therefore, take collected specimens directly to the laboratory for examination. If this is not possible, place the specimen in a container with a preservative. Parents need clear instructions on obtaining an adequate sample and the number of samples required (see Stool Specimens in Chapter 20). In most parasitic infections, other family members, especially children, may be examined to identify those who are similarly affected.
After the diagnosis is confirmed and appropriate treatment is planned, parents need further explanation and reinforcement. Compliance in terms of drug therapy and other measures, such as
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thorough hand washing, is essential for eradication of the parasite. The family needs to understand the nature of transmission and that in some cases the medication must be repeated in 2 weeks to 1 month to kill organisms hatched since initial treatment.
The nurse's most important function is preventive education of children and families regarding hygiene and health habits. Thorough hand washing before eating or handling food and after using the toilet is the most important precautionary method. The Family-Centered Care box lists other preventive practices.
F a m i l y - C e n t e r e d C a r e Preventing Intestinal Parasitic Disease
• Always wash hands and fingernails with soap and water before eating and handling food and after toileting.
• Avoid placing fingers in mouth and biting nails.
• Discourage children from scratching bare anal area.
• Use superabsorbent disposable diapers to prevent leakage.
• Change diapers as soon as soiled and dispose of diapers in closed receptacle out of children's reach.
• Do not rinse cloth or disposable diapers in toilet.
• Disinfect toilet seats and diaper-changing areas; use dilute household bleach (10% solution) or ammonia (Lysol) and wipe clean with paper towels.
• Drink only treated water or bottled water, especially if camping.
• Wash all raw fruits and vegetables and food that have fallen on the floor.
• Avoid growing foods in soil fertilized with human or untreated animal excreta.
• Teach children to defecate only in a toilet, not on the ground.
• Keep dogs and cats away from playgrounds and sandboxes.
• Avoid swimming in pools frequented by diapered children.
• Wear shoes outside.
Giardiasis Giardiasis is caused by the protozoan Giardia intestinalis (formerly called Giardia lamblia and Giardia duodenalis). It is the most common intestinal parasitic pathogen in the United States. Child care centers and institutions providing care for persons with developmental disabilities are common sites for urban giardiasis, and the children may pass cysts for months. Also consider giardiasis in those with a history of recent travel to an endemic area (Yoder, Gargano, Wallace, et al, 2012).
The potential for transmission is great because the cysts—the nonmotile stage of the protozoa— can survive in the environment for months. Chief modes of transmission are person to person, food, and animals, especially puppies. Contaminated water, especially in mountain lakes and streams, and swimming or wading pools frequented by diapered infants are common sources of transmission. In children, person-to-person transmission is the most likely cause. Studies indicate swimming pool filters and interactive water fountains to be sites of contamination (Yoder, Gargano, Wallace, et al, 2012). Although individuals infected with giardiasis may be asymptomatic, common symptoms include abdominal cramps and diarrhea (Box 6-4).
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Box 6-4 C l i n i c a l M a n i f e s t a t i o n s o f G i a r d i a s i s Infants and young children:
• Diarrhea
• Vomiting
• Anorexia
• Growth failure (failure to thrive)—if chronic exposure
Children older than 5 years old:
• Abdominal cramps
• Intermittent loose stools
• Constipation
Stools that are malodorous, watery, pale, and greasy
Spontaneous resolution of most infections in 4 to 6 weeks
Rare, chronic form:
• Intermittent loose, foul-smelling stools
• Possibility of abdominal bloating, flatulence, sulfur-tasting belches, epigastric pain, vomiting, headache, and weight loss
Diagnosis of giardiasis may be made by microscopic examination of stool specimens or duodenal fluid or by identification of G. intestinalis antigens in these specimens by techniques such as enzyme immunoassay (EIA) and direct fluorescence antibody (DFA) assays. Because the Giardia organisms live in the upper intestine and are excreted in a highly variable pattern, repeated microscopic examination of stool specimens may be required to identify trophozoites (active parasites) or cysts. Duodenal specimens are obtained by direct aspiration, biopsy, or the string test. In the string test, the child swallows a gelatin capsule with a nylon string attached. Several hours later, the string is withdrawn, and the contents are sent for laboratory analysis. With the availability of EIA techniques to identify Giardia antigens in stool specimens, other tests are being used less often.
Therapeutic Management The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and nitazoxanide (Alinia). Tinidazole is said to have an 80% to 100% cure rate after a single dose (American Academy of Pediatrics, 2015). Metronidazole and tinidazole have a metallic taste and gastrointestinal side effects, including nausea and vomiting. Nitazoxanide does not have a bitter taste and should be taken with food to avoid gastrointestinal symptoms; it reportedly has very few adverse effects and is available in suspension form. Alternative drug therapy includes albendazole, furazolidone, and quinacrine (John, 2016). Quinacrine is only available from a compounding
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pharmacy. The most important nursing consideration is prevention of giardiasis and education of parents,
child care center staff, and others who assume the daily care of small children. Attention to meticulous sanitary practices, especially during diaper changes, is essential (see Family-Centered Care box on Transmission and Fig. 6-9). Nurses can play an important role in educating parents of small children and day care staff regarding appropriate sanitation. In addition, discourage young children who are infected or who have diarrhea from swimming in community or private pools until they have been infection free for 2 weeks (American Academy of Pediatrics, 2015). Lakes and streams may contain high numbers of Giardia spore cysts, which can be swallowed in the water. Discourage children from swimming in stagnant bodies of water and in water where there are known infected children swimming when there is a high chance of swallowing water. Giardia organisms are resistant to chlorine (Eisenstein, Bodager, and Ginzl, 2008). Encourage parents to take small children to the restroom frequently when swimming, avoid letting children in diapers in swimming areas, and change diapers away from the water source. (See also Centers for Disease Control and Prevention information on recreational water illnesses, http://www.cdc.gov/healthywater/swimming.) After children are infected, family education regarding drug administration is essential.
FIG 6-9 Prevention of giardiasis, especially in day care centers, requires sanitary practices during diaper changes, such as discarding paper diapers in a covered receptacle, changing paper covers on the diaper- changing surface, and having facilities for hand washing nearby. Note: Soiled cloth diapers and clothing
should be stored in a plastic bag for transport home.
Enterobiasis (Pinworms) Enterobiasis, or pinworms, caused by the nematode Enterobius vermicularis, is the most common helminthic infection in the United States. It is universally present in temperate climatic zones and may infect more than 30% of all children at any one time. Crowded conditions, such as in classrooms and day care centers, favor transmission. Infection begins when the eggs are ingested or inhaled (the eggs float in the air). The eggs hatch in the upper intestine and then mature and migrate through the intestine. After mating, adult females migrate out the anus and lay eggs (American Academy of Pediatrics, 2015). The movement of the worms on skin and mucous membrane surfaces causes intense itching. As the child scratches, eggs are deposited on the hands and underneath the fingernails. The typical hand-to-mouth activity of youngsters makes them especially prone to reinfection. Pinworm eggs persist in the indoor environment for 2 to 3 weeks, contaminating anything they contact, such as toilet seats, doorknobs, bed linen, underwear, and
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food. Except for the intense rectal itching associated with pinworms, the clinical manifestations are nonspecific (Box 6-5).
Box 6-5 C l i n i c a l M a n i f e s t a t i o n s o f P i n w o r m s Intense perianal itching is the principal symptom. Evidence of itching in young children includes:
• General irritability
• Restlessness
• Poor sleep
• Bed-wetting
• Distractibility
• Short attention span
• Perianal dermatitis and excoriation secondary to itching
• If worms migrate, possible vaginal (vulvovaginitis) and urethral infection
Diagnostic Evaluation Diagnosis is most commonly made from the tape test (see Nursing Care Management). Repeated tests to collect eggs may be necessary (3 consecutive days in the early morning before the child washes are recommended for testing [American Academy of Pediatrics, 2015]), and if there is a possibility that other family members may be infected, a tape test should be performed on them.
Therapeutic Management The drugs available for treatment of pinworms include pyrantel pamoate (Pin-Rid, Antiminth) and albendazole. Mebendazole is no longer available in the United States, and it is not recommended for children younger than 2 years old. If pyrvinium pamoate is prescribed, advise parents that the drug stains stool and vomitus bright red, as well as clothing or skin that comes in contact with the drug; it is available without prescription and should not be used in children younger than 2 years old without consulting a primary practitioner. Because pinworms are easily transmitted, all household members should be treated. The dose of antiparasitic medication should be repeated in 2 weeks to completely eradicate the parasite and prevent reinfection.
Nursing Care Management Direct nursing care at identifying the parasite, eradicating the organism, and preventing reinfection. Parents need clear, detailed instructions for the tape test. A loop of transparent (not “frosted” or “magic”) tape, sticky side out, is placed around the end of a tongue depressor, which is then firmly pressed against the child's perianal area. A convenient, commercially prepared tape is also available for this purpose. Pinworm specimens are collected in the morning as soon as the child awakens and before the child has a bowel movement or bathes. The procedure may need to be performed on 3 or more consecutive days before eggs are collected. Parents are instructed to place the tongue blade in a glass jar or loosely in a plastic bag so that it can be brought in for microscopic examination. For specimens collected in the hospital, practitioner's office, or clinic, place the tape smoothly on a glass slide, sticky side down, for examination.
Adherence to the drug regimen is usually excellent because only one or two doses are needed. The family should be reminded of the need to take a second dose in 2 weeks to ensure eradication of the eggs.
To prevent reinfection, washing all clothes and bed linens in hot water and vacuuming the house may be recommended. However, there is little documentation on the effectiveness of these measures because pinworms survive on many surfaces. Helpful suggestions include hand washing
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after toileting and before eating, keeping the child's fingernails short to minimize the chance of ova collecting under the nails, dressing children in one-piece sleeping outfits, and daily showering rather than tub bathing. Inform families that recurrence is common. Treat repeated infections in the same manner as the first one.
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Infections of the Skin Bacterial Infections Normally, the skin harbors a variety of bacterial flora, including the major pathogenic varieties of staphylococci and streptococci. The degree of their pathogenicity depends on the invasiveness and toxigenicity of the specific organism, the integrity of the skin (the host's barrier), and the host's immune and cellular defenses. Children with congenital or acquired immune disorders (such as acquired immunodeficiency syndrome [AIDS]), children in a debilitated condition, those receiving immunosuppressive therapy, and those with a generalized malignancy (such as, leukemia or lymphoma) are at risk for developing bacterial infections.
Because of the characteristic “walling-off” process of the inflammatory reaction (abscess formation), staphylococci are more difficult to treat, and the local infected area is associated with an increase in bacteria all over the skin surface that serves as a source of continuing infection. In previous years, MRSA infections were primarily seen in nursing homes and hospitals. In the last decade, the number of MRSA community-acquired infections has risen dramatically (Alter, Vidwan, Sobande, et al, 2011). All of these factors underline the importance of careful hand washing and cleanliness when caring for infected children and their lesions to prevent the spread of infection and as an essential prophylactic measure when caring for infants and small children. Common bacterial skin disorders are outlined in Table 6-3.
TABLE 6-3 Bacterial Infections
Disorder and Organism Manifestations Management Comments Impetigo contagiosa: Staphylococci (Fig. 6-10) Begins as a reddish macule
Becomes vesicular Ruptures easily, leaving superficial,
moist erosion Tends to spread peripherally in sharply
marginated irregular outlines Exudate dries to form heavy, honey-
colored crusts Pruritus common Systemic effects: Minimal or
asymptomatic
Topical bactericidal ointment mupirocin or triple antibiotic ointment
Oral or parenteral antibiotics (penicillin) in cases of severe or extensive lesions
Vancomycin for methicillin-resistant Staphylococcus aureus (MRSA)
Retapamulin 1% ointment, applied twice daily for 5 days
Tends to heal without scarring unless secondary infection occurs
Autoinoculable and contagious Very common in toddlers, preschoolers May be superimposed on eczema
Pyoderma: Staphylococci, streptococci Deeper extension of infection into dermis
Tissue reaction more severe Systemic effects: Fever, lymphangitis,
sepsis, liver disease, heart disease
Soap and water cleansing Topical antiseptic, such as chlorhexidine Mupirocin Antibiotics depending on causative
organism: Cephalexin, nafcillin, intramuscular (IM) benzathine penicillin
Bathing with antibacterial soap as prescribed
Autoinoculable and contagious May heal with or without scarring
Folliculitis (pimple), furuncle (boil), carbuncle (multiple boils): Staphylococcus aureus, methicillin-resistant S. aureus (MRSA)
Folliculitis: Infection of hair follicle Furuncle: Larger lesion with more
redness and swelling at a single follicle
Carbuncle: More extensive lesion with widespread inflammation and “pointing” at several follicular orifices
Systemic effects: Malaise, if severe
Skin cleanliness Local warm, moist compresses Topical antibiotic agents Systemic antibiotics in severe cases Incision and drainage of severe lesions,
followed by wound irrigations with antibiotics or suitable drain implantation
MRSA infections:
• 5-inch soak of cup bleach diluted in a standard 50-gallon tub one fourth filled with water once or twice weekly
• No sharing of towels or washcloths, changing of clothes and underwear daily, and laundering in hot water
• Disposal of razors after one use • Application of mupirocin to nares bid for
2 to 4 weeks
Autoinoculable and contagious Furuncle and carbuncle tend to heal with scar
formation Lesion should never be squeezed
Cellulitis: Streptococci, staphylococci, Haemophilus influenzae (Fig. 6-11)
Inflammation of skin and subcutaneous tissues with intense redness, swelling, and firm infiltration
Lymphangitis “streaking” frequently seen
Involvement of regional lymph nodes common
May progress to abscess formation Systemic effects: Fever, malaise
Oral or parenteral antibiotics Rest and immobilization of both affected
area and child
Hospitalization may be necessary for child with systemic symptoms
Otitis media may be associated with facial cellulitis
Staphylococcal scalded skin syndrome: S. aureus
Macular erythema with “sandpaper” texture of involved skin
Epidermis becomes wrinkled (in 2 days or less), and large bullae appear
Localized bullous impetigo in older child
Systemic antibiotics Gentle cleansing with saline, Burrow
solution, or 0.25% silver nitrate compresses
Infants subject to fluid loss, impaired body temperature regulation, and secondary infection, such as pneumonia, cellulitis, and septicemia
Heals without scarring
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FIG 6-10 Impetigo contagiosa. (From Weston WL, Lane AT: Color textbook of pediatric dermatology, ed 4, St Louis, 2007, Mosby/Elsevier.)
FIG 6-11 Cellulitis of the cheek from a puncture wound. (From Weston WL, Lane AT: Color textbook of pediatric dermatology, ed 4, St Louis, 2007, Mosby/Elsevier.)
Nursing Care Management The major nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications. Impetigo contagiosa and MRSA infection can easily spread by self- inoculation; therefore, caution the child against touching the involved area. Hand washing is mandatory before and after contact with an affected child. Also emphasize hand washing to both the child and the family. For many bacterial infections and for MRSA infection in particular, the child should be provided with washcloths and towels separate from those of other family members. The child's pajamas, underwear, and other clothes should be changed daily and washed in hot water. Razors used for shaving should be discarded after each use and not shared. To prevent recurrence, some infectious disease specialists recommend bathing in a chlorine bath once or twice weekly. A 5-minute soak of 2.5 ml of bleach diluted in 13 gallons of water, or cup of bleach diluted in a standard 50-gallon tub one fourth filled with water, could decrease community- acquired MRSA colonies by more than 99.9% (Fisher, Chan, Hair, et al, 2008; Kaplan, 2008). In addition, mupirocin can be applied to the nares of patients and families twice daily for 1 to 2 weeks to prevent reinfection (Alter, Vidwan, Sobande, et al, 2011). Daily bathing or showering with an antibacterial soap is also recommended.
Children and parents are often tempted to squeeze follicular lesions. They must be warned that squeezing will not hasten the resolution of the infection and that there is a risk of making the lesion worse or spreading the infection. Children should not puncture the surface of the pustule with a needle or sharp instrument. A child with a stye may awaken with the eyelids of the affected eye sealed shut with exudate. Instruct the child or the parents to gently wipe the lid from the inner to
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the outer edge with warm water and a clean washcloth until the exudate has been removed. The child with limited cellulitis of an extremity is usually managed at home on a regimen of oral
antibiotics and warm compresses. Teach the parents the procedures and instruct them in administration of the medication. Children with more extensive cellulitis, especially around a joint with lymphadenitis or on the face, or with lesions larger than 5 cm (2 inches), are usually admitted to the hospital for parenteral antibiotics, incision, and drainage. Nurses are responsible for teaching the family to administer the medication and to apply compresses.
Viral Infections Viruses are intracellular parasites that produce their effect by using the intracellular substances of the host cells. Composed of only a deoxyribonucleic acid or ribonucleic acid core enclosed in an antigenic protein shell, viruses are unable to provide for their own metabolic needs or to reproduce themselves. After a virus penetrates a cell of the host organism, it sheds the outer shell and disappears within the cell, where the nucleic acid core stimulates the host cell to form more virus material from its intracellular substance. In a viral infection, the epidermal cells react with inflammation and vesiculation (as in herpes simplex) or by proliferating to form growths (warts).
Most of the communicable diseases of childhood are associated with rashes, and each rash is characteristic. Common viral disorders of the skin are outlined in Table 6-4.
TABLE 6-4 Viral Skin Infections
Disorder and Organism Manifestations Management Comments
Verruca (warts): Human papillomavirus (various types)
Usually well-circumscribed, gray or brown, elevated, firm papules with a roughened, finely papillomatous texture
Occur anywhere, but usually appear on exposed areas, such as fingers, hands, face, and soles
May be single or multiple Asymptomatic
Not uniformly successful Local destructive therapy, individualized according to location, type, and
number—surgical removal, electrocautery, curettage, cryotherapy (liquid nitrogen), caustic solutions (lactic acid and salicylic acid in flexible collodion, retinoic acid, salicylic acid plasters), laser ablation
Common in children Tend to disappear spontaneously Course unpredictable Most destructive techniques tend to
leave scars Autoinoculable Repeated irritation will cause to
enlarge Verruca plantaris (plantar wart)
Located on plantar surface of feet and, because of pressure, are practically flat; may be surrounded by a collar of hyperkeratosis
Caustic chemical solution applied to wart, foam insole worn with hole cut to relieve pressure on wart; soaked 20 minutes after 2 to 3 days; procedure repeated until wart comes out
Destructive techniques tend to leave scars, which may cause problems with walking
Cold sore, fever blister: Herpes simplex virus (HSV) type 1
Genital herpes: HSV type 2
Grouped burning and itching vesicles on inflammatory base, usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks)
Vesicles dry, forming a crust, followed by exfoliation and spontaneous healing in 8 to 10 days
May be accompanied by regional lymphadenopathy
Avoidance of secondary infection Burrow solution compresses during weeping stages Oral antiviral (acyclovir [Zovirax]) for initial infection or to reduce severity in
recurrence; may also be given prophylactically for recurrent Valacyclovir (Valtrex), an oral antiviral used for episodic treatment of
recurrent genital herpes, reduces pain, stops viral shedding, and has a more convenient administration schedule than acyclovir; primarily recommended for immunocompromised patients
Heal without scarring unless secondary infection
HSV-1 cold sores can be prevented by using sunscreens protecting against ultraviolet A and ultraviolet B light to prevent lip blisters
Aggravated by corticosteroids Positive psychologic effect from
treatment May be fatal in children with
depressed immunity Herpes zoster, shingles: Varicella zoster virus
Caused by same virus that causes varicella (chickenpox)
Virus has affinity for posterior root ganglia, posterior horn of spinal cord, and skin; crops of vesicles usually confined to dermatome following along course of affected nerve
Usually preceded by neuralgic pain (rare in children), hyperesthesias, or itching
May be accompanied by constitutional symptoms
Symptomatic treatment Analgesics for pain Drying lotions may be helpful Ophthalmic variety: Systemic corticotropin (adrenocorticotropic hormone) or
corticosteroids Acyclovir or valacyclovir Preventive vaccine is available for persons >50 years old
Pain in children usually minimal Postherpetic pain does not occur in
children Chickenpox may follow exposure;
isolate affected child from other children in a hospital or school
May occur in children with depressed immunity; can be fatal
Molluscum contagiosum: Poxvirus
Flesh-colored papules (1 to 20) with a central caseous plug (umbilicated) that occur on trunk, face, and extremities; may be transmitted by sexual contact
Usually asymptomatic
Cases in well children resolve spontaneously in about 18 months Treatment reserved for cosmetic purposes; alleviate discomfort; reduce
autoinoculation; prevent secondary infection Numerous chemical removing agents including tretinoin gel 0.01% or
cantharidin (Cantharone) liquid; podophyllin; imiquimod cream These are painful treatments: Use local anesthesia Curettage, electrodessication, or cryotherapy
Common in school-age children Spread by skin-to-skin contact,
including autoinoculation and fomite-to-skin contact
Outbreaks in child care centers have been reported
Dermatophytoses (Fungal Infections) The dermatophytoses (ringworm) are infections caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. These are superficial infections by organisms that live on, not in, the skin. They are confined to the dead keratin layers and are unable to survive in the deeper layers. Because keratin is being shed constantly, the fungus must multiply at a rate that equals the rate of keratin production to maintain itself; otherwise the organism would be shed with the discarded skin cells. Table 6-5 outlines common dermatophytoses.
TABLE 6-5 Dermatophytoses (Fungal Infections)
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Disorder and Organism Manifestations Management Comments Tinea capitis: Trichophyton tonsurans, Microsporum audouinii, Microsporum canis (see Fig. 6-12, A)
Lesions in scalp but may extend to hairline or neck
Characteristic configuration of scaly, circumscribed patches or patchy, scaling areas of alopecia
Generally asymptomatic, but severe, deep inflammatory reaction may occur that manifests as boggy, encrusted lesions (kerions)
Pruritic Diagnosis: Microscopic examination of
scales
Oral griseofulvin or terbinafine Oral ketoconazole for difficult cases Selenium sulfide shampoos, used twice a week, may
decrease infection and fungal shedding (American Academy of Pediatrics, 2015)
Kerion: Griseofulvin and possibly oral corticosteroids for 2 weeks to achieve therapeutic effect (American Academy of Pediatrics, 2015)
Person-to-person transmission Animal-to-person transmission Rarely, permanent loss of hair M. audouinii transmitted from one human to another
directly or from personal items; M. canis usually contracted from household pets, especially cats
Atopic individuals more susceptible
Tinea corporis: Trichophyton rubrum, Trichophyton mentagrophytes, M. canis, Epidermophyton organisms (see Fig. 6-12, B)
Generally round or oval, erythematous scaling patch that spreads peripherally and clears centrally; may involve nails (tinea unguium)
Diagnosis: Direct microscopic examination of scales
Usually unilateral
Oral griseofulvin Local application of antifungal preparation, such as
tolnaftate, naftifine, miconazole, terbinafine, clotrimazole; applied 2.5 cm (1 inch) beyond periphery of lesion; application continued 1 to 2 weeks after no sign of lesion
Topical antifungals with high-potency steroids are not recommended as they may lead to further infection and have local and systemic side effects (American Academy of Pediatrics, 2015)
Usually of animal origin from infected pets but may occur from human transmission, soil or fomites
Majority of infections in children caused by M. canis and M. audouinii
Tinea gladiatorum is commonly seen in wrestlers
Tinea cruris (“jock itch”): Epidermophyton floccosum, T. rubrum, T. mentagrophytes
Skin response similar to that in tinea corporis
Localized to medial proximal aspect of thigh and crural fold; may involve scrotum in males
Pruritic Diagnosis: Same as for tinea corporis
Local application of tolnaftate liquid; terbinafine, clotrimazole, ciclopirox twice daily for 2 to 4 weeks
Rare in preadolescent children Health education regarding transmission via
person-to-person (direct or indirect) Occurs in close association with tinea pedis and
tinea unguium
Tinea pedis (“athlete's foot”): T. rubrum, Trichophyton interdigitale, E. floccosum
Tinea unguium: Nail infection
On intertriginous areas between toes or on plantar surface of feet
Lesions vary: • Maceration and fissuring between toes • Patches with pinhead-sized vesicles on
plantar surface Pruritic Diagnosis: Direct microscopic examination
of scrapings
Local application of terbinafine, ciclopirox or clotrimazole, or miconazole, or ketoconazole
Oral itraconazole, terbinafine or griseofulvin for severe infections or those which do not respond to topical
Acute infections: Compresses or soaks with Burrow solution (1 : 80) (American Academy of Pediatrics, 2015)
Elimination of conditions of heat and perspiration by use of clean, light socks and well-ventilated shoes; avoidance of occlusive shoes
Most frequent in adolescents and adults; rare in children, but occurrence increases with wearing of plastic shoes
Common in locations such as showers, locker rooms, and swimming pools where fungi proliferate
Candidiasis (moniliasis): Candida albicans
Grows in chronically moist areas Inflamed areas with white exudate,
peeling, and easy bleeding Pruritic Diagnosis: Characteristic appearance;
microscopic identification of scrapings; candidemia diagnosed from cultures (blood, cerebrospinal fluid, bone marrow); tissue biopsy
Chronic or recurrent often seen with human immunodeficiency virus (HIV) infection and immunocompromised child
Neonates-thrush-oral nystatin Older children, clotrimazole troches applied to lesions
(American Academy of Pediatrics, 2015) Fluconazole or itraconazole for immunocompromised Esophagitis: Treat with oral or intravenous (IV)
fluconazole or itraconazole; IV amphotericin, voriconazole, micafungin
Treat skin lesions with topical nystatin, miconazole, clotrimazole, ketoconazole, econazole, or ciclopirox (American Academy of Pediatrics, 2015)
Vulvovaginal: Clotrimazole, miconazole, butoconazole, terconazole, and tioconazole used topically (American Academy of Pediatrics, 2015)
Common form of diaper dermatitis Oral form common in infants (see Chapter 8) Vaginal form in females Disseminated disease in very low birthweight
infants and immunosuppressed children; see 2015 Red Book: Report of the Committee on Infectious Diseases (American Academy of Pediatrics, 2015) for treatment
Dermatophytoses are designated by the Latin word tinea, with further designation relating to the area of the body where they are found (e.g., tinea capitis [ringworm of the scalp]) (Fig. 6-12, A). Dermatophyte infections are most often transmitted from one person to another or from infected animals to humans. Fungi exert their effect by means of an enzyme that digests and hydrolyzes the keratin of hair, nails, and the stratum corneum. Dissolved hair breaks off to produce the bald spots characteristic of tinea capitis. In the annular lesions the fungi principally appear in the edge of the inflamed border as they move outward from the inflammation. Diagnosis is made from microscopic examination of scrapings taken from the advancing periphery of the lesion, which almost always produces a scale.
FIG 6-12 A, Tinea capitis. B, Tinea corporis. Both infections are caused by Microsporum canis, the “kitten” or “puppy” fungus. (From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 4, St Louis, 2004,
Mosby.)
Nursing Care Management When teaching families how to care for ringworm, the nurse should emphasize good health and
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hygiene. Because of the infectious nature of the disease, affected children should not exchange grooming items, headgear, scarves, or other articles of apparel that have been in proximity to the infected area with other children. Affected children are provided with their own towels and directed to wear a protective cap at night to avoid transmitting the fungus to bedding, especially if they sleep with another person. Because the infection can be acquired by animal-to-human transmission, all household pets should be examined for the disorder. Other sources of infection are seats with headrests (theater seats), seats in public transportation vehicles, helmets, and gymnasium mats.
Both 2% ketoconazole and 1% selenium sulfide shampoos may reduce colony counts of dermatophytes. These shampoos can be used in combination with oral therapy to reduce the transmission of disease to others. The shampoo should be applied to the scalp for 5 to 10 minutes at least three times per week. The child may return to school after the therapy is initiated.
Alternately, if the child is treated with the drug griseofulvin, the therapy frequently continues for weeks or months, and because subjective symptoms subside, children or parents may be tempted to decrease or discontinue the drug. The nurse should emphasize to family members the importance of maintaining the prescribed dosage schedule and of taking the medication with high-fat foods for best absorption. They are also instructed regarding possible drug side effects, such as headache, gastrointestinal upset, fatigue, insomnia, and photosensitivity. For children who take the drug over many months, periodic testing is required to monitor leukopenia and assess liver and renal function. Newer antifungal medications (such as, terbinafine, itraconazole, and fluconazole) may be used when there are adverse reactions to griseofulvin. Currently, these drugs are being studied to determine their efficacy and safety in treating tinea capitis in children but are not approved by the US Food and Drug Administration for this indication at this time.
Systemic Mycotic (Fungal) Infections Mycotic (systemic or deep fungal) infections have the capacity to invade the viscera, as well as the skin. The most common infections are the lung diseases, which are usually acquired by inhalation of fungal spores. These fungi produce a variable spectrum of disease, and some are common in certain geographic areas. They are not transmitted from person to person but appear to reside in the soil, from which their spores are airborne. The cutaneous lesions caused by deep fungal infections are granulomatous and appear as ulcers, plaques, nodules, fungating masses, and abscesses. The course of deep fungal diseases is chronic with slow progression that favors sensitization (Table 6-6).
TABLE 6-6 Systemic Mycoses
Disorder and Organism Skin Manifestations Systemic Manifestations Treatment Comments
North American blastomycosis: Blastomyces dermatitidis
Chronic granulomatous lesions and microabscesses on any part of body
Initial lesion is a papule; undergoes ulceration and peripheral spread
Pulmonary symptoms, such as cough, fever, chest pain, weakness, and weight loss; rarely develop ARDS
Possible skeletal involvement, with bone destruction and formation of cutaneous abscesses
IV amphotericin B Oral fluconazole or itraconazole
for mild or moderate cases after amphotericin B (American Academy of Pediatrics, 2015)
Usual portal of entry is lungs Source of infection unknown Noninfectious Pulmonary infections may be mild and self-limiting
and require no treatment Progressive disease often fatal
Cryptococcosis: Cryptococcus neoformans (Torula histolytica)
Usually on face; acneiform, firm, nodular, painless eruption
CNS manifestations: Headache, dizziness, stiff neck, and signs of increased intracranial pressure
Low-grade fever, mild cough, lung infiltration
IV amphotericin B; may be administered intrathecally for CNS involvement
Oral flucytosine then fluconazole for meningitis
Excision and drainage of local lesions
Acquired by inhalation of contaminated soil (bird feces) Endemic in Mississippi and Ohio River valleys Increased incidence in persons with defects in T-
lymphocyte mediated immunity (HIV, leukemia, systemic lupus, AIDS, or organ transplant)
No person-to-person transmission
Histoplasmosis: Histoplasma capsulatum
Not distinctive or uniform but most appear as punched- out or granulomatous ulcers
Erythema nodosum in adolescents
General systemic symptoms may include pallor, diarrhea, vomiting, irregular spiking temperature, hepatosplenomegaly, and pulmonary symptoms
Any tissue of body may be involved with related symptoms
IV amphotericin B for severe cases Itraconazole for mild to moderate
infections
Organism cultured from soil, especially where contaminated with fowl droppings
Fungus enters through skin or mucous membranes of mouth and respiratory tract
Endemic in Mississippi and Ohio River valleys Disseminated diseases most common in infants and
children younger than 2 years old—fever, failure to thrive, hepatosplenomegaly, malnutrition, pneumonia (progressive histoplasmosis)
Coccidioidomycosis (valley fever): Coccidioides immitis and C. posadasii
Erythema nodosum Erythema multiforme Erythematous
maculopapular rash
Primary lung disease usually asymptomatic: 60% of children
Symptoms: Cough, fever, malaise, myalgia, headache, chest pain
May be sign of acute febrile illness Disseminated disease is very serious;
occurs in infants (meningitis)
Fluconazole or itraconazole for 3 to 6 months
IV amphotericin B if no response to above
Surgical resection of persistent pulmonary cavities
Inhalation of aero spores from soil Endemic in southwestern United States (C. immitis
almost occurs exclusively in California) Usually resolves spontaneously Increased incidence in dark-skinned races (African-
American, Hispanic, Filipino), pregnant women, diabetics, persons with cardiopulmonary disease, and infants <1 year old
AIDS, Acquired immune deficiency syndrome; ARDS, acute respiratory distress syndrome; CNS, central nervous system; HIV, human immunodeficiency virus; IV, intravenous.
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Scabies Scabies is an endemic infestation caused by the scabies mite Sarcoptes scabiei. Lesions are created as the impregnated female scabies mite burrows into the stratum corneum of the epidermis (never into living tissue), where she deposits her eggs and feces. Scabies is transmitted primarily through prolonged close personal contact, and it affects persons regardless of age, sex, personal hygiene, and socioeconomic status. Scabies can be transmitted through sexual contact (American Academy of Pediatrics, 2015).
Clinical Manifestations The inflammatory response causes intense pruritus that leads to punctate discrete excoriations secondary to the itching. Maculopapular lesions are characteristically distributed in intertriginous areas: interdigital surfaces, the axillary-cubital area, popliteal folds, and the inguinal region. There is variability in the lesions. Infants often develop an eczematous eruption; therefore, the observer must look for discrete papules, burrows, or vesicles (Fig. 6-13). A mite is identified as a black dot at the end of a minute, linear, grayish-brown, threadlike burrow. In children older than 2 years old, most eruptions are on the hands and wrists. In children younger than 2 years old, they are often on the feet and ankles. Children with limited communication ability such as Down syndrome may not complain of itching; therefore, they can get a severe infestation before it is recognized.
FIG 6-13 Scabies. (From McCance K, Huether S: Pathophysiology: the biological basis for disease in adults and children, ed 6, St Louis, 2010, Mosby/Elsevier.)
The inflammatory response and itching occur after the host becomes sensitized to the mite, approximately 30 to 60 days after initial contact. (In persons previously sensitized to the mite, the inflammatory response occurs within 48 hours after exposure.) After this time, anywhere the mite has traveled will begin to itch and develop the characteristic eruption. Consequently, mites will not necessarily be located at all sites of eruption. A person needs prolonged contact with the mite to become infested. It takes about 45 minutes for the mite to burrow under the skin; consequently, transient body contact is less likely to cause transfer of the mite. The diagnosis is made by microscopic identification from scrapings of the burrow.
Therapeutic Management The treatment of scabies is the application of a scabicide. The drug of choice in children and infants older than 2 months old is permethrin 5% cream (Elimite). Alternative drugs are 10% crotamiton (cream or lotion) or oral ivermectin. Lindane can be neurotoxic and is not recommended by the American Academy of Pediatrics (2015) for the treatment of scabies.
Oral Ivermectin may be used to treat scabies in patients with secondary excoriations for whom topical scabicides are irritating and not well tolerated or whose infestation is refractory. However, the safety and efficacy of ivermectin for children younger than 5 years old or children weighing less than 15 kg (33 lbs.) has not been established. Ivermectin is not ovicidal and must be repeated 1 to 2 weeks apart to be effective. Precipitated sulfur 6% in petrolatum may be used in children under 2 years old; it should be applied to the skin (and scalp in infants) for 3 days in a row, but it has an unpleasant smell and may cause skin irritation (Haisley-Royster, 2011). Crotamiton 10% cream is not approved by the US Food and Drug Administration for use in children but may be prescribed
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for adults with scabies. Because of the length of time between infestation and physical symptoms (30 to 60 days), all
persons who were in close contact with the affected child need treatment. This may include boyfriends or girlfriends, babysitters, grandparents, and immediate family members. The objective is to treat as thoroughly as possible the first time. Enough medication for the entire family should be prescribed, with 2 ounces allowed for each adult and 1 ounce for each child.
Nursing Care Management Nurses instructing families in the use of the scabicide should emphasize the importance of following the directions carefully. When permethrin 5% is used, the cream should be thoroughly and gently massaged into all skin surfaces (not just the areas that have a rash) from the head to the soles of the feet. Skin surfaces between the fingers and toes, the folds of the wrist and waist, the umbilicus, and the cleft of the buttocks should not be missed. A toothpick can be used to apply permethrin cream beneath the fingernails and toenails. Take care to avoid contact with the eyes. If permethrin cream accidentally gets into the eyes, they should be flushed immediately with water. Permethrin cream should remain on the skin for 8 to 14 hours, after which time it can be removed by bathing and shampooing.
Touching and holding the child should be minimized until treatment is completed, and the hands should be washed carefully after contact is made. Nurses should wear gloves when caring for the child. Following treatment, freshly laundered bed linen and clothing should be used, and bedclothes and previously worn clothing should be washed in very hot water and dried at the highest setting in the dryer. Aggressive housecleaning is not necessary, but surface vacuuming of heavily used rooms by a person with crusted scabies is recommended (American Academy of Pediatrics, 2015). Families need to know that although the mite will be killed, the rash and the itch will not be eliminated until the stratum corneum is replaced, which takes approximately 2 to 3 weeks. Soothing ointments or lotions, mild antihistamines, and topical corticosteroids can be used for itching. Systemic antibiotics may be given for secondary infection.
Pediculosis Capitis Pediculosis capitis (head lice) is an infestation of the scalp by Pediculus humanus capitis, a common parasite in school-age children. These lice infestations create embarrassment and concern in the family and community. They can also cause a child to be ridiculed by other children.
The louse is a blood-sucking organism that requires approximately five meals a day. The adult louse lives only about 48 hours when away from a human host, and the life span of the average female is 1 month. The female lays her eggs at night at the junction of a hair shaft and close to the skin because the eggs need a warm environment. The nits, or eggs, hatch in approximately 7 to 10 days.
Clinical Manifestations and Diagnostic Evaluation Itching, caused by the crawling insect and insect saliva on the skin, is usually the only symptom. Common sites of involvement are the occipital area, behind the ears, and at the nape of the neck. Observation of the white eggs (nits) firmly attached to the hair shafts confirms the diagnosis. Because of their brief life span and mobility, adult lice are difficult to locate. Nits must be differentiated from dandruff, lint, hair spray, and other items of similar size and shape. On inspection, nits are seen attached to the hair shaft. Scratch marks and/or inflammatory papules caused by secondary infection may be found on the scalp in the vulnerable areas (Fig. 6-14).
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FIG 6-14 Pediculosis capitis. (From Habif TP, Campbell JL, Chapman MS, et al: Skin disease: diagnosis and treatment, ed 2, St Louis, 2005, Mosby.)
Therapeutic Management Treatment consists of the application of pediculicides and manual removal of nit cases. Because of its efficacy and lack of toxicity, the drug of choice for infants and children is permethrin 1% cream rinse (Nix), which kills adult lice and nits (Frankowski, Weiner, and American Academy of Pediatrics Committee on School Health, 2010). This product and preparations of pyrethrin with piperonyl butoxide (RID or A-200 Pyrinate) can be obtained without a prescription and are more effective and safer than lindane. Most experts advise a second treatment at 7 to 10 days to ensure a cure (American Academy of Pediatrics, 2015). However, pyrethrin products are contraindicated for individuals with contact allergy to ragweed or chrysanthemums. If neither permethrin nor pyrethrin products are effective, the prescription drug 0.5% malathion topical (Ovide), which has been approved for treatment of head lice, can be used. However, malathion topical contains flammable alcohol, must remain in contact with the scalp for 8 to 12 hours, and is not recommended for children younger than 2 years old. Benzyl alcohol 5% lotion has been approved by the US Food and Drug Administration for the treatment of head lice in children as young as 6 months old; it should be applied to dry hair, saturated, and rinsed off after 10 minutes. Because benzyl alcohol 5% is not an ovicidal agent, it should be repeated in 7 days (Haisley-Royster, 2011).
Ivermectin lotion 0.5% may be used in children 6 months old and older; the lotion is applied only once to dry hair and left for 10 minutes before rinsing. Oral Ivermectin may be given 9 to 10 days apart, but because of neurotoxicity, it should not be used to treat children weighing less than 15 kg (33 lbs.) (American Academy of Pediatrics, 2015).
Because of concerns that head lice may be developing resistance to chemical shampoos and that repeated exposure of children to strong chemicals on the scalp may be unwise, effective nonchemical control measures are essential. Daily removal of nits from a child's hair with a metal nit or flea comb is an essential control measure following treatment with the pediculicide. The child's entire head should be completely combed every day until no more nits are found. In most instances, a nit comb removes most of the nits. However, in some instances, nits need to be removed by scraping them off strands of hair with the fingernail or using tweezers. Several varieties of nit combs are currently available at community pharmacies.
Nursing Care Management An important nursing role is educating the parents about pediculosis. Nurses should emphasize that anyone can get pediculosis; it has no respect for age, socioeconomic level, or cleanliness. Lice do not jump or fly, but they can be transmitted from one person to another on personal items. Lice are more likely to infest white children, those with straight hair, and girls. Children are cautioned against sharing combs, hair ornaments, hats, caps, scarves, coats, and other items used on or near the hair. Children who share lockers are more likely to become infested, and slumber parties place children at risk. Lice are not carried or transmitted by pets.
Nurses or parents should carefully inspect children who scratch their heads more than usual for bite marks, redness, and nits. The hair is systematically spread with two flat-sided sticks or tongue depressors, and the scalp is observed for any movement that indicates a louse. Nurses should wear
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gloves when examining the hair. Lice are small and grayish-tan, have no wings, and are visible to the naked eye. The nits, or eggs, appear as tiny whitish oval specks adhering to the hair shaft about 6 mm (0.25 inch) from the scalp. The adherent nature of the nits distinguishes them from dandruff, which falls off readily. Empty nit cases, indicating hatched lice, are translucent rather than white and are located more than 6 mm from the scalp (Fig. 6-15).
FIG 6-15 A, Empty nit case. B, Viable nits. (From Stefani AD, Hofmann-Wellenhof R, Zalaudek I: Dermoscopy for diagnosis and treatment monitoring of pediculosis capitis, J Am Acad Dermatol 54(5): 909–911, 2006.)
If evidence of infestation is found, it is important to treat the child according to the directions on the label of the pediculicide. Parents are advised to read the directions carefully before beginning treatment. The child is made as comfortable as possible during the application process because the pediculicide must remain on the scalp and hair for several minutes. Playing “beauty parlor” while shampooing is a useful strategy. The child lies supine with the head over a sink or basin and covers the eyes with a dry towel or washcloth. This prevents medication, which can cause chemical conjunctivitis, from splashing into the eyes. If eye irritation occurs, the eyes must be flushed well with tepid water. It is not necessary to remove the nits after treatment because only live lice cause infestation. However, because none of the pediculicides is 100% effective in killing all the eggs, the makers of some pediculicides recommend manual removal of the nits after treatment. An extra- fine-tooth comb that is included in many commercial pediculicides or is available at community pharmacies facilitates manual removal. If the comb is ineffective in removing the nit cases, the examiner should remove them by scraping them off the strands of hair with his or her fingernails.
Live lice survive for up to 48 hours away from the host, but nits are shed into the environment and are capable of hatching in 7 to 10 days; retreatment may be required. Therefore, measures must be taken to prevent further infestation (see Community Focus box). Spraying with insecticide is not recommended because of the danger to children and animals. Families should also be advised that the pediculicide is relatively expensive, especially when several members of the household require treatment. Families may be inclined to try home remedies to treat the lice (see Research Focus box).
C o m m u n i t y F o c u s Preventing the Spread and Recurrence of Pediculosis
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• Machine wash all washable clothing, towels, and bed linens in hot water and dry in a hot dryer for at least 20 minutes. Dry-clean non-washable items.
• Thoroughly vacuum carpets, car seats, pillows, stuffed animals, rugs, mattresses, and upholstered furniture.
• Seal non-washable items in plastic bags for 14 days if unable to dry-clean or vacuum.
• Soak combs, brushes, and hair accessories in lice-killing products for 1 hour or in boiling water for 10 minutes.
• In day care centers, store children's clothing items (such as hats and scarves and other headgear) in separate cubicles.
• Discourage the sharing of items such as hats, scarves, hair accessories, combs, and brushes among children in group settings, such as day care centers.
• Avoid physical contact with infested individuals and their belongings, especially clothing and bedding.
• Inspect children in a group setting regularly for head lice.
• Provide educational programs on the transmission, detection, and treatment of pediculosis.
R e s e a r c h F o c u s Lice Treatments
A study by Lee, Rios, Aten, and colleagues (2004) showed that home remedies (such as, petroleum jelly, oils, vinegar, butter, alcohol, and mayonnaise) did little to kill louse eggs. Another study by Pearlman (2004) showed that a dry-on pediculicide lotion may effectively treat lice without the use of the current shampoos with neurotoxins, nit removal, or extensive housecleaning. The lotion was applied once a week for 3 weeks. After 8 hours, it dried on the scalp, and the child styled the hair and went to school as usual.
The psychological effects of lice infestations are stressful to children. They are influenced by the reactions of others, including their parents, school nurses, and officials. Some children feel ashamed or guilty. Parents are strongly cautioned against cutting a child's hair or, worse, shaving a child's head. Lice infest short hair as readily as long hair, and these actions only compound the child's distress and serve as a continual reminder to their peers, who are prone to taunt children who have a different appearance.
Prevention The increasing incidence of pediculosis in schoolchildren is a serious concern for school nurses, parents, and community health agencies. However, school head lice screening programs have not proven to have a significant effect on the incidence of head lice in the school setting; parent education programs may be more helpful in the management of head lice. Children with head lice should be allowed to return to school after proper treatment. Both the American Academy of Pediatrics and the National Association of School Nurses discourage a “no nit” policy for schools (see Research Focus box).
R e s e a r c h F o c u s “No-Nit” Policies
A study of 382 school nurses indicated that 60% of these nurses supported a “no-nit” rule of enforced absenteeism for any children with nits in the hair (Price, Burkhart, Burkhart, et al, 1999).
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However, recently the “no-nit” policy has become controversial, and many school systems and some state associations of pediatricians have questioned its value (see Evidence-Based Practice box).
The National Pediculosis Association* offers education and advocates a “no-nit” policy for the reentry of treated children into school (see Translating Evidence into Practice box).
E v i d e n c e - b a s e d P r a c t i c e “No-Nit” School Policies
Ask the Question In schoolchildren, are pediculosis policies (“no-nit” policies) effective methods to decrease lice infestation?
Search for the Evidence Search Strategies Search terms used were: head lice in children, pediculosis, head lice and school-age children, and policies for head lice.
Databases Used MEDLINE, PubMed, Ovid, CINAHL
Critically Analyze the Evidence GRADE criteria: Evidence quality moderate; recommendation strong (Guyatt, Oxman, Vist, et al, 2008)
To determine how often children were excluded from school inappropriately because of head lice, health care providers and non-specialists were invited to submit to the Harvard School of Public Health specimens that they found in children's hair when they suspected head lice (Pollack, Kiszewski, and Spielman, 2000). Analysis of 614 specimens revealed that lice and eggs were present in less than two thirds of these specimens, and only 53% of the specimens contained a live louse or viable eggs. Health professionals as well as non-specialists overdiagnosed pediculosis capitis and failed to distinguish active from extinct infestations. Eighty-two percent of the schools involved in this study had a “no-nits” policy, and noninfested children were excluded as often as children with active infestations.
In a study evaluating the presence of head lice in 1729 school-age children, a total of 28 children (1.6%) were found to have lice and 63 (3.6%) had nits with no lice (Williams, Reichert, MacKenzie, et al, 2001). Repeat assessment 2 weeks later revealed that only 18% of the children with nits alone developed lice. These researchers stated that having five or more nits within 6 mm (0.25 inch) of the head increased the risk of nit conversion, but most children with nits had no lice. The researchers concluded that school policies that excluded children with nits alone from school were not warranted.
The American Academy of Pediatrics updated guidelines for diagnosis and treatment of pediculosis in 2015. These guidelines state that “no-nit” policies in schools are detrimental, causing lost time in the classroom and inappropriate allocation of the school nurse's time, and that “no-nit” polices should be abandoned (Devore and Schutze, 2015).
“No-nit” policies state that when a school nurse finds head lice in a child's hair, that child is promptly sent home from school with directions for the parents to shampoo the child's hair and remove the lice. Parents comply with these directions and send the child back to school after shampooing and meticulously combing the child's hair. If the school nurse finds a single egg or nit remaining in the child's hair, the school's “no-nit” policy demands that the nurse exclude the child from school until the eggs or nits are completely removed. The problem is that the treatment does not eliminate all nits, but the nits left after treatment are inactive or dead, and harmless. Remnants of dead nits may remain attached to the hair for months or years. If the eggs are dead, there is no reason for a child to miss school. In addition, “no-nit” policies have not been proven to be effective in reducing transmission and are not recommended (American Academy of Pediatrics, 2009).
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Apply the Evidence: Nursing Implications A “no-nit” policy inflates the risks associated with lice infestations, increases the probability of overusing pediculicides, and may hinder academic performance by excluding children from school. Several practice implications can be derived from the studies:
1. School nurses should receive training and a microscope or magnifying glass to help them identify head lice correctly.
2. A diagnosis of head lice should be based on observation of live lice rather than dead eggs, dandruff, or other suspicious material in a child's hair.
3. A “no-nit” policy should be invoked only as a last resort.
4. Repeated failure of parents to rid a child's hair of nits is not a sound basis for suspecting neglect or abuse or instituting legal action against the parents.
References American Academy of Pediatrics, Committee on Infectious Diseases, Pickering LK. 2009 red
book: report of the Committee on Infectious Diseases. ed 28. The Academy: Elk Grove Village, IL; 2009.
Devore CD, Schutze GE. Head Lice, clinical report: guidance for the clinician in rendering pediatric care. Pediatrics. 2015;135(5):e1355–e1365.
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926.
Pollack RJ, Kiszewski AE, Spielman A. Overdiagnosis and consequent management of head louse infestations in North America. Pediatr Infect Dis J. 2000;19(8):689–693.
Williams LK, Reichert A, MacKenzie WR, et al. Lice, nits, and school policy. Pediatrics. 2001;107(5):1011–1015.
Bedbugs Bedbugs are classified as insects, and the most common types seen are Cimex lectularius (common bedbug) and Cimex hemipterus (tropical bedbug). Although once considered to be practically nonexistent in the United States, these parasites have emerged within the last decade as troublesome and are often difficult to diagnose and eradicate. Mention is made herein primarily because of the secondary health problems that may occur as a result of their bites: infection, cellulitis, folliculitis, intense urticaria, impetigo, anaphylactic reaction, and sleep loss. However, in some cases the person may be asymptomatic (Doggett, Dwyer, Peñas, et al, 2012).
Bedbugs undergo various life stages, but the small ones are approximately 5 mm in length and are light yellow; once the bedbugs “feed” on blood, they enlarge and become reddish-brown. They tend to inhabit warm, dark areas such as bed mattresses, sofas, and other furniture and emerge at night to feed. There is reportedly no evidence that bedbugs act as vectors for disease transmission (Doggett, Dwyer, Peñas, et al, 2012; Haisley-Royster, 2011).
The clinical manifestations of bedbug bites are outlined in Box 6-6. The cutaneous manifestations of bedbug bites tend to be primarily on arms, legs, and trunk areas.
Box 6-6 C l i n i c a l M a n i f e s t a t i o n s o f B e d b u g s Cutaneous Reactions
• Erythematous papule
• Linear papules
• Red macular lesion
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• Rash
• Wheal
• Vesicles
• Bullae
• Urticaria
Secondary
• Impetiginous lesions with scratching
• Folliculitis
• Cellulitis
• Eczematoid dermatitis
Systemic Reactions
• Asthma exacerbation
• Anaphylaxis
• Fever and malaise (chronic exposure)
Data from Doggett SL, Dwyer D, Peñas PF, et al: Bed bugs: clinical relevance and control options, Clin Microbiol Reviews 25(1):164– 192, 2012; Goddard J, deShazo R: Bedbugs (Cimex lectularius) and clinical consequences of their bites, JAMA 301(13):1358–1366, 2009; Haisley-Royster C: Cutaneous infestations and infections, Adolesc Med State Art Rev 22(1):129–145, 2011.
The treatment of bedbugs should focus on proper identification, treatment of the symptoms, and eradication. Bedbugs can be identified on bedding at night because of their nighttime activity. They tend to hide in dark crevices (floor, walls, furniture) during the daytime and do not stay on the human host. Contrary to several myths, bedbugs do not fly or jump. It is not uncommon for bedbug bites to be misdiagnosed as scabies, chickenpox, spider or mosquito bites, and even food anaphylaxis in some cases (Doggett, Dwyer, Peñas, et al, 2012). There is no specific treatment for bedbugs; topical steroids and systemic antihistamines may be used to treat the urticaria. Secondary skin infections are treated with antibiotics as described previously in this chapter. Eradication of bedbugs is complex and must be handled by professional exterminators; multiple chemical applications are often required to completely eradicate the insects. Suggestions for minimizing exposure when traveling include inspecting the mattresses for signs of infestation; encasing mattress covers may be helpful. Thorough washing of all clothing and bed linens may also help minimize exposure. The use of pesticides and various other control measures is discussed in Doggett, Dwyer, Peñas, and colleagues (2012).
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Systemic Disorders Related to Skin Lesions Rickettsial Infections The organisms responsible for a number of disorders are transmitted to human beings via arthropods (Table 6-7). Mammals become infected only through the bites of infected lice, fleas, ticks, and mites—all of which serve as both infectors and reservoirs. Rickettsiae are intracellular parasites, similar in size to bacteria, that inhabit the alimentary tract of a wide range of natural hosts. Rickettsial diseases are more common in temperate and tropical climates where humans live in association with arthropods. Infection in humans is incidental (except epidemic typhus) and not necessary for the survival of the rickettsial species. However, after the organism invades a human, it causes a disease that varies in intensity from a benign, self-limiting illness to a disease that is fulminating and fatal.
TABLE 6-7 Conditions Caused By Rickettsiae
Disorder, Organism, and Host Manifestations Management Comments
Rocky Mountain spotted fever: Rickettsia rickettsii
Arthropod: Tick Transmission: Tick Mammal source: Wild
rodents; dogs
Gradual onset: Fever, malaise, anorexia, myalgia Abrupt onset: Rapid temperature elevation, chills, vomiting,
myalgia, severe headache Maculopapular or petechial rash primarily on extremities
(ankles and wrists) but may spread to other areas, characteristically on palms and soles
Control: Protection from tick bite by wearing proper apparel, tick repellent
Tetracycline or chloramphenicol Vigorous supportive therapy
Usually self-limiting in children Onset in children may resemble that of any infectious
disease Severe disease rare in children Children and dogs should be inspected regularly if they
play in wooded areas See later in chapter for management of ticks and tick
removal Epidemic typhus:
Rickettsia prowazekii Arthropod: Body louse Transmission: Infected
feces into broken skin Mammal source: Humans
Abrupt onset of chills, fever, diffuse myalgia, headache, malaise Maculopapular rash becomes petechial 4 to 7 days later,
spreading from trunk outward
Control: Immediate destruction of vectors
Tetracycline or chloramphenicol Supportive treatment
Isolate patient until deloused See discussion earlier in chapter for management of
pediculosis Excreta from infected lice also in dust—patient's clothing,
bedding, and possessions should be disinfected and washed in hot water
Endemic typhus: Rickettsia typhi
Arthropod: Rat fleas or lice
Transmission: Flea bite; inhalation or ingestion of flea excreta
Mammal source: Rats
Headache, arthralgia, backache followed by fever; may last 9 to 14 days
Maculopapular rash after 1 to 8 days of fever; begins in trunk and spreads to periphery; rarely involves face, palms, soles
Control: Eliminate rat reservoir, insect vectors, or both
Tetracycline or chloramphenicol Supportive treatment
Fairly common in United States Shorter duration than epidemic typhus Mild, seldom fatal illness Difficult to distinguish from epidemic typhus
Rickettsialpox: Rickettsia akari
Arthropod: Mouse mite Transmission: Mite Mammal source: House
mouse
Maculopapular rash following primary lesion; eschar at site of bite; fever, chills, headache
Control: Eradication of rodent reservoir and mite vector
Tetracycline or chloramphenicol Supportive treatment
Self-limiting, nonfatal disease Endemic in New York City Found in many cities in United States
Lyme Disease Lyme disease is the most common tick-borne disorder in the United States. It is caused by the spirochete Borrelia burgdorferi, which enters the skin and bloodstream through the saliva and feces of ticks, especially the deer tick (Moreno, 2011). Most cases of Lyme disease are reported in the Northeast from southern Maine to northern Virginia in the months of April through October and more commonly occur in children 5 through 9 years old and adults 55 through 59 years old (American Academy of Pediatrics, 2015).
Clinical Manifestations The disease may be initially seen in any of three stages. The first stage, early localized disease, consists of the tick bite at the time of inoculation, followed in 3 to 30 days by the development of erythema migrans at the site of the bite. The lesion begins as a small erythematous papule that enlarges radially up to 30 cm (12 inches) over a period of days to weeks. It results in a large circumferential ring with a raised, edematous doughnut-like border resulting in a bull's-eye appearance (Fig. 6-16). The thigh, groin, and axilla are common sites. The lesion is described as “burning,” feels warm to the touch, and occasionally is pruritic. The single annular rash may be associated with fever, myalgia, headache, or malaise.
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FIG 6-16 Lyme disease. Note annular red rings in erythema chronicum migrans. (From Weston WL, Lane AT: Color textbook of pediatric dermatology, St Louis, 1991, Mosby.)
The second stage, early disseminated disease, occurs 3 to 10 weeks after inoculation. Many patients develop multiple smaller, secondary annular lesions without the indurated center. They may occur anywhere except on the palms and soles, and in untreated patients they disappear in 3 to 4 weeks. Constitutional symptoms, including fever, headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough, are often observed. A focal neurologic finding of cranial nerve palsy (seventh nerve palsy) occurs in 3% to 5% of cases. Lymphocytic meningitis may also develop in this stage, but the symptoms are said to be less acute than viral meningitis (American Academy of Pediatrics, 2015). Additional manifestations include ophthalmic conditions, such as optic neuritis, uveitis, conjunctivitis, and keratitis.
Finally, the third stage and the most serious stage of the disease, is characterized by systemic involvement of neurologic, cardiac, and musculoskeletal systems that appears 2 to 12 months after inoculation. Lyme arthritis is the most common manifestation with pain, swelling, and effusion. In children, the arthritis is characterized by intermittently painful swollen joints (primarily the knees), with spontaneous remissions and exacerbations. Rare neurologic features of pediatric Lyme disease may include chronic demyelinating encephalitis, polyneuritis, and memory problems (Kest and Pineda, 2008).
Cardiac complications, which may appear in a small percentage of persons 4 to 5 weeks after erythema chronicum migrans, are commonly carditis and acute atrioventricular conduction abnormalities and may result in severe heart block (Costello, Alexander, Greco, et al, 2009). Patients may be asymptomatic but can develop syncope, palpitations, dyspnea, chest pain, and severe bradycardia.
Diagnostic Evaluation The diagnosis is based primarily on the history, observation of the lesion, and clinical manifestations. Serologic testing for Lyme disease at the time of a recognized tick bite is not recommended because antibodies are not detectable in most persons (American Academy of Pediatrics, 2015). Laboratory diagnosis can be established in later stages with a two-step approach that includes the screening test EIA or immunofluorescent immunoassay (IFA) and, if the results are equivocal or positive, with Western immunoblot testing, as outlined by the Centers for Disease Control and Prevention (2011a, 2011b) and adopted by the American Academy of Pediatrics (2015).
Therapeutic Management At the time the rash appears or shortly thereafter, children older than 8 years old should be treated with oral doxycycline, and children younger than 8 years old are given amoxicillin or cefuroxime. For patients who are allergic to penicillin, an alternative drug is cefuroxime (American Academy of Pediatrics, 2015).
The length of treatment depends on the clinical response and other disease manifestations, but it usually lasts from 14 to 21 days (American Academy of Pediatrics, 2015). The treatment is effective in preventing second-stage manifestations in most cases. Persons who have removed ticks from themselves should be monitored closely for signs and symptoms of tick-borne diseases for 30 days; in particular, they should be monitored for erythema migrans, a red expanding skin lesion at the site of the tick bite that may suggest Lyme disease. People who develop a skin lesion or viral
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infection–like illness within 1 month of an attached tick should seek prompt medical attention (Wormser, Dattwyler, Shapiro, et al, 2006). Treatment of erythema migrans most often prevents development of later stages of Lyme disease.
Neurologic, cardiac, and arthritic manifestations are managed with oral or IV antibiotics, such as ceftriaxone, cefotaxime, or penicillin G. Follow-up care is important in ensuring that treatment is initiated or terminated as needed.
Nursing Care Management The major emphasis of nursing care should be educating parents to protect their children from exposure to ticks. Children should avoid tick-infested areas or wear light-colored clothing so that ticks can be spotted easily, tuck pant legs into socks, and wear a long-sleeved shirt tucked into pants when in wooded areas. Parents and children need to perform regular tick checks when they are in infested areas (with special attention to the scalp, neck, armpits, and groin areas) (Network to Reduce Lyme Disease in School-Aged Children, 2010). Parents should also be alert for signs of the skin lesion, especially if their children have been in tick-infested areas. The American Academy of Pediatrics (2015) points out that the risk of infection after a deer tick bite, even in endemic regions of the United States, is 1% to 3%; children bitten by a deer tick in nonendemic regions should not receive antibiotic prophylaxis.
Parents should also be educated regarding tick removal in the event of a tick bite. The tick should be grasped firmly with tweezers and pulled straight out. The application of nail polish or petroleum jelly is not recommended and does not appear to have an effect on tick withdrawal as has been hypothesized. Concerns about tick engorgement or tick remains left in the person's body (such as the tick head) appear to be unfounded; there is no need for medical examination of the tick itself. After the tick is removed, wash the bite area with an iodine scrub, rubbing alcohol, or plain soap and water (Centers for Disease Control and Prevention, 2011a, 2011b).
Insect repellents containing diethyltoluamide (DEET) and permethrin can protect against ticks, but parents should use these chemicals cautiously. Although there have been reports of serious neurologic complications in children resulting from frequent and excessive application of DEET repellents, the risk is low when they are used properly. Products with DEET should be applied sparingly according to label instructions and not applied to a child's face, hands, or any areas of irritated skin. Clove oil has been reported as being safe and effective as an insect repellent without the effects of chemicals (Shapiro, 2012). Permethrin-treated clothing has also been shown to be effective in repelling ticks (Miller, Rainone, Dyer, et al, 2011). After the child returns indoors, treated skin should be washed with soap and water. Information about Lyme disease can be obtained from the American Lyme Disease Foundation, Inc.* or from the Centers for Disease Control and Prevention; www.cdc.gov/lyme/.
Cat Scratch Disease Cat scratch disease is the most common cause of regional lymphadenitis in children and adolescents. It usually follows the scratch or bite of an animal (a cat or kitten in 90% of cases) and is caused by Bartonella henselae, a gram-negative bacterium. The disease is usually a benign, self- limiting illness that resolves spontaneously in 4 to 6 weeks (American Academy of Pediatrics, 2015).
The usual manifestations are a painless, nonpruritic erythematous papule at the site of inoculation, followed by regional lymphadenitis. The lymph nodes most commonly involved are axillary epitrochlear, cervical, submandibular, inguinal, and preauricular. The disease may persist for several months before gradual resolution. In some children, especially those who are immunocompromised, the adenitis may progress to suppuration. Some children may develop serious complications that include encephalitis, hepatitis, and Parinaud oculoglandular syndrome. This syndrome is characterized by granulomatous lesions on the palpebral conjunctiva associated with swelling of the ipsilateral preauricular nodes.
Diagnosis is made on the basis of (1) a history of contact with a cat or kitten, (2) the presence of regional lymphadenopathy for several days, and (3) serologic identification of the causative organism by indirect fluorescent antibody assay or polymerase chain reaction test (American Academy of Pediatrics, 2015).
Treatment is primarily supportive. Some experts recommend a 5-day course of oral azithromycin to hasten recovery (American Academy of Pediatrics, 2015). Antibiotics do not shorten the duration
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or prevent progression to suppuration but may be helpful in severe forms of the disease. Trimethoprim-sulfamethoxazole, ciprofloxacin, gentamicin, and rifampin have shown some benefit in uncontrolled clinical studies. Enlarged painful nodes may be treated by needle aspiration.
Children should be cautioned about playing with aggressive kittens that bite or scratch. Wounds should be washed with soap and water. Analgesics may be given for discomfort. Most children can continue normal activities during the disease. The animals are not ill during the time they transmit the disease, and most authorities do not recommend disposal of a cherished pet.
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NCLEX Review Questions 1. Which of the following should be used in the care of all pediatric patients to reduce the risk of
transmission of microorganisms from both recognized and unrecognized sources of infection? a. Transmission-based precautions b. Airborne precautions c. Standard precautions d. Droplet precautions
2. Which childhood vaccine provides some protection against bacterial meningitis, epiglottitis, and bacterial pneumonia? a. Hib vaccine b. Hepatitis B vaccine c. Varicella vaccine d. Influenza vaccine
3. Which vaccine do the Advisory Committee on Immunization Practices (Centers for Disease Control and Prevention) and American College of Obstetricians and Gynecologists recommend that pregnant adolescents and women who are not protected against pertussis receive optimally between 27 and 36 weeks gestation or postpartum prior to discharge from the hospital? a. DTaP b. Td c. IPV d. Tdap
4. Which childhood vaccine provides protection against streptococcal infections, such as otitis media, sinusitis, and pneumonia? a. Rotavirus vaccine b. Hib vaccine c. Pneumococcal vaccine d. MMR vaccine
5. One of the most common intestinal parasitic pathogens in the United States acquired from a contaminated water source such as a lake or swimming pool is: a. Tinea capitis b. Giardia intestinalis c. Pediculosis capitis d. Enterobiasis
6. A 9-year-old child in the emergency department is diagnosed with Lyme disease. The nurse anticipates that the health care personnel orders will include the administration of: a. Cefotaxime b. Aqueous penicillin c. Doxycycline d. Trimethoprim-sulfamethoxazole
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Correct Answers 1. c; 2. a;
3. d; 4. c;
5. b; 6. c
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References Alter SJ, Vidwan NK, Sobande PO, et al. Common childhood bacterial infections. Curr Probl
Pediatr Adolesc Health Care. 2011;41(10):256–283. American Academy of Pediatrics, Committee on Infectious Diseases. Recommended
childhood and adolescent immunization schedule—United States, 2013. Pediatrics. 2013;131(2):397–398.
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Zuckerman JN. The importance of injecting vaccines into muscle: different patients need different needle sizes. BMJ. 2000;321(7271):1237–1238.
*Additional information on immunizations and recommendations for specific conditions can be found in the 2015 Red Book: Report of the Committee on Infectious Diseases (American Academy of Pediatrics, 2015), and from the Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/. *Because of constant changes in the pharmaceutical industry, trade names of single and combination vaccines in this section may differ from those currently available. The reader is encouraged to access the vaccine page of the Center for Biologics Evaluation and Research of the US Food and Drug Administration for the latest licensed vaccine trade names: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093830.htm. *The trivalent inactivated influenza vaccine (TAIV) was changed to inactivated influenza vaccine (IIV) (American Academy of Pediatrics, 2013). *www.immunize.org/vis. †http://www.cdc.gov/vaccines/pubs/vis/default.htm. *Educational materials may be obtained from the National Shingles Foundation, 590 Madison Ave., 21st Floor, New York, NY 10022; 212-222-3390; www.vzvfoundation.org. *PO Box 610189, Newton, MA 02461; 800-323-1305, ext 7971; fax: 800-235-1305; email: [email protected]; www.headlice.org. *PO Box 466, Lyme, CT 06371; http://www.aldf.com.
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U N I T 3 Family-Centered Care of the Newborn
OUTLINE 7 Health Promotion of the Newborn and Family 8 Health Problems of Newborns
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Health Promotion of the Newborn and Family Barbara J. Wheeler
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Adjustment to Extrauterine Life The most profound physiologic change required of neonates is transition from fetal or placental circulation to independent respiration. The loss of the placental connection means the loss of complete metabolic support, especially the supply of oxygen and the removal of carbon dioxide. The normal stresses of labor and delivery produce alterations of placental gas exchange patterns, acid–base balance in the blood, and cardiovascular activity in the infant. Factors that interfere with this normal transition or that interfere with fetal oxygenation (including conditions such as hypoxemia, hypercapnia, and acidosis) affect the fetus's adjustment to extrauterine life.
Immediate Adjustments Respiratory System The most critical and immediate physiologic change required of newborns is the onset of breathing. The stimuli that help initiate the first breath are primarily chemical and thermal. Chemical factors in the blood (low oxygen, high carbon dioxide, and low pH) initiate impulses that excite the respiratory center in the medulla. The primary thermal stimulus is the sudden chilling of the infant, who leaves a warm environment and enters a relatively cooler atmosphere. This abrupt change in temperature excites sensory impulses in the skin that are transmitted to the respiratory center.
Tactile stimulation may assist in initiating respiration. Descent through the birth canal and normal handling during delivery help stimulate respiration in uncompromised infants. Acceptable methods of tactile stimulation include tapping or flicking the soles of the feet or gently rubbing the newborn's back, trunk, or extremities. Slapping the newborn's buttocks or back is a harmful technique and should not be done. Prolonged tactile stimulation, beyond one or two taps or flicks to the soles of the feet or rubbing the back once or twice, can waste precious time in the event of respiratory difficulty and can cause additional damage in infants who have become hypoxemic before or during the birth process (American Academy of Pediatrics, Committee on Infectious Diseases, 2011).
The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and the alveoli. Some lung fluid is removed during the normal forces of labor and delivery. As the chest emerges from the birth canal, fluid is squeezed from the lungs through the nose and mouth. After complete delivery of the chest, brisk recoil of the thorax occurs, and air enters the upper airway to replace the lost fluid. Remaining lung fluid is absorbed by the pulmonary capillaries and lymphatic vessels.
In the alveoli, the surface tension of the fluid is reduced by surfactant, a substance produced by the alveolar epithelium that coats the alveolar surface. The effect of surfactant in facilitating breathing is discussed in relation to respiratory distress syndrome (see Chapter 8).
Circulatory System As important as the initiation of respiration are the circulatory changes that allow blood to flow through the lungs. These changes, which occur more gradually, are the result of pressure changes in the lungs, heart, and major vessels. The transition from fetal to postnatal circulation involves the functional closure of the fetal shunts: the foramen ovale, the ductus arteriosus, and eventually the ductus venosus. (For a review of fetal circulation, see Chapter 23.) Increased blood flow dilates the pulmonary vessels, pulmonary vascular resistance decreases, and systemic resistance increases, thus maintaining blood pressure (BP). As the pulmonary vessels receive blood, the pressure in the right atrium, right ventricle, and pulmonary arteries decreases. Left atrial pressure increases above right atrial pressure, with subsequent foramen ovale closure. With the increase in pulmonary blood flow and dramatic reduction of pulmonary vascular resistance, the ductus arteriosus begins to close.
The most important factors controlling ductal closure are the increased oxygen concentration of the blood and the fall in endogenous prostaglandins. The foramen ovale closes functionally at or soon after birth. The ductus arteriosus is closed functionally by the fourth day. Anatomic closure takes considerably longer. Failure of the ductus arteriosus or foramen ovale to close results in persistence of fetal shunting of blood away from the lungs (see Chapter 23).
Because of the reversible flow of blood through the ductus during the early neonatal period, a
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functional murmur occasionally may be heard. In conditions such as crying or straining, the increased pressure shunts deoxygenated blood from the right side of the heart across the ductal opening, which may cause transient cyanosis.
Physiologic Status of Other Systems Thermoregulation Next to establishing respiration, heat regulation is most critical to the newborn's survival. Although the newborn's capacity for heat production is adequate, three factors predispose newborns to excessive heat loss: • The newborn's large surface area facilitates heat loss to the environment, although this is partially
compensated for by the newborn's usual position of flexion, which decreases the amount of surface area exposed to the environment.
• The newborn's thin layer of subcutaneous fat provides poor insulation for conservation of heat. • The newborn's mechanism for producing heat is different from that of the adult, who can increase
heat production through shivering. A chilled neonate cannot shiver but produces heat through nonshivering thermogenesis (NST), which involves increased metabolism and oxygen consumption.
The principal thermogenic sources are the heart, liver, and brain. An additional source, once believed to be unique to newborns (Zingaretti, Crosta, Vitali, et al, 2009), is known as brown adipose tissue, or brown fat. Brown fat, which owes its name to its larger content of mitochondrial cytochromes, has a greater capacity for heat production through intensified metabolic activity than ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood, which is warmed as it flows through the layers of this tissue. Superficial deposits of brown fat are located between the scapulae, around the neck, in the axillae, and behind the sternum. Deeper layers surround the kidneys, trachea, esophagus, some major arteries, and adrenals. The location of brown fat may explain why the nape of the neck often feels warmer than the rest of the infant's body.
Because of these factors predisposing infants to loss of body heat, it is essential that newly born infants are quickly dried and either placed skin-to-skin with their mothers or provided with warm, dry blankets after delivery.
Although newborns' ability to conserve heat is usually a matter of concern, they may also have difficulty dissipating heat in an overheated environment, which increases the risk of hyperthermia.
Hematopoietic System The blood volume of the newborn depends on the amount of placental transfer of blood. The blood volume of a full-term infant is about 80 to 85 ml/kg of body weight. Immediately after birth, the total blood volume averages 300 ml, but depending on how long umbilical cord clamping is delayed or if the umbilical cord is milked, as much as 100 ml can be added to the blood volume (Rabe, Jewison, Alvarez, et al, 2011).
Fluid and Electrolyte Balance Changes occur in the total body water volume, extracellular fluid volume, and intracellular fluid volume during the transition from fetal to postnatal life. At birth, the total weight of an infant is 73% fluid compared with 58% in an adult. Infants have a proportionately higher ratio of extracellular fluid than adults.
An important aspect of fluid balance is its relationship to other systems. An infant's rate of metabolism is twice that of an adult in relation to body weight. As a result, twice as much acid is formed, leading to more rapid development of acidosis. In addition, immature kidneys cannot sufficiently concentrate urine to conserve body water. These three factors make infants more prone to dehydration, acidosis, and possible overhydration or water intoxication.
Gastrointestinal System The ability of newborns to digest, absorb, and metabolize food is adequate but limited in certain functions. Enzymes are adequate to handle proteins and simple carbohydrates (monosaccharides and disaccharides), but deficient production of pancreatic amylase impairs use of complex
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carbohydrates (polysaccharides). Deficiency of pancreatic lipase limits absorption of fats, especially with ingestion of foods with high saturated fatty acid content, such as cow's milk. Human milk, despite its high fat content, is easily digested because the milk itself contains enzymes (such as lipase), which assist in digestion.
The liver is the most immature of the gastrointestinal organs. The activity of the enzyme glucuronyl transferase is reduced, which affects the conjugation of bilirubin with glucuronic acid and contributes to physiologic jaundice of newborns. 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, newborns are prone to hypoglycemia, which may be prevented by early and effective feeding, ideally breastfeeding.
Some salivary glands are functioning at birth, but the majority do not begin to secrete saliva until about age 2 to 3 months, when drooling is frequent. Newborn stomach capacity is difficult to determine; however, Bergman (2013) reviewed six published studies exploring this, concluding that stomach capacity is about 20 ml at birth, thus, infants require small feedings at 1 hour intervals. The colon also has a small volume; newborns may have a bowel movement after each feeding. Newborns who breastfeed usually have more frequent feedings and more frequent stools than infants who receive formula.
An infant's intestine is longer in relation to body size than that of the adult. Therefore, there are a larger number of secretory glands and a larger surface area for absorption compared with an adult's intestine. Infants have rapid peristaltic waves and simultaneous nonperistaltic waves along the entire esophagus, which propel nutrients forward. The relative immaturity of the peristaltic waves combined with decreased lower esophageal sphincter (LES) pressure, inappropriate relaxation of the LES, and delayed gastric emptying make regurgitation a common occurrence. Progressive changes in the stooling pattern indicate a properly functioning gastrointestinal tract (Box 7-1).
Box 7-1 C h a n g e i n S t o o l i n g Pa t t e r n s o f N e w b o r n s Meconium Infant's first stool; composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels).
Passage of meconium should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very low birth weight infants.
Transitional Stools Usually appear by third day after initiation of feeding; greenish brown to yellowish brown, thin, and less sticky than meconium; may contain some milk curds.
Milk Stool Usually appears by fourth day.
In breastfed infants, stools are yellow to golden, are pasty in consistency, and have an odor similar to that of sour milk.
In formula-fed infants, stools are pale yellow to light brown, are firmer in consistency, and have a more offensive odor.
The neonatal gastrointestinal mucosa performs an important function as a barrier to foreign antigens. Both immune and nonimmune factors may play a vital role in decreasing the absorption of antigens capable of causing serious neonatal illness; however, the functional capacity of this system may be immature or altered. Feeding an infant human milk increases the effectiveness of this defense mechanism (Le Huërou-Luron, Blat, and Boudry, 2010).
Renal System All structural components are present in the renal system, but there is a functional deficiency in the kidneys' ability to concentrate urine and to cope with conditions of fluid and electrolyte stress, such
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as dehydration or a concentrated solute load. Total volume of urine per 24 hours is about 200 to 300 ml by the end of the first week. However,
the bladder voluntarily empties when stretched by a volume of 15 ml, resulting in as many as 20 voidings per day. The first voiding should occur within 24 hours. The urine is colorless and odorless and has a specific gravity of about 1.020.
Integumentary System At birth, all of the structures within the skin are present, but many of the functions of the integument are immature. The outer two layers of the skin, the epidermis and dermis, are loosely bound to each other and very thin. Rete pegs, which later in life anchor the epidermis to the dermis, are not developed. Slight friction across the epidermis, such as from rapid removal of adhesive tape, can cause separation of these layers and blister formation. The transitional zone between the cornified and living layers of the epidermis is effective in preventing fluid from reaching the skin surface.
The sebaceous glands are active late in fetal life and in early infancy because of the high levels of maternal androgens. They are most densely located on the scalp, face, and genitalia and produce the greasy vernix caseosa that covers infants at birth. Plugging of the sebaceous glands causes milia.
The eccrine glands, which produce sweat in response to heat or emotional stimuli, are functional at birth, and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults. The eccrine glands produce sweat in response to higher temperatures than those required in adults, and the retention of sweat may result in milia. The apocrine glands remain small and nonfunctional until puberty.
The growth phases of hair follicles usually occur simultaneously at birth. During the first few months, the synchrony between hair loss and regrowth is disrupted, and there may be overgrowth of hair or temporary alopecia.
Because the amount of melanin is low at birth, newborns are lighter skinned than they will be as children. Consequently, they are more susceptible to the harmful effects of the sun.
Musculoskeletal System At birth, the skeletal system contains more cartilage than ossified bone, although the process of ossification is fairly rapid during the first year. The nose, for example, is predominantly cartilage at birth and may be temporarily flattened or asymmetric because of the force of delivery. The six skull bones are relatively soft and are separated only by membranous seams. The sinuses are incompletely formed in newborns.
Unlike the skeletal system, the muscular system is almost completely formed at birth. Growth in size of muscular tissue is caused by hypertrophy, rather than hyperplasia, of cells.
Defenses Against Infection Infants are born with several defenses against infection. The first line of defense is the skin and mucous membranes, which protect the body from invading organisms. The mature neonatal intestinal mucosal (gut) barrier also plays a vital role as an important defense mechanism against antigens. The second line of defense is the macrophage system, which produces several types of cells capable of attacking a pathogen. The neutrophils and monocytes are phagocytes, which means they can engulf, ingest, and destroy foreign agents. Eosinophils also probably have a phagocytic property because they increase in number in the presence of foreign protein. The lymphocytes (T cells and B cells) are capable of being converted to other cell types, such as monocytes and antibodies. Although the phagocytic properties of the blood are present in infants, the inflammatory response of the tissues to localize an infection is immature.
The third line of defense is the formation of specific antibodies to an antigen. Exposure to various foreign agents is necessary for antibody production to occur. Infants are generally not capable of producing their own immunoglobulin until the beginning of the second month of life, but they receive considerable passive immunity in the form of immunoglobulin G (IgG) from the maternal circulation and from human milk (see Human Milk later in chapter). They are protected against most major childhood diseases, including diphtheria, measles, poliomyelitis, and rubella, for about 3 months, provided the mother has developed antibodies to these illnesses.
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Endocrine System Ordinarily, the endocrine system of newborns is adequately developed, but its functions are immature. For example, the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone, or vasopressin, which inhibits diuresis. This renders young infants highly susceptible to dehydration.
The effect of maternal sex hormones is particularly evident in newborns. The labia are hypertrophied, and the breasts of both genders may be engorged and secrete milk from the first few days of life to as long as 2 months of age. Female newborns may have pseudomenstruation (more often seen as a milky secretion than actual blood) from a sudden drop in progesterone and estrogen levels.
Neurologic System At birth, the nervous system is incompletely integrated but sufficiently developed to sustain extrauterine life. Most neurologic functions are primitive reflexes. The autonomic nervous system is crucial during transition because it stimulates initial respirations, helps maintain acid–base balance, and partially regulates temperature control.
Myelination of the nervous system follows cephalocaudal/proximodistal (head-to-toe/center-to- periphery) laws of development and is closely related to observed mastery of fine and gross motor skills. Myelin is necessary for rapid and efficient transmission of some, but not all, nerve impulses along the neural pathway. The tracts that develop myelin earliest are the sensory, cerebellar, and extrapyramidal tracts. This accounts for the acute senses of taste, smell, and hearing in newborns, as well as the perception of pain. All cranial nerves are present and myelinated except for the optic and olfactory nerves.
Sensory Functions Newborns' sensory functions are remarkably well developed and have a significant effect on growth and development, including the attachment process.
Vision At birth, the eye is structurally incomplete. The fovea centralis is not yet completely differentiated from the macula. The ciliary muscles are also immature, limiting the eyes' ability to accommodate and focus on an object for any length of time. The infant can track and follow objects. The pupils react to light, the blink reflex is responsive to minimal stimulus, and the corneal reflex is activated by a light touch. Tear glands usually do not begin to function until 2 to 4 weeks of age.
Newborns have the ability to focus momentarily on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. In fact, infants' ability to fixate on coordinated movement is greater during the first hour of life than during the succeeding several days. Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques.
Infants also demonstrate visual preferences: medium colors (yellow, green, pink) over bright (red, orange, blue) or dim colors; black-and-white contrasting patterns, especially geometric shapes and checkerboards; large objects with medium complexity rather than small, complex objects; and reflecting objects over dull ones.
Hearing After the amniotic fluid has drained from the ears, infants probably have auditory acuity similar to that of adults. Neonates react to loud sounds of about 90 decibels with a startle (Moro) reflex.
The newborn's response to sounds of low frequency and high frequency differs; the former, such as a heartbeat, metronome, or lullaby, tends to decrease an infant's motor activity and crying, whereas the latter elicits an alerting reaction. There is an early sensitivity to the sound of human voices. For example, infants younger than 3 days old can discriminate the mother's voice from that of other women. As early as 5 days old, newborns can differentiate between stories repeated to them during the last trimester of pregnancy by their mother and the same stories read after birth by a different woman.
The internal and middle ear is large at birth, but the external canal is small. The mastoid process and the bony part of the external canal have not yet developed. Consequently, the tympanic
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membrane and facial nerve are very close to the surface and can be easily damaged.
Smell Newborns react to strong odors such as alcohol and vinegar by turning their heads away. Breastfed infants are able to smell breast milk and will cry for their mothers when they smell leaking milk. Infants are also able to differentiate the breast milk of their mothers from the breast milk of other women by scent alone. Maternal odors are believed to influence the attachment process and successful breastfeeding. Unnecessary routine washing of the breast may interfere with establishment of early breastfeeding.
Taste The newborn has the ability to distinguish among tastes and various types of solutions elicit differing facial reflexes. A tasteless solution elicits no facial expression; a sweet solution elicits an eager suck and a look of satisfaction; a sour solution causes puckering of the lips; and a bitter liquid produces an angry, upset expression.
Touch At birth, infants are able to perceive tactile sensation in any part of the body, although the face (especially the mouth), hands, and soles of the feet seem to be most sensitive. Evidence shows that touch and motion are essential to normal growth and development. Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from infants. In turn, painful stimuli, such as a pinprick, elicit an upset response.
Nursing Care of the Newborn and Family Assessment Newborns require thorough, skilled observation to ensure a satisfactory adjustment to extrauterine life. Physical assessment after delivery can be divided into four phases:
1. The initial assessment, which includes the Apgar scoring system
2. Transitional assessment during the periods of reactivity
3. Assessment of gestational age
4. Systematic physical examination
In addition, the nurse must be aware of behaviors that signal successful reciprocal attachment between the infant and parents. Awareness of the expected normal findings during each assessment process helps the nurse recognize any deviation that may prevent the infant from progressing uneventfully through the early postnatal period. With shorter hospitalizations, the accomplishment of thorough newborn assessment and parent teaching may be a challenge.
Initial Assessment: Apgar Scoring The most frequently used method to assess newborns' immediate adjustment to extrauterine life is the Apgar scoring system, which is based on newborn heart rate, respiratory effort, muscle tone, reflex irritability, and color (Table 7-1). Each item is given a score of 0, 1, or 2. Evaluations of all five categories are made at 1 and 5 minutes after birth and repeated until the infant's condition stabilizes. Total scores of 0 to 3 represent severe distress, scores of 4 to 6 signify moderate difficulty, and scores of 7 to 10 indicate absence of difficulty in adjusting to extrauterine life. The Apgar score is affected by the degree of physiologic immaturity, infection, congenital malformations, maternal sedation or analgesia, and neuromuscular disorders.
TABLE 7-1 Infant Evaluation at Birth—Apgar Scoring System
Sign 0 1 2
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Heart rate Absent Slow, <100 beats/min >100 beats/min Respiratory effort Absent Irregular, slow, weak cry Good, strong cry Muscle tone Limp Some flexion of extremities Well flexed Reflex irritability No response Grimace Cry, sneeze Color Blue, pale Body pink, extremities blue Completely pink
The Apgar score reflects the general condition of the infant at 1 and 5 minutes based on the five parameters described earlier. The Apgar score is not a tool, however, that stands on its own to interpret past events, determine need for newborn resuscitation, or predict future events linked to the infant's eventual neurologic or physical status. Considerable discussion and controversy have centered on Apgar scoring because of its misuse as an indicator for the presence or absence of perinatal asphyxia in the medicolegal field (American Academy of Pediatrics, Committee on Fetus and Newborn and American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, 2006).
Clinical Assessment of Gestational Age Assessment of gestational age is an important criterion because perinatal morbidity and mortality are related to gestational age and birth weight. A frequently used method of determining gestational age is the New Ballard Scale (NBS) by Ballard, Khoury, Wedig, et al (1991) (Fig. 7-1, A). This scale, an abbreviated version of the Dubowitz scale, assesses six external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score correlates with a maturity rating of 20 to 44 weeks of gestation.
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A, Ballard scale for newborn maturity rating. Expanded scale includes extremely premature infants and has been refined to improve accuracy in more mature infants. (A,
From Ballard JL, Khoury JC, Wedig K, et al: New Ballard score expanded to include extremely premature infants, J Pediatr 119:417, 1991.)
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B, Intrauterine growth: birth weight percentiles based on live single births at gestational ages 20 to 44 weeks. (B, Data from Alexander GR, Himes JH, Kaufman RB, et al: A United States national
reference for fetal growth, Obstet Gynecol 87(2):163–168, 1996.)
FIG 7-1
The NBS includes scores that reflect signs of extremely preterm infants, such as fused eyelids, imperceptible breast tissue, sticky, friable, transparent skin, no lanugo, and square-window (flexion of wrist) angle of greater than 90 degrees (see Fig. 7-1, A, and the description of the tests in Box 7-2). For infants with a gestational age of at least 26 weeks, the examination may be performed up to 96 hours after birth; however, it is recommended that the initial examination be performed within the first 48 hours of life. In a study of preterm infants ranging from 29 to 35 weeks at birth, Ballard scores completed after 7 days after birth were found to either overestimate or underestimate gestational age by up to 2 weeks (Sasidharan, Dutta, and Narang, 2009). In a blinded Spanish study, Marín Gabriel, Martín Moreiras, Lliteras Fleixas, et al (2006) compared estimations of gestational age using NBS versus ultrasonography or the mother's last menstrual period. Researchers found general agreement between NBS and ultrasonography or last menstrual period; however, they noted that NBS tends to overestimate gestational age in very preterm newborns and in infants whose mothers had received prenatal corticosteroid therapy.
Box 7-2 Te s t s U s e d i n A s s e s s i n g G e s t a t i o n a l A g e Posture: With infant quiet and in a supine position, observe degree of flexion in arms and legs.
Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs—4*
Square window: With thumb supporting back of arm below wrist, apply gentle pressure with index and third fingers on dorsum of hand without rotating infant's wrist. Measure angle between base of thumb and forearm. Full flexion (hand lies flat on ventral surface of forearm)—4
Arm recoil: With infant supine, fully flex both forearms on upper arms, hold for 5 seconds; pull
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down on hands to fully extend and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion—4
Popliteal angle: With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. While holding knee with thumb and index finger, extend lower leg with index finger of other hand. Measure degree of angle behind knee (popliteal angle). An angle of less than 90 degrees—5
Scarf sign: With infant supine, support head in midline with one hand; use other hand to pull infant's arm across the shoulder so that infant's hand touches shoulder. Determine location of elbow in relation to midline. Elbow does not reach midline—4
Heel to ear: With infant supine and pelvis flat on a firm surface, pull foot as far as possible up toward ear on same side. Measure degree of knee flexion (same as popliteal angle). Knees flexed with a popliteal angle of less than 90 degrees—4
*Numeric ratings correspond with Fig. 7-1, A.
Weight Related to Gestational Age The weight of the infant at birth also correlates with the incidence of perinatal morbidity and mortality. However, birth weight alone is a poor indicator of gestational age and fetal maturity. Maturity implies functional capacity—the degree to which the neonate's organ systems are able to adapt to the requirements of extrauterine life. Therefore, gestational age is more closely related to fetal maturity than is birth weight. Because heredity influences a newborn's size, noting the size of other family members is part of the assessment process.
Intrauterine growth curves are used to classify infants according to birth weight and gestational age. The primary intrauterine growth charts that provide national reference data include the work of Alexander, Himes, Kaufman, et al (1996), which is representative of more than 3.1 million live births in the United States, and Thomas, Peabody, Turnier, et al (2000). Olsen, Groveman, Lawson, et al (2010) published new intrauterine growth curves based on more than 257,000 infants in the United States, noting that use of a contemporary, large, and racially diverse United States sample has produced intrauterine growth curves that differ from those produced earlier. Thomas, Peabody, Turnier, et al (2000) concluded that intrauterine growth measured by head circumference, birth weight, and length varies according to race and gender. These researchers also found that altitude did not seem to significantly affect birth weight, as has been suggested by other authors. It is recommended that readers access and use the most current intrauterine growth chart specific to the referent population being evaluated.
Classification of infants at birth by both birth weight and gestational age provides a more satisfactory method for predicting mortality risks and providing guidelines for management of the neonate than estimating gestational age or birth weight alone. The infant's birth weight, length, and head circumference are plotted on standardized graphs that identify normal values for gestational age (for birth weight see Fig. 7-1, B). Infants whose weight is appropriate for gestational age (AGA) (between the 10th and 90th percentiles) can be presumed to have grown at a normal rate regardless of the time of birth—preterm, term, or postterm. Infants who are large for gestational age (LGA) (above the 90th percentile) can be presumed to have grown at an accelerated rate during fetal life; small for gestational age (SGA) infants (below the 10th percentile) can be assumed to have intrauterine growth restriction or delay.
When gestational age is determined according to a standardized gestational age scale such as the NBS, the newborn will fall into one of the following nine possible categories for birth weight and gestational age: AGA—term, preterm, postterm; SGA—term, preterm, postterm; LGA—term, preterm, postterm. Fig. 7-2 illustrates the disparity between birth weights of three preterm infants of the same gestational age, 32 weeks. Birth weight and gestational age both influence morbidity and mortality; the lower the birth weight and gestational age, the higher the morbidity and mortality.
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FIG 7-2 Three infants, same gestational age, weight 600 g, 1400 g, and 2750 g, respectively, from left to right. (From Perinatal assessment of maturation, National Audiovisual Center, Washington, DC.)
General Measurements Several important measurements of newborns have significance when compared with each other and when recorded over time on a graph. For full-term infants, average head circumference is between 33 and 35.5 cm (13 and 14 inches). Head circumference may be somewhat less immediately after birth because of the molding process that occurs during vaginal deliveries. Usually by the second or third day, the skull is normal in size and contour.
Head circumference may be compared with crown-to-rump length, or sitting height. Crown-to- rump measurements are usually 31 to 35 cm (12.2 to 13.8 inches), thus head circumference is generally equal to or up to 2 cm more than crown-to-rump length. Comparing neonatal head circumference with crown-to-rump length may provide a means for identifying infants at risk for microcephaly, hydrocephalus, cephalhematoma, subgaleal hemorrhage, and subdural hematoma. Prematurity and intrauterine malnutrition may also disrupt the relationship between head circumference and crown-to-rump length.
Abdominal circumference need not be routinely measured in newborns but should be done in the event of abdominal distention to determine changes in girth over time. Abdominal circumference is measured just above the level of the umbilicus because the umbilical cord is still attached, making measurements across the umbilicus too variable in newborns. Measuring the abdominal circumference below the umbilical region is unsuitable because bladder status may affect the reading.
Head-to-heel length is also measured. Because of the usual flexed position of infants, it is important to extend the legs completely when measuring total body length. The average length of newborns is 48 to 53 cm (19 to 21 inches) (Fig. 7-3). Foote, Brady, Burke, et al (2011) have developed an evidence-based practice guideline for measuring length in infants and children.
FIG 7-3 Measurement of infant length.
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Body weight should be measured soon after birth because weight loss occurs fairly rapidly. Normally, neonates lose about 10% of their birth weight by 3 to 4 days of age because of loss of extracellular fluid and meconium, as well as limited food intake, especially in breastfed infants. The birth weight is usually regained by the tenth to fourteenth day of life. Most newborns weigh 2700 to 4000 g (6 to 9 pounds), the average weight being about 3400 g (7.5 pounds). Accurate birth weights and lengths are important because they provide a baseline for assessment of future growth.
Another category of measurements is vital signs. Axillary temperatures are taken because insertion of a thermometer into the rectum can potentially cause perforation of the mucosa if performed incorrectly (see Table 7-3 and Fig. 7-4). Core body temperature varies according to the periods of reactivity but is usually 36.5° to 37.6° C (97.7° to 99.7° F). Skin temperature is slightly lower than core body temperature. Friedrichs, Staffileno, Fogg, et al (2013) report a significant correlation between rectal temperature and body temperature taken in the left axilla of full term infants. The mean difference between rectal and axillary temperature was 0.23° C. The single best method for determining a newborn infant's temperature remains elusive when considering the available studies. Despite their usefulness in older children and adults, the accuracy of tympanic membrane sensors is problematic in infants. A meta-analysis of 101 studies comparing tympanic membrane temperatures with rectal temperatures in children concluded that the tympanic method demonstrated a wide range of variability, limiting its application in a pediatric setting (Craig, Lancaster, Taylor, et al, 2002). Dodd, Lancaster, Craig, et al (2006) concur with this finding, stating that after a systematic review of studies involving almost 4100 children, they found that infrared ear thermometry would fail to diagnose fever in 3 or 4 of every 10 febrile children.
FIG 7-4 Mother taking axillary temperature with digital thermometer.
The Canadian Paediatric Society, Community Paediatrics Committee (2015) outlines concerns regarding the safety and accuracy of tympanic temperature measurement in newborns because of the size of a newborn's external ear canal relative to the size of the thermometer probe. To ensure accuracy, the probe, which may be up to 8 mm (0.3 inch) in diameter, must be deeply inserted into the ear canal to allow orientation of the sensor near or against the tympanic membrane. At birth, the average diameter of the canal is just 4 mm (0.16 inch); at 2 years old, it is just 5 mm (0.2 inch). The Canadian Paediatric Society concludes that current infrared tympanic thermometry lacks sufficient safety and precision to meet clinical needs for use in newborn infants and children younger than 2 years old.
Infrared axillary and digital thermometers are used in many neonatal units because they give rapid readings and are easy to clean; studies demonstrate their usefulness in well, full-term newborns. Jones, Kleber, Eckert, et al (2003) compared rectal temperatures of infants younger than 2 months old with calibrated digital thermometers and mercury glass thermometers; this study of 120 infants found that the digital thermometers measured a higher temperature (mean average of 0.7° F;
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range, 0° to 1.6° F) than the mercury glass thermometers. The researchers concluded that the error in measurement was attributable to the digital thermometer used. Smith, Alcock, and Usher (2013) conducted an extensive review of the literature on temperature measurement in term and preterm infants. These researchers concluded that the most commonly used route when using digital and electronic thermometers for temperature measurement is the axillary route.
Advantages of digital thermometers in neonatal care include relatively easy readability by parents and caretakers in the home, improvement of discharge planning effectiveness, and decreased risk of breakage and associated complications compared with glass thermometers.
Temporal artery thermometers (TATs), in which a battery-powered instrument is gently slid across the newborn's forehead, are available for use in the general pediatric population. Beginning research in the neonatal population suggests TAT may be a reasonable method for newborn temperature measurement. Haddad, Smith, Phillips, et al (2012), in a study of healthy newborns in a mother-baby unit, compared TAT with axillary temperature measurement. Although a slightly statistically significant difference was found between TAT and axillary temperatures, the difference was deemed clinically insignificant, and the unit has adopted TAT as their standard of care for healthy newborns. Similarly, Lee, Flannery-Bergey, Randall-Rollins, et al (2011) found that TAT and axillary temperatures did not differ significantly, and they concluded that TAT measurements are a reasonable alternative to axillary temperature for stable, afebrile infants in the neonatal intensive care unit. A benefit of this type of temperature measurement is that it is not necessary to undress the newborn. In most studies regarding newborn temperature, the glass mercury thermometer is the gold standard against which other methods are compared. There is no universal agreement on placement times for glass thermometers, although 3 minutes for rectal temperature and 5 minutes for axillary temperature are considered to be adequate. In 2007, the American Academy of Pediatrics, Committee on Environmental Health reaffirmed its statement recommending that mercury thermometers no longer be used in clinics and homes to decrease mercury exposure hazard (Goldman, Shannon, American Academy of Pediatrics, et al, 2001).
Nurses must be cognizant of the many variables involved:
Site—axillary, rectal, tympanic, skin
Environment—radiant warmer, open crib, incubator, clothing, or nesting
Purpose—fever, possible sepsis (in which case the temperature may be lower than normal in newborns), and thermoregulation in the transition phase
Instrument—electronic, digital, infrared
Nurses must also be able to make clear clinical decisions based on accurate and objective data. Further research is needed to perfect thermometers that accurately reflect infants' core temperature to effectively plan nursing care and maintain a stable temperature.
Pulse and respirations also vary according to the periods of reactivity and the infant's behaviors but are usually in the range of 120 to 140 beats/min and 30 to 60 breaths/min. Both are counted for a full 60 seconds to detect irregularities in rate or rhythm. The heart rate is taken apically with a stethoscope, and the femoral arteries are palpated for equality of strength or fullness.
Measurement of BP provides baseline data and may indicate cardiovascular problems. BP is most easily and accurately assessed using oscillometry (Dinamap) when the newborn is in a quiet or sleep state using an appropriate cuff width–to-arm ratio of 0.45 to 0.70 (approximately half to three quarters) (Fig. 7-5). For healthy term infants, the average oscillometric systolic/diastolic BP is 65/45 mm Hg on day 1 of life, changing to 69.5/44.5 mm Hg by day 3 (Kent, Kecskes, Shadbolt, et al, 2007). Compare BP in the upper and lower extremities, which should be equal.
N u r s i n g A l e r t Although uncommon, the presence of neonatal hypertension may be a sign of a significant underlying problem (such as renal, cardiac, or thromboembolic pathologic condition), or it may be associated with a medication treatment regimen. Neonatal hypertension is brought to the primary practitioner's attention for further evaluation.
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FIG 7-5 Measurement of blood pressure using oscillometry.
The American Academy of Pediatrics, Section on Cardiology and Cardiac Surgery Executive Committee recommends routine pulse oximetry screening for critical congenital heart disease (CCHD) for all newborns (Mahle, Martin, Beekman, et al, 2012). Delayed diagnosis of CCHD can result in morbidity or mortality to infants. Research has demonstrated that adding pulse oximetry, a noninvasive, painless technology, to newborn assessment can detect CCHD. Practitioners are directed to use motion-tolerant pulse oximeters and to screen infants after 24 hours of age to reduce false-positive results. Oxygen saturation must be measured in the right hand and in one foot; a reading of 95% or greater in either extremity with a 3% or less difference between the upper and lower extremities would be a “pass.” Infants with saturation of less than 90% need immediate evaluation.
A suggested schedule for monitoring heart rate, respiratory rate, and temperature is on admission to the nursery, once every 30 minutes until the newborn has been stable for 2 hours (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2007), and then once every 8 hours until discharge. However, this schedule may vary according to institutional policy. Any change in the infant, such as color, breathing, muscle tone, or behavior, necessitates more frequent monitoring.
General Appearance Before each body system is assessed, it is important to describe the general posture and behavior of the newborn. The overall appearance yields valuable clues to the infant's physical status.
In full-term neonates, the posture is one of complete flexion as a result of in utero position. Most infants are born in a vertex presentation with the head flexed and the chin resting on the upper chest, the arms flexed with the hands clenched, the legs flexed at the knees and hips, and the feet dorsiflexed. The vertebral column is also flexed. It is important to recognize any deviation from this characteristic fetal position.
The infant's behavior is carefully noted, especially the degree of alertness, drowsiness, and irritability; the latter two factors may reflect common signs of neurologic problems. Some questions to mentally ask when assessing behavior include: • Is the infant awakened easily by a loud noise? • Is the infant comforted by rocking, sucking, or cuddling? • Do there seem to be periods of deep and light sleep? • When awake, does the infant seem satisfied after a feeding? • What stimuli elicit responses from the infant? • When disturbed, how much does the infant protest?
Skin The texture of the newborn's skin is velvety smooth and puffy, especially about the eyes, the legs, the dorsal aspect of the hands and the feet, and the scrotum or labia. Skin color depends on racial and familial background and varies greatly among newborns. In general, white infants are usually pink to red. African-American newborns may appear a pinkish or yellowish brown. Infants of
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Hispanic descent may have an olive tint or a slight yellow cast to the skin. Infants of Asian descent may be a rosy or yellowish tan. The color of American Indian newborns varies from a light pink to a dark, reddish brown. By the second or third day of life, the skin turns to its more natural tone and is drier and flakier. Several other color changes that may be noted on the skin are described later in this chapter (see Table 7-4).
At birth, the skin may be partially covered with a grayish white, cheeselike substance called vernix caseosa, a mixture of sebum and desquamating cells. It is absorbed by 24 to 28 hours. A fine, downy hair called lanugo may be present on the skin, especially on the forehead, cheeks, shoulders, and back.
Head General observation of the contour of the head is important because molding occurs in almost all vaginal deliveries. In a vertex delivery, the head is usually flattened at the forehead, with the apex rising and forming a point at the end of the parietal bones and the posterior skull or occiput dropping abruptly. The usual, more oval contour of the head is apparent by 1 to 2 days after birth. The change in shape occurs because the bones of the cranium are not fused, allowing for overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Such molding usually does not occur in infants born by elective cesarean section.
Six bones—the frontal, occipital, two parietals, and two temporales—make up the cranium. Between the junction of these bones are bands of connective tissue called sutures. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels. The two most prominent fontanels in infants are the anterior fontanel formed by the junction of the sagittal, coronal, and frontal sutures and the posterior fontanel formed by the junction of the sagittal and lambdoid sutures (Fig. 7-6, A).
N u r s i n g T i p The location of the sutures is easily remembered because the coronal suture “crowns” the head, and the sagittal suture “separates” the head.
FIG 7-6 A, Location of sutures and fontanels. B, Palpating the anterior fontanel.
The skull is palpated for all patent sutures and fontanels, noting size, shape, molding, or abnormal closure. The sutures feel like cracks between the skull bones, and the fontanels feel like wider soft spots at the junction of the sutures. These are palpated by using the tip of the index finger and running it along the ends of the bones (see Fig. 7-6, B).
The anterior fontanel is diamond shaped and measures anywhere from barely palpable to 4 to 5
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cm (≈2 inches) at its widest point (from bone to bone rather than from suture to suture). The posterior fontanel is easily located by following the sagittal suture toward the occiput. The posterior fontanel is triangular, usually measuring between 0.5 and 1 cm (<0.5 inch) at its widest part. The fontanels should feel flat, firm, and well demarcated against the bony edges of the skull. Frequently, pulsations are visible at the anterior fontanel. Coughing, crying, or lying down may temporarily cause the fontanels to bulge and become more taut.
Palpate the skull for any unusual masses or prominences, particularly those resulting from birth trauma, such as caput succedaneum or cephalhematoma (see Chapter 8). Because of the pliability of the skull, exerting pressure at the margin of the parietal and occipital bones along the lambdoid suture may produce a snapping sensation similar to the indentation of a ping-pong ball. This phenomenon, known as physiologic craniotabes, may be found normally, especially in newborns of breech birth, but also may indicate hydrocephalus, congenital syphilis, or rickets.
Assess the degree of head control. Although head lag is normal in newborns, the degree of ability to control the head in certain positions should be recognized. If a supine infant is pulled from the arms into a semi-Fowler position, marked head lag and hyperextension are noted (Fig. 7-7, A). However, as the infant is brought forward into a sitting position, the infant will attempt to control the head in an upright position. As the head falls forward onto the chest, many infants will attempt to right it into the erect position. Also, if the infant is held in ventral suspension (i.e., held prone above and parallel to the examining surface), the infant will hold the head in a straight line with the spinal column (see Fig. 7-7, B). When lying on the abdomen, newborns have the ability to lift the head slightly, turning it from side to side. Marked head lag is seen in neonates with Down syndrome, prematurity, hypoxia, and neuromuscular compromise.
FIG 7-7 Head control in an infant. A, Inability to hold the head erect when pulled to sitting position. B, Ability to hold the head erect when placed in ventral suspension.
Eyes Because newborns tend to have their eyes tightly closed, it is best to begin the examination of the eyes by observing the eyelids for edema, which is normally present for the first 2 days after delivery. The eyes are observed for symmetry. Tears may be present at birth, but purulent discharge from the eyes shortly after birth is abnormal. To visualize the surface structures of the eyes, the infant is held supine, and the head is gently lowered. The eyes will usually open, similar to the mechanism of a doll's eyes. The sclera should be white and clear.
The cornea is examined for the presence of any opacities or haziness. The corneal reflex is normally present at birth but may not be elicited unless neurologic or eye damage is suspected. The pupil will usually respond to light by constricting. The pupils are normally malaligned. A searching nystagmus is common. Strabismus is a normal finding because of the lack of binocularity. The color of the iris is noted. Most light-skinned newborns have slate gray or dark blue eyes, and dark- skinned infants have brown eyes.
A funduscopic examination may be difficult to perform because of the infant's tendency to keep the eyes tightly closed. However, a red reflex should be elicited. The absence of a red reflex in a newborn may indicate a cataract, glaucoma, retinal abnormalities, or retinoblastoma (see Chapter 4).
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N u r s i n g T i p To elicit a red reflex, place the infant in a dark room. In an alert state, many newborns open their eyes in a supported sitting position.
Ears The ears are examined for position, structure, and auditory function. The top of the pinna should lie in a horizontal plane to the outer canthus of the eye. The pinna is often flattened against the side of the head from pressure in utero. An otoscopic examination may be difficult to perform if the canals are filled with vernix caseosa and amniotic fluid, making visualization of the tympanic membrane difficult.
Auditory ability is tested by a number of objective hearing tests. Making a loud noise close to the infant's head may or may not elicit a response; the lack of a response, however, is not a definite indication of hearing loss. The startle reflex (Table 7-2) may be observed when there is a sudden loud noise near the infant or the bassinet is accidentally bumped, but this often depends on the infant's state at the time.
TABLE 7-2 Assessment of Reflexes in the Newborn
Reflexes Expected Behavioral Responses Localized Eyes Blinking or corneal
Infant blinks at sudden appearance of a bright light or at approach of an object toward cornea; persists throughout life.
Pupillary Pupil constricts when a bright light shines toward it; persists throughout life. Doll's eye As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicates
neurologic damage. Nose Sneeze Sneezing is a spontaneous response of nasal passages to irritation or obstruction; persists throughout life. Glabellar Tapping briskly on glabella (bridge of nose) causes eyes to close tightly. Mouth and Throat Sucking Infant begins strong sucking movements of circumoral area in response to stimulation; persists throughout infancy even without stimulation, such as during sleep. Gag Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag; persists throughout life. Rooting Touching or stroking the cheek alongside of mouth causes infant to turn head toward that side and begin to suck; should disappear at about 3 to 4 months old but may
persist for up to 12 months. Extrusion When tongue is touched or depressed, infant responds by forcing it outward; disappears by 4 months old. Yawn Yawning is a spontaneous response to decreased oxygen by increasing amount of inspired air; persists throughout life. Cough Irritation of mucous membranes of larynx or tracheobronchial tree causes coughing; persists throughout life; usually present after first day of birth. Extremities Grasp Touching palms of hands or soles of feet near base of digits causes flexion of fingers and toes (see Fig. 7-8, A); palmar grasp lessens after age 3 months old to be replaced by
voluntary movement; plantar grasp lessens by 8 months old. Babinski Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex (see Fig. 7-8, B); disappears after 1 year old. Ankle clonus
Briskly dorsiflexing foot while supporting knee in partially flexed position results in one or two oscillating movements (“beats”); eventually, no beats should be felt.
Mass Moro Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape
followed by flexion and adduction of extremities; legs may weakly flex; infant may cry (Fig. 7-9, A); disappears after 3 to 4 months old, usually strongest during first 2 months.
Startle A sudden loud noise causes abduction of the arms with flexion of elbows; hands remain clenched; disappears by 4 months old. Perez While infant is prone on a firm surface, thumb is pressed along spine from sacrum to neck; infant responds by crying, flexing extremities, and elevating pelvis and head;
lordosis of the spine, as well as defecation and urination, may occur; disappears by 4 to 6 months old. Tonic neck When infant's head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex (see Fig. 7-9, B); disappears by 3 to 4 months old to be replaced by
symmetric positioning of both sides of body. Trunk incurvation (Galant)
Stroking infant's back alongside spine causes hips to move toward stimulated side; disappears by 4 weeks old.
Dance or step
If infant is held so that sole of foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking (see Fig. 7-9, C); disappears after 3 to 4 weeks old to be replaced by deliberate movement.
Crawl When placed on abdomen, infant makes crawling movements with arms and legs (see Fig. 7-9, D); disappears at about 6 weeks old. Placing When infant is held upright under arms and dorsal side of foot is briskly placed against hard object, such as table, leg lifts as if foot is stepping on table; age of disappearance
varies.
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FIG 7-9 A, Moro reflex. B, Tonic neck reflex. C, Dance reflex. D, Crawl reflex. (Courtesy of Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Nose The nose is usually flattened after birth, and bruises are common. Patency of the nasal canals can be assessed by holding a hand over the infant's mouth and one canal and noting the passage of air through the unobstructed opening. If nasal patency is questionable, report it because most newborns are obligatory nose breathers and are unable to breathe orally in response to nasal occlusion. Sneezing and thin white mucus are common up to several hours after birth.
Mouth and Throat An external defect of the mouth (such as, cleft lip) is readily apparent; however, the internal structures require careful inspection. The palate is normally highly arched and somewhat narrow. Rarely, teeth may be present. A common finding is Epstein pearls, small, white, epithelial cysts along both sides of the midline of the hard palate. They are insignificant and disappear in several weeks.
The frenulum of the upper lip is a band of thick pink tissue that lies under the inner surface of the upper lip and extends to the maxillary alveolar ridge. It is particularly evident when the infant yawns or smiles. It disappears as the maxilla grows.
The lingual frenulum attaches the underside of the tongue to the lower palate midway between the ventral surface of the tongue and the tip. In some cases, a tight lingual frenulum, formerly referred to as tongue-tie, may restrict adequate sucking. Further evaluation may be required to ascertain adequate sucking, particularly in breastfed infants. The treatment for a tight lingual frenulum advocated by the American Academy of Pediatrics, Committee on Fetus and Newborn (2010) is frenotomy, a safe and effective surgical procedure that may improve comfort, effectiveness, and ease of breastfeeding for the mother and infant (Brookes and Bowley, 2014; Forlenza, Paradise Black, McNamara, et al, 2010). Research continues in an effort to determine how best to select which infants will benefit from the procedure and when to perform it (Emond, Ingram, Johnson, et al, 2014; Power and Murphy, 2015).
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Elicit the sucking reflex by placing a nipple or nonlatex gloved finger in the infant's mouth. The infant should exhibit a strong, vigorous suck. The rooting reflex is elicited by stroking the cheek and noting the infant's response of turning toward the stimulated side and sucking.
The uvula can be inspected while the infant is crying and the chin is depressed. However, it may be retracted upward and backward during crying. Tonsillar tissue is generally not seen in newborns. Natal teeth, teeth present at birth, as opposed to neonatal teeth, which erupt during the first month of life, are seen infrequently and erupt chiefly at the position of the lower incisors. Teeth are reported because they are frequently found with developmental abnormalities and syndromes, including cleft lip and palate. Most natal teeth are loosely attached. However, current thinking suggests preserving them until they exfoliate naturally (Maheswari, Kumar, Karunakaran, et al, 2012) unless the tooth is attached loosely or breastfeeding is impaired by the neonate's biting the breast.
Neck Because the newborn's neck is short and covered with folds of tissue, adequate assessment of the neck requires allowing the head to fall gently backward in hyperextension while the back is supported in a slightly raised position. Observe for range of motion, shape, and any abnormal masses and palpate each clavicle for possible fractures.
Chest The shape of the newborn's chest is almost circular because the anteroposterior and lateral diameters are equal. The ribs are flexible, and slight intercostal retractions are normally seen on inspiration. The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is generally raised and slightly curved.
Inspect the breasts for size, shape and nipple formation, location, and number. Breast enlargement appears in many newborns of both genders by the second or third day and is caused by maternal hormones. Occasionally, a milky substance is secreted by the infant's breasts. Supernumerary nipples may be found on the chest, on the abdomen, or in the axilla.
Lungs The normal respirations of newborns are irregular and abdominal, and the rate is between 30 and 60 breaths/min. Pauses in respiration of less than 20 seconds' duration are considered normal. After the initial forceful breaths required to initiate respiration, subsequent breaths should be nonlabored and fairly regular in rhythm. Periodic breathing is commonly seen in full-term newborns and consists of rapid nonlabored respirations followed by pauses of less than 20 seconds; periodic breathing may be more prominent during sleep and is not accompanied by status changes, such as cyanosis or bradycardia. Occasional irregularities occur in relation to crying, sleeping, stooling, and feeding.
Perform auscultation when the infant is quiet. Bronchial breath sounds should be equal bilaterally. Any differences in auscultatory findings between symmetric sites are reported. Crackles soon after birth indicate the presence of fluid, which represents the normal transition of the lungs to extrauterine life. However, wheezes, persistence of medium or coarse crackles after the first few hours of life, and stridor should be reported for further investigation.
Heart Heart rate is auscultated and may range from 100 to 180 beats/min shortly after birth and, when the infant's condition has stabilized, from 120 to 140 beats/min. The point of maximum intensity (PMI) may be palpated and is usually found at the fourth to fifth intercostal space, medial to the left midclavicular line. The PMI gives some indication of the location of the heart, which may be displaced in conditions, such as congenital diaphragmatic hernia or pneumothorax. Dextrocardia, an anomaly wherein the heart is on the right side of the body, is reported because the abdominal organs may also be reversed, with associated circulatory abnormalities.
Auscultation of the specific components of the heart sounds is difficult because of the rapid rate and effective transmission of respiratory sounds. However, the first (S1) and second (S2) sounds should be clear and well defined; the second sound is somewhat higher in pitch and sharper than the first. A murmur is frequently heard in newborns, especially over the base of the heart or at the
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left sternal border at the third or fourth interspace. In newborns, a murmur is not necessarily associated with specific cardiac defects but frequently represents the incomplete functional closure of fetal shunts. (See Chapter 4 for other characteristics of murmurs.) However, always record and report all murmurs and other unusual heart sounds.
Abdomen The normal contour of the abdomen is cylindric and usually prominent with few visible veins. Bowel sounds are heard within the first 15 to 20 minutes after birth. Visible peristaltic waves may be observed in some newborns.
Inspect the umbilical cord to determine the presence of two arteries, which look like papular structures, and one vein, which has a larger lumen than the arteries and a thinner vessel wall. At birth, the umbilical cord appears bluish white and moist. After clamping, it begins to dry and appears a dull, yellowish brown. It progressively shrivels in size and turns greenish black.
If the umbilical cord appears unusually large in diameter at the base, inspect for the presence of a hematoma or small omphalocele. If the cord is clamped over an existing omphalocele, part of the intestine will be clamped, causing tissue necrosis. One practical rule of thumb is to cut the cord distally 4 to 5 inches from a questionable enlargement until further examination is carried out by a practitioner. The extra length can later be cut if no pathologic condition has been identified.
N u r s i n g A l e r t An umbilical cord that is draining and erythematous at the base should be investigated by the primary practitioner. The cord undergoes a process of dry gangrene decay, which has an odor; therefore, odor alone may not be a reliable index of suspicion for omphalitis.
Palpate after inspecting the abdomen. The liver is normally palpable 1 to 3 cm (≈0.5 to 1 inch) below the right costal margin. The tip of the spleen can sometimes be felt, but a palpable spleen more than 1 cm below the left costal margin suggests enlargement and warrants further investigation. Although both kidneys should be palpated, this maneuver requires considerable practice. When felt, the lower half of the right kidney and the tip of the left kidney are 1 to 2 cm above the umbilicus. During examination of the lower abdomen, palpate for femoral pulses, which should be strong and equal bilaterally.
Female Genitalia Normally, the labia minora, labia majora, and clitoris are edematous, especially after a breech delivery. However, the labia and clitoris must be carefully inspected to identify any evidence of ambiguous genitalia or other abnormalities. Normally, in a girl, the urethral opening is located behind and below the clitoris.
A hymenal tag is occasionally visible from the posterior opening of the vagina. It is composed of tissue from the hymen and the labia minora. It usually disappears in several weeks. Generally, the vaginal vault is not inspected.
Vaginal discharge may be noted during the first week of life. This pseudomenstruation is a manifestation of the abrupt decrease of maternal hormones and usually disappears by 2 to 4 weeks of age. Fecal discharge from the vaginal opening indicates a rectovaginal fistula and is always reported. Vernix caseosa may be present in large amounts between the labia; it will disappear after several days with routine bathing and care.
Male Genitalia The penis is inspected for the urethral opening, which is located at the tip. However, the opening may be totally covered by the prepuce, or foreskin, which covers the glans penis. A tight prepuce is a common finding in newborns. It should not be forcefully retracted; locating the urinary meatus is usually possible without retracting the foreskin. Smegma, a white cheesy substance, is commonly found around the glans penis under the foreskin. Small, white, firm lesions called epithelial pearls may be seen at the tip of the prepuce. An erection is common in newborns.
The scrotum may be large, edematous, and pendulous in full-term neonates, especially in infants born in breech position. It is more deeply pigmented in dark-skinned infants. A noncommunicating hydrocele commonly occurs unilaterally and disappears within a few months. Always palpate the
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scrotum for the presence of testes (see Chapter 4). In small newborns, particularly preterm infants, the undescended testes may be palpable within the inguinal canal. Absence of the testes may also be a sign of ambiguous genitalia (disorders of sex development), especially when accompanied by a small scrotum and penis. Inguinal hernias may or may not be manifested immediately after birth. A hernia is more easily detected when the infant is crying. Palpable lymph nodes are most commonly found in the inguinal area.
Back and Rectum Inspect the spine with the infant prone. The shape of the spine is gently rounded, with none of the characteristic S-shaped curves seen later in life. Any abnormal openings, masses, dimples, or soft areas are noted. A protruding sac anywhere along the spine, but most commonly in the sacral area, indicates some type of spina bifida. A small sinus, which may or may not be communicating with the spine, is a pilonidal sinus. It is frequently covered with a tuft of hair. Although it may have no pathologic significance, a pilonidal cyst may indicate the existence of spina bifida occulta or be a portal of entry into the spinal column. With the infant still prone, note symmetry of the gluteal folds. Report any evidence of asymmetry. Skilled examiners test for developmental dysplasia of the hip (see Chapter 29).
The presence of an anal orifice and passage of meconium from the anal orifice during the first 24 to 48 hours of life indicates anal patency. If an imperforate anus is suspected, report this to the primary practitioner for further evaluation.
N u r s i n g A l e r t The presence of meconium or stool in the rectal area is not an indication of rectal patency; a fistula may exist wherein stool is evacuated via the vagina, scrotum, or raphe. Therefore, it is imperative that anal patency be checked with a small rubber catheter if doubt regarding patency exists.
Extremities Examine the extremities for symmetry, range of motion, and signs of malformation. Count the fingers and toes and note any supernumerary digits (polydactyly) or fusion of digits (syndactyly). A partial syndactyly between the second and third toes is a common variation seen in otherwise normal infants. The nail beds should be pink, although slight blueness is evident in acrocyanosis.
The palms of the hands should have the usual creases. Full-term newborns usually have creases covering the entire sole of the foot. The soles of the feet are flat with prominent fat pads.
Observe range of motion of the extremities throughout the entire examination. The absence of arm movement signals a potential birth injury paralysis, such as Klumpke or Erb-Duchenne palsy. An asymmetric or partial Moro reflex should alert the practitioner to further evaluate upper extremity mobility. Examine the lower extremities for limb length, symmetry, and hip abduction and flexion. Newborns demonstrate full range of motion in the elbow, hip, shoulder, and knee joints. Movements should be symmetric, smooth, and unrestricted.
Also assess muscle tone. By attempting to extend a flexed extremity, determine if tone is equal bilaterally. Extension of any extremity is usually met with resistance, and when released, the extremity returns to its previous flexed position. Hypotonia suggests some degree of hypoxia or neurologic disorder and is common in an infant with Down syndrome. Asymmetry of muscle tone may indicate a degree of paralysis from brain damage or nerve damage. Failure to move the lower limbs suggests a spinal cord lesion or injury. Sustained rhythmic tremors, twitches, and myoclonic jerks characterize neonatal seizures or may indicate neonatal abstinence syndrome. (See Neonatal Seizures and Drug-Exposed Infants, Chapter 8.) Sudden asynchronous jerking movements, quivering, or momentary tremors are usually normal.
Neurologic System Assessing neurologic status is a critical part of the physical examination of newborns. Much of the neurologic testing takes place during evaluation of body systems, such as eliciting localized reflexes and observing posture, muscle tone, head control, and movement. However, several important mass (total body) reflexes also need to be elicited. These should be tested at the end of the examination because they may disturb the infant and interfere with auscultation. Two common
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newborn reflexes are elicited. The first is the grasp reflex. Touching the palms of the hands or soles of the feet near the base of the digits causes flexion or grasping (Fig. 7-8, A). The other is the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toe to dorsiflex and the other toes to hyperextend (see Fig. 7-8, B).
FIG 7-8 A, Plantar or grasp reflex. B, Babinski reflex. 1, Direction of stroke. 2, Dorsiflexion of big toe. 3, Fanning of toes. (A, From Zitelli BJ, McIntire SC, Nowalk AJ: Zitelli and Davis' atlas of pediatric physical diagnosis, ed 6, St Louis,
2012, Saunders/Elsevier.)
These reflexes, as well as several local reflexes, are described in Table 7-2. Record and report the absence, asymmetry, persistence, or weakness of a reflex.
Transitional Assessment: Periods of Reactivity Newborns exhibit behavioral and physiologic characteristics that may at first appear to be signs of stress. However, during the initial 24 hours, changes in heart rate, respiration, motor activity, color, mucus production, and bowel activity occur in an orderly, predictable sequence that is normal and indicates lack of stress.
For 6 to 8 hours after birth, the newborn is in the first period of reactivity. During the first 30 minutes, the infant is very alert, cries vigorously, may suck his or her fingers or fist, and appears very interested in the environment. At this time, the newborn's eyes are usually open, making this an excellent opportunity for the mother, father, and child to see each other. Because the healthy newborn has a vigorous suck, this is also an opportune time to begin breastfeeding. The infant will usually grasp the nipple quickly, satisfying both the mother and the infant. This is particularly important to point out to the parents because after this initially highly active state, the infant may be sleepy and uninterested in sucking. Physiologically, the respiratory rate during this period is as high as 80 breaths/min, crackles may be heard, heart rate reaches 180 beats/min, bowel sounds are active, mucus secretions are increased, and temperature may decrease. Maintaining appropriate temperature for newborns is best accomplished by practicing skin-to-skin care, whereby only a diaper is worn to allow majority of skin surface to be in contact with the mother's skin. A light blanket is used to cover the mother and newborn. Research has shown that skin-to-skin is effective in ensuring the newborn does not become hypothermic (Moore, Anderson, Bergman, et al, 2012).
After this initial stage of alertness and activity, the infant enters the second stage of the first reactive period, which generally lasts 2 to 4 hours. Heart and respiratory rates decrease, temperature continues to fall, mucus production decreases, and urine and stool are usually not passed. The infant is in a state of sleep and relative calm. Any attempt at stimulation usually elicits minimal response. Because of the continued decline in body temperature, undressing or bathing is avoided during this time.
The second period of reactivity begins when the infant awakens from this deep sleep; it lasts
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about 2 to 5 hours and provides another excellent opportunity for child and parents to interact. The infant is again alert and responsive, heart and respiratory rates increase, the gag reflex is active, gastric and respiratory secretions are increased, and passage of meconium frequently occurs. This period is usually over when the amount of respiratory mucus has decreased. After this stage is a period of stabilization of physiologic systems and a vacillating pattern of sleep and activity.
Behavioral Assessment Another important area of assessment is observation of behavior. Infants' behavior helps shape their environment, and their ability to react to various stimuli affects how others relate to them. The principal areas of behavior for newborns are sleep, wakefulness, and activity (such as crying).
One method of systematically assessing the infant's behavior is the use of the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) (Brazelton and Nugent, 1996). The BNBAS is an interactive examination that assesses the infant's response to 28 items organized according to the clusters in Box 7-3. It is generally used as a research or diagnostic tool and requires special training.
Box 7-3 C l u s t e r s o f N e o n a t a l B e h a v i o r s i n B r a z e l t o n N e o n a t a l B e h a v i o r a l A s s e s s m e n t S c a l e Habituation: Ability to respond to and then inhibit response to discrete stimulus (light, rattle, bell,
pinprick) while asleep
Orientation: Quality of alert states and ability to attend to visual and auditory stimuli while alert
Motor performance: Quality of movement and tone
Range of state: Measure of general arousal level or arousability of infant
Regulation of state: How infant responds when aroused
Autonomic stability: Signs of stress (tremors, startles, skin color) related to homeostatic (self- regulating) adjustment of the nervous system
Reflexes: Assessment of several neonatal reflexes
In addition to its use as an initial and ongoing tool to assess neurologic and behavioral responses, the scale can be used in assessment of initial parent–child relationships, as a preventive instrument that identifies a caregiver who may benefit from a role model, and as a guide to help parents focus on their infant's individuality and develop a deeper attachment to their child (Bruschweiler-Stern, 2009). Studies have demonstrated that showing parents the unique characteristics of their infant causes a more positive perception of the infant to develop, with increased interaction between infant and parent.
Patterns of Sleep and Activity Newborns begin life with a systematic schedule of sleep and wakefulness that is initially evident during the periods of reactivity. After this initial period, it is not unusual for the infant to sleep almost constantly for the next 2 to 3 days to recover from the exhausting birth process.
Infants have six distinct sleep–wake states, which represent a particular form of neural control (Table 7-3). As maturity increases, each state becomes more precisely defined according to the behaviors observed. State is defined as a “group of characteristics that regularly occur together” (Blackburn, 2013) and includes body activity, eye and facial movements, respiratory pattern, and response to internal and external stimuli. The six sleep–wake states are quiet (deep) sleep, active (light) sleep, drowsy, quiet alert, active alert, and crying. Infants respond to internal and external environmental factors by controlling sensory input and regulating the sleep–wake states; the ability to make smooth transitions between states is called state modulation. The ability to regulate sleep– wake states is essential in infants' neurobehavioral development. The more immature the infant, the
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less able he or she is able to cope with external and internal factors that affect the sleep–wake patterns.
TABLE 7-3 States of Sleep and Activity
State and Behavior Implications for Parenting Deep Sleep (Quiet) Closed eyes Regular breathing No movement except for occasional sudden bodily twitch No eye movement
Continue usual house noises because external stimuli do not arouse infant. Leave infant alone if sudden loud noise awakens infant and he or she cries. Do not attempt to feed.
Light Sleep (Active) Closed eyes Irregular breathing Slight muscular twitching of body Rapid eye movement (REM) under closed eyelids May smile
External stimuli that did not arouse infant during deep sleep may minimally arouse child. Periodic groaning or crying is usual; do not interpret as an indication of pain or discomfort.
Drowsy Eyes may be open Irregular breathing Active body movement variable with occasional mild startles
Most stimuli arouse infant but may return to sleep state. Pick infant up during this time rather than leaving in crib. Provide mild stimulus to awaken. Infant may enjoy nonnutritive sucking.
Quiet Alert Eyes wide open and bright Responds to environment by active body movement and staring at close-range objects Minimal body activity Regular breathing Focuses attention on stimuli
Satisfy infant's needs such as hunger or nonnutritive sucking. Place infant in area of home where activity is continuous. Place a toy in crib or play yard. Place objects within 17.5 to 20 cm (7 to 8 inches) of infant's view. Intervene to console.
Active Alert May begin with whimpering and slight body movement Eyes open Irregular breathing
Remove intense internal or external stimuli because infant has increased sensitivity to stimuli.
Crying Progresses to strong, angry crying and uncoordinated thrashing of extremities Eyes open or tightly closed Grimaces Irregular breathing
Comforting measures that were effective during alert state are usually ineffective. Rock and swaddle to decrease crying. Intervene to reduce fatigue, hunger, or discomfort.
Portions adapted from Blackburn S, Loper DL: Maternal, fetal, and neonatal physiology: a clinical perspective, Philadelphia, 1992, Saunders.
Recognition and knowledge of sleep–wake states is important in the planning of nursing care. It is also important for nurses to help parents and caregivers understand the significance of the infant's behavioral responses to daily caregiving and how these states can be altered. A classic example is a newborn who feeds vigorously in the active alert state but poorly when he or she progresses to the crying state. The neurologic assessment of a newborn in the active alert state will differ significantly from that performed during the deep sleep state.
Newborns typically spend as much as 16 to 18 hours sleeping and do not necessarily follow a pattern of light–dark diurnal rhythm. With increasing age, sleep–wake states change, with increasing amounts of time spent in awake alert states and decreasing amounts of sleep time. Approximately 50% of total sleep time is spent in irregular or rapid eye movement sleep.
Cry Newborns should begin extrauterine life with a strong, lusty cry. The duration of crying is as variable in each infant as the duration of sleep patterns. Newborns may cry as little as 5 minutes or as much as 2 hours or more per day. Feeding usually terminates the state of crying when hunger is the cause. Holding the infant skin-to-skin, swaddling or wrapping an infant snugly in a blanket (while ensuring the hands remain free to allow for self-calming and avoid overheating) calms infants, promotes sleep, and maintains body temperature. Rocking the infant may reduce crying and induce quiet alertness or sleep.
Variations in the initial cry can indicate abnormalities. A weak, groaning cry or grunting during expiration usually indicates respiratory disturbance. Absent, weak, or constant crying requires further investigation for possible drug withdrawal or a neurologic problem.
Assessment of Attachment Behaviors One of the most important areas of assessment is careful observation of behaviors that are thought to indicate the formation of emotional bonds between the newborn and family, especially the mother. Such behaviors include the en face position; undressing and touching the infant; smiling, kissing, and talking to the infant; and holding, rocking, and cradling the child close to the body (see Nursing Care Guidelines box). Because assessment is closely related to interventions that promote attachment (e.g., encouraging these behaviors in parents), assessing attachment behaviors is further discussed later in the chapter.
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N u r s i n g C a r e G u i d e l i n e s Assessing Attachment Behavior
• When the infant is brought to the parents, do they reach out for the child and call the child by name?
• Do the parents speak about the child in terms of identification—who the infant looks like; what appears special about their child compared with other infants?
• When parents are holding the infant, what kind of body contact is there? Do they feel at ease in changing the infant's position? Are fingertips or whole hands used? Are there parts of the body that they avoid touching or parts of the body they investigate and scrutinize?
• When the infant is awake, what kinds of stimulation do the parents provide? Do they talk to the infant, to each other, or to no one? How do they look at the infant—direct visual contact, avoidance of eye contact, or looking at other people or objects?
• How comfortable do the parents appear in terms of caring for the infant? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers?
• What type of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking?
• If the infant is fussy, what kinds of comforting techniques do the parents use, such as rocking, swaddling, talking, or stroking?
Physical Assessment An essential aspect of the care of the newborn is a thorough physical assessment that includes estimation of gestational age and physical examination to identify normal characteristics and existing abnormalities. These initial and ongoing assessments are critical to establishing baseline data for planning, implementing, and evaluating care and are a nursing priority in caring for the newborn. The discussion of physical examination focuses on normal findings and variations from the norm that require little or no intervention. Readers are encouraged to review Chapter 4 for further discussion of examination techniques. General guidelines for conducting a physical examination are presented in the Nursing Care Guidelines box. Table 7-4 summarizes physical examination of newborns.
N u r s i n g C a r e G u i d e l i n e s Physical Examination of the Newborn
1. Provide a normothermic and nonstimulating examination area.
2. Check that equipment and supplies are working properly and are accessible.
3. Undress only the body area examined to prevent heat loss.
4. Proceed in an orderly sequence (usually head to toe) with the following exceptions:
• Observe the infant's attitude and position of flexion first to avoid disturbing him or her.
• Perform all procedures that require quiet next, such as auscultating the lungs, heart, and abdomen.
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• Perform disturbing procedures, such as testing reflexes, last.
• Measure head and length at same time to compare results.
5. Proceed quickly to avoid stressing the infant.
6. Comfort the infant during and after the examination.
• Talk softly.
• Hold the infant's hands against his or her chest.
• Swaddle and hold the infant.
• Offer a nonlatex gloved finger to suck.
• Use containment and positioning to maximize developmental state regulation.
TABLE 7-4 Physical Assessment of the Newborn
Usual Findings Common Variations or Minor Abnormalities Potential Signs of Distress or MajorAbnormalities General Appearance Posture: Flexion of head and extremities, which rest on chest and abdomen
Frank breech: Extended legs, abducted and fully rotated thighs, flattened occiput, extended neck
Limp posture, extension of extremities
Skin At birth, bright red, puffy, smooth Second to third day, pink, flaky, dry Vernix caseosa Lanugo Edema around eyes, face, legs, dorsa of hands, feet, and
scrotum or labia Acrocyanosis: Cyanosis of hands and feet Cutis marmorata: Transient mottling when infant is
exposed to decreased temperature
Neonatal jaundice after first 24 hours Ecchymoses or petechiae caused by birth trauma Milia: Distended sebaceous glands that appear as tiny white papules on cheeks,
chin, and nose Miliaria or sudamina: Distended sweat (eccrine) glands that appear as minute
vesicles, especially on face Erythema toxicum: Pink papular rash with vesicles superimposed on thorax,
back, buttocks, and abdomen; may appear in 24 to 48 hours and resolve after several days
Jaundice appearing in first 24 hours Generalized cyanosis Pallor Mottling Grayness Plethora Hemorrhage, ecchymoses, or petechiae that
persist Sclerema: Hard and stiff skin Poor skin turgor Rashes, pustules, or blisters Café-au-lait spots: Light brown spots Nevus flammeus: Port-wine stain
Harlequin color change: Clearly outlined color change as infant lies on side; lower half of body becomes pink, and upper half is pale
Mongolian spots: Irregular areas of deep blue pigmentation, usually in sacral and gluteal regions; seen predominantly in newborns of African, American Indian, Asian, or Hispanic descent
Telangiectatic nevi (“stork bites”): Flat, deep pink localized areas usually seen on back of neck
Head Fontanels flat, soft, and firm Widest part of fontanel measured from bone to bone,
not suture to suture
Molding after vaginal delivery Third sagittal (parietal) fontanel Bulging fontanel because of crying or coughing Caput succedaneum: Edema of soft scalp tissue Cephalhematoma (uncomplicated): Hematoma between periosteum and skull
bone
Fused sutures Bulging or depressed fontanels when quiet Widened sutures and fontanels Craniotabes: Snapping sensation along
lambdoid suture that resembles indentation of ping-pong ball
Eyes Eyelids usually edematous Color: Slate gray, dark blue, brown Absence of tears Presence of red retinal reflex Corneal reflex in response to touch Pupillary reflex in response to light Blink reflex in response to light or touch Rudimentary fixation on objects and ability to follow to
midline
Epicanthal folds in Asian infants Searching nystagmus or strabismus Subconjunctival (scleral) hemorrhages: Ruptured capillaries, usually at limbus
Pink color of iris Purulent discharge Upward slant in non-Asians Hypertelorism (3 cm) Hypotelorism Congenital cataract(s) Constricted or dilated fixed pupil Absence of red retinal reflex White reflex (leukocoria) Absence of pupillary or corneal reflex Inability to follow object or bright light to
midline Yellow sclera
Ears Position: Top of pinna on horizontal line with outer
canthus of eye Startle reflex elicited by a loud, sudden noise Pinna flexible, cartilage present
Inability to visualize tympanic membrane because of filled aural canals Pinna flat against head Irregular shape or size Pits or skin tags Preauricular sinus
Low placement of ears Absence of startle reflex in response to loud
noise should be evaluated but is not diagnostic
Minor abnormalities may be signs of various syndromes, especially renal
Nose Nasal patency Nasal discharge: Thin white mucus (transient) Sneezing
Flattened and bruised Nonpatent canals Thick, bloody nasal discharge Flaring of nares (alae nasi) Copious nasal secretions or stuffiness (may
be minor) Mouth and Throat Intact, high-arched palate Uvula in midline
Natal teeth: Teeth present at birth; benign but may be associated with congenital defects
Cleft lip Cleft palate
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Frenulum of tongue Frenulum of upper lip Sucking reflex: Strong and coordinated Rooting reflex Gag reflex Extrusion reflex Absent or minimal salivation Vigorous cry
Epstein pearls: Small, white epithelial cysts along midline of hard palate Large, protruding tongue or posterior displacement of tongue
Receding chin (lower jaw): Micrognathia Profuse salivation or drooling Candidiasis (thrush): White, adherent
patches on tongue, palate, and buccal surfaces
Inability to pass nasogastric tube Hoarse, high-pitched, weak, absent, or other
abnormal cry Neck Short, thick, usually surrounded by skinfolds Tonic neck reflex
Torticollis (wry neck): Head held to one side with chin pointing to opposite side Excessive skinfolds Resistance to flexion Absence of tonic neck reflex Fractured clavicle; crepitus
Chest Anteroposterior and lateral diameters equal Slight sternal retractions evident during inspiration Xiphoid process evident Breast enlargement
Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Supernumerary nipples Secretion of milky substance from breasts
Depressed sternum Marked retractions of chest and intercostal
spaces during respiration Asymmetric chest expansion Redness and firmness around nipples Wide-spaced nipples
Lungs Respirations chiefly abdominal Cough reflex absent at birth; may be present by 1 to 2
weeks Bilateral equal bronchial breath sounds
Irregular rate and depth of respirations, periodic breathing Crackles shortly after birth
Inspiratory stridor Expiratory grunt Intercostal, substernal, or suprasternal
retractions Persistent irregular breathing Periodic breathing with repeated apneic
spells lasting >20 seconds Seesaw respirations (paradoxic) Unequal breath sounds Persistent fine, medium, or coarse crackles Wheezing Cough Diminished breath sounds Peristaltic bowel sounds on one side with
diminished breath sounds on same side Heart Apex: Fourth to fifth intercostal space, lateral to left
sternal border S2 slightly sharper and higher in pitch than S1
Sinus arrhythmia: Heart rate increasing with inspiration and decreasing with expiration
Transient cyanosis on crying or straining
Dextrocardia: Heart on right side Displacement of apex, muffled or distant Cardiomegaly Abdominal bruit Murmur Thrill Persistent central cyanosis Hyperactive precordium
Abdomen Cylindric Liver: Palpable 2 to 3 cm below right costal margin Spleen: Tip palpable at end of first week of age Kidneys: Palpable 1 to 2 cm above umbilicus Umbilical cord: Bluish white at birth with two arteries
and one vein Femoral pulses: Equal bilaterally
Umbilical hernia Diastasis recti: Midline gap between recti muscles Wharton jelly: Unusually thick umbilical cord
Abdominal distention Localized bulging Distended veins Absent bowel sounds Enlarged liver and spleen Ascites Visible peristaltic waves Scaphoid or concave abdomen Moist umbilical cord Presence of only one artery in umbilical
cord Urine, stool, or pus leaking from umbilical
cord or cord insertion site Periumbilical erythema Palpable bladder distention after scanty
voiding Absent femoral pulses Cord bleeding or hematoma Omphalocele or gastroschisis: Protrusion
of abdominal contents through abdominal wall or cord
Female Genitalia Labia and clitoris usually edematous Urethral meatus behind clitoris Vernix caseosa between labia Urination within 24 hours
Pseudomenstruation: Blood-tinged or mucoid discharge Hymenal tag
Enlarged clitoris with urethral meatus at tip Fused labia Absence of vaginal opening Meconium from vaginal opening No urination within 24 hours Mass in labia Ambiguous genitalia Bladder exstrophy
Male Genitalia Urethral opening at tip of glans penis Testes palpable in each scrotum Scrotum usually large, edematous, pendulous, and
covered with rugae; usually deeply pigmented in dark-skinned ethnic groups
Smegma Urination within 24 hours
Urethral opening covered by prepuce Inability to retract foreskin Epithelial pearls: Small, firm, white lesions at tip of prepuce Erection or priapism Testes palpable in inguinal canal Scrotum small
Hypospadias: Urethral opening on ventral surface of penis
Epispadias: Urethral opening on dorsal surface of penis
Chordee: Ventral curvature of penis Testes not palpable in scrotum or inguinal
canal No urination within 24 hours Inguinal hernia Hypoplastic scrotum Hydrocele: Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
Back and Rectum Spine intact; no openings, masses, or prominent curves Trunk incurvation reflex Anal reflex Patent anal opening Passage of meconium within 48 hours
Green liquid stools in infant under phototherapy Delayed passage of meconium in very low birth weight neonates
Anal fissures or fistulas Imperforate anus Absence of anal reflex No meconium within 36 to 48 hours Missing vertebrae Pilonidal cyst or sinus Tuft of hair along spine Spina bifida cystica
Extremities Ten fingers and toes Full range of motion Nail beds pink with transient cyanosis immediately
after birth Creases on anterior two thirds of sole Sole usually flat Symmetry of extremities Equal muscle tone bilaterally, especially resistance to
opposing flexion
Partial syndactyly between second and third toes Second toe overlapping third toe Wide gap between first (hallux) and second toes Deep crease on plantar surface of foot between first and second toes Asymmetric length of toes Dorsiflexion and shortness of hallux
Polydactyly: Extra digits Syndactyly: Fused or webbed digits Phocomelia: Hands or feet attached close to
trunk Hemimelia: Absence of distal part of
extremity Hyperflexibility of joints Persistent cyanosis of nail beds Yellowing of nail beds
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Equal bilateral brachial pulses Sole covered with creases Transverse palmar (simian) crease Fractures Decreased or absent range of motion Dislocated or subluxated hip Limitation in hip abduction Unequal gluteal or leg folds Unequal knee height Audible clunk on abduction of hip Asymmetry of extremities Unequal muscle tone or range of motion
Neuromuscular System Extremities usually in some degree of flexion Extension of an extremity followed by previous
position of flexion Head lag while sitting but momentary ability to hold
head erect Ability to turn head from side to side when prone Ability to hold head in horizontal line with back when
held prone
Quivering or momentary tremors Hypotonia: Floppy, poor head control, extremities limp
Hypertonia: Jittery, arms and hands tightly flexed, legs stiffly extended, startles easily
Asymmetric posturing (except tonic neck reflex)
Opisthotonic posturing: Arched back Signs of paralysis Tremors, twitches, and myoclonic jerks Marked head lag in all positions
The nursing care of newborns is discussed on the following pages. The nursing process in the care of newborns is outlined in the Nursing Process box.
N u r s i n g P r o c e s s The Healthy Newborn and Family
Assessment Assess the newborn according to the guidelines on pp 206–210.
Diagnosis (Problem Identification) After a thorough assessment, several nursing diagnoses for healthy newborns include:
• Readiness for Enhanced Parenting
• Risk for Injury
• Effective Breastfeeding
• Risk for Imbalanced Body Temperature
• Readiness for Enhanced Nutrition
• Ineffective Breathing Pattern
• Risk for Infection
• Risk for Neonatal Jaundice
Planning Numerous outcomes for healthy newborns are discussed 211–225. Expected patient outcomes include:
• Newborn airway will remain patent.
• Effective breathing pattern will be established.
• Thermoregulation will be maintained.
• Parent–infant attachment behaviors will be observed.
• Breastfeeding or bottle feeding will be established.
• Infant will exhibit no evidence of infection; immune status will be maintained.
• Newborn will remain free of injury.
• Family will demonstrate ability to care for the infant's basic needs.
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• Newborn jaundice will be detected and monitored effectively.
Implementation Intervention strategies for healthy newborns and family are discussed 211–225.
Evaluation The effectiveness of nursing interventions for the newborn and family is determined by continual assessment and evaluation of care based on the following guidelines:
• Observe infant's color and respiratory pattern.
• Monitor axillary temperature regularly; observe for signs of temperature instability, such as respiratory distress.
• Observe for any evidence of infection, especially at the umbilicus or site of circumcision; check identification; and verify administration of prophylactic eye treatment, vitamin K injection, hepatitis B vaccine, and hearing and newborn screening tests, including bilirubin screening.
• Monitor infant's feeding ability and oral intake.
• Monitor daily weight.
• Observe interactions between infant and family members; interview family regarding their feelings about the newborn.
• Observe parents' ability to provide care for infant; interview parents regarding any concerns about infant's care at home.
• Observe parents' correct use of car safety seat restraint on discharge.
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Maintain a Patent Airway Establishing a patent airway is a primary objective in the delivery room. When the newborn is supine, a neutral neck position (i.e., avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway.
The American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (2011) recommends the supine position during sleep for healthy newborns. This recommendation is based on the association between sleeping prone and sudden infant death syndrome (see Chapter 10). Since the initial recommendation in 1992 that all infants be placed in the supine position to sleep, there has been no evidence of an increased number of complications, such as choking or vomiting, when infants are placed in this position (Krous, Masoumi, Haas, et al, 2007; Malloy, 2002). There has, however, been an increase in the number of infants with cranial asymmetry, particularly unilateral flattening of the occiput (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Health care professionals must educate parents on prevention of positional plagiocephaly by encouraging alternate positions when infants are awake (Laughlin, Luerssen, Dias, et al, 2011).
A bulb syringe is kept near the infant and is used if suctioning is required. If more forceful removal of secretions is required, mechanical suction is used. The use of the properly sized catheter and correct suctioning technique is essential to prevent mucosal damage and edema. Gentle suctioning is necessary to prevent reflex bradycardia, laryngospasm, and cardiac arrhythmias from vagal stimulation. Oropharyngeal suctioning is performed for up to 5 seconds, with sufficient time between each attempt to allow the infant to reoxygenate.
N u r s i n g A l e r t To avoid aspiration of amniotic fluid or mucus, clear the pharynx first and then the nasal passages using a bulb syringe: remember, mouth before nose. Vital signs are closely monitored, and any indication of respiratory distress is immediately reported.
N u r s i n g A l e r t The cardinal signs of respiratory distress in a newborn include tachypnea, nasal flaring, grunting, intercostal retractions, and cyanosis.
Maintain a Stable Body Temperature Conserving the newborn's body heat is an essential nursing goal. At birth, a major cause of heat loss is evaporation, the loss of heat through moisture. The amniotic fluid that bathes the infant's skin favors evaporation, especially when combined with the cool atmosphere of the delivery room. Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in skin-to-skin contact with the mother, covered by a blanket.
Another major cause of heat loss is radiation, the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant. Loss of heat through radiation increases as these solid objects become colder and closer to the infant. The temperature of ambient or surrounding air has no effect on loss of heat through radiation. This is a critical point to remember when attempting to maintain a constant temperature for the infant because even though the temperature of the ambient air is optimal, the infant can become hypothermic.
An example of radiant heat loss is the placement of the crib close to a cold window or air- conditioning unit. The cold from either source will cool the crib walls, and subsequently, the body of the neonate. To prevent this, place cribs as far away as possible from exterior walls, windows, and ventilating units. Heat loss can also occur through conduction and convection. Conduction involves loss of heat from the body because of direct contact of skin with a cooler solid object. Placing the infant on a padded, covered surface and providing insulation through clothes and blankets rather than directly on a cool hard table can minimize heat loss. Placing the newborn skin- to-skin with the mother on her chest or abdomen immediately after delivery is physically beneficial in terms of conserving heat, as well as fostering maternal attachment and breastfeeding.
Convection is similar to conduction except that heat loss is aided by surrounding air currents. For
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example, placing the infant in the direct flow of air from a fan or air-conditioner vent will cause rapid heat loss through convection. Transporting the neonate in a crib with solid sides reduces airflow around the infant.
Protect from Infection and Injury The most important practice for preventing cross-infection is thorough hand washing of all individuals involved in the infant's care. Other procedures to prevent infection include eye care, umbilical care, bathing, and care of the circumcision. Artificial nails are prohibited (World Health Organization, 2009), and long fingernails are discouraged for health care providers because the former have been implicated in the transmission of sepsis. Vitamin K is administered to protect against hemorrhage.
Identification Proper identification of the newborn is absolutely essential. The nurse must verify that identifying bands are securely fastened and verify the information (name, gender, mother's admission number, date, and time of birth) against the birth records and the child's actual gender. This identification process should take place optimally in the delivery room. Electronic tags that give off a radio frequency may also be used to prevent newborn abductions (Vincent, 2009). A tag is placed on the newborn and removed at the time of discharge by hospital personnel.
A proactive hospital emergency plan should be implemented to prevent infant abduction and to respond promptly and effectively in the event one happens. A mock newborn abduction drill is an effective method that can be used to evaluate staff competence and response to the incident (National Center for Missing and Exploited Children, 2015). All hospital personnel should be educated regarding newborn abduction, preventive aspects, and methods to identify the potential risk of such an occurrence.
The nurse should discuss safety issues with the mother the first time the infant is brought to her. The National Center for Missing and Exploited Children* (2015) has reported that 58% of infant abductions occur in the mother's room. A written copy of the safety instructions should also be given to the parent. Parents are instructed to look at identification badges of nurses and hospital personnel who come to take infants and not to relinquish their infants to anyone without proper identification. Mothers are also advised not to leave the infant alone in the crib while they shower or use the bathroom; rather, they should ask to have the infant observed by a health care worker if a family member is not present in the room. Parents and staff are encouraged to use a password system when the newborn is taken from the room as a routine security measure. The nurse should document in the chart that these instructions were given and that appropriate identification band checks are routinely made throughout each shift. Nursing staff are also educated regarding the “typical” abductor profile and to be constantly aware of visitors with unusual behavior.
The typical profile of an abductor is a female between the ages of 12 and 55 years (generally is in early 20s) who is often overweight and has low self-esteem; she may be emotionally disturbed because of the loss of her own child or an inability to conceive and may have a strained relationship with her husband or partner. The typical abductor may also be seen visiting the newborn nursery or neonatal intensive care unit area before the abduction and may ask questions about the care of or the health of a specific newborn. The abductor may familiarize herself with the hospital routine and may also impersonate a health care worker. Parents are made aware of the fact that infant safety measures must be implemented in the home as well. Measures to prevent and decrease infant abduction after discharge to the home include avoiding the publication of birth announcements in the local newspaper and avoiding using yard decorations to announce a newborn's arrival (National Center for Missing and Exploited Children, 2015).*
Eye Care Prophylactic eye treatment against ophthalmia neonatorum, infectious conjunctivitis of the newborn, includes the use of (1) silver nitrate (1%) solution, (2) erythromycin (0.5%) ophthalmic ointment or drops, or (3) tetracycline (1%) ophthalmic ointment or drops (preferably in single-dose ampules or tubes). All three are effective against gonococcal conjunctivitis. Chlamydia trachomatis is the major cause of ophthalmia neonatorum in the United States; topical antibiotics (tetracycline and erythromycin) and silver nitrate are not effective in the prevention and treatment of chlamydial
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conjunctivitis. A 14-day course of oral erythromycin or ethylsuccinate may be given for chlamydial conjunctivitis (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). The administration or oral erythromycin to infants younger than 6 weeks old has been associated with the development of infantile hypertrophic pyloric stenosis; therefore parents should be informed of the potential risks and signs of the illness (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012).
Herpes simplex virus may also cause neonatal conjunctivitis; treatment in such cases involves the use of topical and systemic antiviral medications.
Recent publications have explored alternate substances for ophthalmia neonatorum prevention, with a focus on growing concerns about the development of antimicrobial resistance. Colostrum (Ghaemi, Navaei, Rahimirad, et al, 2014) and povidone iodine (2.5%) (David, Rumelt, and Weintraub, 2011; Meyer, 2014) have been studied with small samples of infants. These substances may prove to be reasonable alternatives for ophthalmia neonatorum prophylaxis in the future.
Because studies on maternal attachment emphasize that in the first hour of life a newborn has a greater ability to focus on coordinated movement than at any other time during the next several days and because eye contact is very important in the development of maternal–infant bonding, the routine administration of silver nitrate or topical ophthalmic antibiotics can be postponed for up to 1 hour after birth. However, practitioners must ensure that the drug is given by 1 hour of age.
Vitamin K Administration Shortly after birth, vitamin K is administered to prevent hemorrhagic disease of the newborn. Normally, vitamin K is synthesized by the intestinal flora. However, because infants' intestines are relatively sterile at birth and because breast milk contains low levels of vitamin K, the supply is inadequate for at least the first 3 or 4 days. The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver, which is needed for blood clotting. The vastus lateralis muscle is the traditionally recommended injection site, but the ventrogluteal (not the dorsogluteal) muscle can be used.
Several countries have noted resurgence in later onset of vitamin K deficiency bleeding (VKDB) after practicing orally administered prophylaxis (American Academy of Pediatrics Committee on Fetus and Newborn, 2003). Current recommendations are that vitamin K be given to all newborns as a single intramuscular dose of 0.5 to 1.0 mg (American Academy of Pediatrics Committee on Fetus and Newborn, 2003; Fetus and Newborn Committee, 2014). Additional study is needed on the efficacy, safety, and bioavailability of oral preparations and on the most effective dosing regimens to prevent VKDB.
Hepatitis B Vaccine Administration To decrease the incidence of hepatitis B virus in children and its serious consequences (cirrhosis and liver cancer) in adulthood, the first of three doses of hepatitis B vaccine are recommended soon after birth and before hospital discharge for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). The injection is given in the vastus lateralis muscle because this site is associated with a better immune response than is the dorsogluteal area. Giving the infant concentrated oral sucrose can reduce the pain of the injection (Stevens, Yamada, Lee, et al, 2013).
Preterm infants born to HBsAg-negative women should be vaccinated as early as 30 days of age regardless of gestational age or birth weight. Infants born to HBsAg-positive mothers should be immunized within 12 hours after birth with hepatitis B vaccine and hepatitis B immune globulin (HBIG) at separate sites, regardless of gestational age or birth weight (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). In Canada, hepatitis B vaccine is given to newborns only if their mothers are HBsAg positive at birth (see Immunizations, Chapter 6).
Newborn Screening for Disease A number of genetic disorders can be detected in the newborn period. There is no national policy for newborn screening in the United States; therefore, the extent of neonatal screening is determined by state laws and voluntary guidelines. All states require screening for phenylketonuria (PKU) and congenital hypothyroidism; many states also have programs that include screening for sickle cell disease and galactosemia. Because concern has been voiced regarding the inconsistency among states in screening for genetic disorders based on cost, population demographics, resource
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availability, and political environment, the Task Force on Newborn Screening was formed by the American Academy of Pediatrics and other federal health care agencies to address this issue. A number of resolutions and policies have been developed to better address the issue of newborn screening (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b).
The nurse's responsibility is to educate parents regarding the importance of screening and to collect appropriate specimens at the recommended time (after 24 hours of age). With early newborn discharge before 24 hours, some authorities recommend a repeat screening for PKU within 2 weeks (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b). Accurate screening depends on high- quality blood spots on approved filter paper forms. The blood should completely saturate the filter paper spot on one side only. The paper should not be handled, placed on wet surfaces, or contaminated with any substance (see Atraumatic Care box).
At r a u m a t i c C a r e Heel Punctures
Heel lancing is necessary to obtain blood for newborn blood tests, including newborn screening. Studies have shown that venipuncture performed by an experienced phlebotomist elicited fewer pain responses (as measured by the Premature Infant Pain Profile [PIPP]) from full-term newborns than did heel punctures (Shah and Ohlsson, 2011). Furthermore, the need for additional skin punctures was reduced with venipuncture. Although maternal anxiety was initially higher in the venipuncture group, mothers who observed the venipuncture reported observing less pain response than mothers who observed heel punctures.
Oral sucrose and nonnutritive sucking have proved effective in decreasing the pain associated with heel punctures in preterm and full-term infants; however, the exact dose range that proves optimal effectiveness varies among studies (Stevens, Yamada, Lee, et al, 2013). Evidence indicates that as little as 0.05 to 0.5 ml of a 24% oral sucrose solution is effective in decreasing pain in full- term and preterm infants (Stevens, Yamada, Lee, et al, 2013). The best analgesic effect is achieved when sucrose is administered 2 minutes before the painful procedure with a pacifier or syringe and is repeatedly administered in small amounts (i.e., 0.05 to 0.5 ml) at 2-minute intervals throughout the painful procedure. The effect appears to begin at 2 minutes and lasts about 4 minutes, thus analgesic effect may wane if procedures are prolonged (Stevens, Yamada, Lee, et al, 2013). A number of commercially available oral sucrose solutions now exist. When these are not available, the pharmacy may mix an oral sucrose solution to ensure a clean product. Strict attention must be paid to aseptic technique with this method to prevent contamination of the solution and subsequent problems.
Breastfeeding is correlated with pain relief in full-term newborns undergoing painful procedures, as demonstrated by reduction in infants' crying time and reduction in pain scores, but breast milk given by syringe has not shown the same efficacy as breastfeeding itself (Shah, Herbozo, Aliwalas, et al, 2012). Comparison of sucrose with breastfeeding has produced mixed results, with some authors reporting superior pain relief with breastfeeding (Codipietro, Ceccarelli, and Ponzone, 2008), and some concluding similarity of effect when comparing sucrose to breast milk (Simonse, Mulder, and van Beek, 2012). In the latter study, however, small groups of late- preterm infants (LPIs) were provided with breast milk either by direct breastfeeding (n = 23) or by bottle (n = 23) and were compared with LPIs who received sucrose. Thus, it is difficult to determine optimal pain prevention treatment when comparing breastfeeding with sucrose and more research is needed.
In a small randomized double-blind prospective study of infants younger than 37 weeks gestation, the combination of sucrose and the eutectic mixture of local anesthetic (EMLA) cream demonstrated higher analgesic effect than sucrose alone during venipuncture (Biran, Gourrier, Cimerman, et al, 2011).
Nonpharmacologic strategies unrelated to feeding have also demonstrated pain relief potential. Having the mother hold the infant in skin-to-skin contact has been shown to significantly reduce the child's distress during the procedure (Johnston, Filion, Campbell-Yeo, et al, 2009; Johnston, Stevens, Pinelli, et al, 2003). Use of music as a calming measure for neonates was explored in a systematic review of nine studies (Hartling, Shaik, Tjosvold, et al, 2009). The authors concluded that although there was preliminary evidence for some therapeutic benefits of music for specific
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indications, more methodologically rigorous trials are needed to determine the contribution of music to neonatal pain relief. A recent Cochrane Review examined 51 randomized controlled trails and concluded that nonpharmacologic interventions (such as nonnutritive sucking, skin-to-skin holding, swaddling/facilitated tucking, and rocking or holding) can significantly manage pain behaviors associated with painful procedures in preterm infants, neonates, and older infants (Pillai Riddell, Racine, Turcotte, et al, 2011).
These studies provide evidence of a number of effective ways to decrease the pain associated with heel puncture in full-term and preterm newborns. It is essential that nurses use all available resources to advocate for the prevention and management of neonatal pain during such procedures. Because the overall goal is to decrease the effect of painful interventions such as heel stick on infants, a combination of pharmacologic and nonpharmacologic interventions is recommended. Also see the Atraumatic Care box later in this chapter.
The American Academy of Pediatrics recommends routine prenatal and perinatal human immunodeficiency virus (HIV) counseling and testing for all pregnant women (Pickering, American Academy of Pediatrics, Committee on Infectious Diseases, 2012). Benefits of early identification of HIV-infected infants are early antiretroviral therapy and aggressive nutritional supplementation; appropriate changes in their immunization schedule; monitoring and evaluation of immunologic, neurologic, and neuropsychologic functions for possible changes caused by antiretroviral therapy; initiation special educational services; evaluation for the need of other therapies, such as immunoglobulin for the prevention of bacterial infections; tuberculosis screening and treatment; and management of communicable disease exposures.
Cesarean section performed before the rupture of membranes or the onset of labor, may prevent mother-to-child transmission of HIV in optimally treated women and is associated with a reduction in the risk of mother-to-child transmission among HIV-infected women who are either not receiving antiretroviral therapy or are receiving minimal therapy. For infants whose mother's HIV status is unknown, rapid HIV antibody testing provides information within 12 hours of the infant's birth. Antiretroviral prophylaxis is started as soon as possible, pending completion of confirmatory HIV testing. Breastfeeding is delayed until confirmatory testing is done.
For information on additional diseases that may be screened in the newborn period, see Newborn Screening Fact Sheets (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b).
Universal Newborn Hearing Screening It is estimated that screening children by high-risk factors alone fails to identify approximately 50% of all newborns with congenital hearing loss. Infants who are hard of hearing or deaf, but who receive intervention before 6 months old, score 20 to 40 percentile points higher on school-related measures (language, social adjustment, and behavior), compared with hearing-impaired children who receive later intervention (Patel and Feldman, 2011). For these reasons, the American Academy of Pediatrics, Joint Committee on Infant Hearing (2007) recommends universal hearing screening of all newborns before discharge from the birthing hospital. For infants born by cesarean delivery, it is preferable to delay otoacoustic emission (OAE) testing until after 48 hours of age, because testing earlier than this is associated with significantly higher rates of failure, possibly as a result of retained fluid in the middle ear (Smolkin, Mick, Dabbah, et al, 2012). Newborns who fail the initial screening require referral for outpatient retesting and intervention by 1 month old (American Academy of Pediatrics, Joint Committee on Infant Hearing Screening, 2007). A subsequent audiologic assessment should be performed at least once by 24 to 36 months old if the infant has any hearing risk factors despite passing the newborn hearing screening (Harlor, Bower, Committee on Practice and Ambulatory Medicine, et al, 2009).
Bathing Bath time is an opportunity for the nurse to accomplish much more than general hygiene. It is an excellent time for observing the infant's behavior, state of arousal, alertness, and muscular activity. With the possibility of transmission of viruses (such as hepatitis B virus and HIV via maternal blood and blood-stained amniotic fluid) as part of standard precautions, nurses should wear gloves when handling newborns until blood and amniotic fluid are removed by bathing.
Older studies suggested that healthy full-term newborns with a stable body temperature could be safely bathed as early as 1 hour of age without experiencing problems, provided that effective
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thermoregulation measures are taken after the bath (Behring, Vezeau, and Fink, 2003; Medves and O'Brien, 2004; Varda and Behnke, 2000). More recent studies have demonstrated that early bathing (within the first hour of life), interferes with skin-to-skin holding and breastfeeding, compromising basic protection against neonatal infection (Sobel, Silvestre, Mantaring, et al, 2011). In a large study of more than 800 late preterm infants, researchers concluded that early bathing may interfere with transition to extrauterine life and optimal adaptation of body processes, possibly contributing to problems such as hypothermia and hypoglycemia (Medoff-Cooper, Holditch-Davis, Verklan, et al, 2012). Nursing interventions such as bathing should be based on individualized assessment, and the initial newborn bath should be delayed until completion of initial skin-to-skin holding and breastfeeding.
The bath time provides an opportunity for the nurse to involve the parents in the care of their child, to teach correct hygiene procedures, and to learn about their infant's individual characteristics (Fig. 7-10). The appropriate types of bathing supplies and the need for safety in terms of water temperature and supervision of the infant at all times during the bath are stressed.
FIG 7-10 Bath time is an excellent opportunity for parents to learn about their newborn.
Parents are encouraged to examine their infant closely during bathing. Frequently, normal variations (such as, Epstein pearls, mongolian spots, or “stork bites”) cause parents much distress if they are unaware of the significance of such findings. Minor birth injuries may appear as major defects to them. Explaining how these occurred and when they will disappear reassures parents of their infant's normalcy. Common variations are discussed further in Chapter 8.
One of the most important considerations in skin cleansing is preservation of the skin's acid mantle, which is formed from the uppermost horny layer of the epidermis; sweat; superficial fat; metabolic products; and external substances, such as amniotic fluid, microorganisms, and chemicals. Infants' skin surface has a pH of about 5 soon after birth, and the bacteriostatic effects of this pH are significant. In addition, newborn skin is covered with host-defense proteins, such as lysozyme and lactoferrin, which contribute importantly to a newborn's defense against bacterial infections (Walker, Akinbi, Meinzen-Derr, et al, 2008). Consequently, use only plain warm water for bathing. If a cleanser is needed, it should be mild and have a neutral pH. Alkaline soaps, oils, powder, and lotions are not used because they alter the acid mantle, thus providing a medium for bacterial growth. Talcum powder has the added risk of aspiration if it is applied too close to the infant's face. Parents should be involved in a discussion regarding the newborn's bath at home. It is recommended that for the first 2 to 4 weeks the infant be bathed no more than two or three times per week with a plain warm sponge bath. This practice helps maintain the integrity of the newborn's skin and allows time for the umbilical cord to completely dry. Routine daily soap
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bathing for newborns is no longer recommended.
Care of the Umbilicus Because the umbilical stump is an excellent medium for bacterial growth, various methods of cord care have been practiced to prevent infection. Some methods popular in the past include the use of an antimicrobial agent (such as, bacitracin or triple dye) and agents (such as alcohol or povidone iodine). The use of antiseptic agents has been shown to prolong cord drying and separation (Zupan, Garner, and Omari, 2004). A Cochrane review of 21 studies found no significant difference between cords treated with antiseptics compared with dry cord care or placebo; there were no reported systemic infections or deaths, and a trend toward reduced colonization was found in cords treated with antiseptics (Zupan, Garner, and Omari, 2004). Recommendations for cord care by the Association of Women's Health, Obstetric and Neonatal Nursing (2013) include cleaning the umbilical cord initially with sterile water or a neutral pH cleanser and then subsequently cleaning the cord with water.
Nurses working in neonatal care must carefully evaluate the available studies and compare the risks and benefits regarding the method of cord care within their own population of newborns and families. Regardless of the method used, nurses must include cord care teaching in the discharge planning, because it has been demonstrated to be a concern for parents after discharge to the home. Particularly in the developing world, infants may encounter increased risk of potentially life- threatening sepsis; thus, antimicrobial treatment may be appropriate in some settings (Mullany, Darmstadt, Katz, et al, 2009).
The diaper is folded in front below the cord to avoid irritation and wetness on the site. The area is kept free of urine and stool and cleansed daily with water if needed. Parents are instructed regarding stump deterioration and proper umbilical care. The stump deteriorates through the process of dry gangrene. Cord separation time is influenced by a number of factors, including the type of cord care, type of delivery, and other perinatal events. The average cord separation time is 5 to 15 days. It takes a few more weeks for the cord base to heal completely after cord separation. During this time, care consists of keeping the base clean and dry and observing for any signs of infection.
Circumcision Circumcision, the surgical removal of the foreskin on the glans penis, is usually done in the hospital, although it is not a common practice in most countries. In the United States, however, between approximately 40% and 70% of newborn boys are circumcised, depending on the region (Owings, Uddin, Williams, et al, 2013). The Centers for Disease Control and Prevention National Center for Health Statistics reports that the overall national rate of newborn circumcision has fallen from 64.5% of newborns in 1979 to 58.3% of newborns in 2010 (Owings, Uddin, Williams, et al, 2013). Despite the frequency of the procedure in the United States, there is controversy regarding the benefits and risks (Box 7-4).
Box 7-4 R i s k s a n d B e n e f i t s o f N e o n a t a l C i r c u m c i s i o n Risks
Complications:
• Hemorrhage
• Infection
• Meatitis (from loss of protective foreskin)
• Adhesions
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• Concealed penis
• Urethral fistula
• Meatal stenosis
• Necrosis or amputation
Pain in unanesthetized infants: Long-term consequences unknown, but short-term stresses include increased heart rate, behavior changes, prolonged crying, increased cortisol levels, and decreased blood oxygenation
Benefits*
Prevention of penile cancer and posthitis (inflammation of prepuce)
Decreased incidence of balanitis (inflammation of glans), urinary tract infections in male infants, and some sexually transmitted infections later in life (herpes, syphilis, gonorrhea)
Decreased incidence of human immunodeficiency virus (HIV) infection, human papillomavirus (HPV), and cervical cancer (in female partner)
Prevention of complications associated with later circumcision
Preservation of male's body image that is consistent with peers (only in countries or cultures where procedure is common)
*Although there is risk reduction for these conditions with circumcision, the absolute risk of conditions (such as penile cancer and infant urinary tract infections) is so low that neither the American Academy of Pediatrics nor the American Medical Association recommends circumcision for prevention. There is growing evidence regarding circumcision and decreased transmission of sexually transmitted infections (Weiss, Dickson, Agot, et al, 2010). The Joint United Nations Programme on HIV/AIDS (2010) suggests long-term HIV prevention strategy is likely to include the provision of neonatal circumcision.
Research has explored the possible link between circumcision and reduced transmission of communicable illnesses, such as human papillomavirus (HPV) and HIV in later life. The American Academy of Pediatrics Task Force on Circumcision (2012) states that current evidence indicates the health benefits of newborn male circumcision outweigh the risks, and that the procedure should be made available to families who choose it. Despite encouraging outcome data, the health benefits are not yet great enough to recommend routine circumcision of all male newborns (American Academy of Pediatrics Task Force on Circumcision, 2012; Jagannath, Fedorowicz, Sud, et al, 2012).
The current American Academy of Pediatrics Task Force on Circumcision (2012) statement emphasizes parental autonomy to determine what is in the best interest of their newborn. The policy encourages the primary care practitioner to ensure that parents have been given accurate and unbiased information about the risks, benefits, and alternatives before making an informed choice and that they understand that circumcision is an elective procedure. In addition to examining the medical benefits of male newborn circumcision, the American Academy of Pediatrics recommends that procedural analgesia be provided if parents decide to have their male infant circumcised.
Nurses are in a unique position to educate parents regarding the care of their newborns, and they must take responsibility for ensuring that each parent has accurate and unbiased information with which to make an informed decision. Parents need to know the options for pain control, and nurses must be proactive in advocating for circumcision analgesia. Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions may still be performed with either insufficient analgesia or no analgesia at all. Nurses can use the American Academy of Pediatrics Task Force on Circumcision's policy statement (2012) to advocate for the use of optimal pain relief for circumcision.
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A combination of nonpharmacologic and pharmacologic strategies is recommended for optimal pain prevention and control. Topical eutectic mixture of local anesthetics (EMLA) cream alone is insufficient for neonatal circumcision, although it may be useful for decreasing the pain of needle insertion when used in combination with local anesthesia via subcutaneous ring block of the penis or dorsal penile nerve block (Paix and Peterson, 2012).
Nurses should use nonpharmacologic interventions that can reduce the pain of this operative procedure (see Atraumatic Care box). Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions may still be performed with either insufficient analgesia or no analgesia at all.
At r a u m a t i c C a r e Guidelines for Pain Management during Neonatal Circumcision*
Pharmacologic Interventions Use of Dorsal Penile Nerve Block or Ring Block with Topical Analgesia One hour before the procedure, administer acetaminophen as ordered. One hour before the procedure, apply EMLA.†
For the DPNB: Place a thick layer (1 g) of EMLA (lidocaine–prilocaine) cream around the penis where the prepuce (foreskin) attaches to the glans. Avoid placing cream on the tip of the penis where EMLA may come in contact with the urethral opening.
For the ring block: Apply EMLA to the prepuce as described earlier and to the shaft of the penis. A topical anesthetic used in conjunction with the DPNB or ring block decreases the pain of inserting the needle used for injecting the anesthetic.
Cover the penis with a “finger cot” that is cut from a vinyl glove or a piece of plastic wrap and secure the bottom of the covering with tape. Avoid using large amounts of tape on the skin because removing the adhesive causes pain and can irritate or remove the fragile skin.
If the infant urinates during the time EMLA is applied (1 hr) and a significant amount of EMLA is removed, reapply the cream and covering. The total application of EMLA should not exceed a surface area of 10 cm2 (1.25 × 1.25 inches).
Remove the cream with a clean cloth or tissue. Blanching of the skin is an expected reaction to EMLA's application under an occlusive dressing; erythema and some edema may also occur.
Nonpharmacologic Interventions (To Accompany the Preceding Pharmacologic Interventions) If a Circumstraint board is used, pad it with blankets.
Provide the parents, caregiver, or another staff member with the option of being present during the circumcision.
Swaddle the upper body and legs to provide warmth and containment and to reduce movement (see Fig. 7-11).
If the patient is not swaddled and is unclothed, use a radiant warmer to prevent hypothermia. Shield the infant's eyes from overhead lights.
Prewarm any topical solutions to be used in sterile preparation of the surgical site by placing them in a warm blanket or towel.
Play infant relaxation music before, during, and after the procedure; allow the parents or other caregiver the option of providing the music of choice.
After the procedure, remove restraints and swaddle. Immediately have the parent, other caregiver, or nursing staff hold the infant. Continue to have the infant suck on the pacifier or offer feeding.
Combination analgesia is recommended: oral sucrose, acetaminophen, topical anesthetic, and DPNB or ring block in addition to nonpharmacologic comfort measures, such as containment, positioning, nonnutritive sucking, and breastfeeding.
DPNB, Dorsal penile nerve block; EMLA, eutectic mixture of local anesthetics.
References
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Cyna AM, Middleton P. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cochrane Database Syst Rev. 2008;8(4) [CD003005].
Joint United Nations Programme on HIV/AIDS. Neonatal and child male circumcision: a global review. http://www.who.int/hiv/pub/malecircumcision/neonatal_child_MC_UNAIDS.pdf; 2010.
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2010;(1) [CD001069].
Yamada J, Stinson J, Lamba J, et al. A review of systematic reviews on pain interventions in hospitalized infants. Pain Res Manage. 2008;13(5):413–420.
*There is sufficient evidence and support for use of pharmacologic and nonpharmacologic interventions to holistically manage neonatal pain. Combined analgesia, including pharmaceuticals and nonpharmacologic interventions (such as swaddling, sucking, and sucrose), are recommended during the procedure to provide holistic pain management.
†EMLA is approved for use in infants age 37 or more weeks of gestation, provided practitioners follow recommendations regarding maximal dose and limits for exposure time to the medication. In addition, practitioners are advised not to use EMLA with infants who are receiving potentially methemoglobinemia-inducing medications, such as acetaminophen or phenobarbital. Although the package insert warns that patients taking acetaminophen are at greater risk for developing methemoglobinemia, there have been no reported cases of this complication occurring in children taking acetaminophen and using EMLA.
Four types of anesthesia and analgesia are used in newborns undergoing circumcision: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as EMLA (prilocaine–lidocaine) or LMX4 (4% lidocaine), and concentrated oral sucrose. Oral acetaminophen and comfort measures (such as music, sucking on a pacifier, and soothing voices) have not proved to be effective in reducing the pain of circumcision when used alone. The Cochrane group exploring pain relief for neonatal circumcision found that DPNB was the most effective intervention for decreasing the pain of circumcision (Brady-Fryer, Wiebe, and Lander, 2009).
Circumcision should not be performed immediately after delivery because of neonates' unstable physiologic status and increased susceptibility to stress. Preoperative nursing care usually includes allowing the infant nothing by mouth before the procedure to prevent aspiration of vomitus (≈2 hours); however, the necessity of this practice has been questioned (Kraft, 2003). Additional measures include the surgical time-out, checking for a signed consent form, and adequately restraining the infant, usually on a special board (Fig. 7-11) or physiologic circumcision restraint chair. All of the equipment used for the procedure, such as gloves, instruments, dressings, and draping towels, must be sterile.
FIG 7-11 Proper positioning of infant in Circumstraint. (Photo by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
The procedure involves freeing the foreskin from the glans penis by using a scalpel, Gomco or Mogen clamp (see Cultural Considerations box), or Plastibell. In the Gomco technique, the foreskin is clamped, cut with a scalpel, and removed; the clamp crushes the nerve endings and blood vessels, promoting hemostasis. In the Plastibell procedure, the foreskin is removed using a plastic ring and a string tied around the foreskin like a tourniquet. The excess foreskin is trimmed. In about 5 to 8 days, the plastic ring separates and falls off.
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C u l t u r a l C o n s i d e r a t i o n s Circumcision
In the Jewish culture, circumcision is performed during a ceremony called a berith, or brit, which takes place on the eighth day of life. A specially trained professional known as a mohel stretches the prepuce over the glans, pulling it though a slit in a shield (usually a Mogen clamp) and cutting it with a knife. The traditional technique is not sterile, and bleeding is controlled by tight bandaging around the penis (Cohen, Drucker, Vainer, et al, 1992). The infant may be given some sweet wine before the procedure. Blankets instead of straps are usually used to restrain the infant on a board, and the parents are present. Although risk of injury as a result of neonatal circumcision is low, risk is increased when circumcision is done out of hospital by non-professional practitioners, and suggested techniques for avoiding injury and repair of injury are available (Banihani, Fox, Gander, et al, 2014; Pippi Salle, Jesus, Lorenzo, et al, 2013).
Female circumcision (mutilation), or female genital mutilation (FGM), is also practiced in some countries, particularly in Africa, the Middle East, and Southeast Asia, and among immigrants from these countries. In the most extensive operations (excision or infibulation), the clitoris, labia minora, and medial aspects of the labia majora may be partially or completely removed. The remaining labia are sewn closed except for a small opening for urine and menses (World Health Organization, 2014). Anesthesia is used rarely. In African and Asian cultures, female circumcision is used to prove virginity and to reduce sexual pleasure, thus promoting fidelity. The World Health Organization (2010) condemns all forms of FGM. FGM is associated with an increased risk for adverse obstetric outcomes and numerous physical problems, which often may not receive medical care (World Health Organization, 2010, 2014).
After the procedure is completed, the infant is released from the restraints and comforted. If the parents were not present during the procedure, they are informed of the infant's status and reunited with their son.
Care of the circumcised penis depends on the type of procedure performed. If a clamp (Gomco or Mogen) was used, a petrolatum gauze dressing may be applied loosely to prevent adherence to the diaper. If the Plastibell was applied, no special dressing is required. Because the area is tender, the diaper is applied loosely to prevent friction against the penis. The penis is evaluated for excessive bleeding in the first few hours after the procedure, and the first void is recorded. A recommended standard is to evaluate the site every 30 minutes for at least 2 hours and then at least every 2 hours thereafter.
Normally, on the second day, a yellowish white exudate forms as part of the granulation process. This is not a sign of infection and is not forcibly removed. As healing progresses, the exudate disappears. Parents are educated to report any evidence of bleeding, unusual swelling, or absence of voiding to the practitioner.
Provide Optimal Nutrition Selection of a feeding method is one of the major decisions parents face. In general, there are two choices: (1) human milk and (2) commercially prepared whole cow's milk formula. These two methods have significant nutritional, economic, and psychological advantages and differences. Nurses should be at the forefront in providing parent(s) with accurate and unbiased information needed to make a conscientious informed decision regarding the feeding method.
Human Milk Human milk is the best option for infant nutrition up to 1 year old. Breast milk consists of a number of micronutrients that are called bioavailable, meaning these nutrients are available in quantities and qualities that make them easily digestible by the newborn's intestine and absorbed for energy and growth. Breast milk offers a variety of immunologic properties that are found exclusively in human milk. Human milk has been shown to be effective in protecting newborns against respiratory tract infections, gastrointestinal infections, otitis media, numerous allergies, type 2 diabetes, and atopy.
The fat content of human milk is composed of lipids, triglycerides, and cholesterol; cholesterol is
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an essential element for brain growth. The function of these lipids is to allow optimal intestinal absorption of essential fatty acids and polyunsaturated fatty acids (PUFAs). Furthermore, lipids contribute approximately 50% of the total calories in human milk (Lawrence and Lawrence, 2011). Although the overall fat content in human milk is higher than in cow's milk, it is used more efficiently by infants.
The primary source of carbohydrate in human milk is lactose, which is present in higher concentrations (6.8 g/dl) than in cow's milk–based formula (4.9 g/dl). The carbohydrates not only serve as a large portion of total calories in human milk but also have protective functions; the oligosaccharides (prebiotic) in human milk stimulate the growth of Lactobacillus bifidus (a probiotic) and prevent bacteria from adhering to epithelial surfaces. Human milk contains two proteins, whey (lactalbumin) and casein (curd), in a ratio of approximately 60 : 40 (vs. 80 : 20 in most cow's milk– based formula). This ratio in human milk makes it more digestible and produces the soft stools seen in breastfed infants. Thus, human milk has a laxative effect, and constipation is uncommon. The whey protein lactoferrin in human milk has iron-binding characteristics with bacteriostatic capabilities, particularly against gram-positive and gram-negative aerobes, anaerobes, and yeasts (Lawrence and Lawrence, 2011).
Lysozyme is found in large quantities in human milk and has bacteriostatic functions against gram-positive bacteria and Enterobacteriaceae organisms. Human milk also contains numerous other host defense factors, such as macrophages, granulocytes, and T and B lymphocytes. Casein in human milk greatly enhances the absorption of iron, thus preventing iron-dependent bacteria from proliferating in the gastrointestinal tract. Secretory immunoglobulin A (IgA) is found in high levels in colostrum, but levels gradually decline over the first 14 days of life. Secretory IgA prevents bacteria and viruses from invading the intestinal mucosa in breastfed newborns, thus protecting from infection. The whey protein is also believed to play an important role in preventing the development of certain allergies.
Several digestive enzymes also present in human milk include amylases, lipases, proteases, and ribonucleases, which enhance the digestion and absorption of various nutrients. The amounts of lipid- and water-soluble vitamins, electrolytes, minerals, and trace elements in human milk are sufficient for growth, development, and energy needs during the first 6 months of life. The one possible exception is vitamin D, which is found in varying amounts depending on the mother's intake of vitamin D–fortified food and exposure to ultraviolet light. Therefore, to prevent vitamin D–deficiency rickets, the American Academy of Pediatrics Section on Breastfeeding now recommends that infants who are exclusively breastfed or who are ingesting less than 1000 ml/day of vitamin D–fortified formula be supplemented with 400 IU vitamin D (oral) per day (Wagner, Greer, American Academy of Pediatrics Section on Breastfeeding, 2008). The Canadian Pediatric Society, First Nations, Inuit, and Métis Health Committee (2007) suggests that for children living in its northernmost climates, it may be reasonable to double this recommendation to 800 IU per day to compensate for extremely limited exposure to sunlight.
Additional beneficial components of human milk include prostaglandins, epidermal growth factor, docosahexaenoic acid (DHA), arachidonic acid (AA), taurine, cystine, carnitine, cytokine, interleukins, and natural hormones (such as, thyroid-releasing hormone, gonadotropin-releasing hormone, and prolactin). Studies have demonstrated that breastfeeding is associated with a decrease in the incidence of diabetes (Le Huërou-Luron, Blat, and Boudry, 2010; Pereira, Alfenas Rde, and Araújo, 2014; Young, Martens, Taback, et al, 2002); a decrease in the incidence of infections of all kinds, which may be an effect sustained into childhood (Li, Dee, Li, et al, 2014); and higher intelligence scores compared with cow's milk–based formula–fed infants (Michaelsen, Lauritzen, and Mortensen, 2009). Studies have demonstrated that breastfeeding has an analgesic effect on newborns during painful procedures, such as heel puncture (Shah, Herbozo, Aliwalas, et al, 2012).
Breastfeeding Human milk is the preferred form of nutrition for all infants. Healthy People 2020 has a goal to increase breastfeeding rates in the United States to 81.9% in early postpartum and to 61% for mothers who continue to breastfeed for at least 6 months (US Department of Health and Human Services, 2015). Some have voiced concern that early discharge of new mothers from hospitals, more aggressive marketing of infant formulas to the public, and more employed mothers contributed to the decline of breastfeeding. In addition, some hospital practices may undermine breastfeeding. Early separation of the mother and newborn, delays in initiating breastfeeding, provision of
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formula in the hospital and in discharge packs, conflicting information by health care workers, and formula coupons given at discharge have been implicated in the decline of breastfeeding after discharge. Rooming-in has correlated positively with successful breastfeeding, but the use of pacifiers has sometimes been associated with earlier weaning from breast to bottle.
Studies exploring breastfeeding mothers' reasons for early cessation of breastfeeding suggest several factors contribute to this decision, such as problems with lactation, concerns with newborn or maternal health, and lower maternal education (Odom, Li, Scanlon, et al, 2013). Modifiable factors associated with a decreased risk of early cessation of breastfeeding include professional and social support (Meedya, Fahy, and Kable, 2010; Odom, Li, Scanlon, et al, 2013; Thulier and Mercer, 2009). These findings have important implications for nurses in education and discussion regarding breastfeeding before, during, and after pregnancy.
The American Academy of Pediatrics Section on Breastfeeding (2012) has reaffirmed its position recommending exclusive breastfeeding until 6 months old, with continued breastfeeding until at least 1 year old and beyond as long as is mutually desirable by mother and infant. The Academy also supports programs that enable women to continue breastfeeding after returning to work. In its support of breastfeeding practices, the Academy further discourages the advertisement of infant formula to breastfeeding mothers and distribution of formula discharge packs without the advice of a health care provider.
The Baby-Friendly Initiative (BFI) is a joint effort of the World Health Organization and the United Nations Children's Fund to encourage, promote, and support breastfeeding as the model for optimum infant nutrition. Ten evidence-informed practices were developed by the BFI as a guideline for caregivers worldwide to promote breastfeeding (World Health Organization, United Nations Children's Fund, and Wellstart International, 2009) (Box 7-5). Research indicates that BFI designation is associated with higher rates of breastfeeding initiation (Abrahams and Labbok, 2009); however, BFI designation did not appear to affect breastfeeding rates among women with higher educational levels in a United States sample (Hawkins, Stern, Baum, et al, 2014). In addition, Atchan, Davis, and Foureur (2013), in a review of the evidence exploring association between BFI status and outcomes, note that the lack of clearly worded and sensitive indicators, inaccurate reporting, and the lack of studies with sufficient sample size has limited the ability of researchers to make conclusive statements about the existence of direct causal effect between breastfeeding practices and the initiative, although there is clearly a positive association. In addition to the physiologic qualities of human milk, the most outstanding psychological benefit of breastfeeding is the close mother–child relationship. The infant is nestled close to the mother's skin, can hear the rhythm of her heartbeat, can feel the warmth of her body, and has a sense of peaceful security. The mother has a close feeling of union with her child and feels a sense of accomplishment and satisfaction as the infant sucks milk from her.
Box 7-5 Te n S t e p s t o S u c c e s s f u l B r e a s t f e e d i n g Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk unless medically indicated.
7. Practice rooming-in—allowing mothers and infants to remain together—24 hours a day.
8. Encourage breastfeeding on demand.
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9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups, and refer mothers to them on discharge from the hospital or clinic.
Data from World Health Organization, United Nations Children's Fund, and Wellstart International: Baby-friendly hospital initiative: revised, updated and expanded for integrated care, 2009, http://whqlibdoc.who.int/publications/2009/9789241594967_eng.pdf.
Human milk is the most economical form of feeding. It is always available, ready to serve at body temperature, and free of contamination. Although human milk is not sterile, healthy full-term infants can tolerate varying amounts of nonpathogenic and pathogenic organisms. Human milk's protection against infection can provide additional cost savings in terms of fewer medical visits and less time lost from work for the employed mother.
Breastfed infants, especially beyond 2 to 3 months old, tend to grow at a satisfactory but slower rate than bottle-fed infants.
Contraindications to breastfeeding include the following (Lawrence and Lawrence, 2011; American Academy of Pediatrics Section on Breastfeeding, 2012; Wagner, Greer, American Academy of Pediatrics Section on Breastfeeding, et al, 2008): • Maternal chemotherapy antimetabolites and certain antineoplastic drugs • Active tuberculosis not under treatment in the mother • HIV in the mother in the industrialized world: In the developing world, risks to non-breastfeeding
infants from malnutrition and infectious disease are significant, so the benefits of breastfeeding may outweigh the risk of acquiring HIV from human milk (American Academy of Pediatrics Section on Breastfeeding, 2012)
• Galactosemia in the infant • Maternal herpes simplex lesion on a breast • Cytomegalovirus (CMV): May be a risk to extremely low birth weight preterm infants (<1500 gm).
CMV is not a risk for full-term infants whose mother is seropositive for CMV. • Maternal substance abuse with street drugs (e.g., phencyclidine [PCP], cocaine, and cannabis)
(Note: Adequately-nourished narcotic-dependent mothers may be encouraged to breastfeed if they are enrolled in a supervised methadone maintenance program and have negative screening for HIV and illicit drugs.)
• Human T-cell leukemia virus types I and II • Mothers who are receiving diagnostic or radioactive isotopes or who have had exposure to
radioactive materials (for as long as there is radioactivity in milk) A small number of medications are contraindicated for breastfeeding mothers. Consult a
reference such as LactMed, an online source published by the National Library of Medicine/National Institutes of Health (National Library or Medicine, 2015).
Some herbal products are presented as safe and effective alternatives to prescription or over-the- counter medications. Certain herbal agents, called galactogogues, are reported to increase breast milk production. However, insufficient data are available to confirm or deny the assertion of increased milk production using herbal galactogogues or to ensure that the herbal preparations are safe for breastfeeding infants (Jackson, 2010; Zuppa, Sindico, Orchi, et al, 2010). Mothers are cautioned to seek advice from a practitioner to ensure that the herbal preparations do not have the potential for harm.
Breastfeeding with twins and other multiples requires specialized professional support. If both twins are full term, they can begin feeding immediately after birth (Fig. 7-12); late preterm infants should be evaluated individually but may be breastfed if stable. Simultaneous feeding promotes the rapid production of milk needed for both infants and makes the milk that would normally be lost in the letdown reflex available to one of the twins. When only one infant is hungry, the mother should feed singly. She should also alternate breasts when feeding each infant and avoid favoring one breast for one infant. The suckling patterns of infants vary, and each infant needs the visual stimulation and exercise that alternating breasts provides.
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FIG 7-12 Simultaneous breastfeeding of twins.
A concern mothers may have is the perceived inconvenience or loss of freedom and independence if they chose to breastfeed. Being committed to feeding the infant every 2 to 3 hours can seem overwhelming, especially to women with multiple responsibilities. Many women resume their careers shortly after their pregnancy and may believe bottle feeding is less work than breastfeeding. The preparation, storage, and heating of formula are important considerations for the family when comparing the effort required for bottle feeding versus breastfeeding. Combining breastfeeding and employment is possible, and many employers now provide space for mothers to pump and store their milk. This is likely an acknowledgement of the demonstrated health benefits of breastfeeding—a breastfed infant is far less likely to have infections of any sort; thus, the infant's mother is far less likely to need time away from work to care for an ill infant. Although breastfeeding is the preferred form of infant feeding, mothers' decisions regarding their preferences must be supported and respected.
Successful breastfeeding probably depends more on the mother's desire to breastfeed, satisfaction with breastfeeding, and available support systems than on any other factors. Mothers need support, encouragement, and assistance during their postpartum hospital stays and at home to enhance their opportunities for success and satisfaction.
Three main criteria have been proposed as essential in promoting positive breastfeeding: (1) absence of a rigid feeding schedule; (2) correct positioning of the infant at the breast to achieve a deep, areolar latch; and (3) correct suckling technique. Correct suckling for breastfeeding is defined as a wide-open mouth, tongue under the areola, and expression of milk by effective alveolar compression (Fig. 7-13).
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FIG 7-13 The tongue is under the areola with the tip of the nipple at the back of the wide-open mouth.
The following interventions promote breastfeeding: • Frequent and early breastfeeding, especially during the first hour of life; immediate skin-to-skin
contact; non-separation of mother and infant; and feeding on demand • Direct modeling of the importance of breastfeeding by health care providers, such as
implementing demand feeding with no formula supplementation and decreased emphasis on infant formula products
• Increased information and support to mothers after discharge, including phone follow-up • Early breast pumping every 2 to 3 hours for 10 to 15 minutes bilaterally if the newborn is unable
to breastfeed immediately (increases oxytocin production and thus milk production) Nurses play a significant role in the breastfeeding decision and must make themselves available
to families for guidance and support. Several excellent books and organizations, such as La Leche League International,* are available as resources for professionals and breastfeeding mothers.
N u r s i n g A l e r t Do not use microwaves to defrost or warm human milk. High-temperature microwaving (72° to 98° C [162° to 208° F]) significantly destroys the antiinfective factors and vitamin C and may cause hot spots that could burn the baby's mouth (American Dietetic Association, Pediatric Nutrition Practice Group, 2011). Human milk may be thawed or warmed in warm tap water (be sure the milk is not contaminated by the water bath), or by placing in a commercial bottle warmer. Test the temperature of the milk before feeding.
Bottle Feeding Bottle feeding generally refers to the use of bottles for feeding commercial or evaporated milk formula rather than using the breast, although human milk may be expressed and fed with a bottle. Bottle feeding is an acceptable method of feeding. Nurses should not assume that new parents automatically know how to bottle feed their infants. One study noted 77% of formula-feeding mothers did not receive instruction on formula preparation from a health professional; consequently, hands, bottles, and nipples were not washed properly, and storage and heating practices were unsafe in many instances (Labiner-Wolfe, Fein, and Shealy, 2008). Parents who choose bottle feeding also need support and assistance in meeting their infants' needs.
Providing newborns with nutrition is only one aspect of feeding. Holding them close to the body while rocking or cuddling them helps to ensure the emotional component of feeding. Similar to breastfed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, they should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provides for oral gratification.
Propping the bottle during infant feeding is discouraged because: • It denies the infant the important component of close human contact. • The infant may aspirate formula into the trachea and lungs. • It may facilitate the development of middle ear infections. If the infant lies flat and sucks, milk
that has pooled in the pharynx becomes a suitable medium for bacterial growth. Bacteria may then enter the eustachian tube, which leads to the middle ear, causing acute otitis media.
• It encourages continuous pooling of formula in the mouth, which can lead to nursing caries when the teeth erupt (see Chapter 12).
Commercially Prepared Formulas The analysis of human and whole cow's milk indicates that the latter is unsuitable for infant nutrition. Whole cow's milk has a high protein content and low fat and lipid content, and it may cause intestinal bleeding and lead to iron-deficiency anemia in infants. Questions have also been raised regarding the unmodified protein content of whole cow's milk, which may trigger an undesired immune response and thus increase the incidence of allergies in children at an early age.
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Commercially prepared formulas are cow's milk based and have been modified to resemble the nutritional content of human milk. These formulas are altered from cow's milk by removing butterfat, decreasing the protein content, and adding vegetable oil and carbohydrate. Some cow's milk–based formulas have demineralized whey added to yield a whey-to-casein ratio of 60 to 40. The standard cow's milk–based formulas, regardless of the commercial brand, have essentially the same compositions of vitamins, minerals, protein, carbohydrates, and essential amino acids with minor variations, such as the source of carbohydrate, nucleotides to enhance immune function; and long-chain polyunsaturated fatty acids (LCPUFAs), DHA and AA. DHA and AA are both found in large quantities in human milk but until recently were not present in most infant formulas. Studies suggest both preterm and full-term infants receiving formula supplemented with DHA and AA have improved brain function and visual acuity when compared with those receiving formula without DHA and AA (Tai, Wang, and Chen, 2013). Sources for LCPUFAs include egg yolk lipid, phospholipids, and triglycerides. There do not appear to be any adverse effects associated with LCPUFA supplementation in preterm infants with respect to the incidence of bronchopulmonary disease, necrotizing enterocolitis, or other conditions of prematurity (Kleinman and Greer, 2014).
The US Food and Drug Administration regulates the manufacture of infant formula in the United States to ensure product safety. Standard cow's milk–based formulas are sold as low iron and iron fortified; however, the American Academy of Pediatrics states only the iron-fortified formulas meet the requirements of infants (Kleinman and Greer, 2014).
There are four main categories of commercially prepared infant formulas: (1) cow's milk–based formulas, available in 20 kcal/fl oz as liquid (ready to feed), powder (requires reconstitution with water), or a concentrated liquid (requires dilution with water); (2) soy-based formulas, available commercially in ready-to-feed 20 kcal/fl oz powder and concentrated liquid forms, commonly used for children who are lactose or cow's milk protein intolerant; (3) casein- or whey-hydrolysate formulas, commercially available in ready-to-feed and powder forms and used primarily for children who cannot tolerate or digest cow's milk– or soy-based formulas; and (4) amino acid formulas.
The American Academy of Pediatrics Committee on Nutrition recommends the use of soy protein–based formulas for infants with galactosemia and hereditary lactose intolerance and when a vegetarian diet is preferred (Kleinman and Greer, 2014). For infants with documented allergies caused by cow's milk, extensively hydrolyzed protein formula should be considered, because up to 14% of these infants also have a soy protein allergy. Some researchers have speculated that exclusive use of soy formula in infants may adversely affect their endocrine, reproductive, and immune systems. This concern is related to isoflavones in soy and possible alteration in sexual maturity, immune response, and thyroid function (Barthold, Hossain, Olivant-Fisher, et al, 2012; Chen and Rogan, 2004; Greim, 2004). Others report no long-term untoward effects from the ingestion of isoflavones in soy formula (Giampietro, Bruno, Furcolo, et al, 2004; Merritt and Jenks, 2004). A 2010 report by the National Toxicology Program concluded there was minimal concern for adverse effects on development of infants who consumed soy formula (McCarver, Bhatia, Chambers, et al, 2011). The position of the American Academy of Pediatrics Committee on Nutrition is that there is no conclusive evidence that dietary soy products adversely affect human development, reproduction, or endocrine function (Kleinman and Greer, 2014). The casein- or whey-hydrolysate formulas are considered to be less antigenic than either cow's milk–based or soy- based formulas. The protein hydrolysate formulas (casein and whey) are derived from cow's milk– based formulas by a process of heat, filtration, and enzyme treatment designed to break the peptide chains into more digestible proteins. There are also amino acid formulas, designed for infants who are extremely sensitive to cow's milk–based, soy-based, and partially hydrolyzed casein- and whey- based formulas. A variety of formulas are manufactured for infants and children with special needs. A formula company representative can provide product books that describe the purpose and content of each formula.
Follow-up formulas are marketed as a transitional formula for infants older than 6 months of age who are also eating solid foods. These generally contain a higher percentage of calories from protein and carbohydrate sources, a higher amount of iron and vitamins, and a lower amount of fat than standard cow's milk–based formulas. Many nutrition experts and the American Academy of Pediatrics Committee on Nutrition, however, dispute the necessity of follow-up formulas if the infant is receiving an adequate amount of solid foods containing sufficient iron, vitamins, and minerals (Kleinman and Greer, 2014).
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Preparation of Formula Persons preparing infant formula must wash their hands well and then wash all of the equipment used to prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples may be done in a dishwasher or a commercial home sterilizer (electric or microwave steam sterilizer, or chemical sterilizer), following manufacturer instructions. Equipment may also be sterilized by boiling. Fill a large pan with water and completely submerge all washed equipment, ensuring there are no trapped air bubbles. Cover the pan with a lid and bring it to a rolling boil, making sure the pan does not boil dry. Keep the pain covered until the equipment is needed.
Powdered infant formula is not sterile, and it has been associated with severe illness attributable to Cronobacter species (formerly known as Enterobacter sakazakii) and Salmonella enterica (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). Careful preparation and handling reduce the risk of illness; reconstitution with water brought to a rolling boil, and mixed when it is at or above 70° C is helpful, because this is hot enough to inactivate Cronobacter and other pathogens (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012; World Health Organization, 2007). Bottled water is not considered sterile and must be boiled before use.
Following the manufacturer's instructions for preparing the formula is essential to ensure the infant receives adequate calories and fluid for adequate growth. Parents are cautioned not to alter the reconstitution or dilution of infant formula except under the specific directions of the primary practitioner. Powdered formula and concentrated formula are prepared and bottled and refrigerated if not used for feeding immediately. Warming the formula is optional, although many parents prefer to warm it before feeding. Any milk remaining in the bottle after the feeding is discarded because it is an excellent medium for bacterial growth. Opened cans of ready-to-feed or concentrated formula are covered and refrigerated immediately until the next feeding. Because of incidents involving contamination of powdered formula with Cronobacter species and subsequent infant death in a neonatal unit, it is now recommended that hospital formula preparation for newborns follow separate guidelines; these are discussed in Chapter 7.
Laws governing the labeling of infant formulas require that the directions for preparation and use of the formula include pictures and symbols for non-reading individuals. In addition, manufacturers are translating the directions into foreign languages, such as Spanish and Vietnamese, to prevent misunderstanding and errors in formula preparation.
N u r s i n g A l e r t Stress to families that the proportions must not be altered—neither diluted with extra water to extend the amount of formula nor concentrated to provide more calories.
Alternate Milk Products In the United States, few infants are fed evaporated milk formula, and its use is not recommended by the American Academy of Pediatrics, Committee on Nutrition (Kleinman and Greer, 2014). However, it has advantages over whole milk. It is readily available in cans; needs no refrigeration if unopened; is less expensive than commercial formula; provides a softer, more digestible curd; and contains more lactalbumin and a higher calcium-to-phosphorus ratio. Disadvantages of evaporated milk for infant nutrition include low iron and vitamin C concentrations, excessive sodium and phosphorus, decreased vitamin A and D (except in fortified forms), and poorly digested fat. A common rule for preparing evaporated milk formula is diluting the 13-oz can of milk with 19.5 ounces of water and adding 3 Tbsp of sugar or commercially processed corn syrup.
Evaporated milk must not be confused with condensed milk, which is a form of evaporated milk with 45% more sugar. Because of its high carbohydrate concentration and disproportionately low fat and protein content, condensed milk is not used for infant feeding. Likewise, skim and low-fat milk must not be used for infant milk, because they are deficient in caloric concentration, significantly increase the renal solute load and water demands, and deprive the body of essential fatty acids.
Goat's milk is a poor source of iron and folic acid. It has an excessively high renal solute load as a result of its high protein content, making it unsuitable for infant nutrition (Kleinman and Greer, 2014). Some believe that goat's milk is less allergenic than other available milk sources and may feed it to their infants to reduce allergic milk reactions. However, infants allergic to cow's milk are
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just as likely to be allergic to goat's milk; other complications (such as, hypernatremia and metabolic acidosis) may ensue as a result of the high sodium and protein concentration found in goat's milk compared with human milk (Basnet, Schneider, Gazit, et al, 2010). Raw, unpasteurized milk from any animal source is unacceptable for infant nutrition.
Feeding Schedules Ideally, feeding schedules should be determined by the infant's hunger. Demand feedings involve feeding infants when they signal readiness. Scheduled feedings are arranged at predetermined intervals. Although this may be satisfactory for bottle-fed infants, it hinders the breastfeeding process. Breastfed infants tend to be hungry every 2 to 3 hours because of the easy digestibility of the milk; therefore, they should be fed on demand.
Supplemental feedings should not be offered to breastfed infants before lactation is well established, because they may satiate the infant and may cause nipple preference. Supplemental water is not needed in breastfed infants even in hot climates (Kleinman and Greer, 2014). Satiated infants suck less vigorously at the breast, and milk production depends on the breast being emptied at each feeding. If milk is allowed to accumulate in the ducts (causing breast engorgement) ischemia results, suppressing the activity of the acini, or milk-secreting cells. Consequently, milk production is reduced. In addition, the process of sucking from a bottle is different from breast nipple compression. The relatively inflexible rubber nipple prevents the tongue from its usual rhythmic action. Infants learn to put the tongue against the nipple holes to slow down the more rapid flow of fluid. When infants use these same tongue movements during breastfeeding, they may push the human nipple out of the mouth and may not grasp the areola properly.
Usually by 3 weeks old, lactation is well established. Bottle-fed infants consume about 2 to 3 oz of formula at each feeding and are fed approximately six times a day. The quantity of formula consumed is based on the caloric need of 108 kcal/kg/day; therefore, a newborn who weighs 3 kg requires 324 kcal/day. Because commercial formula has 20 kcal/oz, approximately 16 oz (480 ml) provides the daily caloric requirement. Breastfed infants may feed as frequently as 10 to 12 times a day.
Feeding Behavior Five behavioral stages occur during successful feeding. Recognizing these steps can assist nurses in identifying potential feeding problems caused by improper feeding techniques. Prefeeding behavior, such as crying or fussing, demonstrates the infant's level of arousal and degree of hunger. To encourage the infant to grasp the breast properly, it is preferable to begin feeding during the quiet alert state before the infant becomes upset. Approach behavior is indicated by sucking movements or the rooting reflex. Attachment behavior includes activities that occur from the time the infant receives the nipple and sucks (sometimes more pronounced during initial attempts at breastfeeding). Consummatory behavior consists of coordinated sucking and swallowing. Persistent gagging might indicate unsuccessful consummatory behavior. Satiety behavior is observed when infants let the parent know that they are satisfied, usually by falling asleep.
Promote Parent–Infant Bonding (Attachment) The process of parenting is based on a relationship between the parent and infant. Neonates are complex individuals, capable of influencing and shaping their environments, particularly their interaction with significant others. Promoting positive parent–child relationships necessitates an understanding of behavioral steps in attachment, variables that enhance or hinder this process, and methods of teaching parents to develop a stronger relationship with their children, especially by recognizing potential problems (see also Assessment of Attachment Behaviors, earlier in the chapter).
Infant Behavior Nurses must appreciate the individuality and uniqueness of each infant. According to the individual temperament, infants change and shape the environment, which influences their future development (see Patterns of Sleep and Activity, earlier in the chapter). An infant who sleeps 20 hours a day will be exposed to fewer stimuli than one who sleeps 16 hours a day. In turn, each infant will likely elicit a different response from parents. An infant who is quiet, undemanding, and
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passive may receive much less attention than one who is responsive, alert, and active. Behavioral characteristics such as irritability and consolability can influence the ease of transition to parenthood and the parents' perception of the infant.
Nurses can positively influence the attachment of the parent and child. The first step is recognizing individual differences and explaining to the parents that such characteristics are normal. For example, some people believe that infants sleep throughout the day except for feedings. For some newborns, this may be true, but for many, it is not. Understanding that the infant's wakefulness is part of a biologic rhythm and not a reflection of inadequate parenting can be crucial in promoting healthy parent–child relationships. Another aspect of helping parents' concerns includes supplying guidelines on how to enhance the infant's development during awake periods. Placing the child in a crib to stare at the same mobile every day is not exciting, but carrying the infant into each room as one does daily chores can be fascinating.
Infants enjoy human contact and often respond to visual and auditory stimuli in different ways depending on their sleep–wake state and the type of stimuli provided. Infants prefer black and white objects, geometric patterns and shapes, and reflective surfaces, such as mirrors and eyeglasses. However, evidence indicates that infants prefer contact with human faces and enjoy interactions with others more than objects or television images.
Maternal Attachment Mothers may demonstrate a predictable and orderly pattern of behavior during the development of the attachment process. When mothers are presented with their nude infants, they begin to examine the infant with their fingertips, concentrating on touching the extremities, and then proceed to massage and encompass the trunk with their entire hands. Assuming the en face position, in which the mother's and infant's eyes meet in visual contact in the same vertical plane, is significant in the formation of affectional ties (Fig. 7-14). Some authors have suggested that mothers experiencing depression, as well as adolescent mothers, may have lower rates of secure attachment with their infants (Flaherty and Sadler, 2011), necessitating the need for caregivers to monitor such mothers closely and to model attachment behaviors. Nurses must observe for maternal attachment behaviors and exercise caution in interpreting such behaviors.
FIG 7-14 En face position between the parent and infant can be significant in attachment process.
Several studies have attempted to substantiate the long-term benefits of providing parents with opportunities to optimally bond with their infants during the initial postpartum period. Although there has been some evidence that increased parent–child contact encourages prolonged breastfeeding and may minimize the risks of parenting disorders, conclusions about the long-term effects of such early intervention on parenting and child development must be viewed cautiously. In addition, some authorities claim that the emphasis on bonding has been unjustified and may lead to guilt and fear in parents who did not have early contact with their infants. There is concern that the literal interpretation of “sensitive” or “critical” times for bonding might imply that without early contact, optimum bonding cannot occur or, conversely, that early contact alone is sufficient to ensure competent parenting.
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The nurse should stress to parents that although early bonding is valuable, it does not represent an “all or none” phenomenon. Throughout the child's life, there will be multiple opportunities for development of parent–child attachment. Bonding is a complex process that develops gradually and is influenced by numerous factors, only one of which is the type of initial contact between the newborn and parent.
In a concept analysis of parent–infant attachment, Goulet, Bell, St-Cyr, et al (1998) describes attributes of parent–infant attachment as proximity, reciprocity, and commitment. Within these attributes are further dimensions, which include contact, emotional state, individualization, complementarity, sensitivity, centrality, and parent role exploration. The researchers describe the parent–infant attachment process as one that is complex and therefore cannot be evaluated simply by the observations of attitudes and behaviors of parents toward their infants (Goulet, Bell, St-Cyr, et al, 1998). Further research into the reciprocal relationships between infants and parents and the situational factors that influence such relationships is recommended.
One component of successful maternal attachment is the concept of reciprocity (Brazelton, 1974). As the mother responds to the infant, the infant must respond to the mother by some signal, such as sucking, cooing, eye contact, grasping, or molding (conforming to other's body during close physical contact). The first step is initiation in which interaction between infant and parent begins. Next is orientation, which establishes the partners' expectations of each other during the interaction. After orientation is acceleration of the attention cycle to a peak of excitement. The infant reaches out and coos, both arms jerk forward, the head moves backward, the eyes dilate, and the face brightens. After a short time, deceleration of the excitement and turning away occur in which the infant's eyes shift away from the parent's and the child may grasp his or her shirt. During this cycle of nonattention, repeated verbal or visual attempts to reinitiate the infant's attention are ineffective. This deceleration and turning away probably prevents the infant from being overwhelmed by excessive stimuli. In a good interaction, both partners have synchronized their attention– nonattention cycles. Parents or other caregivers who do not allow the infant to turn away and who continually attempt to maintain visual contact encourage the infant to turn off the attention cycle and thus prolong the nonattention phase.
Although this description of reciprocal interacting behavior is usually observed in infants by 2 to 3 weeks of age, nurses can use this information to teach parents how to interact with their newborns. Recognizing the attention versus nonattention cycles and understanding that the latter is not a rejection of the parent helps parents develop competence in parenting.
Paternal Engrossment Fathers also show specific attachment behaviors to their newborns. This process of paternal engrossment, forming a sense of absorption, preoccupation, and interest in the infant, includes (1) visual awareness of the newborn, especially focusing on the beauty of the child; (2) tactile awareness, often expressed in a desire to hold the infant; (3) awareness of distinct characteristics with emphasis on those features of the infant that resemble the father; (4) perception of the infant as perfect; (5) development of a strong feeling of attraction to the child that leads to intense focusing of attention on the infant; (6) extreme elation; and (7) feeling a sense of deep self-esteem and satisfaction. These responses are greatest during the early contacts with the infant and are intensified by the neonate's normal reflex activity, especially the grasp reflex and visual alertness. In addition to behavioral reactions, fathers also demonstrate physiologic responses such as increased heart rate and BP during interactions with their newborns.
The process of engrossment has significant implications for nurses. It is imperative to recognize the importance of early father–infant contact in releasing these behaviors. Fathers need to be encouraged to express their positive feelings, especially if such emotions are contrary to any belief that fathers should remain stoic. If this is not clarified, fathers may feel confused and attempt to suppress the natural sensations of absorption, preoccupation, and interest in order to conform to societal expectations.
Mothers also need to be aware of the responses of the father toward the newborn, especially because one of the consequences of paternal preoccupation with the infant is less overt attention toward the mother. If both parents are able to share their feelings, each can appreciate the process of attachment toward their child and will avoid the unfortunate conflict of being insensitive and unaware of the other's needs. In addition, a father who is encouraged to form a relationship with his newborn is less likely to feel excluded and abandoned after the family returns home and the
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mother directs her attention toward caring for the infant. Ideally, the process of engrossment should be discussed with parents before the delivery, such as
in prenatal classes, to reinforce the father's awareness of his natural feelings toward the expected child. Focusing on the future experience of seeing, touching, and holding one's newborn may also help expectant fathers become more comfortable in accepting their paternal feelings. This in turn can assist them in being more supportive toward the mother, especially as the labor and delivery draw near.
At the infant's birth, the nurse can play a vital role in helping the father express engrossment by assessing the neonate in front of the couple; pointing out normal characteristics; encouraging identification through consistent referral to the child by name; encouraging the father to cuddle, hold, talk to, or feed the infant; and demonstrating whenever necessary the soothing powers of caressing, stroking, and rocking the child (Fig. 7-15). Fathers are encouraged to be with the mother during labor and delivery, to spend time alone with the mother and newborn after delivery, and to room-in with the mother and infant. Many hospitals and birthing centers have adopted a family- centered focus, including sleeping accommodations that more closely resemble the home environment for the new parents.
FIG 7-15 A desire to hold the infant and participate in caregiving activities is an indication of paternal engrossment.
Fathers, like mothers, may demonstrate attachment not only after the infant's birth but during fetal life as well. Paternal attachment may proceed at a different pace than maternal attachment. Paternal preoccupation with events of labor and delivery and the spouse's health may detract from paternal attachment. Research has noted that, although fathers spend similar amounts of time in interaction with their newborns as do mothers, the nature of their interaction is different. Mothers and infants focus on face-to-face exchange and mutual gazing, co-vocalization, and affectionate touch. Fathers' time with their infants includes quick peaks of high positive emotionality, including joint laughter and open exuberance. Interactions with fathers tend to center on physical games or games with an object focus rather than on face-to-face signals (Feldman, 2007).
The nurse observes for the same indications of affection from the father as those expected in the mother, such as making visual contact in the en face position and embracing the infant close to the body. When present, such behaviors are reinforced. If such responses are not obvious, the nurse needs to assess the father's feelings regarding this birth, cultural beliefs that may affect his expression of emotions, and other factors that influence his perception of the infant and the mother in order to facilitate a positive attachment during this critical period.
Siblings Although the attachment process has been discussed almost exclusively in terms of the parents and
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infants, it is essential that nurses be aware of other family members, such as siblings and members of the extended family, who need preparation for the acceptance of this new child. Young children in particular need sensitive preparation for the birth to minimize sibling jealousy.
In support of family-centered care, siblings are generally encouraged to visit the mother in hospital and to hold the newborn (Fig. 7-16). Another trend has been the presence of siblings at childbirth. Unlike sibling visitation, the evidence supporting this practice has been controversial, yet family-centered care encompasses siblings, grandparents, and other significant persons who comprise the extended family unit. Children exhibit different degrees of involvement in the birth process. Some reported benefits include children's increased knowledge of the birth process, less regressive behavior after the birth, and more mothering and caregiving behavior toward the infant. Some practitioners add facilitated family bonding and assimilation of the newborn into the family as positive outcomes. Parents whose children attended the birth have echoed these same benefits and have expressed their desire to repeat the experience should another pregnancy occur. Despite these positive findings, opponents believe that allowing children to observe a delivery could lead to emotional difficulties, although there is no research to support this contention. As research mounts, birthing centers that allow siblings at the birth are developing more definitive guidelines, such as an age requirement of at least 4 to 5 years old, the presence of a supportive person for the sibling only, and an adequate sequence of preparation in which parents explore all options for preparing their other children.
FIG 7-16 Sibling holds infant sister on the first day home from the hospital.
From observations during sibling visitation, there is evidence that sibling attachment occurs. However, the en face position is assumed much less often among the newborn and siblings than between mother and newborn, and when this position is used, it is brief. Siblings focus more on the head or face than on touching or talking to the infant. The siblings' verbalizations are often focused less on attracting the infant's attention and more on addressing the mother about the newborn. Children who have established a prenatal relationship with the fetus have demonstrated more attachment behaviors, supporting the suggestion of encouraging prenatal acquaintance. Additional research is needed to establish theories on sibling bonding as have been constructed for parental bonding.
Multiple Births and Subsequent Children A component of attachment that has special meaning for families with multiple births, monotropy
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refers to the principle that a person can become optimally attached to only one individual at a time. If a parent can form only one attachment at a time, how can all of the siblings of a multiple birth receive optimum emotional care? Research on bonding and multiple births is still lacking despite the recent increase in multiple births, and even less is known about paternal engrossment and sibling attachment. In regard to mother–twin bonding, the conclusions of different authors vary. Some report that mothers bond equally to each twin at the time of birth even if one twin is ill. Others suggest that mothers of twins may take months or years to form individual attachments to each child or even longer if the twins are identical.
Nurses can be instrumental in promoting bonding of multiple births. The most important principle is to assist the parents in recognizing the individuality of the children, especially in monozygotic (identical) twins. The mother should visit with each newborn, including a sick infant, as much as possible after birth. Non-separation and breastfeeding are encouraged. Any characteristics that are unique to each child are emphasized, and each infant is called by name rather than referring to “the twins.” Asking the family questions (such as “How do you tell Ashley and Amy apart?” and “In what ways are Ashley and Amy different and similar?”) helps point out their individual characteristics. Behaviors on the BNBAS can be used to illustrate these differences and to stress effective strategies for dealing with multiple personalities at the same time.
Co-bedding (bed sharing) of twins or other multiples may be done in the hospital with the goal of maintaining the bond between siblings that was formed in utero (Fig. 7-17). Much research is focused on exploring the safety and benefits of the practice of co-bedding (Hayward, Campbell-Yeo, Price, et al, 2007) (see also Sudden Infant Death Syndrome, Chapter 10); however, the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (2011) has recommended against families co-bedding with infants at home. Because neither the safety nor the benefits of co- bedding for newborns has been documented in the literature, the Academy recommends families are counseled to follow safe sleeping practices, which currently dictate that infants sleep alone for optimal safety.
FIG 7-17 Newborn twins are placed in same bed during the newborn transition period.
Another area of attachment that has received minimal attention is maternal bonding of multiparous mothers. Research suggests that there are several additional tasks to “taking on” a second child. These include: • Promoting acceptance and approval of the second child • Grieving and resolving the loss of an exclusive dyadic relationship with the first child • Planning and coordinating family life to include a second child • Reformulating a relationship with the first child • Identifying with the second child by comparing this child with the first child in terms of physical
and psychological characteristics • Assessing one's affective capabilities in providing sufficient emotional support and nurturance
simultaneously to two children
Prepare for Discharge and Home Care
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With shorter postpartum hospital stays as well as a trend toward mother–infant care, also called dyad or couplet care, discharge planning, referral, and home visits have become increasingly important components of comprehensive newborn care. First-time, as well as experienced, parents benefit from guidance and assistance with the infant's care, such as breastfeeding or bottle feeding, and with the family's integration of a new member, particularly sibling adjustment.
To assess and meet these needs, teaching must begin early, ideally before the birth. Not only is the postpartum stay sometimes very short (as little as 12 to 24 hours), but mothers are also in the taking-in phase, during which they may demonstrate passive and dependent behaviors. On the first postpartum day, as a result of fatigue and excitement about the newborn, mothers may not be able to absorb large amounts of information. This time may need to be spent highlighting essential aspects of care, such as infant safety and feeding. Parents may also be given a list of mother and infant care topics so that they can choose issues they wish to review. Teaching before discharge should focus on newborn feeding patterns, monitoring diapers for voiding and stooling, jaundice, and infant crying.
The American Academy of Pediatrics, Committee on Fetus and Newborn (2010) has established guidelines for postpartum discharge (see Family-Centered Care box). The Academy emphasizes that each mother–infant dyad should be evaluated individually to determine the optimal time of discharge.
F a m i l y - C e n t e r e d C a r e Early Newborn Discharge Criteria
• It was a singleton birth between 38 and 42 weeks of gestation.
• Baby was delivered by uncomplicated vaginal delivery.
• Birth weight is appropriate for gestational age (AGA).
• Physical examination was normal.
• Vital signs are within normal range and stable for the 12 hours preceding discharge.
• Infant has urinated and passed at least one stool.
• Infant has completed at least two successful feedings.
• Clinical significance of jaundice, if present, has been determined and appropriate management or follow-up plans put in place.
• Appropriate maternal and infant blood tests have been performed.
• Appropriate neonatal immunizations have been administered.
• Newborn hearing screening has been completed per hospital protocol and state regulations.
• Family, environmental, and social risk factors have been assessed.
• Documentation is in place that the mother has received usual infant care training and has demonstrated competency.
• Support persons are available to assist mother and her infant after discharge.
• Continuing medical care is planned, including that infants discharged sooner than 48 hours be examined within 48 hours of discharge from the hospital.
Data from American Academy of Pediatrics, Committee on Fetus and Newborn: Hospital stay for healthy term newborns, Pediatrics 125(2):405–409, 2010.
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Although some mothers and newborns may be safely discharged within 12 to 24 hours without detriment to their health, others require a longer stay. Follow-up home care within days (or even hours after discharge when minor problems are anticipated) appears to be the emerging trend in an effort to curtail hospital costs and provide adequate mother–newborn care with minimal complications (see Community Focus boxes).
C o m m u n i t y F o c u s Early Newborn Discharge Checklist
Feeding: Adequate latch-on and suckling demonstrated for breastfeeding newborn; successfully feeding 1.5 to 2 oz of formula every 3 to 4 hours with minimum spitting up and no vomiting
Elimination: Voiding every 4 to 6 hours or more often; one stool passed in first 24 to 28 hours
Circumcision: Evidence of voiding; nonbleeding circumcision (does not require pressure); no excess edema at site
Color: Pink centrally and buccal mucosa moist; no evidence of jaundice in first 24 hours
Cord: No signs or symptoms of infection; if used, drying agent applied per institution protocol (see Care of the Umbilicus)
Newborn screening: Completed phenylketonuria (PKU) and other screenings per state law
Vital signs: Stable heart rate, respiratory rate, and temperature for at least 12 hours before discharge; no apnea
Activity: Wakeful periods before feedings; moves all extremities
Home visit or primary practitioner visit: Follow-up appointment within 48 hours after discharge
C o m m u n i t y F o c u s Newborn Home Care after Early Discharge*
Wet diapers: Minimum of 1 for each day of life (day 2 = 2 wets; day 3 = 3 wets) until fifth or sixth day, at which time 5 or 6 per day to 14 days, then 6 to 10 per day
Breastfeeding: Successful latch-on and feeding every 1.5 to 3 hours daily; audible swallowing
Formula feeding: Successfully taking at least 1 to 2 oz every 3 to 4 hours; voiding as described earlier
Circumcision: Wash with warm water only; yellow exudate forming, with no bleeding; Plastibell intact for 48 hours
Stools: At least one every 48 to 72 hours (bottle feeding), or two or three per day (breastfeeding)
Color: Pink to ruddy when crying; pink centrally when at rest or asleep
Activity: Has four or five wakeful periods per day and alerts to environmental sounds and voices
Jaundice: Physiologic jaundice (i.e., jaundice not appearing in the first 24 hours); feeding, voiding, and stooling as noted earlier or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth; hemolysis and ABO/Rh problem suspected), decreased activity, poor feeding, or dark orange skin color persisting on the fifth day in light-skinned newborn; obtain transcutaneous (or serum) bilirubin before discharge and identify risk with an hour-
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specific nomogram (see Hyperbilirubinemia, Chapter 8).
Umbilical cord: Kept above diaper line; drying, no drainage; periumbilical area nonerythematous
Vital signs: Heart rate, 120 to 140 beats/min at rest; respiratory rate, 30 to 55 breaths/min at rest without evidence of sternal retractions, grunting, or nasal flaring; temperature, 36.3° to 37° C (97.3° to 98.6° F) axillary
Position of sleep: On back
*Any deviation from this list or suspicion of poor newborn adaptation should be immediately reported to the practitioner.
Despite the changing spectrum of well-newborn health care, the nurse's role continues to be that of providing ongoing assessments of each mother–newborn dyad to ensure a safe transition to home and a successful adaptation into the family unit. The ultimate safety and success of early newborn discharge from hospital are contingent on using clear discharge criteria and having a high- quality early follow-up program.
With family structures changing, it is essential that nurses identify the primary caregiver, which may not always be the mother but may be a father, grandparent, or babysitter. Depending on the family composition, the mother's primary support system in the care of the newborn may not always be the traditional husband or male companion.
Nurses should not assume that terminology associated with mother–infant care is understood. Words relating to the anatomy (e.g., meconium, labia, edema, and genitalia) and to breastfeeding (e.g., areola, colostrum, and let-down reflex) may be unfamiliar to mothers. Mothers with other children do not necessarily understand more words, and younger, less educated mothers may be at particular risk for not understanding teaching.
An essential area of discharge counseling is the safe transportation of the newborn home from the hospital. Ideally, this information should be provided before delivery to allow parents an opportunity to purchase a suitable infant car safety seat. When purchasing a car safety seat, parents should consider cost and convenience. The convertible-type seats are more expensive initially but cost less than two separate systems (infant-only model and infant-toddler convertible model). Convenience is a major factor because a cumbersome restraint may be used less often or used improperly. Before buying a car safety seat, it is best to look carefully at different models. For example, some types are too large for subcompact cars. Asking friends about the advantages and disadvantages of their restraints is helpful, but borrowing a car seat or purchasing a used one can be dangerous. Parents should use only a restraint that has directions for use and a certification label stating that it complies with federal motor vehicle safety standards (both should be on the seat). They should not use a restraint that has been involved in a crash. Some service clubs and hospitals have loan programs for restraints. Information about approved models and other aspects of car safety seat restraints is available from several organizations and sources.*
Parents are cautioned against placing an infant in the front seat of a car with a passenger-side air bag. It is now recommended that infants and toddlers ride rear facing in a child safety seat in the back seat of the car until they are 2 years old or until they reach the maximum height and weight recommended by the car seat manufacturer (Committee on Injury, Violence, and Poison Prevention and Durbin, 2011; Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Studies indicate that toddlers (up to 24 months of age) are safer riding in convertible seats in the rear-facing position (Bull and Durbin, 2008). A convertible safety seat is positioned semi-reclined and facing the rear of the car. After the child has outgrown the rear-facing seat, a forward-facing seat with a harness is recommended.
N u r s i n g A l e r t In a car seat, padding is never placed underneath or behind the infant, because it creates slackness in the harness, leading to the possibility of the child's ejection from the seat in the event of a crash. In vehicles with front passenger-side air bags, the rear-facing safety seat must be placed in the back seat to avoid injury to the infant from the released air bag forcing the safety seat against the vehicle
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seat or passenger door.
Although federal safety standards do not specify the minimum weight of an infant and the appropriate type of restraint, newborns weighing 2 kg (4.4 pounds) receive relatively good support in convertible seats with a seat back–to-crotch strap height of 14 cm (5.5 inches) or less. Rolled blankets or towels may be needed between the crotch and legs to prevent slouching and can be placed along the sides to minimize lateral movements. Placing the infant in a safety seat at a 45- degree angle will prevent slumping and airway obstruction (Committee on Injury, Violence, and Poison Prevention and Durbin, 2011; Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Seats with shields (large padded surfaces in front of the child) and armrests (found on some older models) are unacceptable because of their proximity to the infant's face and neck. (For a discussion of appropriate car restraints for preterm infants, see Community Focus box, Chapter 8; and for infants, see Motor Vehicle Injuries in Chapters 9 and 11.)
In the United States and Canada, all states and provinces have mandated the use of child restraints. Therefore, hospitals and birthing centers should have policies regarding the safe discharge of newborns in car safety seats and provisions for parents to learn to use the devices correctly. In addition, hospital personnel should ensure that infants born before 37 weeks of gestation have a period of observation in the selected car seat to monitor for possible apnea, bradycardia, and oxygen desaturation (Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Parents are more likely to use a restraint correctly and consistently if the proper use of one is demonstrated and its necessity is stressed.
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NCLEX Review Questions 1. Identify the anatomic changes that occur shortly after birth that affect the newborn's adaptation to
extrauterine existence. Select all that apply. a. Closure of the foramen ovale b. Closure of the ductus arteriosus c. Increase in pulmonary vascular resistance d. Closure of the ductus venosus e. Decrease in pulmonary vascular resistance
2. In the newly born infant thermogenesis is achieved by: a. Shivering. b. Brown fat metabolism. c. Overhead warming unit. d. Skin-to-skin contact with mother.
3. What does the Apgar scoring system assess? Select all that apply. a. Respiratory effort b. Heart rate c. Core temperature d. Reflex irritability e. Muscle tone f. Color
4. A newborn whose mother is positive for Chlamydia trachomatis should be optimally treated with which of these to prevent ophthalmia? a. Silver nitrate solution (1%) b. Tetracycline ophthalmic ointment (1%) c. Oral erythromycin d. Erythromycin ophthalmic solution (0.5%)
5. A healthy infant is born to a mother with known high-risk behaviors whose HIV status is undetermined. The mother states that she wishes to breastfeed her infant. The nurse's response to the mother's request should be based on which of the following information? a. HIV is rarely transmitted to the newborn through maternal milk. b. Breastfeeding should be withheld until HIV status (maternal) is determined. c. Breastfeeding should be avoided completely in mothers with high-risk behaviors. d. In such infants, antiretroviral medication should be started within 12 hours of birth.
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Correct Answers 1. a, b, d, e; 2. b;
3. a, b, d, e, f; 4. c;
5. b
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Guidelines for perinatal care,. ed 6. American Academy of Pediatrics: Elk Grove Village, IL; 2007.
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Health Problems of Newborns Debbie Fraser
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Birth Injuries Several factors predispose an infant to birth injuries (Mangurten and Puppala, 2011; Verklan and Lopez, 2011). Maternal factors include uterine dysfunction that leads to prolonged or precipitous labor, preterm or postterm labor, and cephalopelvic disproportion. Injury may result from dystocia caused by fetal macrosomia, multifetal gestation, abnormal or difficult presentation (not caused by maternal uterine or pelvic conditions), and congenital anomalies. Intrapartum events that can result in scalp injury include the use of intrapartum monitoring of fetal heart rate and collection of fetal scalp blood for acid–base assessment. Obstetric birth techniques can cause injury. Forceps birth, vacuum extraction, version and extraction, and cesarean birth are potential contributory factors. Often more than one factor is present, and multiple predisposing factors may be related to a single maternal condition.
Soft Tissue Injury Various types of soft tissue injury may be sustained during the process of birth, primarily in the form of bruises or abrasions secondary to dystocia. Soft tissue injury usually occurs when there is some degree of disproportion between the presenting part and the maternal pelvis (cephalopelvic disproportion). The use of forceps to facilitate a difficult vertex delivery may produce bruising or abrasion on the sides of the neonate's face. Petechiae or ecchymoses may be observed on the presenting part after a breech or brow delivery. After a difficult or precipitous delivery, the sudden release of pressure on the head can produce scleral hemorrhages or generalized petechiae over the face and head. Petechiae and ecchymoses may also appear on the head, neck, and face of an infant born with a nuchal cord, giving the infant's face a cyanotic appearance. A well-defined circle of petechiae and ecchymoses or abrasions may also be seen on the occipital region of the newborn's head when a vacuum suction cup is applied during delivery. Rarely, lacerations occur during cesarean section.
These traumatic lesions generally fade spontaneously within a few days without treatment. However, petechiae may be a manifestation of an underlying bleeding disorder or a systemic illness (such as an infection) and should be further evaluated as to their origin. Nursing care is primarily directed toward assessing the injury and providing an explanation and reassurance to the parents.
Head Trauma Trauma to the head and scalp that occurs during the birth process is usually benign but occasionally results in more serious injury. The injuries that produce serious trauma, such as intracranial hemorrhage and subdural hematoma, are discussed in relation to neurologic disorders in the newborn (see Table 8-9). Skull fractures are discussed in association with other fractures sustained during the birth process. The three most common types of extracranial hemorrhagic injury are caput succedaneum, cephalhematoma, and subgaleal hemorrhage.
Caput Succedaneum The most commonly observed scalp lesion is caput succedaneum, a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery (Fig. 8-1, A). The swelling consists of serum, blood, or both accumulated in the tissues above the bone, and it often extends beyond the bone margins. The swelling may be associated with overlying petechiae or ecchymoses. No specific treatment is needed, and the swelling subsides within a few days. Careful observation for signs of infection is needed if the skin over the caput is abraded or broken down.
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FIG 8-1 A, Caput succedaneum. B, Cephalhematoma. C, Subgaleal hemorrhage. (A and B, From Seidel HM, Ball JM, Davis JE, et al: Mosby's guide to physical examination, ed 6, St Louis, 2006, Mosby.)
Cephalhematoma Infrequently, a cephalhematoma is formed when blood vessels rupture during labor or delivery producing bleeding into the area between the bone and its periosteum. The injury occurs most often with primiparous delivery and is more likely with forceps delivery and vacuum extraction. Unlike caput succedaneum, the boundaries of the cephalhematoma are sharply demarcated and do not extend beyond the limits of the bone (suture lines) (see Fig. 8-1, B). The cephalhematoma may involve one or both parietal bones. The occipital bones are less commonly affected, and the frontal bones are rarely affected. The swelling is usually minimal or absent at birth and increases in size on the second or third day. Blood loss is usually not significant.
No treatment is indicated for uncomplicated cephalhematoma. Most lesions are absorbed within 2 weeks to 3 months. Lesions that result in severe blood loss to the area or that involve an underlying fracture require further evaluation. Hyperbilirubinemia may result during resolution of the hematoma. A local infection can develop and is suspected when a sudden increase in swelling occurs. Parents should be counseled that, in some cases, a small area of calcification may develop and persist.
Subgaleal Hemorrhage Subgaleal hemorrhage is bleeding into the subgaleal compartment (see Fig. 8-1, C). The subgaleal compartment is a potential space that contains loosely arranged connective tissue; it is located beneath the galea aponeurosis, the tendinous sheath that connects the frontal and occipital muscles and forms the inner surface of the scalp. The injury occurs as a result of forces that compress and then drag the head through the pelvic outlet (Verklan and Lopez, 2011). Instrumented delivery, particularly vacuum extraction and forceps delivery, increases the risk of subgaleal hemorrhage.
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Additional risk factors include prolonged second stage of labor, prolonged rupture of membranes, fetal distress, failed vacuum extraction, and maternal primiparity (Swanson, Veldman, Wallace, et al, 2012). The bleeding extends beyond bone, often posteriorly into the neck, and continues after birth with the potential for serious complications, such as anemia or hypovolemic shock.
Early detection of the hemorrhage is vital; serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are essential. A boggy fluctuant mass over the scalp that crosses the suture line and moves as the baby is repositioned is an early sign of subgaleal hemorrhage. Other signs include pallor, tachycardia, and increasing head circumference (Mouhayar and Charafeddine, 2012). Another sign of subgaleal hemorrhage is a forward and lateral positioning of the newborn's ears because the hematoma extends posteriorly. Disseminated intravascular coagulation (DIC) has also been reported in association with subgaleal hemorrhage (Schierholz and Walker, 2010). Computed tomography (CT) or magnetic resonance imaging (MRI) is useful in confirming the diagnosis. Replacement of lost blood and clotting factors is required in acute cases of hemorrhage. Monitoring the infant for changes in level of consciousness and a decrease in the hematocrit are also key to early recognition and management. An increase in serum bilirubin levels may be seen as a result of the degradation of red blood cells (RBCs) within the hematoma.
Nursing Care Management Nursing care is directed toward assessment and observation of the common scalp injuries and vigilance in observing for possible associated complications (such as infection) or, as in the case of subgaleal hemorrhage, acute blood loss and hypovolemia. Nursing care of a newborn with a subgaleal hemorrhage includes careful monitoring for signs of hemodynamic instability and shock (Schierholz and Walker, 2010). Because caput succedaneum and cephalhematoma usually resolve spontaneously, parents need reassurance of their usual benign nature.
Fractures The clavicle, or collarbone, is the bone most frequently fractured during the birth process. Clavicular fracture is more common with shoulder dystocia or a difficult vertex or breech delivery of infants who are large for gestational age. Crepitus (the coarse crackling sensation produced by the rubbing together of fractured bone fragments) may be felt or heard on examination. A palpable, spongy mass, representing localized edema and hematoma, may also be a sign of a fractured clavicle. The infant may be reluctant to move the arm on the affected side, and the Moro reflex may be asymmetric. Radiographs usually reveal a complete fracture with overriding of the fragments.
Fractures of long bones, such as the femur or the humerus, are sometimes difficult to detect by radiographic examination in infants. Although osteogenesis imperfecta is a rare finding, a newborn infant with a fracture should be assessed for other evidence of this congenital disorder.
Fractures of the neonatal skull are uncommon. The bones, which are less mineralized and more compressible than bones in older infants and children, are separated by membranous seams that allow sufficient alteration in the head contour so that it adjusts to the birth canal during delivery. Skull fractures usually follow a prolonged, difficult delivery or forceps extraction. Most fractures are linear, but some may be visible as depressed indentations that compress or decompress like a ping-pong ball. Management of depressed skull fractures is controversial; many resolve without intervention. Nonsurgical elevation of the indentation using a hand breast pump or vacuum extractor has been reported (Mangurten and Puppala, 2011). Surgery may be required in the presence of bone fragments or signs of significant blood clots (intracranial pressure [ICP]) (Hill, 2012). A similar finding in neonates is craniotabes, which is usually benign or may be associated with prematurity or hydrocephalus (Johnson, 2015). In this condition, the cranial bone(s) move freely on palpation and may easily compress.
N u r s i n g A l e r t A newborn with a fractured clavicle may have no symptoms, but suspect a fracture if an infant has limited use of the affected arm, malpositioning of the arm, asymmetric Moro reflex, or focal swelling or tenderness or if he or she cries in pain when the arm is moved.
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N u r s i n g A l e r t Any newborn who is large for gestational age or weighs more than 3855 g (8.5 pounds) and is delivered vaginally should be evaluated for a fractured clavicle.
Nursing Care Management Often, no intervention is needed other than maintaining proper body alignment, careful dressing and undressing of the infant, and handling and carrying that support the affected bone. For example, if the infant has a fractured clavicle, it is important to support the upper and lower back rather than pulling the infant up from under the arms. Placing the infant in a side-lying position with the affected side down should also be avoided. Linear skull fractures usually require no treatment. A ping-pong ball–type skull fracture may require decompression by surgical intervention. The infant is carefully observed for signs of neurologic complications. The parents of infants with a fracture of any bone should be involved in caring for the infant during hospitalization as part of discharge planning for care at home.
Paralysis Facial Paralysis Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to that nerve. The primary clinical manifestations are loss of movement on the affected side, such as an inability to completely close the eye, drooping of the corner of the mouth, and absence of wrinkling of the forehead and nasolabial fold (Fig. 8-2). The paralysis is most noticeable when the infant cries. The mouth is drawn to the unaffected side, the wrinkles are deeper on the normal side, and the eye on the involved side remains open.
FIG 8-2 Facial nerve palsy. (From Clark-Gambelunghe MB, Clark D: Sensory development, Pediatr Clin North Am 62[2]:367– 384, 2015.)
No medical intervention is necessary. The paralysis usually disappears spontaneously in a few days but may take as long as several months.
Brachial Palsy Plexus injury results from forces that alter the normal position and relationship of the arm, shoulder, and neck. Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus
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and usually results from stretching or pulling away of the shoulder from the head, as might occur with shoulder dystocia or with a difficult vertex or breech delivery. Other identified risk factors include an infant with birth weight of more than 4000 g (8.8 pounds), multiparous pregnancy, a vacuum-assisted extraction, prolonged labor, and a previous history of brachial plexus injury (Lindqvist, Ajne, Cooray, et al, 2014; Hale, Bae, and Waters, 2009). The less common lower plexus palsy, or Klumpke palsy, results from severe stretching of the upper extremity while the trunk is relatively less mobile.
The clinical manifestations of Erb palsy are related to the paralysis of the affected extremity and muscles. The arm hangs limp alongside the body while the shoulder and arm are adducted and internally rotated. The elbow is extended, and the forearm is pronated, with the wrist and fingers flexed; a grasp reflex may be present because finger and wrist movement remain normal (Tappero, 2015) (Fig. 8-3). In lower plexus palsy, the muscles of the hand are paralyzed, with consequent wrist drop and relaxed fingers. In a third and more severe form of brachial palsy, the entire arm is paralyzed and hangs limp and motionless at the side. The Moro reflex is absent on the affected side for all forms of brachial palsy.
FIG 8-3 Left-sided brachial plexus (Erb) palsy. Note the extended, internally rotated arm and pronated wrist on the affected side.
Treatment of the affected arm is aimed at preventing contractures of the paralyzed muscles and maintaining correct placement of the humeral head within the glenoid fossa of the scapula. Complete recovery from stretched nerves usually takes 3 to 6 months. Full recovery is expected in 88% to 92% of infants (Verklan and Lopez, 2011). However, avulsion of the nerves (complete disconnection of the ganglia from the spinal cord that involves both anterior and posterior roots) results in permanent damage. For injuries that do not improve spontaneously by 3 to 6 months, surgical intervention may be needed to relieve pressure on the nerves or to repair the nerves with grafting (Yang, 2014). In some cases, injection of botulinum toxin A into the pectoralis major muscle may be effective in reducing muscle contractures after birth-related brachial plexus injuries (Yang, 2014).
Phrenic Nerve Paralysis Phrenic nerve paralysis results in diaphragmatic paralysis as demonstrated by ultrasonography, which shows paradoxic chest movement and an elevated diaphragm. Initially, radiography may not demonstrate an elevated diaphragm if the neonate is receiving positive-pressure ventilation (Verklan and Lopez, 2011). The injury sometimes occurs in conjunction with brachial palsy. Respiratory distress is the most common and important sign of injury. Because injury to the phrenic nerve is usually unilateral, the lung on the affected side does not expand, and respiratory efforts are ineffectual. Breathing is primarily thoracic, and cyanosis, tachypnea, or complete respiratory failure may be seen. Pneumonia and atelectasis on the affected side may also occur.
Nursing Care Management
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Nursing care of an infant with facial nerve paralysis involves aiding the infant in sucking and helping the mother with feeding techniques. Because part of the mouth cannot close tightly around the nipple, the use of a soft rubber nipple with a large hole may be helpful. The infant may require gavage feeding to prevent aspiration. Breastfeeding is not contraindicated, but the mother will need additional assistance in helping the infant grasp and compress the areolar area.
If the eyelid of the eye on the affected side does not close completely, artificial tears can be instilled daily to prevent drying of the conjunctiva, sclera, and cornea. The eyelid is often taped shut to prevent accidental injury. If eye care is needed at home, the parents are taught the procedure for administering eye drops before the infant is discharged from the nursery (see Chapter 20).
Nursing care of the newborn with brachial palsy is concerned primarily with proper positioning of the affected arm. The affected arm should be gently immobilized on the upper abdomen if a fracture is present; passive range-of-motion exercises of the shoulder, wrist, elbow, and fingers are initiated at 7 to 10 days of age (Yang, 2014). Wrist flexion contractures may be prevented with the use of supportive splints. In dressing the infant, preference is given to the affected arm. Undressing begins with the unaffected arm, and redressing begins with the affected arm to prevent unnecessary manipulation and stress on the paralyzed muscles. Teach parents to use the “football” position when holding the infant and to avoid picking up the child from under the axillae or by pulling on the arms.
The infant with phrenic nerve paralysis requires the same nursing care as any infant with respiratory distress. Mechanical ventilation may be required to prevent further respiratory compromise.
The family's emotional needs are also an important part of nursing care; the family will need reassurance regarding the neonate's progress toward an optimal outcome. Follow-up is also essential because of the extended length of recovery.
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Cranial Deformities In a normal newborn, the cranial sutures are separated by membranous seams several millimeters wide. Up to 2 days after birth, the cranial bones are highly mobile, which allows them to mold and slide over one another, adjusting the circumference of the head to accommodate to the changing shape and character of the birth canal. The principal sutures in the infant's skull are the sagittal, coronal, and lambdoidal sutures, and the major soft areas at the juncture of these sutures are the anterior and posterior fontanels.
After birth, growth of the skull bones occurs in a direction perpendicular to the line of the suture, and normal closure occurs in a regular and predictable order. Although there are wide variations in the age at which closure takes place in individual children, normally all sutures and fontanels are ossified by the following ages:
Eight weeks: Posterior fontanel closed
Six months: Fibrous union of suture lines and interlocking of serrated edges
Eighteen months: Anterior fontanel closed
After 12 years: Sutures unable to be separated by increased ICP
Solid union of all sutures is not completed until late childhood. Craniostenosis, closure of a suture before the expected time, inhibits the perpendicular growth. Because normal increase in brain volume requires expansion, the skull is forced to grow in a direction parallel to the fused suture. This alteration in skull growth always produces a distortion of the head shape when the underlying brain growth is normal. A small head with closed and normal shape is a result of deficient brain growth; the suture closure is secondary to this brain growth failure. Failure of brain growth is not secondary to suture closure.
Various types of cranial deformities are encountered in early infancy. These include an enlarged head with frontal protrusion (bossing; characteristic of hydrocephalus), parietal bossing that is seen in chronic subdural hematoma, a small head, and a variety of skull deformities. Some occur during prenatal development; in others, head circumference is usually within normal limits at birth, and the deviation from normal development becomes apparent with advancing age.
Prognosis The majority of infants with craniostenosis have normal brain development. The exceptions are those with genetic disorders that involve brain pathologic conditions.
Nursing Care Management Nursing care of families in which there is a child with a cranial defect involves identifying children with deformities and referring them for evaluation. Because no therapy is available for children with microcephaly, nursing care is directed toward helping parents adjust to caring for a child with brain damage (see Chapter 18).
Infants who benefit from surgery require special emphasis on observation for signs of anemia because of the large blood loss during surgery (see Family-Centered Care box). Nursing care includes observation for signs of hemorrhage, infection, pain, and swelling, as well as parental education for suture care and safety. Surgical sutures should remain dry and intact. Parents need to observe for any signs of redness, drainage, or swelling and report any temperature greater than 38.4° C (101° F).
F a m i l y - C e n t e r e d C a r e Blood Donation
Parents may wish to provide a compatible blood donor for their infant undergoing a planned
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surgical correction for craniostenosis. Nurses need to inform and guide parents through the blood bank procedure.
Early surgical management of craniostenosis in children 3 to 9 months old allows proper expansion of the brain and the creation of an acceptable appearance (Ursitti, Fadda, Papetti, et al, 2011). Parents require special support and education during this time, especially from the health care team.
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Common Problems in the Newborn Erythema Toxicum Neonatorum Erythema toxicum neonatorum, also known as flea-bite dermatitis or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The lesions are firm, 1- to 3-mm, pale yellow or white papules or pustules on an erythematous base; they resemble flea bites. The rash appears most commonly on the face, proximal extremities, trunk, and buttocks, but it may be located anywhere on the body except the palms and soles. The rash is more obvious during crying episodes. There are no systemic manifestations, and successive crops of lesions heal without pigmentation changes. The rash usually lasts about 5 to 7 days. The etiology is unknown. However, a smear of the pustule will show numerous eosinophils and a relative absence of neutrophils. When the diagnosis is questionable, bacterial, fungal, or viral cultures should be obtained. Although no treatment is necessary, parents are usually concerned about the rash and need to be reassured of its benign and transient nature.
Candidiasis Candidiasis, also known as moniliasis, is not uncommon in newborns. Candida albicans, the usual organism responsible, may cause disease in any organ system. It is a yeastlike fungus (it produces yeast cells and spores) that can be acquired from a maternal vaginal infection during delivery; from person-to-person transmission (especially from poor hand-washing technique); or from contaminated hands, bottles, nipples, or other articles. Mucocutaneous, cutaneous, and disseminated candidal infections are all observed in this age group. Candidiasis is usually a benign disorder in neonates, often confined to the oral and diaper regions. In extremely preterm infants, there is an increased risk of serious systemic infections caused by Candida. Diaper dermatitis caused by Candida organisms manifests as a moist, erythematous eruption with small white or yellow pebbly pustules. Small areas of skin erosion may also be seen (see Diaper Dermatitis, Chapter 10).
Oral Candidiasis Oral candidiasis (thrush) is characterized by white, adherent patches on the tongue, palate, and inner aspects of the cheeks (Fig. 8-4). It is often difficult to distinguish from coagulated milk. The infant may refuse to suck because of pain in the mouth.
FIG 8-4 Oral candidiasis (thrush). (From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology, ed 5, St Louis, 2016, Elsevier.)
This condition tends to be acute in newborns and chronic in infants and young children. Thrush appears when the oral flora is altered as a result of antibiotic therapy or poor hand washing by the
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infant's caregiver. Although the disorder is usually self-limiting, spontaneous resolution may take as long as 2 months, during which time lesions may spread to the larynx, trachea, bronchi, and lungs and along the gastrointestinal tract. The disease is treated with good hygiene, application of a fungicide, and correction of any underlying disturbance. The source of infection should be treated to prevent reinfection.
Topical application of 1 ml nystatin (Mycostatin) over the surfaces of the oral cavity four times a day, or every 6 hours, is usually sufficient to prevent spread of the disease or prolongation of its course. Several other drugs may be used, including amphotericin B (Fungizone), clotrimazole (Lotrimin, Mycelex), fluconazole (Diflucan), or miconazole (Monistat, Micatin) given intravenously, orally, or topically. To prevent relapse, therapy should be continued for at least 2 days after the lesions disappear (Lawrence and Lawrence, 2011). Gentian violet solution may be used in addition to one of the antifungal drugs in chronic cases of oral thrush; however, the former does not treat gastrointestinal Candida infection. Some practitioners avoid its use because it is messy, easily stains clothing, and may be irritating to the oral mucosa. Fluconazole is reportedly more effective than nystatin, but it does not have US Food and Drug Administration approval for use in infants (Maley and Arbiser, 2013).
N u r s i n g A l e r t Oral candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a tongue blade are unsuccessful. The primary caregiver may also report that the infant does not nurse well or bottle feed as previously.
Nursing Care Management Nursing care is directed toward preventing spread of the infection and correctly applying the prescribed topical medication. For candidiasis in the diaper area, the caregiver is taught to keep the diaper area clean and to apply the medication to affected areas as prescribed (see also Diaper Dermatitis, Chapter 10). Older infants with candidal diaper dermatitis can introduce the yeast into the mouth from contaminated hands. Placing clothes over the diaper can prevent this cycle of self- infection.
In cases of oral thrush, nystatin is administered after feedings. Distribute the medication over the surface of the oral mucosa and tongue with an applicator or syringe; the remainder of the dose is deposited in the mouth to be swallowed by the infant to treat any gastrointestinal lesions.
In addition to good hygienic care, other measures to control thrush include rinsing the infant's mouth with plain water after each feeding before applying the medication and boiling reusable nipples and bottles for at least 20 minutes after a thorough washing (spores are heat resistant). If used, pacifiers should be boiled for at least 20 minutes once daily. If the mother is breastfeeding, it is recommended that simultaneous treatment of the infant and mother occur if either is infected (Lawrence and Lawrence, 2011).
Herpes Simplex Virus Neonatal herpes is one of the most serious viral infections in newborns, with a mortality rate of up to 60% in infants with disseminated disease. Approximately 86% to 90% of herpes simplex transmission occurs during passage through the birth canal (Shet, 2011). The risk of transmission of genital herpes during vaginal birth is estimated to be between 30% and 50% with active primary infection at term (Gardella and Brown, 2011). However, in up to 80% of cases of neonatal herpes simplex virus (HSV) infection, the mother has no history or symptoms of infection at the time of birth, but serologic testing reveals evidence of the herpes virus (Gardella and Brown, 2011).
Neonatal herpes manifests in one of three ways: (1) with skin, eye, and mouth (SEM) involvement; (2) as localized central nervous system (CNS) disease; or (3) as disseminated disease involving multiple organs. In skin and eye disease, a rash appears as vesicles or pustules on an erythematous base. Clusters of lesions are common. The lesions ulcerate and crust over rapidly. Up to 17% of neonates with disseminated disease do not develop a skin rash (Berardi, Lugli, Rossi, et al, 2011). Ophthalmologic findings include keratoconjunctivitis, chorioretinitis, cataracta, and retinal detachment; neurologic involvement (such as, microcephaly and encephalomalacia) may also develop (Berardi, Lugli, Rossi, et al, 2011). Disseminated infections may involve virtually every
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organ system, but the liver, adrenal glands, and lungs are most commonly affected. In HSV meningitis, infants develop multiple lesions with cortical hemorrhagic necrosis. It can occur alone or with oral, eye, or skin lesions. The presenting symptoms, which may occur in the second to fourth weeks of life, include lethargy, poor feeding, irritability, and local or generalized seizures.
Nursing Care Management Neonates with herpesvirus or suspected infection (as a result of exposure) should be carefully evaluated for clinical manifestations. The absence of skin lesions in the neonate exposed to maternal herpesvirus does not indicate absence of disease. Contact precautions (in addition to standard precautions) should be instituted according to the American Academy of Pediatrics and American College of Obstetricians and Gynecologists (2012) guidelines or hospital protocol. It is recommended that swabs of the mouth, nasopharynx, conjunctivae, rectum, and any skin vesicles be obtained from the exposed neonate; in addition, urine, blood, and cerebrospinal fluid (CSF) specimens should be obtained for culture. Therapy with acyclovir and vidarabine is initiated if the culture results are positive or if there is strong suspicion of herpesvirus infection (American Academy of Pediatrics, Committee on Infectious Diseases, and Pickering, 2012). High-dose acyclovir (60 mg/kg/day) has been shown to decrease mortality rates in infants with disseminated HSV (Berardi, Lugli, Rossi, et al, 2011).
Birthmarks Discolorations of the skin are common findings in newborn infants (see discussion on skin assessment of newborns, Chapter 7). Most, such as mongolian spots or telangiectatic nevi, involve no therapy other than reassurance to parents of the benign nature of these discolorations. However, some can be a manifestation of a disease that suggests further examination of the child and other family members (e.g., the multiple light brown café-au-lait spots that often characterize the autosomal dominant hereditary disorder neurofibromatosis and are common findings in Albright syndrome).
Darker or more extensive lesions demand further scrutiny, and excision of the lesion is recommended when feasible. Such lesions include a reddish brown solitary nodule that appears on the face or upper arm and usually represents a spindle and epithelioid cell nevus (juvenile melanoma); a giant pigmented nevus (or bathing trunk nevus), a dark brown to black, irregular plaque that is at risk of transformation to malignant melanoma; and the dark brown or black macules that become more numerous with age (junctional or compound nevi).
Vascular birthmarks may be divided into the following categories: vascular malformations, capillary hemangiomas, and mixed hemangiomas. Vascular stains (malformations) are permanent lesions that are present at birth and are initially flat and erythematous. Any vascular structure, capillary, vein, artery, or lymphatic may be involved. The two most common vascular stains are the transient macular stain (stork bite, salmon patch, or angel kiss) and the port-wine stain, or nevus flammeus. The port-wine lesions are pink, red, or, rarely, purple stains of the skin that thicken, darken, and proportionately enlarge as the child grows (Fig. 8-5, A). The macular stain is most often located on the eyelids, glabella, or nape of the neck and usually fades over several months but may be prominent with crying or environmental temperature changes (Morelli, 2011).
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FIG 8-5 A, Port-wine stain. B, Strawberry hemangioma. (From Zitelli BJ, McIntire SC, Nowalk AJ: Zitelli and Davis' atlas of pediatric physical diagnosis, ed 6, St Louis, 2012, Saunders/Elsevier.)
Port-wine stains may also be associated with structural malformations, such as glaucoma or leptomeningeal angiomatosis (tumor of blood or lymph vessels in the pia-arachnoid) (Sturge- Weber syndrome) or bony or muscular overgrowth (Klippel-Trenaunay-Weber syndrome). Children with port-wine stains on the eyelids, forehead, or cheeks should be monitored for these syndromes with periodic ophthalmologic examination, neurologic imaging, and measurement of extremities.
The treatment of choice for port-wine stains is the use of the flashlamp-pumped pulsed-dye laser. A series of treatments is usually needed. The treatments can significantly lighten or completely clear the lesions with almost no scarring or pigment change.
Capillary hemangiomas, sometimes referred to as strawberry hemangiomas, are benign cutaneous tumors that involve only capillaries. These hemangiomas are bright red, rubbery nodules with a rough surface and a well-defined margin (see Fig. 8-5, B). Strawberry hemangiomas may not be apparent at birth but may appear within a few weeks and enlarge considerably during the first year of life and then begin to involute spontaneously. It may take 5 to 12 years for complete resolution, and a significant number of patients may be left with residual findings, such as telangiectasia, redundant fatty tissue, or skin atrophy (Ji, Chen, Li, et al, 2014). Topical or systemic propranolol may be used in some cases to shrink the lesions (Püttgen, 2014). Cavernous venous hemangiomas involve deeper vessels in the dermis and have a bluish red color and poorly defined margins. These latter forms may be associated with the trapping of platelets (Kasabach-Merritt syndrome) and subsequent thrombocytopenia (Kelly, 2010; Witt, 2015).
Hemangiomas may also occur as part of the PHACE syndrome (Sidbury, 2010):
Posterior fossa brain malformation
Hemangiomas (segmental cervicofacial)
Arterial anomalies
Cardiac defects, including coarctation of the aorta
Eye anomalies
Although most hemangiomas require no treatment because of their high rate of spontaneous involution, some vision and airway obstruction may necessitate therapy. Systemic propranolol or prednisone may deter further growth. Subcutaneous injections of interferon or vincristine may be required if prednisone therapy and the pulsed-dye laser fail to control a problematic hemangioma; however, the associated side effects may outweigh the benefits of therapy in some cases (Holland and Drolet, 2010).
Nursing Care Management Birthmarks, especially those on the face, are upsetting to parents. Families need an explanation of the type of lesion, its significance, and possible treatment.* They can benefit from seeing
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photographs of other infants before and after treatment for port-wine stains or after the passage of time for hemangiomas. Pictures taken to follow the involution process may further help parents gain confidence that progress is taking place.
If laser therapy is performed, the lesion will have a purplish black appearance for 7 to 10 days, after which the blackness fades and gives way to redness with an eventual lightening of the treated area. During the treatment phase, parents are cautioned to avoid any trauma to the lesion or picking at the scab. The child's fingernails are trimmed as an added precaution. Washing the area gently with water and dabbing it dry is adequate, although in some cases, a topical antibiotic ointment may be used. No salicylates should be taken during the treatment phase, because they decrease the effects of the therapy. The child should be kept out of the sun for several weeks and then protected with a sunscreen of at least SPF 25. Complications associated with laser treatment include redness and bruising and, less commonly, hyperpigmentation, hypopigmentation, and atrophic scarring (Zheng, Zhang, Zhou, et al, 2013).
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Nursing Care of the High-Risk Newborn and Family Identification of High-Risk Newborns A high-risk neonate can be defined as a newborn, regardless of gestational age or birth weight, who has a greater than average chance of morbidity or mortality because of conditions or circumstances associated with birth and the adjustment to extrauterine existence. The high-risk period encompasses human growth and development from the time of viability (the gestational age at which survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28 days after birth; thus, it includes threats to life and health that occur during the prenatal, perinatal, and postnatal periods.
There has been increased interest in late-preterm infants of 34 to weeks of gestation who may receive the same treatment as term infants. Late-preterm infants often experience similar morbidities to preterm infants, including respiratory distress, hypoglycemia requiring treatment, temperature instability, poor feeding, jaundice, and adverse neurodevelopmental outcomes (Jefferies, Lyons, Shah, et al, 2013). Therefore, assessment and prompt intervention in life- threatening perinatal emergencies often make the difference between a favorable outcome and a lifetime of disability. It is estimated that late-preterm infants represent 70% of the total preterm infant population and that the mortality rate for this group is up to five times higher than that of term infants (Cheong and Doyle, 2012). Because late-preterm infants' birth weights often range from 2000 to 2500 g (4.4 to 5.5 pounds) and they appear relatively mature compared with smaller preterm infants, they may be cared for in the same manner as healthy term infants while risk factors for late- preterm infants are overlooked. Late-preterm infants are often discharged early from the birth institution and have a significantly higher rate of rehospitalization than term infants (Bowers, Curran, Freda, et al, 2012). Discussions regarding high-risk infants in this chapter also refer to late- preterm infants who are experiencing a delayed transition to extrauterine life. Nurses in newborn nurseries should be familiar with the characteristics of neonates and recognize the significance of serious deviations from expected observations. When providers can anticipate the need for specialized care and plan for it, the probability of successful outcome is increased.
The Association of Women's Health, Obstetric and Neonatal Nurses has published the Assessment and Care of the Late Preterm Infant (2010) guide for the education of perinatal nurses, regarding the late-preterm infant's risk factors and appropriate care and follow-up care.
Classification of High-Risk Newborns High-risk infants are most often classified according to birth weight, gestational age, and predominant pathophysiologic problems. The more common problems related to physiologic status are closely associated with the state of maturity of the infant and usually involve chemical disturbances (e.g., hypoglycemia, hypocalcemia) or consequences of immature organs and systems (e.g., hyperbilirubinemia, respiratory distress, hypothermia). Because high-risk factors are common to several specialty areas—particularly obstetrics, pediatrics, and neonatology—specific terminology is needed to describe the developmental status of the newborn (Box 8-1).
Box 8-1 C l a s s i f i c a t i o n o f H i g h - R i s k I n f a n t s Classification According to Size
Low birth weight (LBW) infant: An infant whose birth weight is less than 2500 g (5.5 pounds) regardless of gestational age
Very low birth weight (VLBW) infant: An infant whose birth weight is less than 1500 g (3.3 pounds)
Extremely low birth weight (ELBW) infant: An infant whose birth weight is less than 1000 g (2.2 pounds)
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Appropriate for gestational age (AGA) infant: An infant whose weight falls between the 10th and 90th percentiles on intrauterine growth curves
Small for date (SFD) or small for gestational age (SGA) infant: An infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves (see also Fig. 8-1, B)
Intrauterine growth restriction (IUGR): Found in infants whose intrauterine growth is restricted (sometimes used as a more descriptive term for SGA infants)
Symmetric IUGR: Growth restriction in which the weight, length, and head circumference are all affected
Asymmetric IUGR: Growth restriction in which the head circumference remains within normal parameters while the birth weight falls below the 10th percentile
Large-for-gestational-age (LGA) infant: An infant whose birth weight falls above the 90th percentile on intrauterine growth charts
Classification According to Gestational Age
Preterm (premature) infant: An infant born before completion of 37 weeks of gestation regardless of birth weight
Full-term infant: An infant born between the beginning of the 38 weeks and the completion of the 42 weeks of gestation regardless of birth weight
Late-preterm infant: An infant born between 340/7 and 360/7 weeks of gestation regardless of birth weight
Postterm (postmature) infant: An infant born after 42 weeks of gestational age regardless of birth weight
Classification According to Mortality
Live birth: Birth in which the neonate manifests any heartbeat, breathes, or displays voluntary movement regardless of gestational age
Fetal death: Death of the fetus after 20 weeks of gestation and before delivery with absence of any signs of life after birth
Neonatal death: Death that occurs in the first 27 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 27 days
Perinatal mortality: Total number of fetal and early neonatal deaths per 1000 live births
Formerly, weight at birth was considered to reflect a reasonably accurate estimation of gestational age; that is, if an infant's birth weight exceeded 2500 g (5.5 pounds), the infant was considered to be mature. However, accumulated data have shown that intrauterine growth rates are not the same for all infants and that other factors (e.g., heredity, placental insufficiency, maternal disease) influence intrauterine growth and birth weight. From these data, a more definitive and meaningful classification system that encompasses birth weight, gestational age, and neonatal outcome has been developed. (See Fig. 8-2 for size comparison of newborn infants.)
Care of High-Risk Newborns Systematic Assessment A thorough systematic physical assessment is an essential component in the care of high-risk infants (see Nursing Care Guidelines box). Subtle changes in feeding behavior, activity, color,
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oxygen saturation (SaO2), or vital signs often indicate an underlying problem. Low birth weight (LBW) preterm infants, especially very low birth weight (VLBW) or extremely low birth weight (ELBW) infants, are ill equipped to withstand prolonged physiologic stress and may die within minutes of exhibiting abnormal symptoms if the underlying pathologic process is not corrected. Alert nurses are aware of subtle changes and react promptly to implement interventions that promote optimum functioning in high-risk neonates. Changes in the infant's status are noted through ongoing observations of the infant's adaptation to the extrauterine environment.
N u r s i n g C a r e G u i d e l i n e s Physical Assessment
General Assessment
Using an electronic scale, weigh daily, or more often if indicated.
Measure length and head circumference at birth.
Describe general body shape and size, posture at rest, ease of breathing, presence and location of edema.
Describe any apparent deformities.
Describe any signs of distress—poor color, hypotonia, lethargy, apnea.
Respiratory Assessment
Describe shape of chest (barrel, concave), symmetry, presence of incisions, chest tubes, or other deviations.
Describe use of accessory muscles—nasal flaring or substernal, intercostal, or suprasternal retractions.
Determine respiratory rate and regularity.
Auscultate and describe breath sounds—crackles, wheezing, wet or diminished sounds, grunting, diminished air movement, stridor, equality of breath sounds.
Describe cry if not intubated.
Describe ambient oxygen and method of delivery; if intubated, describe size and position of tube, type of ventilator, and settings.
Determine oxygen saturation by pulse oximetry and partial pressure of oxygen, and describe carbon dioxide by transcutaneous carbon dioxide (tcPCO2).
Cardiovascular Assessment
Determine heart rate and rhythm.
Describe heart sounds, including any murmurs.
Determine the point of maximum impulse (PMI), the point at which the heartbeat sounds and palpates loudest (a change in the PMI may indicate a mediastinal shift).
Describe infant's color: Cyanosis (may be of cardiac, respiratory, or hematopoietic origin), pallor, plethora, jaundice, mottling.
Assess color of mucous membranes, lips.
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Determine blood pressure (BP) as indicated. Indicate extremity used and cuff size.
Describe femoral pulses, capillary refill, and peripheral perfusion (mottling).
Describe monitors, their parameters, and whether alarms are in the “on” position.
Gastrointestinal Assessment
Determine presence of abdominal distention—increase in circumference, shiny skin, evidence of abdominal wall erythema, visible peristalsis, visible loops of bowel, status of umbilicus.
Determine any signs of regurgitation and time related to feeding; describe character and amount of residual if gavage fed; if nasogastric tube is in place, describe type of suction and drainage (color, consistency, pH).
Describe amount, color, consistency, and odor of any emesis.
Palpate liver margin (1 to 3 cm below right costal margin).
Describe amount, color, and consistency of stools.
Describe bowel sounds—presence or absence (must be present if feeding).
Genitourinary Assessment
Describe any abnormalities of genitalia.
Describe amount (as determined by weight), color, pH, lab stick findings, and specific gravity of urine.
Check weight.
Neurologic–Musculoskeletal Assessment
Describe infant's movements—random, purposeful, jittery, twitching, spontaneous, elicited; describe level of activity with stimulation; evaluate based on gestational age.
Describe infant's position or attitude—flexed, extended.
Describe reflexes observed—Moro, sucking, Babinski, plantar, and other expected reflexes.
Determine level of response and consolability.
Determine changes in head circumference (if indicated), size and tension of fontanels, suture lines.
Determine pupillary responses in infant older than 32 weeks of gestation.
Check hip alignment (only experienced practitioner should perform).
Temperature
Determine axillary temperature.
Determine relationship to environmental temperature.
Skin Assessment
Note any skin lesions or birthmarks.
Describe any discoloration, reddened area, signs of irritation, blisters, abrasions, or denuded areas, especially where monitoring equipment, infusions, or other apparatus come in contact with skin;
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also check and note any skin preparation used (e.g., skin disinfectants).
Determine texture and turgor of skin—dry, smooth, flaky, peeling, and so on.
Describe any rash, skin lesion, or birthmarks.
Determine whether intravenous (IV) infusion catheter is in place and observe for signs of infiltration.
Describe parenteral infusion lines—location, type (arterial, venous, peripheral, umbilical, central, peripheral central venous), type of infusion (medication, saline, dextrose, electrolyte, lipids, total parenteral nutrition), type of infusion pump and rate of flow, type of catheter, and appearance of insertion site.
Observational assessments of high-risk infants are made according to each infant's acuity; critically ill infants require close observation and assessment of respiratory function, including continuous pulse oximetry, electrolytes, and evaluation of blood gases. Accurate documentation of the infant's status is an integral component of nursing care. With the aid of continuous, sophisticated cardiopulmonary monitoring, nursing assessments and daily care may be coordinated to allow for minimal handling of the infant (especially very low birth weight [VLBW] or extremely low birth weight [ELBW] infants) to decrease the effects of environmental stress.
Monitoring Physiologic Data Most neonates needing close observation are placed in a controlled thermal environment and monitored for heart rate, respiratory activity, and temperature. The monitoring devices are equipped with an alarm system that indicates when the vital signs are above or below preset limits. However, it is essential to check the apical heart rate and compare it with the monitor reading.
Blood pressure (BP) is monitored routinely in sick neonates by either internal or external means. Direct recording with arterial catheters may be used but carries the risks inherent in any procedure in which a catheter is introduced into an artery. BP values gradually increase over the first month of life in preterm and term infants. BP norms vary by gestational age and weight, medications (such as, corticosteroids), and disease process. One of the primary considerations in the preterm infant is the relationship between systemic BP and the determination of adequate cerebral blood flow. In the neonatal intensive care unit (NICU), frequent laboratory examinations and their interpretation are integral parts of the ongoing assessment of infants' progress. Accurate intake and output records are kept on all acutely ill infants. An accurate output can be obtained by collecting urine in a plastic urine collection bag specifically made for preterm infants (see Urine Specimens, Chapter 20) or by weighing the diapers, which is the simplest and least traumatic means of measuring urinary output. The pre-weighed wet diaper is weighed on a gram scale, and the gram weight of the urine is converted directly to milliliters (e.g., 25 g = 25 ml).
Blood examinations are a necessary part of the ongoing assessment and monitoring of the high- risk newborn's progress. The tests most often performed are blood glucose, bilirubin, calcium, hematocrit, serum electrolytes, and blood gases. Samples may be obtained from the heel; by venipuncture; by arterial puncture; or by an indwelling catheter in an umbilical vein, an umbilical artery, or a peripheral artery (see the Atraumatic Care box in Chapter 7 and Collection of Specimens, Chapter 20).
When numerous blood samples must be drawn, it is important to maintain an accurate record of the amount of blood being removed, especially in ELBW and VLBW infants, who can ill afford to have their blood supply depleted during the acute phase of their illness. There is an increased emphasis on drawing as little blood as possible from high-risk neonates to minimize the depletion of blood volume and avoid blood transfusions and associated complications. To avoid the need for repeated arterial punctures, pulse oximetry, which measures the saturation or percentage of oxygen in the hemoglobin, is typically used. The nurse notes changes in oxygenation (or other aspects being monitored) associated with handling and adjusts the infant's care accordingly. The frequency of vital signs is determined by the infant's acuity level (seriousness of condition) and response to handling.
The nursing process in the care of high-risk newborns and their families is described in the Nursing Process box.
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N u r s i n g P r o c e s s The High-Risk Newborn and Family
Assessment At birth, the newborn is given a rapid yet thorough assessment to determine any apparent problems and identify those that demand immediate attention. This examination is primarily concerned with evaluation of cardiopulmonary and neurologic functions. The assessment includes assignment of an Apgar score (see Chapter 7 and evaluation for any obvious congenital anomalies or evidence of neonatal distress). A systematic assessment is carried out after the high-risk newborn is stable (see also Clinical Assessment of Gestational Age, Chapter 7).
Diagnosis (Problem Identification) Many nursing diagnoses may be evident after a careful assessment of the infant at risk. Some apply to all infants; others vary according to the needs and characteristics of individual infants and their families. Because a number of health problems accompany high-risk infants, the nurse is also alert to other conditions and complications discussed later in this chapter and elsewhere in the book. The nursing diagnoses that represent general guides for nursing intervention are:
• Ineffective Breathing Pattern—related to pulmonary and neuromuscular immaturity
• Ineffective Thermoregulation—related to immature temperature control and decreased subcutaneous fat
• Risk for Infection—risk factors include deficient immunologic defenses, exposure to environmental pathogens, required invasive procedures and invasive equipment
• Imbalanced Nutrition: Less Than Body Requirements—related to inability to ingest nutrients
• Risk for Impaired Skin Integrity—risk factors include immature skin structure, physical immobility, decreased fluid intake, and invasive procedures
• Risk for Imbalanced Fluid Volume—risk factors include immature skin structure; extra fluid losses via skin, lungs, and urine; decreased ability to take in required amount of fluid to sustain hydration
• Delayed Growth and Development—related to preterm birth, immature physiologic capabilities at birth, neonatal intensive care unit (NICU) environment, separation from parents, effects of concomitant illnesses
• Interrupted Family Processes—related to preterm birth, situational crisis, interruption of parent– infant interaction
• Anticipatory Grieving—related to unexpected birth of high-risk infant, knowledge deficit regarding infant's prognosis and eventual outcome
Planning The nursing care plan for the high-risk infant depends to a large extent on the diagnosis of the health problem(s) that place the infant at risk. However, the following expected outcomes are appropriate for many high-risk infants and their families:
• Infant will exhibit adequate oxygenation.
• Infant will maintain stable body temperature.
• Infant will exhibit no evidence of nosocomial infection.
• Infant will receive adequate hydration and nutrition.
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• Infant will maintain skin integrity.
• Infant will receive appropriate developmental support and care.
• Parents will experience positive parent–infant interactions.
• Parents will exhibit positive caretaking abilities with high-risk infant.
• Family will receive appropriate support, including preparation for home care or for infant's death.
Implementation Intervention strategies for high-risk infants and their families are discussed on pp. 237 to 255.
Evaluation The effectiveness of nursing interventions is determined by continual reassessment and evaluation of care based on the following observational guidelines:
• Take vital signs and perform respiratory assessments at time intervals based on infant's condition and needs; observe infant's respiratory efforts and response to therapy; check functioning of equipment; review laboratory test results.
• Measure body temperature at specified intervals.
• Observe infant's behavior and appearance for evidence of sepsis; monitor lab values for sepsis.
• Assess for hydration; assess and measure fluid intake; observe infant during feeding; measure amount of human milk, formula, or parenteral intake; weigh daily.
• Observe infant's skin for signs of irritation, excoriation, and breakdown.
• Observe infant's response to developmental care.
• Observe parental interaction with infant; interview family regarding their feelings, concerns, and readiness for home care.
• Assess family and observe their behaviors during and after the death of their infant.
Respiratory Support The primary objective in the care of high-risk infants is to establish and maintain adequate respiration. Many infants require supplemental oxygen and assisted ventilation. All infants require appropriate positioning to maximize oxygenation and ventilation. Oxygen therapy is provided on the basis of the infant's requirements and illness (see Respiratory Distress Syndrome later in this chapter).
Thermoregulation After or concurrent with the establishment of respiration, the most crucial need of LBW infants is application of external warmth. Prevention of heat loss in distressed infants is absolutely essential for survival, and maintaining a neutral thermal environment is a challenging aspect of neonatal intensive nursing care. Heat production is a complicated process that involves the cardiovascular, neurologic, and metabolic systems; and immature neonates have all of the problems related to heat production that are faced by full-term infants (see Thermoregulation, Chapter 7). However, LBW infants are placed at further disadvantage by a number of additional problems. They have an even smaller muscle mass and fewer deposits of brown fat for producing heat, lack insulating subcutaneous fat, and have poor reflex control of skin capillaries.
To reduce the risk of cold stress, at-risk newborns are placed skin-to-skin with their mother if medically stable or in a heated environment immediately after birth, where they remain until they are able to maintain thermal stability, which is the capacity to balance heat production and conservation with heat dissipation. Because overheating produces an increase in oxygen and calorie consumption, infants are also jeopardized in a hyperthermic environment. A neutral thermal
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environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and calorie expenditure (Bissinger and Annibale, 2010). Studies indicate that optimum thermoneutrality cannot be predicted for every high-risk infant's needs. In healthy term infants, it is recommended that axillary temperatures be maintained at 36.5° to 37.5° C (97.7° to 99.5° F); in preterm infants, axillary temperatures of 36.3° and 36.9° C (97.3° and 98.4° F) are considered appropriate (Brown and Landers, 2011).
VLBW and ELBW infants, with thin skin and almost no subcutaneous fat, can control body heat loss or gain only within a limited range of environmental temperatures. In these infants, heat loss from radiation, evaporation, and transepidermal water loss is three to five times greater than in larger infants, and a decrease in body temperature is associated with an increase in mortality. Further research is needed to define a neutral thermal environment for ELBW infants.
The consequences of cold stress that produce additional hazards to neonates are (1) hypoxia, (2) metabolic acidosis, and (3) hypoglycemia. Increased metabolism in response to chilling creates a compensatory increase in oxygen and calorie consumption. If available oxygen is not increased to accommodate this need, arterial oxygen tension is decreased. This is further complicated by a smaller lung volume in relation to the metabolic rate, which creates diminished oxygen in the blood and concurrent pulmonary disorders. A small advantage is gained by the presence of fetal hemoglobin because its increased capacity to carry oxygen allows the infant to exist for longer periods in conditions of lowered oxygen tension.
The three primary methods for maintaining a neutral thermal environment are the use of an incubator, a radiant warmer (Fig. 8-6), and an open bassinet with cotton blankets. A dressed infant under blankets can maintain a certain temperature within a wider range of environmental temperatures; however, the need for closer observation of high-risk infant may require that the infant remain partially unclothed. The incubator should always be pre-warmed before placing an infant in it. The use of double-walled incubators significantly improves the infant's ability to maintain a desirable temperature and reduce energy expenditure related to heat regulation. Inside or outside the incubator, head coverings are effective in preventing heat loss. A fabric-insulated or wool cap is more effective than one fashioned from stockinette. The use of a heated gel mattress with radiant heat has been shown to significantly decrease the incidence of radiation heat loss and preserve an adequate neutral thermal environment for the VLBW neonate (Lewis, Sanders, and Brockopp, 2011; Altimier, 2012). An effective means for maintaining the desired range of temperature in the infant is the use of a manually adjusted or automatically controlled (servo- controlled) incubator. The latter mechanism, when set at the upper and lower limits of the desired circulating air temperature range, adjusts automatically in response to signals from a thermal sensor attached to the abdominal skin. If the infant's temperature drops, the warming device is triggered to increase heat output. The servo control is usually set to a desired skin temperature between 36° and 36.5° C (96.8° and 97.7° F) (Brown and Landers, 2011).
FIG 8-6 Nurse caring for an infant in a radiant warmer. (Photo courtesy E. Jacobs, Texas Children's Hospital, Houston, TX.)
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A high-humidity atmosphere contributes to body temperature maintenance by reducing evaporative heat loss. A number of “microenvironments” may be used with VLBW and ELBW infants to minimize evaporative and insensible water losses. These include items such as food- grade plastic bags or plastic wrap, humidified reservoirs for incubators, and humidified plastic heat shields covered with plastic wrap (Fig. 8-7). When such environments are used, special care must be taken to avoid bacterial contamination of the warm and humid environment by organisms such as Pseudomonas and Serratia, which have an affinity for moist environments; postnatally acquired pneumonia from such organisms may be fatal, particularly in VLBW infants. A systematic review of practices to decrease hypothermia at birth in LBW infants found that plastic wraps (polyethylene) or bags kept preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia (Lewis, Sanders, and Brockopp, 2011; McCall, Alderdice, Halliday, et al, 2010). This practice is now recommended in the Neonatal Resuscitation Program guidelines published by the American Heart Association (Kattwinkel, Perlman, Aziz, et al, 2010).
FIG 8-7 Infant under plastic wrap, which produces a draft-free environment. (Photo courtesy E. Jacobs, Texas Children's Hospital, Houston, TX.)
Skin-to-skin (kangaroo) contact between a stable preterm infant and parent is also a viable option for interaction because of the maintenance of appropriate body temperature by the infant. Other benefits of skin-to-skin contact are discussed later in this chapter.
Protection from Infection Protection from infection is an integral part of all newborn care, but preterm and sick neonates are particularly susceptible. The protective environment of a regularly cleaned and changed incubator provides effective isolation from airborne infective agents. However, thorough, meticulous, and frequent hand washing is the foundation of a preventive program. This includes all persons who come in contact with infants and their equipment. After handling another infant or equipment, no one should ever touch an infant without first washing their hands.
Personnel with infectious disorders are either barred from the unit until they are no longer infectious or are required to wear suitable shields, such as masks or gloves, to reduce the likelihood of contamination. An annual influenza vaccination is recommended for NICU personnel. Standard precautions as a method of infection control are instituted in all nursery areas to protect the infants and staff (see Chapter 20). The benefit of “gowning” by visitors and hospital staff to control infection is not supported by research. Sibling visitation in the NICU has not been shown to increase nosocomial infections (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2012); however, appropriate screening for upper respiratory illness in siblings is often recommended.
The sources of infection rise in direct relationship to the number of persons and pieces of equipment coming in contact with the infants. Equipment used in the care of infants is cleaned on a
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regular basis in accordance with the manufacturer's recommendations or institutional protocol; this includes cleaning of cribs, mattresses, incubators, radiant warmers, cardiorespiratory monitors, pulse oximeters, and vital sign–monitoring equipment after usage with one infant and before usage with another. Because organisms thrive best in water, plumbing fixtures and humidifying equipment are particularly hazardous. Disposable equipment used for water-related therapies, such as nebulizers and plastic tubing, is changed regularly.
Hydration High-risk infants often receive supplemental parenteral fluids to supply additional calories, electrolytes, and water. Adequate hydration is particularly important in preterm infants because their extracellular water content is higher (70% in full-term infants and up to 90% in preterm infants), their body surface is larger, and the capacity for handling fluid shifts is limited in preterm infants' underdeveloped kidneys. Therefore, these infants are highly vulnerable to fluid depletion.
Parenteral fluids may be given to the high-risk neonate via several routes depending on the nature of the illness, the duration and type of fluid therapy, and unit preference. Common routes of fluid infusion include peripheral, peripherally inserted central venous (or percutaneous central venous), surgically inserted central venous, and umbilical venous catheters. The preferred sites for peripheral intravenous (IV) infusions in neonates are the peripheral veins on the dorsal surfaces of the hands or feet. Alternative sites are scalp veins and antecubital veins. Special precautions and frequent observations must accompany the use of peripheral lines (Njere, Islam, Parish, et al, 2011). In many neonatal centers, the percutaneous central venous catheter (peripherally inserted central catheter [PICC]) is used for parenteral therapy and medication administration because of less expense and decreased neonatal trauma.
In most facilities, NICU nurses insert peripheral IV catheters and maintain the infusions. IV fluids must always be delivered by continuous infusion pumps that deliver minute volumes at a preset flow rate. The catheter is secured to the skin with a transparent dressing (see Skin Care later in this chapter) with care taken not to cause undue pressure from the catheter hub and tubing. Because all infants, especially those who are ELBW and VLBW, are highly vulnerable to any fluid shifts, infusion rates are carefully regulated and checked hourly to prevent tissue damage from extravasation, fluid overload, or dehydration. Pulmonary edema, congestive heart failure, patent ductus arteriosus, and intraventricular hemorrhage may occur with fluid overload. Dehydration may cause electrolyte disturbances with potentially serious CNS effects.
Infants who are ELBW, tachypneic, receiving phototherapy, or in a radiant warmer have increased insensible water losses that require appropriate fluid adjustments. Nurses must monitor fluid status by daily (or more frequent) weights and accurate intake and output of all fluids, including medications and blood products. Serum electrolytes are monitored per unit protocol, and urine electrolytes are obtained as warranted by the infant's condition. ELBW infants often require more frequent monitoring of these parameters because of their inordinate transepidermal fluid loss, immature renal function, and propensity to dehydration or overhydration. Intolerance of even dextrose 5% is not uncommon in ELBW infants, with subsequent glycosuria and osmotic diuresis. Alterations in behavior, alertness, or activity level in these infants receiving IV fluids may signal an electrolyte imbalance, hypoglycemia, or hyperglycemia. Nurses should also be observant for tremors or seizures in VLBW or ELBW infants, because these may be a sign of hyponatremia or hypernatremia.
N u r s i n g A l e r t Nurses should be constantly alert for signs of intravenous (IV) infiltration (e.g., erythema, edema, color change of tissue, blanching at site) and for signs of overhydration (weight gain of >30 g [1 oz] in 24 hours, periorbital edema, tachypnea, and crackles on lung auscultation).
A common problem observed in infants who have an umbilical artery catheter in place is vasoconstriction of peripheral vessels, which can seriously impair circulation. The response is triggered by arterial vasospasm caused by the presence of the catheter, the infusion of fluids, or injection of medication. Blanching of the buttocks, genitalia, or legs or feet is an indication of vasospasm. The problem is recognized promptly and reported to the practitioner. The nurse must also observe for signs of thrombi in infants with umbilical venous or arterial lines. The precipitation
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of microthrombi in the vascular bed with the use of such catheters is commonly manifested by a sudden bluish discoloration seen in the toes, called catheter toes. The problem is promptly reported to the practitioner because failure to alleviate the existing pathologic condition may result in the loss of toes or even a foot or leg.
Infants with umbilical venous or arterial catheters should also be observed closely for catheter dislodging and subsequent bleeding or hemorrhage; urinary output, renal function, and gastrointestinal function are also evaluated in these infants. Although the intent of such catheters is to effectively deliver IV fluids (and sometimes medications) and to obtain arterial blood gas samples, they are not without inherent complications.
Nutrition Optimum nutrition is critical in the management of LBW and preterm infants, but there are difficulties in meeting for their nutritional needs. The various mechanisms for ingestion and digestion of foods are not fully developed; the more immature the infant, the greater the problem. In addition, the nutritional requirements for this group of infants are not known with certainty. It is known that all preterm infants are at risk because of poor nutritional stores and several physical and developmental characteristics.
An infant's nutritional needs for rapid growth and daily maintenance must be met in the presence of several anatomic and physiologic disabilities. Although some sucking and swallowing activities are demonstrated before birth and in preterm infants, coordination of these mechanisms does not occur until approximately 32 to 34 weeks of gestation, and they are not fully synchronized until 36 to 37 weeks. Initial sucking is not accompanied by swallowing, and esophageal contractions are uncoordinated. Consequently, infants are highly prone to aspiration and its attendant dangers. As infants mature, the suck–swallow pattern develops but is slow and ineffectual, and these reflexes may also become easily exhausted.
The amount and method of feeding are determined by the infant's size and condition. Nutrition can be provided by either the parenteral or the enteral route or by a combination of the two. Infants who are ELBW, VLBW, or critically ill often obtain the majority of their nutrients by the parenteral route because of their inability to digest and absorb enteral nutrition. Hypoxic insults or illness and major organ immaturity further preclude the use of enteral feeding until the infant's condition has stabilized; necrotizing enterocolitis (NEC) has previously been associated with enteral feedings in acutely ill or distressed infants (see Necrotizing Enterocolitis later in this chapter). Total parenteral nutritional support of acutely ill infants may be accomplished successfully with commercially available IV solutions specifically designed to meet the infant's nutritional needs, including protein, amino acids, trace minerals, vitamins, carbohydrates (dextrose), and fat (lipid emulsion).
Studies have shown that there are benefits to the early introduction of small amounts of enteral feedings in metabolically stable preterm infants. These minimal enteral (trophic gastrointestinal priming) feedings have been shown to stimulate the infant's gastrointestinal tract, preventing mucosal atrophy and subsequent enteral feeding difficulties. Minimal enteral feedings with as little as 1 ml/kg of breast milk or preterm formula may be given by gavage as soon as the infant is medically stable. Parenteral nutrition is continued until the infant is able to tolerate an amount of enteral feeding sufficient to sustain growth. An increased incidence of NEC in VLBW infants receiving minimal enteral nutrition has not been substantiated (Ramani and Ambalavanan, 2013). Minimal enteral feedings have been proven to increase mineral absorption, increase gut hormone activity, and substantially decrease the incidence of feeding intolerance in preterm infants (Poindexter and Denne, 2010). Minimal enteral feedings are recommended as the standard of care for feeding VLBW infants (King, 2010).
Although the timing of the first feeding has been a matter of controversy, most authorities now believe that early feeding (provided that the infant is medically stable) reduces the incidence of complicating factors, such as hypoglycemia and dehydration, and the degree of hyperbilirubinemia. The feeding regimen used varies in different units.
Breastfeeding Ample evidence indicates that human milk is the best source of nutrition for term and preterm infants. Studies indicate that small preterm infants are able to breastfeed if they have adequate sucking and swallowing reflexes and there are no other contraindications, such as respiratory complications or concurrent illness (Sharon, Melinda, and Donna, 2013). Mothers who wish to
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breastfeed their preterm infants are encouraged to pump their breasts until their infants are sufficiently stable to tolerate breastfeeding. Appropriate guidelines for the storage of expressed mother's milk should be followed to decrease the risk of milk contamination and destruction of its beneficial properties.
Milk produced by mothers whose infants are born before term contains higher concentrations of protein, sodium, chloride, and immunoglobulin A (IgA). Growth factors, hormones, prolactin, calcitonin, thyroxine (T4), steroids, and taurine (an essential amino acid) are also present in human milk. Secretory IgA concentration is higher in the milk from mothers of preterm infants than in the milk from mothers of full-term infants. IgA is important in the control of bacteria in the intestinal tract, where it inhibits adherence and proliferation of bacteria on epithelial surfaces. Additional protection from infection is provided by leukocytes, lactoferrin, and lysozyme, all of which are present in human milk. The milk produced by mothers for their infants changes in content over the first 30 days postnatally, at which time it is similar to full-term human milk. Despite its benefits, LBW infants (<1500 g [3.3 pounds]) who are exclusively fed unfortified human milk demonstrate decreased growth rates and nutritional deficiencies even beyond the hospitalization period. These infants often have inadequacies of calcium, phosphorus, protein, sodium, vitamins, and energy. Specially designed supplements for human milk have been developed to address these deficits. Fortifiers containing protein; carbohydrate; calcium; phosphorus; magnesium; sodium; and varied amounts of zinc, copper, and vitamins are used to supplement breastmilk. Because fortifiers do not contain sufficient iron, supplemental iron is added, usually when the infant reaches 1 month of age.
A number of studies regarding the effects of long-chain polyunsaturated fatty acids on cognitive development, visual acuity, and physical growth in full-term and preterm infants have prompted formula companies to add docosahexaenoic acid (DHA) and arachidonic acid (AA) to their infant formulas. AA and DHA are present in human milk, and their presence has been reported to lead to an increase in cognitive development in human milk–fed infants compared with infants fed a formula without these fatty acids. However, one meta-analysis of four clinical trials demonstrated no clinically significant developmental benefits to supplementation of formula with AA and DHA in term and preterm infants at 18 months of age (Beyerlein, Hadders-Algra, Kennedy, et al, 2010).
Preterm infants may be able to successfully breastfeed earlier than previously believed (28 to 36 weeks); in addition, preterm infants who are breastfed rather than bottle fed demonstrate fewer incidences of oxygen desaturation; absence of bradycardia; warmer skin temperature; and better coordination of breathing, sucking, and swallowing (Gardner and Lawrence, 2011). Preterm infants should be carefully evaluated for readiness to breastfeed, including assessment of behavioral state, ability to maintain body temperature outside an artificial heat source, respiratory status, and readiness to suckle at the mother's breast. The latter may be accomplished with nonnutritive sucking at the breast during skin-to-skin (kangaroo) contact so the mother and newborn may become accustomed to each other (Gardner and Lawrence, 2011). Nasal cannula oxygen may also be provided during preterm breastfeeding on the basis of the infant's assessed requirements.
Time, patience, and dedication on the part of the mother and the nursing staff are needed to help infants with breastfeeding. The process is begun slowly—beginning with one feeding daily and gradually increasing the feedings as the infant tolerates them. Supplementary bottle feeding is inefficient because the infant expends energy and calories to feed twice. Supplementing by gavage feeding or using a training nipple is more energy and calorie efficient. Breastfeeding preterm infants often requires additional guidance by a lactation consultant; continued support and encouragement by the nursing staff and family members are essential. In addition, postdischarge breastfeeding often requires further guidance, counseling, and support by nursing staff (Ahmed and Sands, 2010).
Because of the antiinfective and growth-promoting properties of human milk, as well as its superior nutrition, donor milk is used in many NICUs for preterm or sick infants when the mother's milk is not available (American Academy of Pediatrics Section on Breastfeeding, 2012). Donor milk is also used therapeutically for medical purposes, such as in transplant recipients who are immunocompromised. Unprocessed human milk from unscreened donors is not recommended because of the risk of transmission of infectious agents (American Academy of Pediatrics Section on Breastfeeding, 2012).
The Human Milk Banking Association of North America* has established guidelines for the operation of donor human milk banks (Human Milk Banking Association, 2015). Donor milk banks collect, screen, process (pasteurize), and distribute milk donated by breastfeeding mothers who are
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feeding their own infants and pumping a few extra ounces each day for the milk bank.
Nipple Feeding Vigorous infants can be fed from a nipple with little difficulty, but compromised preterm infants require alternative methods. The amount to be fed is determined largely by the infant's weight gain and tolerance of previous feeding and is increased by small increments until a satisfactory caloric intake is ensured.
The rate of increase that is well tolerated varies from one infant to another, and determining this rate is often a nursing responsibility. Preterm infants require more time and patience to feed compared with full-term infants, and the oropharyngeal mechanism may be stressed by an attempt to feed too rapidly. It is important not to tire the infants or overtax their capacity to retain the feedings. When infants require a prolonged time (arbitrarily, more than 30 minutes) to complete a feeding, gavage feeding may be considered for the next time.
A developmental approach to feeding considers the individual infant's readiness rather than initiating feedings based on weight and age or a predetermined time schedule. Feeding readiness is determined by each infant's medical status, energy level, ability to sustain a brief quiet alert state, gag reflex (demonstrated with a gavage tube insertion), spontaneous rooting and sucking behaviors, and hand-to-mouth behaviors (Jones, 2012; Newland, L'hullier, and Petrey, 2013). A preterm infant may experience difficulty coordinating sucking, swallowing, and breathing with resultant apnea, bradycardia, and decreased oxygen saturation. The infant's ability to suck on a pacifier does not indicate complete readiness for nipple feeding or ability to coordinate the aforementioned activities without some degree of stress; a gradual introduction of nippling in preterm infants is based on careful evaluation of their ability to maintain adequate cardiopulmonary functions while feeding. When infants are unable to tolerate bottle feedings, intermittent feedings by gavage are instituted until they gain enough strength and coordination to use the nipple.
N u r s i n g A l e r t Poor feeding behaviors such as apnea, bradycardia, cyanosis, pallor, and decreased oxygen saturation in any infant who has previously fed well may indicate an underlying illness.
The nipple used should be relatively firm and stable. Although a high-flow, pliable nipple requires less energy to use, it may provide a flow rate that is too rapid for some preterm infants to manage without a risk of aspiration. A firmer nipple facilitates a more “cupped” tongue configuration and allows for a more controlled, manageable flow rate.
The infant is positioned in the feeder's arms or placed semiupright in the lap (Fig. 8-8) and is held with the back curved slightly to simulate the position assumed naturally by most full-term newborns. The use of gentle cheek and jaw support for preterm infants has been shown to facilitate feedings. Stroking the infant's lips, cheeks, and tongue before feeding helps promote oral sensitivity. Inward and upward support to the infant's cheeks and a slightly upward lift to the chin are provided by the fingers to assist nipple compression during feeding.
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FIG 8-8 Nipple feeding the preterm infant. A, The infant is first brought to a quiet alert state in preparation for feeding. B, After readiness is demonstrated, the infant is nipple fed. (Courtesy of Jeff Barnes,
Education and Eastern Oklahoma Perinatal Center, St. Francis Hospital, Tulsa, OK.)
Bottle feedings are continued if infants are able to tolerate the feedings and take the required amount. Some preterm infants respond more slowly than full-term infants; therefore, the feeding interval and the amount of the feeding are individualized. Preterm infants are often slow feeders and require patience, frequent rest periods, and burping (or bubbling).
Gavage Feeding Gavage feeding is a safe means of meeting the nutritional requirements of infants who are unable to feed orally. These infants are usually too weak to suck effectively, are unable to coordinate swallowing, and lack a gag reflex. Gavage feedings may be provided by continuous drip regulated via infusion pump or by intermittent bolus feedings. Studies have demonstrated an overall decrease in total milk fat concentration delivery when continuous gavage infusions are administered, which suggests that intermittent or bolus gavage of expressed mother's milk be administered when possible (Rogers, Hicks, Hamzo, et al, 2010).
A size 5-, 6-, or 8-Fr feeding tube is used to instill the feeding, and the usual methods for determining correct placement are used (see Chapter 20 for technique). Although the more relaxed lower esophageal sphincter makes passage of the tube easier, there may be changes in heart rate and BP in response to vagal stimulation. When an indwelling tube is required, consideration should be given to using a product made of Silastic rather than polyvinyl chloride (PVC), because PVC becomes stiff when exposed to body fluids.
The stomach is aspirated, the contents measured, and the aspirate returned as part of the feeding. However, this practice may vary depending on circumstances and individual unit protocol. The amount of aspirate depends on the time since the previous feeding or concurrent illness.
The milk or formula is allowed to flow by gravity, and the length of time varies. This procedure is not used as a timesaving method for the nurse. Complications of indwelling tubes include aspiration, obstructed nares, mucous plugs, purulent rhinitis, epistaxis, infection, and possible stomach perforation. Current practice dictates a radiograph as the only certain way to determine nasogastric tube placement. Methods such as auscultation of an air bubble, and nose-ear-xiphoid (NEX) measurements for insertion depth, and pH measurements are considered imprecise when used as the only method for determination of placement (de Boer, Smit, and Mainous, 2009; Ellett, Cohen, Croffie, et al, 2014; Farrington, Lang, Cullen, et al, 2009; Quandt, Schraner, Ulrich Bucher, et al, 2009; Renner, 2010). One study found that age-related, height-based gastric tube insertion length was more precise than either nose-ear-xiphoid or nose–ear–mid-umbilicus measurements in placing nasogastric tubes in neonates younger than 1 month old; the researchers recommend that nose-ear- xiphoid measurements for insertion depth be abandoned because of their unreliability in accurately placing feeding tubes in neonates (Cirgin Ellett, Cohen, Perkins, et al, 2011). Further research is needed to determine optimal positioning of feeding tubes in high-risk infants on intermittent bolus or continuous gavage feedings.
N u r s i n g A l e r t
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The nurse must observe preterm infants closely for behaviors that indicate readiness for oral feedings. These include:
• A strong, vigorous suck
• Coordination of sucking and swallowing
• A gag reflex
• Sucking on the gavage tube, hands, or a pacifier
• Rooting and wakefulness before and sleeping after feedings
When these behaviors are noted, infants can be challenged with oral feedings that are introduced slowly.
The infant may be held during gavage feedings by the caregiver or parent. If necessary, oxygen may be supplied via nasal cannula to facilitate handling. It is not recommended that the infant be removed from a primary source of oxygen for feedings, because doing so decreases oxygen availability. Nonnutritive sucking (NNS) on a pacifier may help bring the infant to a quiet alert state in preparation for feeding. Proposed benefits of NNS include improved weight gain, improved milk intake, more stable heart rate and oxygen saturation, earlier age at full oral feeds, and improved behavioral state. A systematic review of NNS found that infants receiving NNS were discharged significantly earlier than non-NNS infants and that they experienced a more rapid transition from tube to bottle feedings and better bottle-feeding performance. Additional research suggests that NNS may provide relief of mild to moderate pain associated with procedures such as heel sticks (Liaw, Yang, Ti, et al, 2010).
N u r s i n g A l e r t An increase in gastric residuals, abdominal distention, bilious vomiting, temperature instability, apneic episodes, and bradycardia may be indicative of early necrotizing enterocolitis (NEC) and should be reported to the practitioner.
Feeding Resistance Any feeding technique that bypasses the mouth precludes the opportunity for the infant to practice sucking and swallowing or to experience normal hunger and satiation cycles. Infants may demonstrate aversion to oral feedings by such behaviors as averting the head to the presentation of the nipple, extruding the nipple by tongue thrust, gagging, or even vomiting.
Other observations include disinterest in or active resistance to oral play, diminished spontaneity and motivation, and shallow interpersonal relationships, probably related to the absence of some early incorporative patterns of normal oral experiences. The longer the period of nonoral feeding, the more severe the feeding problems, especially if this period occurs during a time when the infant progresses from reflexive to learned and voluntary feeding actions. Infancy is the period during which the mouth is the primary instrument for reception of stimulation and pleasure.
Infants identified as being at risk for feeding resistance should be provided with regular oral stimulation, such as stroking the oral area from the cheeks to the lips, touching the tongue, placing some of the feeding on the lips and tongue, and associating feeding with pleasurable activities (holding, talking, making eye contact) based on the child's developmental level. Those who exhibit feeding aversion should begin a stimulation program to overcome resistance and acquire the ability to take nourishment by the oral route. Because management requires long-term commitment, successful implementation of a plan for oral stimulation depends on maximum parental involvement and a multidisciplinary team approach.
Energy Conservation One of the major goals of care for the high-risk infant is conservation of energy. Much of the care described in this section is directed toward this end (e.g., disturbing the infant as little as possible, maintaining a neutral thermal environment, gavage feeding as appropriate, promoting
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oxygenation, and judiciously implementing any caregiving activities that increase oxygen intake and caloric consumption). An infant who is not required to expend excess energy to breathe, eat, or alter body temperature can use this energy for growth and development. Diminishing environmental noise levels and shading the infant from bright lights also promote rest (see Developmental Outcome later in this chapter).
Early in hospitalization, the prone position is best for most preterm infants and results in improved oxygenation, better-tolerated feedings, and more organized sleep–rest patterns. Infants exhibit less physical activity and energy expenditure when placed in the prone position (Fig. 8-9). Prolonged supine positioning for preterm infants is not desirable, because they appear to lose their sense of equilibrium when supine and use vital energy in attempts to recover balance by postural changes. In addition, prolonged supine positioning is associated with long-term problems, such as widely abducted hips (frog-leg position), retracted and abducted shoulders, ankle and foot eversion, and increased neck extension (Byrne and Garber, 2013). The American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome (2011) continues to affirm its position that healthy infants be placed to sleep in a supine position.* When medically stable, preterm infants should also be placed in a supine position to sleep unless conditions, such as gastroesophageal reflux or upper airway anomalies, make this impractical (see also Sudden Infant Death Syndrome, Chapter 10). Prone positioning for play should be provided in the nursery and encouraged after discharge.
FIG 8-9 A, Preterm infant slowly transitioned to the prone position on a prone roll. B, Preterm infant positioned on a prone roll. (Courtesy of Halbouty Premature Nursery, Texas Children's Hospital, Houston, TX; photos by Paul
Vincent Kuntz.)
Skin Care The skin of preterm infants is characteristically immature relative to that of full-term infants. In most preterm infants, the skin barrier properties resemble those of the term infant by 2 to 4 weeks' postnatal age, regardless of gestational age at birth. Because of its increased sensitivity and fragility,
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alkaline-based soap that might destroy the skin's acid mantle is avoided. The increased permeability of the skin facilitates absorption of ingredients. All skin products (e.g., alcohol, chlorhexidine, povidone iodine) should be used with caution; the skin is rinsed with water afterward because these substances may cause severe irritation and chemical burns in VLBW and ELBW infants.
The skin is easily excoriated and denuded; therefore, care must be taken to avoid damage to the delicate structure. The total skin is thinner than that of full-term infants and lacks rete pegs, appendages that anchor the epidermis to the dermis. Therefore, there is less cohesion between the thinner skin layers. The use of adhesive tape or bandages may excoriate the skin or adhere to the skin surface so well that the epidermis can be separated from the dermis and pulled away with the tape. The use of pectin barriers and hydrocolloid adhesives may be useful, because these products mold well to skin contours and adhere in moist conditions. Recommendations for protecting the integrity of the skin of preterm infants include using minimal adhesive tape, backing the tape with cotton, and delaying adhesive and pectin barrier removal until adherence is reduced (Lund and Kuller, 2014). Emollients, such as Eucerin or Aquaphor, have been used to promote skin integrity and prevent dry, cracking, and peeling skin in infants at risk for skin breakdown; however, the use of such agents has been shown to increase the risk for coagulase-negative infections in preterm infants and therefore should not be routinely used (Lund and Kuller, 2014).
It is unsafe to use scissors to remove dressings or tape from the extremities of very small and immature infants, because it is easy to snip off tiny extremities or nick loosely attached skin. Solvents used to remove tape are avoided, because they tend to dry and burn the delicate skin. Guidelines for skin care are listed in the Nursing Care Guidelines box.
N u r s i n g C a r e G u i d e l i n e s Neonatal Skin Care
General Skin Care Assessment
Assess skin every day or more often as needed for redness, dryness, flaking, scaling, rashes, lesions, excoriation, and breakdown.
Identify risk factors for skin injury: Gestational age ≤32 weeks, high-frequency ventilation, extracorporeal membrane oxygenation (ECMO), hypotension requiring vasopressors.
Use a valid assessment tool to provide reliable and objective measurement of skin condition.
Evaluate and report abnormal skin findings and analyze for possible causes.
Intervene according to interpretation of findings or physician order.
Bathing Initial Bath
Assess to ensure that the infant has a stable temperature for a minimum of 2 to 4 hours before first bath.
Use cleansing agents with neutral pH and minimal dyes or perfume.
Use standard precautions; wear gloves.
Do not completely remove vernix; allow vernix to wear off with normal care and handling.
Bathe preterm infant younger than 32 weeks in warm water only for the first week.
Routine
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Decrease frequency of baths to every second or third day by daily cleansing of eye, oral, and diaper areas and pressure points.
Use pH neutral cleanser or soaps no more than two or three times a week.
Avoid rubbing skin during bathing or drying.
Immerse stable infants fully (except head) in an appropriate-size tub.
Use swaddled immersion bathing technique: Slowly unwrap after gently lowering into water for sensitive but stable infants needing assistance with motor system reactivity.
Emollients
Apply sparingly to dry, flaking, fissured areas as needed.
Choose petrolatum-based products that are free of preservatives, dyes, and perfumes.
Observe neonates ≤750 g receiving emollient therapy for increased risk of coagulase-negative Staphylococcus (ConS) infections. Consider dispensing emollients from hospital pharmacy, unit dose, or patient-specific container.
Adhesives
Decrease use as much as possible.
Use semipermeable dressings to secure intravenous (IV) lines, nasogastric or orogastric tubes, silicone catheters, and central lines.
Use hydrogel electrodes.
Consider pectin barriers beneath adhesives to protect skin.
Secure pulse oximeter probe or electrodes with elasticized dressing material (carefully avoid restricting blood flow).
Do not use adhesive remover, solvents, or bonding agents.
Avoid removing adhesives for at least 24 hours after application.
Adhesive removal can be facilitated using water, mineral oil, or petrolatum.
Remove adhesives or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away the product from the skin with the other hand.
Antiseptic Agents
Apply before invasive procedures.
Consider the potential for skin breakdown or irritation with disinfectant.
No specific disinfectant is recommended over another for all neonates; remove completely with water or saline after use.
Avoid use of isopropyl alcohol for skin prep or removal of other disinfectants.
Transepidermal Water Loss
Minimize transepidermal water loss (TEWL) and heat loss in small preterm infants at <30 weeks of gestation by:
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• Maintaining ambient humidity during first weeks of life.
• Applying occlusive polyethylene body bag immediately at delivery and removing after infant is stabilized in the neonatal intensive care unit (NICU).
• Considering increasing humidity to 70% to 90% by using a humidified incubator for first 7 days; decrease to 50% until 28 days of age.
• Using supplemental conductive heat and reduce radiant heat source.
Skin Breakdown Prevention
Decrease pressure from externally applied forces using water, air, or gel mattresses; or cotton bedding.
Provide adequate nutrition, including protein, fat, and zinc.
Apply transparent adhesive dressings to protect arms, elbows, and knees from friction injury.
Use emollient in the diaper area (groin and thighs) to reduce urine irritation.
Treating Skin Breakdown
Irrigate wound every 4 to 8 hours with warm half-strength normal saline.
Culture wound, and treat if signs of infection are present (excessive redness, swelling, pain on touch, heat, or resistance to healing).
Use transparent adhesive dressing for uninfected wounds.
Apply hydrogel with or without antibacterial or antifungal ointments (as ordered) for infected wounds (may need to moisten before removal).
Use hydrocolloid for deep, uninfected wounds (leave in place for 5 to 7 days) or as an ostomy barrier and to improve appliance adhesion.
Avoid use of antiseptic solutions for wound cleansing (use for intact skin only).
Treating Diaper Dermatitis
Maintain clean, dry skin; use absorbent diapers and change often.
If mild irritation occurs, use petrolatum barrier.
For developing dermatitis, apply a generous quantity of zinc-oxide barrier.
For severe dermatitis, identify cause and treat (frequent stooling from spina bifida, severe opiate withdrawal, or malabsorption syndrome).
Treat Candida albicans with antifungal ointment or cream.
Avoid powders and antibiotic ointments (see Care of the Umbilicus and Circumcision, Chapter 7).
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Other Skin Care Concerns Use of Substances on Skin
Evaluate all substances that come in contact with infant's skin.
Before using any topical agent, analyze components of preparation, and:
• Use sparingly and only when necessary.
• Confine use to smallest possible area.
• Whenever possible and appropriate, wash off with water.
• Monitor infant carefully for signs of toxicity and systemic effects.
Use of Thermal Devices
When prewarming heels before phlebotomy, avoid temperatures over 40° C.
Provide warm ambient humidity, directed away from infant; use aerosolized sterile water and maintain ambient temperature so as to not exceed 40° C.
Document use of all heating devices.
Use of Fluid Therapy and Hemodynamic Monitoring
Be certain fingers or toes are visible whenever extremity is used for peripheral IV or arterial line.
Secure catheter or needle with transparent dressing and tape to promote easy visualization of site.
Assess site hourly for signs of infiltration and inadequate perfusion (check capillary refill, pulses, color).
Avoid use of restraints (e.g., arm boards); if used, check that they are secured safely and not restricting circulation or movement (check for pressure areas).
Data from Association of Women's Health, Obstetric and Neonatal Nurses: Evidence-based clinical practice guideline: neonatal skin care, ed 3, Washington, DC, 2013, The Association; Edraki M, Paran M, Montaseri S, et al: Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants, J Caring Sci 3(2):83–91, 2014; Lund CH, Durand DJ: Skin and skin care. In Gardner SL, Carter BS, Enzman-Hines M, Hernandez JA, editors: Merenstein & Gardner's handbook of neonatal intensive care, ed 7, St Louis, 2011, Mosby/Elsevier; Lund CH, Kuller JM: Integumentary system. In Kenner C, Lott J, editors: Comprehensive neonatal care: an interdisciplinary approach, ed 5, New York, 2014, Springer; Ness MJ, Davis DMR, Carey W: Neonatal skin care: a concise review, Int J Derm 52(1):14–22, 2013.
During skin assessment of preterm infants, nurses are alert to the subtle signs that indicate zinc deficiency, a problem sometimes seen in infants who have inadequate intake or abnormal losses of zinc. Breakdown usually occurs in the areas around the mouth, buttocks, fingers, and toes. In preterm and VLBW infants, it may also occur in the creases of the neck, wrists, and ankles and around wounds. Zinc deficiency is most likely to appear in preterm infants with inadequate zinc intake, an ileostomy, short-bowel syndrome, or chronic diarrhea. Suspicious lesions are reported to the practitioner so that zinc supplements can be prescribed. Skin injuries have been reported during the use of phototherapy blankets. Caution is warranted in using these products in ELBW infants and infants who are at risk for skin breakdown.
Administration of Medications Administration of therapeutic agents (such as drugs, ointments, IV infusions, and oxygen) requires judicious handling and meticulous attention to detail. The computation, preparation, and
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administration of drugs in minute amounts often require collaboration among members of the health care team to reduce the chance for error. In addition, the immaturity of an infant's detoxification mechanisms and inability to demonstrate symptoms of toxicity (e.g., signs of auditory nerve involvement from ototoxic drugs, such as gentamicin) complicate drug therapy and require that nurses be particularly alert for signs of adverse reaction (see Administration of Medication, Chapter 20).
Nurses should be aware of the hazards of administering bacteriostatic and hyperosmolar solutions to infants. Benzyl alcohol, a common preservative in bacteriostatic water and saline, has been shown to be toxic to newborns, and products containing this preservative should not be used to flush IV catheters, to dilute or reconstitute medications, or as an anesthetic to start IV lines. It is recommended that medications with preservative (such as benzyl alcohol) be avoided whenever possible. Nurses must read labels carefully to detect the presence of preservatives in any medication to be administered to an infant.
Hyperosmolar solutions present a potential danger to preterm infants. Hyperosmolar solutions given orally to infants can produce clinical, physiologic, and morphologic alterations, the most serious of which is NEC. Oral and parenteral medications should be sufficiently diluted to prevent complications related to hyperosmolality.
There has been heightened awareness of the impact of medication errors and subsequent poor outcomes for high-risk neonates. Nurses, physicians, and pharmacists must work in cooperation to implement strategies in the NICU environment to eradicate medication errors. Technology alone has not proved to be the solution; therefore, nurses must be extremely vigilant when administering medications to preterm and high-risk infants.
Developmental Outcome Much attention has been focused on the effects of early developmental intervention on both normal and preterm infants. Infants respond to a great variety of stimuli, and the atmosphere and activities of the NICU are overstimulating. Consequently, infants in NICUs are subjected to inappropriate stimulation that can be harmful. For example, the noise level that results from monitoring equipment, alarms, and general unit activity has been correlated with the incidence of intracranial hemorrhage, especially in ELBW and VLBW infants. Personnel should reduce noise-generating activities, such as closing doors (including incubator portholes), listening to loud radios, talking loudly, and handling equipment (e.g., trash containers). Berg (2010) suggests monitoring sound levels in the NICU to address problem areas. Nursing care activities (such as taking vital signs, changing the infant's position, weighing, and changing diapers) are associated with frequent periods of hypoxia, oxygen desaturation, and elevated ICP. The more immature the infant, the less able he or she is to habituate to a single procedure, such as taking an oscillometric BP, without becoming overstimulated.
Twenty-four-hour surveillance of sick infants implies maximum visibility and often bright lights. Units should establish a night-day sleep pattern by darkening the room, covering cribs with blankets, or placing eye patches over the infant's eyes at night. Infants need scheduled rest periods during which the lights are dimmed, the incubators are covered with blankets, and the infants are not disturbed for handling of any kind (Altimier and White, 2014). Sleep periods should be undisturbed for at least 50 minutes to allow complete sleep cycles.
Infants' eyes should be shielded from bright procedure lights to prevent potential harm. Many experts suggest that the human face, especially the parent's, is the best visual stimulus and that visual stimuli be kept to a minimum early in development. Developmental care, accentuating the infant's unique ability to achieve behavioral state organization, is tailored to the developmental level and tolerance of each infant based on a comprehensive behavioral assessment. During the early stages of development (especially before 33 weeks of gestation), external stimulation produces uncoordinated, random activity, such as jerky limb extension, hyperflexion, and irregular vital signs. At this stage, infants need to have minimum environmental stimulation. Using the developmental model of supportive care, the nurse closely monitors physiologic and behavioral signs to promote organization and well-being of the high-risk infant during handling. Softly calling the infant by name and then gently placing a hand on the body signal that care is beginning and alleviate the abrupt interruption that precedes caregiving. Infants are handled with slow, controlled movements (some infants are unstable if moved abruptly), and their random movements are controlled with limbs held flexed close to their bodies during turning or other position changes.
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This containment or facilitated tucking may also be used before invasive procedures, such as heel stick to alleviate distress. Blanket swaddling and nesting or containment have been shown to decrease physiologic and behavioral stress during routine care procedures, such as bathing, weighing, and heel stick. A nest constructed by placing blanket rolls underneath the bed sheet helps infants maintain an attitude of flexion when prone or side lying.
Although it must be individually adjusted, skin-to-skin contact (kangaroo care) and short periods of gentle massage can help reduce stress in preterm infants. Regular passive skin-to-skin contact between parents (mother or father) and LBW infants has been shown to alleviate stress. The parent wears a loose-fitting, open-front top, and the undressed (except for diaper) infant is placed in a vertical position on the parent's bare chest, which permits direct eye contact, skin-to-skin sensations, and close proximity (Fig. 8-10). Skin-to-skin contact between the parent and infant, in addition to being a safe and effective method for VLBW infant–parent acquaintance, can have a positive healing effect for the mother with a high-risk pregnancy. Mothers may experience psychological healing related to preterm delivery and regain the mothering role through early skin- to-skin contact with their VLBW infants. Major neonatal benefits of skin-to-skin care include a reduced risk of mortality, fewer nosocomial infections, decreased length of hospital stay, maintenance of neonatal thermal stability and oxygen saturation, increased feeding vigor, and improved growth (Conde-Agudelo, Belizán, and Diaz-Rossello, 2011; Gardner and Hernandez, 2011). In full-term newborns, skin-to-skin contact has a strong analgesic effect during procedures, such as heel lance (Cong, Ludington-Hoe, McCain, et al, 2009). LBW infants receiving skin-to-skin contact with breastfeeding mothers maintained higher oxygen saturation and were less likely to have desaturations below 90%, and their mothers were more likely to continue breastfeeding both in the hospital and for 1 month after discharge. Kangaroo care of preterm infants fosters appropriate neurobehavioral development by promoting stability of heart and respiratory function, minimizes purposeless movements, offers maternal proximity for attention, improves the infant's behavioral state, and permits self-regulating behaviors (Gardner and Hernandez, 2011).
FIG 8-10 Father providing skin-to-skin (kangaroo) care. (Courtesy of Judy Meyr, St Louis, MO.)
Additional research studies have confirmed the beneficial effects of developmental care with preterm infants. In addition to requiring fewer days of mechanical ventilation, preterm infants who received individualized developmental care had shorter hospital stays; a significant decrease in
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complications, such as intraventricular hemorrhage and bronchopulmonary dysplasia; improved neurodevelopmental scores; and a decrease in feeding intolerance (McAnulty, Duffy, Butler, et al, 2009).
The arena of developmental care for preterm infants has expanded to include a wide variety of interventions, such as infant massage, soothing soft music, recordings of parents reading stories, positioning to enhance self-regulatory abilities, enhancement of hand-to-mouth activities, uninterrupted sleep periods, decreased environmental light and noise, and even the use of stuffed animals to facilitate infant positioning. As a result of such interventions, parents may perceive the NICU environment as less threatening. Active participation in providing such an environment for their special infant also involves the parents in the provision of daily care when the newborn is critically ill and cannot be fed or held.
When infants have reached sufficient developmental organization and stability, interventions are designed and implemented to support their growing abilities. Nurses and parents become adept at learning to read infants' behavioral cues and supplying appropriate interventions (Table 8-1). Clues include both approach and avoidance behaviors. Approach behaviors that are supported and enhanced include tongue extension, hand clasp, hand-to-mouth movements, sucking, looking, and cooing. Signs of stress or fatigue that signal the infant's need for “time-out” are described in Table 8- 1.
TABLE 8-1 Signs of Stress or Fatigue in Neonates
Subsystem Signs of Stress Autonomic Physiologic instability Respiratory Tachypnea, pauses, gasping, sighing Color Mottled, dusky, pale or gray Visceral Hiccups, gagging, choking, spitting up, grunting and straining as if having a bowel movement, coughing, sneezing, yawning Autonomic Tremors, startles, twitches Motor Fluctuating tone; lack of control over movement, activity, and posture Flaccidity Low tone in trunk; limp, floppy upper and lower extremities; limp, drooping jaw (gape face) Hypertonicity Arm or leg extensions, arm(s) outstretched with fingers splayed in salute gesture, fingers stiffly outstretched, trunk arching, neck hyperextended Hyperflexion Trunk, extremities Activity Squirming; frantic, diffuse activity or little or no activity or responsiveness State Disorganized quality to state behaviors, including available states, maintenance of state control, and transition from one state to another Sleep Whimpering sounds, irregular respirations, fussing, grimacing, restless appearance Awake Glazed, unfocused look; staring; worried or pained expression; hyperalert or panicked appearance; eye roving; crying; cry-face; actively averting gaze
or closing eyes; irritability; prolonged awake periods; inconsolability Abrupt or rapid state changes
Other state-related behaviors and attention interaction
Efforts to attend to and interact with environmental stimulation eliciting signs of stress and disorganized subsystem functioning
Autonomic Physiologic instability of varying degrees with autonomic, respiratory, color, and visceral responses Motor Fluctuating tone, increased motor activity, progressively frantic diffuse activity if stimulation continues State Roving eyes; gaze averting; glazed, unfocused look or worried, panicked expression; weak cry; cry-face; irritability
Closed eyes and sleeplike withdrawal Abrupt state changes Signs of stress when presented with more than one type of stimulus at a time
Data from Bradley C, Ritter R: Developmental care for the sick and preterm infant. In Kenner C, Lott J, editors: Comprehensive neonatal care: an interdisciplinary approach, ed 5, New York, 2014, Springer; Gardner SL, Goldson, E: The neonate and the environment: impact on development. In Gardner SL, Carter BS, Enzman-Hines M, et al, editors: Merenstein and Gardner's handbook of neonatal intensive care, ed 7, St Louis, 2011, Mosby/Elsevier; Lin H-C, Huang L-C, Li T-C, et al: Relationship between energy expenditure and stress behaviors of preterm infants in the neonatal intensive care unit, J Spec Ped Nurs 19(4):331–338, 2014.
When infants are recovering and are free of support systems, medically stable, and on room air or smaller amounts of oxygen, they are assessed to document behavioral state organization and ability to self-regulate. When the infant is stable and mature enough to begin developmental intervention, activities are individualized according to each infant's cues, temperament, state, behavioral organization, and particular needs. Intervention periods are short (e.g., 2 to 3 minutes of voices, 5 minutes of quiet music). Hearing and vestibular interventions are initiated earlier than visual stimulation. One type of intervention at a time is applied to document the infant's tolerance and response (see Nursing Care Guidelines box). An intervention program for convalescing infants includes parents and siblings early in the infant's hospitalization; teaching parents to be responsive to the infant's individual cues is an important function of the NICU nurse. Parents, siblings, and health care providers are encouraged to adhere to the established developmental care plan to avoid disruption in sleep–wake cycles and minimize inappropriate stimuli.
N u r s i n g C a r e G u i d e l i n e s Developmental Interventions
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General Guidelines
Individualize interventions for each infant.
Offer stimulus only during periods of alertness.
Begin one type of stimulus at a time.
Provide intervention for short periods.
Space periods according to infant's tolerance.
Continually assess infant's response to developmental interventions.
Titrate interventions according to infant's cues.
Terminate stimulation if infant displays evidence of overstimulation (see Table 8-1).
Provide 50-minute uninterrupted sleep periods.
Handle to promote or maintain behavioral organization, providing for flexion, containment, firm pressure, grasp, and nonnutritive sucking (NNS).
Tactile
Stroke skin slowly and gently in head-to-toe direction (assess tolerance first).
Provide alternate textures (e.g., satin, velvet).
Provide firm boundaries: foot bracing, blankets, “nesting.”
Encourage skin-to-skin (kangaroo) holding by parents and siblings as tolerated.
Provide containment holding in cupped palms of hand for nesting and comfort.
Auditory
Reduce noise levels.
Mother's voice is the best.
Maintain 50 dB with maximum 55 dB for only 10 minutes per hour.
Play audio recording of parents' and siblings' voices.
Softly play simple, soothing music,* recording of womb sounds, or music box for short periods only.
Call infant by name at each interaction.
Vestibular
Position with limbs and trunk in flexion with hands to face at midline.
Slowly change position during handling; avoid quick position changes.
Side-to-side slow movement is preferred over rocking.
Place in sling (hammock) and rock.
Close infant's fist around cloth toy.
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Lift head to upright position, tip to right and then to left, stopping at midline (only with stable, more mature infants).
Avoid rapid horizontal to vertical movements in ill infant to minimize intracranial pressure (ICP) and autonomic consequences (desaturation, apnea, bradycardia).
Olfactory
Pass open container or a cotton gauze dipped in breast milk under nose.
Place cloth doll that has been in close contact with mother's skin in the infant's bed; avoid perfumes, scented soaps, and powders.
Use a pacifier dipped in mother's breast milk during gavage feeding for NNS.
Gustatory
Place infant's hand or a pacifier in mouth when sucking movements are observed or during gavage feeding.
Place one or two drops of milk in infant's mouth with each tube feeding.
Provide nonnutritive sucking at mother's breast.
Visual
Reduce light levels and protect eyes from direct lights, such as examination or procedure lights.
Place photographs of parents and siblings in visual range (19 to 22 cm [7.5 to 8.5 inches]) in en face position (maintain for short periods when awake and alert; constant picture in close proximity may be too much stimulus).
Initiate eye contact; repeat as tolerated once the infant reaches equivalent of 30 weeks of gestation. Monitor carefully for stress responses.
*Suggested infant relaxation music: Heartbeat Lullabies by Terry Woodford. Available from Baby-Go-To-Sleep Center, Audio Therapy Innovations, Inc., PO Box 550, Colorado Springs, CO 80901; 800-537-7748; http://www.babygotosleep.com.
Developmental care of preterm neonates is an ongoing process in the NICU and is incorporated into the daily care given to each infant. The nurse is cognizant of the preterm infant's developmental needs, temperament, and newborn state, as well as environmental conditions that adversely affect the infant; nursing care is planned accordingly to enhance optimum physical, psychosocial, and neurologic development. This task is often difficult to accomplish when invasive treatments or interventions are required to stabilize the critically ill neonate.
Family Support and Involvement Professional health workers often are so absorbed in the lifesaving physical aspects of care that they ignore the emotional needs of infants and their families. The significance of early parent–child interaction and infant stimulation has been documented by reliable research. Nurses, aware of these infant and family needs, must incorporate activities that facilitate family interaction into the nursing care plan.
The birth of a preterm infant is an unexpected and stressful event for which families are emotionally unprepared. They find themselves simultaneously coping with their own needs, the needs of their infant, and the needs of their family (especially when they have other children). To compound the situation, their infant's precarious condition engenders an atmosphere of apprehension and uncertainty. They are faced with multiple crises and overwhelming feelings of responsibility, helplessness, and frustration.
All parents have some anxieties about the outcome of a pregnancy, but after a preterm birth, the
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concern is heightened regarding both the viability and the normalcy of their infant. Mothers may see their infant only briefly before the newborn is removed to the intensive care unit or even to another hospital, leaving them with just the recollection of the infant's very small size and unusual appearance. They often feel alone or lost on the mother–baby unit, belonging neither with mothers who have lost their infants nor with those who have delivered healthy, full-term infants. The staff and physicians are often guarded in discussing the infant's condition; mothers are continually expecting to hear that their infant has died, and they are sensitive to the anxieties of other mothers and staff members. Going home without their infant only compounds their feelings of disappointment, failure, and deprivation.
When an infant is to be transported from the hospital, the parents need a description of the facility where the infant is going. They need to know the location, reputation, and nature of the facility and the care that the infant is expected to receive. The name of the infant's physician and the telephone number of the nursery should be given to them, and unfamiliar terms (such as neonatologist, ventilator, infusion, and incubator) should be explained. Explanations should be kept simple, and parents are given the opportunity to ask questions. If booklets are available that describe the facility, they are given to the family.
Perhaps most important, the parents should have some contact with the infant before the transport. Being able to see, touch, and (if possible) hold their infant may help decrease the parents' anxiety. Often a photograph or even a videotape of their infant can serve as tangible evidence of the newborn's existence until the parents are able to travel to the regional facility. When possible, it is often advisable to transfer the mother to the same institution as her infant.
Parents need to be informed of their infant's progress and reassured that the infant is receiving proper care. They need to understand the smallest aspects of the infant's condition and treatment. Parents need a realistic, honest, and direct assessment of the situation. Using nonmedical terminology, moving at a pace that is comfortable for parents to assimilate the information, and avoiding lengthy technical explanations facilitate communication with family members. Psychologic tasks that must be accomplished by parents during their infant's care are presented in Box 8-2.
Box 8-2 P s y c h o l o g i c a l Ta s k s o f Pa r e n t s o f a H i g h - R i s k I n f a n t • Work through the events surrounding labor and delivery.
• Acknowledge that the infant's life is endangered and begin the anticipatory grieving process.
• Confront and recognize feelings of inadequacy and guilt in not delivering a healthy child.
• Adapt to the neonatal intensive care environment.
• Resume parental relationships with the sick infant and initiate the caregiving role.
• Prepare to take the infant home.
Modified from Siegel R, Gardner SL, Dickey LA: Families in crisis: theoretical and practical considerations. In Gardner SL, Carter BS, Enzman-Hines M, et al, editors: Merenstein and Gardner's handbook of neonatal intensive care, ed 7, St Louis, 2011, Mosby/Elsevier.
Facilitating Parent–Infant Relationships Because of their physiologic instability, infants are separated from their mothers immediately and surrounded by a complex, impenetrable barrier of glass windows, mechanical equipment, and special caregivers. There is some evidence indicating that the emotional separation that accompanies the physical separation of mothers and infants may interfere with the normal mother– infant attachment process discussed in Chapter 7. Maternal attachment is a cumulative process that begins before conception, strengthens by significant events during pregnancy, and matures through mother–infant contact during the neonatal period and infancy.
When an infant is sick, the necessary physical separation appears to be accompanied by an emotional estrangement by the parents, which may seriously damage the capacity for parenting
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their infant. This detachment is further hampered by the tenuous nature of the infant's condition. When survival is in doubt, parents may be reluctant to establish a relationship with their infant. They prepare themselves for the infant's death while continuing to hope for recovery. This anticipatory grief (see Chapter 17) and hesitancy to embark on a relationship are evidenced by behaviors, such as delay in giving the infant a name, reluctance in visiting the nursery (or when they do visit, focusing on equipment and treatments rather than on their infant), and hesitancy to touch or handle the infant when given the opportunity.
Family-centered care of high-risk newborns includes encouraging and facilitating parental involvement rather than isolating parents from their infant and associated care. This is particularly important in relation to mothers; to reduce the effects of physical separation, mothers are united with their newborn at the earliest opportunity.
Preparing the parents to see their infant for the first time is an important nursing responsibility. The nurse prepares parents for their infant's appearance, the equipment attached to the child, and the general atmosphere of the unit. The initial encounter with the intensive care unit is a stressful experience, and the frightening array of people, equipment, and activity is likely to be overwhelming. A book of photographs or pamphlets describing the NICU environment (infants in incubators or under radiant warmers, monitors, mechanical ventilators, and IV equipment) provides a useful and nonthreatening introduction to the NICU.
Parents are encouraged to visit their infant as soon as possible. Even if they saw the infant at the time of transport or shortly after birth, the infant may have changed considerably, especially if a number of medical and equipment requirements are associated with the infant's hospitalization. At the bedside, the nurse should explain the function of each piece of equipment and the role it plays in facilitating recovery. Explanations may often need to be patiently repeated because parents' anxiety over the infant's condition and the surroundings may prevent them from really “hearing” what is being said. When possible, some items related to therapy can be removed; for example, phototherapy can be temporarily discontinued and eye patches removed to permit eye-to-eye contact.
Parents appreciate the support of a nurse during the initial visit with their infant, but they may also appreciate some time alone with the infant for a short while. It is important during the early visits to emphasize the positive aspects of their infant's behavior and development so that the parents can focus on their infant as an individual rather than on the equipment that surrounds the child. For example, the nurse may describe the infant's spontaneous behaviors during care, such as the grasp reflex and spontaneous movement, or make comments about the infant's biologic functions. Most institutions have open visiting policies so that parents and siblings may visit their infant as often as they wish.
Parents vary greatly in the degree to which they are able to interact with their infant. Some may wish to touch or hold their infant during the first visit, but others may not feel comfortable enough to even enter the nursery. These reactions depend on a variety of prenatal and postnatal factors, such as the parity of the mother and her preparation before birth; the infant's size, condition, and physical appearance; and the type of treatment the infant is receiving. It is essential to recognize that the individualized pacing and quality of the interactions are more important than an early onset of these interactions. Parents may not be receptive to early and extended infant contact, because they need time to adjust to the impact of an infant with birth problems and must be helped to grieve before they can accept their infant.
The parents' inability to focus on their infant is a clue for the nurse to assist the parents in expressing feelings of guilt, anxiety, helplessness, inadequacy, anger, and ambivalence. Nurses can help parents deal with these distressing feelings and recognize that they are normal responses shared by other parents. It is important to point out and reinforce the positive aspects of parents' behavior and interactions with their infant.
Most parents feel shaky and insecure about initiating interaction with their infant. Nurses can sense parents' level of readiness and offer encouragement in these initial efforts. Parents of preterm infants follow the same acquaintance process as do parents of term infants. They may quickly proceed through the process or may require several days or even weeks to complete the process. Parents begin by touching their infant's extremities with their fingertips and poking the infant tenderly and then proceed to caresses and fondling (Figs. 8-11 and 8-12). Touching is the first act of communication between parents and child. Parents need to be prepared for their infant's exaggerated and generalized startle responses to touch so that they will not interpret these as negative reactions to their overtures. It may be necessary to limit tactile stimuli when the infant is
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critically ill and labile, but the nurse can offer other options such as speaking softly or sitting at the bedside.
FIG 8-11 Father interacting with newborn receiving intensive care.
FIG 8-12 Mother and father interacting with their preterm infant. (Photo courtesy of E. Jacobs, Texas Children's Hospital, Houston, TX.)
Parents of acutely ill preterm infants may express feelings of helplessness and lack of control. Involving the parent in some type of caregiving activity, no matter how minor it may seem to the nurse, enables the parent to “take on” a more active role. Examples of such caregiving for an acutely ill infant who cannot be held and is seemingly not responding positively include moistening the infant's lips with a small amount of sterile water on a cotton-tipped swab or slipping the diaper from under the infant when it is wet or soiled.
Eventually, parents begin to endow their infant with an identity—as part of the family. When an infant no longer appears as a foreign object and begins to take on aspects of family members, such as the father's chin or the sister's nose, nurses can facilitate this incorporation. Parents are encouraged to bring in clothes, a toy, a stuffed animal, or a family snapshot for their infant, and the nurse can help parents set goals for themselves and for the infant. Parents may become involved by reading a children's storybook or nursery rhymes in a soft, soothing voice. Some families record the parents' voices telling or reading stories and play the audio when the infant is able to cope with such stimuli. Feeding schedules are discussed, and parents are encouraged to visit at times when
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they can become involved in the care of their infant (Fig. 8-13).
FIG 8-13 Father feeding preterm infant. (Photo courtesy of E. Jacobs, Texas Children's Hospital, Houston, TX.)
Throughout the parent–infant acquaintance process, the nurse listens carefully to what the parents say to assess their concerns and their progress toward incorporating their infant into their lives. The manner in which parents refer to their infant and the questions they ask reveal their worries and feelings and can serve as valuable clues to future relationships with the infant. The alert nurse is attuned to these subtle indications of parents' needs, which provide guidelines for nursing intervention. Often all that the parents need is reassurance that they will have the support of the nurse during caregiving activities and that the behaviors about which they are concerned are normal reactions and will disappear as the infant matures.
Parents need guidance in their relationships with their infant and assistance in their efforts to meet their infant's physical and developmental needs. The nursing staff must help parents understand that their preterm infant offers few behavioral rewards and show them how to accept small rewards from their infant. The infant's reactions and behaviors are explained to parents, who take their infant's jerky, rejective behavior personally. They need reassurance that these behaviors are not a reflection on their parenting skills. Parents are taught to recognize their infant's cues regarding stimulation, handling, and other interaction, especially aversive behaviors that indicate a need for rest. Nurses need to include parents in planning their infant's care and sensory stimulation materials, such as a music box or recording.
Above all, nurses must encourage and reinforce parents during their caregiving activities and interactions with their infant to promote healthy parent–child relationships. It is also helpful for the parents to have contact and communication with a consistent group of nurses. This decreases the different information given to parents and often instills confidence that although the parents cannot be at their infant's bedside 24 hours a day, there are competent and caring nurses whom they may call to inquire about the infant's status. Periodic parent conferences involving the staff caring for the child serve to clarify misunderstandings or problems related to the infant's condition.
Siblings In the past, concerns about sibling visitation in the NICU focused on fears of infection and disruption of nursing routines. These fears have not been substantiated, and sibling visits should be a part of the normal operation of NICUs (Fig. 8-14). Clearly defined policies and procedures should be developed to facilitate sibling visitation (American Academy of Pediatrics and American College
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of Obstetricians and Gynecologists, 2012; Gooding, Cooper, Blaine, et al, 2011).
FIG 8-14 Siblings visiting in the neonatal intensive care unit (NICU). (Photo courtesy of E. Jacobs, Texas Children's Hospital, Houston, TX.)
The birth of a preterm infant is a difficult time for siblings, who rely on the support of understanding parents. When the happy anticipation is changed to sadness, worry, and altered routines, siblings are bewildered and deprived of their parents' attention. They know something is wrong, but they have only a dim understanding of what it is. Concern about the negative effects on visiting siblings of seeing the ill newborn has not been confirmed. Children have not hesitated to approach or touch the infant, and children younger than 5 years old have been less reluctant than older children; in addition, there have been no measurable differences between previsit and postvisit behaviors.
The potential benefits of sibling visits must be weighed against exposure of the child to the environment of the NICU. Children must be prepared for the unfamiliar NICU atmosphere, but contact with the infant appears to have a positive effect on siblings by helping them deal with the reality rather than the bizarre fantasies that are characteristic of young children. Such visits also help to bond the family as a unit.
Support Groups Parents need to feel that they are not alone. Parent support groups have been of immeasurable value to families of infants in the NICU. Some groups consist of parents who have infants in the hospital and share the same anxieties and concerns. Other groups include parents who have had infants in the NICU and who have dealt with the crisis effectively. The groups are usually under the leadership of a staff person and involve physicians, nurses, and social workers, but the parents can offer other parents something that no one else can provide.
An excellent resource for parents of preterm infants is the book by Jeanette Zaichkin, Newborn Intensive Care: What Every Parent Needs to Know (American Academy of Pediatrics, 2010). This resource has technical and anecdotal information regarding different problems facing preterm infants, common treatments and therapies, preparation for home discharge, and home care for the preterm infant.
Discharge Planning and Home Care Parents become apprehensive and excited as the time for discharge approaches. They have many concerns and insecurities regarding the care of their infant. They fear that the child may still be in danger, that they will be unable to recognize signs of distress or illness in their infant, and that the infant may not yet be ready for discharge. Nurses need to begin early to assist parents in acquiring or increasing their skills in the care of their infant. Appropriate instruction must be provided and sufficient time allowed for the family to assimilate the information and learn the continuing special care requirements. Where rooming-in or other live-in arrangements are available, parents can stay for a few days and nights and assume the care of their infant under the supervision and support of the nursery staff.
There should be appropriate medical and nursing follow-up and referrals to services that can
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benefit the family, including developmental follow-up. Parents of preterm infants should also be given adequate information about immunizations with other discharge planning information. With the trend toward earlier discharge, many hospital-based home health care agencies become involved in the follow-up and care of NICU “graduates” in the home. For the parents of an infant being discharged with equipment (such as, an oxygen tank, apnea monitor, or even a ventilator), discharge planning requires multidisciplinary collaborative practice to ensure that the family has not only the appropriate resources but also the available assistance for dealing with the infant's needs. Many communities have organized support groups, including those discussed previously, those designed for parents of infants who require special care because of specific defects or disabilities, and those for parents of multiple births.
Car seat safety is an essential aspect of discharge planning, and infants younger than 37 weeks of gestation should have a period of observation in an appropriate car seat to monitor for possible apnea, bradycardia, and decreased oxygen saturation (Bull, Engle, Committee on Injury, Violence, and Poison Prevention and the Committee on Fetus and Newborn, et al, 2009) (see Community Focus box). Several models can be adapted for small infants with the placement of blanket rolls on each side of the infant to support the head and trunk. For adequate support without slumping, the seat back–to-crotch strap distance must be 14 cm (5.5 inches) or less; a small rolled blanket may be placed between the crotch strap and the infant to reduce slouching. The distance from the lower harness strap to the seat bottom should be 25.5 cm (10 inches) or less to decrease the potential for the harness straps to cross the infant's ears (Howard-Salsman, 2006). The rear-facing position provides support for the head, neck, and back, thereby reducing the stress to the neck and spinal cord in a vehicle crash. Car seat manufacturers must specify recommended minimum and maximum weights for the occupant; therefore, it is important to check the manufacturer's recommendations before purchasing a car seat for a smaller infant. Additional guidelines are available from the American Academy of Pediatrics (Durbin and Committee on Injury, Violence, and Poison Prevention, 2011). See Chapter 9 for a discussion of infant car restraints and the Parents Central website* for a complete list of appropriate car seats for infants.
C o m m u n i t y F o c u s Preterm and Near-Term Infant Car Seat Evaluation
The American Academy of Pediatrics (Bull, Engle, and Committee on Injury, Violence, and Poison Prevention and the Committee on Fetus and Newborn, et al, 2009) recommends that infants born before 37 weeks of gestation be evaluated for apnea, bradycardia, and oxygen desaturation episodes before hospital discharge.* The American Academy of Pediatrics suggests that facilities develop policies for the implementation of a program of evaluation; however, few evidence-based practice recommendations have been published to date delineating specific requirements for such a program. Based on the available literature, suggestions for providing a car seat evaluation of infants born before 37 weeks of gestation include:
• Use the parents' car seat for the evaluation.
• Perform the evaluation 1 to 7 days before the infant's anticipated discharge.
• Secure the infant in the car seat per guidelines using blanket rolls on the side.
• Set the pulse oximeter low alarm at 88% (or per unit protocol).
• Set the heart rate low alarm limit at 80 beats/min and apnea alarm at 20 seconds (cardiorespiratory monitor).
• Leave the infant undisturbed semiupright in the car seat for a minimum of 90 to 120 minutes or for the time period parents state it takes (whichever is longer) to arrive at their home.
• Document the infant's tolerance to the car seat evaluation.
• An episode of desaturation, bradycardia, or apnea (20 seconds or more) constitutes a failure, and
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evaluation by the practitioner must occur before discharge. If the infant experiences this in a semiupright position, a car bed with the infant supine should be considered, and similar testing should be undertaken in the car bed.
• Repeat the test after 24 hours after modifications have been made to the car seat, car bed, or infant's position in either restraint system.
• It is recommended that a certified car seat technician place the infant in the car seat (or bed) if a failure occurs (see National Highway Traffic Safety Administration website† for car seat inspection station).
• If the infant is being discharged on an apnea or cardiorespiratory monitor, this equipment should be used during the trip home.
• The technician will demonstrate appropriate positioning of the infant in the restraint device to the parents and have the parents do a return demonstration.
• Document the interventions, the infant's tolerance, and the parents' return demonstration.
*Infants at risk for obstructive apnea (e.g., Pierre Robin sequence or congenital neuromuscular disorders such as spinal muscular atrophy) may also need to be evaluated in a semiupright car seat or car bed before discharge.
†http://www.nhtsa.gov.
Modified from American Academy of Pediatrics: Safe transportation of premature and low birth weight infants, Pediatrics 123(5):1424–1429, 2009; O'Neil J, Yonkman J, Taltry J, et al: Transporting children with special health care needs, Pediatrics 124(2):596–603, 2009; Bull MJ, Engle WA, and Committee on Injury, Violence, and Poison Prevention and the Committee on Fetus and Newborn, et al: Safe transportation of preterm and low birth weight infants at hospital discharge, Pediatrics 123(5):1424–1429, 2009.
An important part of discharge planning and care of preterm infants is nutrition for continued growth; thus, the choice of feeding must be carefully addressed. Human milk should be fortified according to the infant's corrected age and physiologic needs. In a Cochrane review, fortification of human milk with a multinutrient supplement for at least 12 weeks after hospital discharge was found to result in higher rates of growth (McCormick, Henderson, Fahey, et al, 2010). Full-term infant formulas are not considered adequate for proper growth in preterm infants.
Knowing that staff members are available for telephone or personal contact when the parents take the infant home provides a measure of security to anxious parents. Many NICU facilities maintain a policy of open communication between staff and parents both during the infant's hospitalization and after discharge. It is the responsibility of the NICU staff to make certain that parents are prepared to care for their infant, both emotionally and physically. At the same time, it is important that parents establish a trusting relationship with the infant's primary care provider in the community before discharge from the acute care facility.
Neonatal Loss The precarious nature of many high-risk infants makes death a real and ever-present possibility. Although infant mortality has been reduced sharply with improved technology, the mortality rate is still greatest during the neonatal period. Nurses in the NICU are the persons who must prepare the parents for an inevitable death, provide end-of-life care for the infant and family, and facilitate a family's grieving process after an expected or unexpected death.
The loss of an infant has special meaning for the grieving parents. It represents a loss of a part of themselves (especially for mothers), a loss of the potential for immortality that offspring represent, and the loss of the dream child that has been fantasized about throughout the pregnancy. There is often a sense of emptiness and failure. In addition, when an infant has lived for such a short time, there may be few, if any, pleasant memories to serve as a basis for the identification and idealization that are part of the resolution of a loss.
To help parents understand that the death is a reality, it is important that they be encouraged to hold their infant before death and, if possible, be present at the time of death so that their infant can die in their arms if they choose. Many who deny the need to hold their infant may later regret the
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decision. Parents are given the opportunity to actually “parent” the infant in any manner they wish or are
able to do before and after the death. This may include seeing, touching, holding, caressing, and talking to their infant privately; the parents may also wish to bathe and dress the infant. If parents are hesitant about seeing their dead infant, it is advisable to keep the body in the unit for a few hours because many parents change their minds after the initial shock of the death.
Parents may need to see and hold the infant more than once—the first time to say “hello” and the last time to say “good-bye.” If parents wish to see the infant after the body has been taken to the morgue, the infant should be retrieved, wrapped in a blanket, rewarmed in a radiant warmer, and taken to the mother's room or other private place. The nurse should stay with the parents and provide them an opportunity for private time alone with their dead infant. Individual grief responses of the mother and father should be recognized and handled appropriately; gender differences and cultural and religious beliefs will affect the parents' grief responses.
A hospice approach for families with infants for whom the decision has been made to not prolong life and who are receiving only palliative care may be implemented in such cases. Another approach is to send the family home with the infant and allow them to spend time together until the eventual death; hospice services may be available, and supportive care is provided in the home setting. Some families find this option less restrictive and more family oriented than being in the hospital setting. See Chapter 17 for further discussion of hospice care.
A photograph of the infant taken before or after death is highly desirable. Parents may wish to have a special family portrait taken with the infant and other family members; this often helps personalize and make the experience more tangible. The parents may not wish to see the photograph at the time of death, but the chance to refer to it later will help make their infant seem more real, which is a part of the normal grief process. A photograph of their infant being held by the hand or touched by an adult offers a more positive image than a morgue type of photograph. A bereavement or memory packet can be given to the grieving parents and family; it may include the infant's handprints and footprints; a lock of hair; the bedside name card; the ID bracelet or armbands; and, as appropriate to the family's religious beliefs, a certificate of baptism.
Naming the deceased infant is an important step in the grieving process. Some parents may hesitate to give the newborn a name that had been chosen during the pregnancy for their “special baby.” However, having a tangible person for whom to grieve is an important component of the grieving process.
A nurse who is familiar to the family should be present during the discussion about the dead or dying infant. The nurse should talk with parents openly and honestly about funeral arrangements, because few parents have had experience with this aspect of death. Many funeral homes now offer inexpensive arrangements for these special cases. Someone from the NICU should take the responsibility for acquiring this type of information. It is often helpful to parents for the NICU to have a list of local funeral homes, services offered, and prices. Families need to be informed of the options available, but a funeral is preferable because the ritual provides an opportunity for parents to feel the support of friends and relatives. A member of the clergy of the appropriate faith may be notified if the parents wish. Issues regarding an autopsy or organ donation (when appropriate) are approached in a multidisciplinary fashion (primary practitioner and primary nurse) with respect, sensitivity to cultural and religious beliefs, tact, and consideration of the family's wishes. For additional suggestions for helping families who experience neonatal loss, see Grief and Perinatal Loss by Gardner and Dickey (2011), and “The Dying Neonate: Family-Centered End-of-Life Care” (Lisle- Porter and Podruchny, 2009).
Before the parents leave the hospital, they are given the telephone number of the unit (if they do not have it) and invited to call any time that they have any further questions. Many intensive care units make a point to contact the parents several weeks after a neonatal death to assess the parents' coping mechanisms, evaluate the grieving process, and provide support as needed. Several organizations are available to offer support and understanding to families who have lost a newborn; these organization include the Compassionate Friends,* Aiding Mothers and Fathers Experiencing Neonatal Death (AMEND),† and Share Pregnancy and Infant Loss Support, Incorporated.‡ See Chapter 17 for further discussion of the family and the grief process.
Nurses who care for critically ill infants also experience grief; NICU nurses may feel helpless and sorrowful. It is important that such grief be allowed and that nurses attend the funeral or memorial service as a part of working through the grief process. Nurses may fear that showing emotion is unprofessional and that the expression of grief indicates “loss of control.” These fears are
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unfounded. Studies have demonstrated that to continue to be effective managers and providers of care, nurses must be allowed to grieve and support each other through the process (Gardner and Dickey, 2011).
Baptism Because many Christian parents wish to have their child baptized if death is anticipated or is a decided possibility, this may become a nursing responsibility. Whenever possible, it is most desirable that a representative of the parents' faith (e.g., a Roman Catholic priest or a Protestant minister) perform such a ritual. When death is imminent, a nurse or a physician can perform the baptism by simply pouring water on the infant's forehead (a medicine dropper is a convenient means) while repeating the words, “I baptize you in the name of the Father and of the Son and of the Holy Spirit.” This includes a birth of any gestational age, particularly when the parents are Roman Catholic.
When the parents' faith is uncertain, a conditional baptism can be carried out by saying, “If you are capable of receiving baptism, I baptize you in the name of the Father and of the Son and of the Holy Spirit.” The baptism is recorded in the infant's chart, and a notice is placed on the crib or incubator. Parents are informed at the first opportunity.
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High Risk Related to Dysmaturity Preterm Infants Prematurity accounts for the largest number of admissions to NICUs. Immaturity of most organ systems places infants at risk for a variety of neonatal complications (e.g., hyperbilirubinemia, respiratory distress syndrome [RDS], intellectual and motor delays). According to the Centers for Disease Control and Prevention, low birth weight and prematurity were the second leading cause of infant mortality in the United States in 2011 (Kochanek, Murphy, and Xu, 2015). The actual cause of prematurity is not known in most instances. Factors such as poverty, maternal infections, previous preterm delivery, multiple pregnancies, pregnancy-induced hypertension, and placental problems that interrupt the normal course of gestation before completion of fetal development are responsible for a large number of preterm births. Additional factors are listed in Box 8-3.
Box 8-3 E t i o l o g y o f P r e t e r m B i r t h Maternal Factors Socioeconomic
• Malnutrition
• Age
• Race
Chronic medical conditions
• Heart disease
• Renal disease
• Diabetes
• Hypertension
Behavioral
• Substance abuse
• Smoking
• Poor or absent prenatal care
Factors Related to Pregnancy
Multiple pregnancy
Low body mass index (<19.8 kg/m2) (Fanaroff, 2011)
Abruptio placentae or placenta previa
Incompetent cervix
Maternal hypertension
Premature rupture of membranes or chorioamnionitis
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Polyhydramnios or oligohydramnios
Infection
Trauma
Fetal Factors
Chromosomal abnormalities
Congenital anomalies
Nonimmune hydrops
Erythroblastosis
Unknown Factors
The outlook for preterm infants is largely, but not entirely, related to the state of physiologic and anatomic immaturity of the various organs and systems at the time of birth. Infants at term have advanced to a state of maturity sufficient to allow a successful transition to the extrauterine environment. Preterm infants must make the same adjustments but with functional immaturity proportional to the stage of development reached at the time of birth. These adjustments, however, may be limited or even hindered by the external environment to which the preterm infant is exposed. Exposure to excessive stimuli, bacteria, and viruses make the environment less conducive for preterm infants to grow and develop. The degree to which infants are prepared for extrauterine life can be predicted to some extent by birth weight and estimated gestational age (see Clinical Assessment of Gestational Age, Chapter 7).
Within the past decade, increasing attention has been given to late preterm infants, that is, infants born between 34 and weeks' gestation. Such infants have some of the same risk factors as those born before 34 weeks' gestation, but physical characteristics and adaptation to extrauterine life are variable. Late preterm infants have metabolic and physical immaturity that places them at risk for greater mortality and morbidity than term infants (Cheong and Doyle, 2012). Studies have demonstrated decreased cognitive and motor function in late preterm infants at 24 months compared with term infants (Woythaler, McCormick, and Smith, 2011). In the following sections, the discussion of preterm infants continues to apply to all infants who are born before a completed gestational age of 37 weeks. Because prematurity now encompasses a wider age, weight, and physiologic maturity range, physical characteristics described may also vary; such descriptions are generalized for description purposes.
Diagnostic Evaluation Preterm infants have a number of distinct characteristics at various stages of development. Identification of these characteristics provides valuable clues to the gestational age and hence to the infant's physiologic capabilities. The general, outward physical appearance changes as the infant progresses to maturity. Characteristics of skin, general attitude (or posture) when supine, appearance of hair, and amount of subcutaneous fat provide cues to a newborn's physical development. Observation of spontaneous, active movements and response to stimulation and passive movement contributes to the assessment of neurologic status. The appraisal is made as soon as possible after admission to the nursery because much of the observation and management of infants depends on this information.
On inspection, preterm infants are very small and appear scrawny, because they have only minimal subcutaneous fat deposits (or none in some cases) and have a proportionately large head in relation to the body, which reflects the cephalocaudal direction of growth. The skin is bright pink (often translucent, depending on the degree of immaturity), smooth, and shiny, with small blood vessels clearly visible underneath the thin epidermis. The fine lanugo hair is abundant over the body (depending on gestational age) but is sparse, fine, and fuzzy on the head. The ear cartilage is soft and pliable, and the soles and palms have minimal creases, resulting in a smooth appearance. The bones of the skull and the ribs feel soft, and the eyes may be closed. Male infants have few
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scrotal rugae, and the testes are undescended; in girls, the labia and clitoris are prominent. Fig. 8-15 compares the features of full-term and preterm infants.
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FIG 8-15 Clinical and neurologic examinations comparing preterm and full-term infants. (Data from Pierog SH, Ferrara A: Medical care of the sick newborn, ed 2, St Louis, 1976, Mosby.)
In contrast to full-term infants' overall attitude of flexion and continuous activity, preterm infants may be inactive and listless. The extremities maintain an attitude of extension and remain in any position in which they are placed. Reflex activity is only partially developed—sucking is absent, weak, or ineffectual; swallow, gag, and cough reflexes are absent or weak; and other neurologic signs are absent or diminished. Physiologically immature, preterm infants are unable to maintain body temperature, have limited ability to excrete solutes in the urine, and have increased susceptibility to infection. A pliable thorax, immature lung tissue, and an immature regulatory center lead to periodic breathing, hypoventilation, and frequent periods of apnea. They are more susceptible to biochemical alterations such as hyperbilirubinemia and hypoglycemia, and they have a higher extracellular water content that renders them more vulnerable to fluid and electrolyte derangements. Preterm infants exchange fully half of their extracellular fluid volume every 24 hours compared with one seventh of the volume in adults.
The soft cranium is subject to characteristic unintentional deformation caused by positioning from one side to the other on a mattress. The head looks disproportionately longer from front to back, is flattened on both sides, and lacks the usual convexity seen at the temporal and parietal areas. This positional molding is often a concern to parents and may influence the parents' perception of the infant's attractiveness and their responsiveness to the infant. Positioning the infant on a waterbed or gel mattress can reduce or minimize cranial molding.
Neurologic impairment (e.g., intraventricular hemorrhage) and serious sequelae correlate with the size and gestational age of infants at birth and with the severity of neonatal complications. The greater the degree of immaturity, the greater the degree of potential disability. A greater incidence of cerebral palsy, attention-deficit/hyperactivity disorder (ADHD), visual-motor deficits, and altered intellectual functioning is observed in preterm than in full-term infants. However, behavioral development can be enhanced when families are provided with support and infants are referred to appropriate services for neurologic and developmental interventions. Parental interest and involvement are important variables in the developmental progress of infants.
Therapeutic Management When delivery of a preterm infant is anticipated, the intensive care nursery is alerted and a team approach implemented. Ideally, a neonatologist, an advanced practice nurse, a staff nurse, and a respiratory therapist are present for the delivery. Infants who do not require resuscitation are immediately transferred in a heated incubator to the NICU, where they are weighed and where IV lines, oxygen therapy, and other therapeutic interventions are initiated as needed. Resuscitation is conducted in the delivery area until infants can be safely transported to the NICU.
Subsequent care is determined by the infant's status. The general care of preterm infants differs from that of full-term infants primarily in the areas of respiratory support, temperature regulation,
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nutrition, susceptibility to infection, activity intolerance, neurodevelopmental care, and other consequences of physical immaturity.
Nursing Care Management The nursing care, similar to the therapeutic management, is individualized for each infant. See appropriate discussions in the Nursing Care of the High-Risk Newborn and Family section for additional details of care.
Postterm Infants Infants born beyond 42 weeks as calculated from the mother's last menstrual period (or by gestational age assessment) are considered to be postterm regardless of birth weight. This constitutes 3.5% to 15% of all pregnancies. The cause of delayed birth is unknown. Some infants are appropriate for gestational age but show the characteristics of progressive placental dysfunction. These infants display characteristics such as absence of lanugo, little if any vernix caseosa, abundant scalp hair, and long fingernails. The skin is often cracked, parchment-like, and desquamating. A common finding in postterm infants is a wasted physical appearance that reflects intrauterine deprivation. Depletion of subcutaneous fat gives them a thin, elongated appearance. The little vernix caseosa that remains in the skinfolds may be stained a deep yellow or green, which is usually an indication of meconium in the amniotic fluid.
There is a significant increase in fetal and neonatal mortality in postterm infants compared with those born at term. They are especially prone to fetal distress associated with the decreasing efficiency of the placenta, macrosomia, and meconium aspiration syndrome. The greatest risk occurs during the stresses of labor and delivery, particularly in an infant of a primigravida, or a woman delivering her first child. Close surveillance with fetal assessment and induction of labor is usually recommended when infants are significantly overdue.
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High Risk Related to Physiologic Factors Hyperbilirubinemia Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, or icterus, a yellowish discoloration of the skin, sclerae, and nails. Hyperbilirubinemia is a common finding in newborns and in most instances is relatively benign. However, in extreme cases, it can indicate a pathologic state.
Hyperbilirubinemia may result from increased unconjugated or conjugated bilirubin. The unconjugated form or indirect hyperbilirubinemia (Table 8-2) is the type most commonly seen in newborns. The following discussion of hyperbilirubinemia is limited to unconjugated hyperbilirubinemia.
TABLE 8-2 Comparison of Major Types of Unconjugated Hyperbilirubinemia*
Physiologic Jaundice Breastfeeding-Associated Jaundice (EarlyOnset) Breast Milk Jaundice (Late Onset) Hemolytic Disease
Cause Immature hepatic function plus increased bilirubin load from RBC hemolysis
Decreased milk intake related to fewer calories consumed by infant before mother's milk is well established; enterohepatic shunting
Possible factors in breast milk that prevent bilirubin conjugation
Less frequent stooling
Blood antigen incompatibility causing hemolysis of large numbers of RBCs
Liver's inability to conjugate and excrete excess bilirubin from hemolysis
Onset After 24 hours (preterm infants, prolonged)
2nd to 4th day 4th to 8th day During first 24 hours (levels increase >5 mg/dl/day)
Peak 3rd to 4th day 3rd to 5th day 10th to 15th day Variable Duration Declines on 5th to 7th day Variable May remain jaundiced for 3 to 12 weeks or more Depends on severity and treatment Therapy Increase frequency of feedings
and avoid supplements. Evaluate stooling pattern. Monitor TcB or TSB level. Perform risk assessment (see
Fig. 8-16, A). Use phototherapy if bilirubin
levels increase significantly or significant hemolysis is present.
Breastfeed frequently (10 to 12 times/day); avoid supplements such as water, dextrose water, and formula.
Evaluate stooling pattern; stimulate as needed. Perform risk assessment (see Fig. 8-16, A). Use phototherapy if bilirubin levels increase
significantly or significant hemolysis is present.
If phototherapy is instituted, evaluate benefits and harm of temporarily discontinuing breastfeeding; additional assessments may be required.
Assist mother with maintaining milk supply; feed expressed milk as appropriate.
After discharge, follow up according to hour of discharge.
Increase frequency of breastfeeding; use no supplementation, such as glucose water; cessation of breastfeeding is not recommended.
Perform risk assessment (see Fig. 8-16, A). Consider performing additional evaluations: G6PD,
direct and indirect serum bilirubin, family history, and others as necessary.
May include home phototherapy with a temporary (10 to 12 hours) discontinuation of breastfeeding; a subsequent TSB may be drawn to evaluate a drop in serum levels.
Assist mother with maintenance of milk supply and reassurance regarding her milk supply and therapy.
Use formula supplements only at practitioner's discretion.
Monitor TcB or TSB level. Perform risk assessment (see Fig. 8-16, A). Postnatal: Use phototherapy; administer IV
immunoglobulin per protocol; if severe, perform exchange transfusion.
Prenatal: Perform transfusion (fetus). Prevent sensitization (Rh incompatibility) of
Rh-negative mother with Rho(D) immune globulin (RhIg).
If mother is breastfeeding, assist with maintenance and storage of milk; may bottle feed expressed milk as appropriate to therapy.
Minimize maternal–infant separation and encourage contact as appropriate.
*Table depicts patterns of jaundice in term infants; patterns in preterm infants vary according to factors such as gestational age, birth weight, and illness. G6PD, Glucose-6-phosphate dehydrogenase; IV, intravenous; RBC, red blood cell; RhIg, Rh immunoglobulin; TcB, transcutaneous bilirubin; TSB, total serum bilirubin.
Pathophysiology Bilirubin is one of the breakdown products of the hemoglobin that results from RBC destruction. When RBCs are destroyed, the breakdown products are released into the circulation, where the hemoglobin splits into two fractions: heme and globin. The globin (protein) portion is used by the body, and the heme portion is converted to unconjugated bilirubin, an insoluble substance bound to albumin.
In the liver, the bilirubin is detached from the albumin molecule and, in the presence of the enzyme glucuronyl transferase, is conjugated with glucuronic acid to produce a highly soluble substance, conjugated bilirubin, which is then excreted into the bile. In the intestine, bacterial action reduces the conjugated bilirubin to urobilinogen, the pigment that gives stool its characteristic color. Most of the reduced bilirubin is excreted through the feces; a small amount is eliminated in the urine.
Normally, the body is able to maintain a balance between the destruction of RBCs and the use or excretion of byproducts. However, when developmental limitations or a pathologic process interferes with this balance, bilirubin accumulates in the tissues to produce jaundice. Possible causes of hyperbilirubinemia in newborns are: • Physiologic (developmental) factors (prematurity) • An association with breastfeeding or breast milk
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• Dehydration (limited oral intake) • Excess production of bilirubin (e.g., hemolytic disease, biochemical defects, bruises) • Disturbed capacity of the liver to secrete conjugated bilirubin (e.g., enzyme deficiency, bile duct
obstruction) • Combined overproduction and undersecretion (e.g., sepsis) • Some disease states (e.g., hypothyroidism, galactosemia, infant of a diabetic mother [IDM]) • Genetic predisposition to increased production or delayed metabolism (American Indians, Asians,
Mediterranean) The most common cause of hyperbilirubinemia is the relatively mild and self-limited physiologic
jaundice. Unlike hemolytic disease of the newborn (HDN) (see later in chapter), physiologic jaundice is not associated with any pathologic process. Although almost all newborns experience elevated bilirubin levels, only about 50% to 60% demonstrate observable signs of jaundice (Blackburn, 2011).
Two phases of physiologic jaundice have been identified in full-term infants. In the first phase, bilirubin levels of formula-fed white and African-American infants gradually increase to approximately 5 to 6 mg/dl by 3 to 4 days of life and then decrease to a plateau of 2 to 3 mg/dl by the fifth day (Blackburn, 2011). Bilirubin levels maintain a steady plateau state in the second phase without increasing or decreasing until approximately 12 to 14 days, at which time levels decrease to the normal value of 1 mg/dl (Blackburn, 2011). This pattern varies according to racial group, method of feeding (breast vs. bottle), and gestational age. In preterm formula-fed infants, serum bilirubin levels may peak as high as 10 to 12 mg/dl at 5 or 6 days of life and decrease slowly over a period of 2 to 4 weeks (Blackburn, 2011).
As noted earlier, infants of Asian descent (as well as American Indians) have mean bilirubin levels almost twice those seen in whites or African Americans. An increased incidence of hyperbilirubinemia is seen in newborns from certain geographic areas, particularly areas around Greece. These populations may have glucose-6-phosphate dehydrogenase (G6PD) deficiency, which can cause hemolytic anemia.
On average, newborns produce twice as much bilirubin as adults because of higher concentrations of circulating erythrocytes and a shorter life span of RBCs (only 70 to 90 days in contrasted to 120 days in older children and adults). In addition, the liver's ability to conjugate bilirubin is reduced because of limited production of glucuronyl transferase. Newborns also have a lower plasma-binding capacity for bilirubin because of reduced albumin concentrations compared with older children. Normal changes in hepatic circulation after birth may contribute to excess demands on liver function.
Normally, conjugated bilirubin is reduced to urobilinogen by the intestinal flora and excreted in feces. However, the relatively sterile and less motile newborn bowel is initially less effective in excreting urobilinogen. In the newborn intestine, the enzyme β-glucuronidase is able to convert conjugated bilirubin into the unconjugated form, which is subsequently reabsorbed by the intestinal mucosa and transported to the liver. This process, known as enterohepatic circulation, or shunting, is accentuated in newborns and is thought to be a primary mechanism in physiologic jaundice (Blackburn, 2011). Feeding (1) stimulates peristalsis and produces more rapid passage of meconium, thus diminishing the amount of reabsorption of unconjugated bilirubin; and (2) introduces bacteria to aid in the reduction of bilirubin to urobilinogen. Colostrum, a natural cathartic, facilitates meconium evacuation.
Breastfeeding is associated with an increased incidence of jaundice as a result of two distinct processes. Breastfeeding-associated jaundice (early-onset jaundice) begins at 2 to 4 days of age and occurs in approximately 12% to 35% of breastfed newborns (Blackburn, 2011). The jaundice is related to the process of breastfeeding and probably results from decreased caloric and fluid intake by breastfed infants before the milk supply is well established because decreased milk intake is associated with increased enterohepatic circulation of bilirubin (Soldi, Tonetto, Varalda et al, 2011). Reduced fluid intake results in dehydration, which also concentrates the bilirubin in the blood.
Breast milk jaundice (late-onset jaundice) begins at age 5 to 7 days and occurs in 2% to 4% of breastfed infants (Blackburn, 2011). Rising levels of bilirubin peak during the second week and gradually diminish. Despite high levels of bilirubin that may persist for 3 to 12 weeks, these infants are well. The jaundice may be caused by factors in the breast milk (pregnanediol, fatty acids, and β- glucuronidase) that either inhibit the conjugation or decrease the excretion of bilirubin. Less
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frequent stooling by breastfed infants may allow for an extended time for reabsorption of bilirubin from stools.
Diagnostic Evaluation The degree of jaundice is determined by serum bilirubin measurements. Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dl. In newborns, levels must exceed 5 mg/dl before jaundice (icterus) is observable. It is important to note, however, that the evaluation of jaundice is not based solely on serum bilirubin levels but also on the timing of the appearance of clinical jaundice; gestational age at birth; age in days since birth; family history, including maternal Rh factor; evidence of hemolysis; feeding method; infant's physiologic status; and the progression of serial serum bilirubin levels. The following criteria are indicators of pathologic jaundice that, when present, warrant further investigation as to the cause of the jaundice: • Persistent jaundice over 2 weeks in a full-term formula-fed infant • Total serum bilirubin levels over 12.9 mg/dl (term infant) or over 15 mg/dl (preterm infant); the
upper limit for breastfed infant is 15 mg/dl • Increase in serum bilirubin by 5 mg/dl/day • Direct bilirubin exceeding 1.5 to 2 mg/dl • Total serum bilirubin level over the 95th percentile for age (in hours) on an hour-specific
nomogram (Fig. 8-16)
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FIG 8-16 A, Nomogram for designation of risk in 2840 well newborns at 36 or more weeks of gestational age with birth weights of 2000 g (4.4 pounds) or more or 35 or more weeks of gestational age and birth
weights of 2500 g (5.5 pounds) or more based on the hour-specific serum bilirubin values. (This nomogram should not be used to represent the natural history of neonatal hyperbilirubinemia.) B,
Guidelines for phototherapy in hospitalized infants of 35 or more weeks of gestation. G6PD, Glucose-6- phosphate dehydrogenase. (A, From Bhutani VK, Johnson L, Sivieri EM: Predictive ability of a predischarge hour-specific serum
bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns, Pediatrics 103[1]:6–14, 1999. B, From American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia: Management of hyperbilirubinemia in the newborn infant 35 or
more weeks of gestation, Pediatrics 114[1]:297–316, 2004.)
This is not an all-inclusive list; other factors are also evaluated. Factors placing newborns at higher risk for hyperbilirubinemia include maternal race (e.g., Asian
or Asian American), late preterm birth, jaundice observed in the first 24 hours of life, significant bruising, cephalhematoma, exclusive breastfeeding, blood group incompatibility or hemolytic disease (such as, G6PD), and history of sibling with hyperbilirubinemia (Muchowski, 2014).
Noninvasive monitoring of bilirubin via cutaneous reflectance measurements (transcutaneous bilirubinometry [TcB]) allows for repetitive estimations of bilirubin and, when used correctly, may decrease the need for invasive monitoring. The new TcB monitors provide accurate measurements within 2 mg/dl in most neonatal populations at serum levels below 15 mg/dl (Schmidt, Wheeler, Jackson, et al, 2009). TcB monitors must be used according to published guidelines as a screening tool, not as a predictor of need for therapy; multiple readings over time at a consistent site (e.g., sternum or forehead) are of more value than a single reading. After phototherapy has been initiated, TcB is no longer useful as a screening tool.
The use of hour-specific serum bilirubin levels to predict newborns at risk for rapidly rising levels has now become the standard of care as well as an official recommendation by the American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia (2004) for the monitoring of healthy neonates of 35 weeks of gestation or older. The use of a nomogram with three levels (high, intermediate, or low risk) of rising total serum bilirubin values assists in the determination of which newborns might need further evaluation after discharge (Romagnoli, Tiberi, Barone, et al, 2012) (see Fig. 8-16, A). The hour-specific bilirubin risk nomogram is used to determine the infant's risk for developing hyperbilirubinemia requiring medical treatment or more frequent screening. Risk factors recognized to place infants in the high-risk category include gestational age of younger than 38 weeks, breastfeeding, a sibling who had significant jaundice, and jaundice appearing before discharge (Kamath, Thilo, and Hernandez, 2011).
It is also recommended that healthy term infants receive follow-up care and bilirubin risk assessment with TcB or the hour-specific nomogram within 3 days of discharge if discharged at less than 24 hours of age. Newborns discharged at 24 to 48 hours should receive follow-up evaluation within 4 days (96 hours), and those discharged between 48 and 72 hours should receive follow-up within 5 days (American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia, 2004; Blackburn, 2011). The serum bilirubin may be obtained at the time of the metabolic screening, thus precluding the need for additional blood sampling. The newest guidelines for monitoring and treating neonatal hyperbilirubinemia are published extensively elsewhere, and readers are referred to “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation (Clinical Practice Guideline)” (American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia, 2004) for an in-depth overview of management guidelines.
Complications Unconjugated bilirubin is highly toxic to neurons; therefore, an infant with severe jaundice is at risk of developing bilirubin encephalopathy, a syndrome of severe brain damage resulting from the deposition of unconjugated bilirubin in brain cells. Kernicterus describes the yellow staining of the brain cells that may result in bilirubin encephalopathy. The damage occurs when the serum concentration reaches toxic levels, regardless of cause. There is evidence that a fraction of unconjugated bilirubin crosses the blood–brain barrier in neonates with physiologic hyperbilirubinemia. When certain pathologic conditions exist in addition to elevated bilirubin levels, there is an increase in the permeability of the blood–brain barrier to unconjugated bilirubin and thus potential irreversible damage. The exact level of serum bilirubin required to cause damage is not yet known.
Multiple factors contribute to bilirubin neurotoxicity; therefore, serum bilirubin levels alone do not predict the risk of brain injury. Factors that are known to enhance the development of bilirubin encephalopathy include metabolic acidosis, lowered serum albumin levels, intracranial infections
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(such as meningitis), and abrupt fluctuations in BP. In addition, any condition that increases the metabolic demands for oxygen or glucose (e.g., fetal distress, hypoxia, hypothermia, hypoglycemia) also increases the risk of brain damage at lower serum levels of bilirubin.
The signs of bilirubin encephalopathy are those of CNS depression or excitation. Prodromal symptoms consist of decreased activity, lethargy, irritability, hypotonia, and seizures. Later these subtle findings are followed by development of athetoid cerebral palsy, gaze palsies, and deafness (Watson, 2009). Motor skills are delayed, and dental enamel hypoplasia may also occur. Those who survive may eventually show evidence of neurologic damage, such as cognitive delay, ADHD, delayed or abnormal motor movement (especially ataxia or athetosis), behavior disorders, perceptual problems, or sensorineural hearing loss.
Therapeutic Management The primary goals in the treatment of hyperbilirubinemia are to identify infants at high risk for hyperbilirubinemia; monitor serum bilirubin levels; prevent bilirubin encephalopathy; and, as in any blood group incompatibility, to reverse the hemolytic process. The main form of treatment involves the use of phototherapy. Exchange transfusion is generally used for reducing dangerously high bilirubin levels that may occur with hemolytic disease.
Intravenous immunoglobulin (IVIG) is effective in reducing bilirubin levels in infants with Rh isoimmunization and ABO incompatibility (Watson, 2009) and is recommended by the American Academy of Pediatrics (American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia, 2004). The evidence supporting the use of IVIG is limited and further research is recommended (Keir, Dunn, and Callum, 2013).
Healthy near-term and full-term infants with jaundice may also benefit from early initiation of feedings and frequent breastfeeding. These preventive measures are aimed at promoting increased intestinal motility, decreasing enterohepatic shunting, and establishing normal bacterial flora in the bowel to effectively enhance the excretion of unconjugated bilirubin.
Phototherapy consists of the application of a special source of light (irradiance) to the infant's exposed skin (Fig. 8-17). Light promotes bilirubin excretion by photoisomerization, which alters the structure of bilirubin to a soluble form (lumirubin) for easier excretion.
FIG 8-17 A, An infant receiving phototherapy; note the nested boundaries for comfort and eye protection. B, A newborn laying on a BiliBlanket, which may be used with overhead lights to provide
intensive phototherapy. (Courtesy E. Jacobs, Texas Children's Hospital, Houston, TX.)
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Studies indicate that blue fluorescent light is more effective than white fluorescent in reducing bilirubin levels. However, because blue light alters the infant's coloration, the normal light of fluorescent bulbs in the spectrum of 420 to 460 nm is often preferred so the infant's skin can be better observed for color (jaundice, pallor, cyanosis) or other conditions. Increasing irradiance to the 430 to 490 nm band provides best results. For phototherapy to be effective, the infant's skin must be fully exposed to an adequate amount of the light source. A diaper and boundary materials for postural support may be left in place; periodically turning the neonate under phototherapy has not been shown to accelerate bilirubin clearance (Stokowski, 2011). When serum bilirubin levels are rapidly increasing or approximating critical levels, intensive phototherapy is recommended. Intensive phototherapy with a higher irradiance is considered to be more effective than standard phototherapy for rapid reduction of serum bilirubin levels (Edris, Ghany, Razek, et al, 2014). The color of the infant's skin does not influence the efficacy of phototherapy. Best results occur within the first 4 to 6 hours of treatment (Stokowski, 2011). Phototherapy alone is not effective in the management of hyperbilirubinemia when levels are at a critical level or are rising rapidly; it is designed primarily for the treatment of moderate hyperbilirubinemia.
Available commercial phototherapy delivery systems are numerous and include halogen spotlights, light-emitting diodes, fluorescent tubes or bank lights, and fiberoptic mattresses (Stokowski, 2011). A Cochrane review of 24 studies indicated that conventional phototherapy was more effective at lowering serum bilirubin values than fiberoptic lights alone; when two fiberoptic devices were used simultaneously in preterm infants, the therapy was as effective as conventional therapy at reducing serum bilirubin levels. Combination phototherapy (fiberoptic mattress and conventional overhead lights) was found to be more effective than conventional therapy alone. The authors further concluded that fiberoptic phototherapy is a safe and effective alternative to conventional therapy in preterm infants. The authors also pointed out that no trials were available to show that fiberoptic therapy is more effective than conventional phototherapy (Mills and Tudehope, 2005).
The American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia (2004) practice parameter guidelines provide suggestions for initiating phototherapy (see Fig. 8-16, B) and for implementing exchange transfusion in healthy term infants.
Some clinicians believe that preterm infants have a higher risk of developing pathologic jaundice at lower serum bilirubin levels than healthy term infants because of associated illness factors that may increase the entry of bilirubin into the brain; however, research has failed to confirm this belief (Watchko and Maisels, 2010). Until further research is completed, the recommendations for starting phototherapy in infants weighing less than 1500 g is 5 to 8 mg/dl, 8 to 12 mg/dl for infants weighing 1500 to 1999 g, and 11 to 14 mg/dl for infants weighing 2000 to 2499 g (Watchko and Maisels, 2010). However, each infant should be carefully evaluated with other illness and risk factors in mind rather than depending on absolute values for all infants in a specific group. Prophylactic phototherapy may be used in preterm infants to prevent a significant increase in serum bilirubin levels (Stokowski, 2011).
Phototherapy has not been found to cause long-term adverse effects. The effectiveness of treatment is determined by a decrease in total serum bilirubin levels. Concurrently, the infant's total physical status is assessed continually because the suppression of jaundice by phototherapy may mask signs of sepsis, hemolytic disease, or hepatitis.
Recommendations for prevention and management of early-onset jaundice in breastfed infants include encouraging frequent breastfeeding, preferably every 2 hours; avoiding glucose water, formula, and water supplementation; and monitoring for early stooling. The infant's weight, voiding, and stooling should be evaluated along with the breastfeeding pattern (Lawrence and Lawrence, 2011). Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding after the infant is home, and they are encouraged to call the primary care practitioner if there are indications the infant is not feeding well, is difficult to arouse for feedings, or is not voiding and stooling adequately (Burgos, Flaherman, and Newman, 2012).
Phototherapy as a treatment for hyperbilirubinemia is further discussed later in the chapter.
Prognosis Early recognition and treatment of hyperbilirubinemia prevents unnecessary medical therapies, parent–infant separation, breastfeeding disruption and possibly failure, and neurologic damage (bilirubin encephalopathy). Phototherapy is a safe and effective method of decreasing serum
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bilirubin levels in newborns with mild to moderate hyperbilirubinemia.
Nursing Care Management The nursing care of infants with jaundice is discussed in the Nursing Process box and in the following section.
N u r s i n g P r o c e s s The Newborn with Jaundice
Assessment Assess for signs of clinical jaundice.
Diagnosis (Problem Identification) After the nursing assessment, a number of nursing diagnoses may be evident. Additional nursing diagnoses that may apply include:
• Risk for Neonatal Jaundice—risk factors include but are not limited to physiologic immaturity of the liver, increased production of unconjugated bilirubin, enterohepatic circulation
• Risk for Impaired Parent–Infant Attachment—risk factors include separation from parents for treatment of elevated bilirubin levels, eye shields, phototherapy, perception of fragile status of infant
• Interrupted Breastfeeding—related to increasing serum bilirubin levels
• Risk for Deficient Fluid Volume—risk factors include increased extracellular fluid (ECF) volume, immature kidney function, increased body temperature, decreased oral fluid intake, increased fluid losses in stool and urine
• Risk for Impaired Skin Integrity—risk factors include increased stooling, decreased oral intake, immature skin function, increased body metabolism and fluid losses
• Interrupted Family Processes—related to required treatment and physical separation from infant because of treatment (phototherapy)
Planning Expected outcomes include:
• Infant will receive appropriate monitoring for jaundice in the newborn period.
• Infant will receive appropriate therapy as needed to reduce serum bilirubin levels.
• Infant will experience no complications from therapy.
• Mother–infant dyad will achieve successful breastfeeding.
• Family will receive emotional support.
• Family will be prepared for home phototherapy (if prescribed).
• Family will receive appropriate education about neonatal jaundice.
Implementation Numerous nursing interventions are discussed later in the chapter.
Evaluation The effectiveness of nursing interventions for the family and infant with jaundice is determined by
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continual reassessment and evaluation of care based on the following guidelines:
• Observe skin color; review bilirubinometric or laboratory findings.
• Evaluate feedings and elimination pattern.
• Check placement of eye shields; observe skin for signs of dehydration; monitor infant's temperature.
• Interview family members and observe parent–infant interactions.
Part of the routine physical assessment includes observing for evidence of jaundice at regular intervals. Jaundice is most reliably assessed by observing the infant's skin color from head to toe and the color of the sclerae and mucous membranes. Applying direct pressure to the skin, especially over bony prominences (such as, the tip of the nose or the sternum), causes blanching and allows the yellow stain to be more pronounced. For dark-skinned infants, the color of the sclerae, conjunctiva, and oral mucosa is the most reliable indicator. Also, bilirubin (especially at high levels) is not uniformly distributed in the skin. The nurse should observe the infant in natural daylight for a true assessment of color.
The TcB is a useful screening device and is used to detect neonatal jaundice in full-term infants. Because phototherapy reduces the accuracy of the instrument, its value is limited to assessments made before the initiation of phototherapy. Institutions in which the device is used set up their own criteria based on their experience with their particular instrument. Blood samples are also taken for the measurement of bilirubin in the laboratory.
With short hospital stays, jaundice may appear after discharge. A careful history from the parents may reveal significant familial patterns of hyperbilirubinemia (e.g., older siblings who had jaundice). Other considerations in assessment include the ethnic origin of the family (e.g., higher incidence in Asian infants); type of delivery (e.g., induction of labor); and infant characteristics, such as weight loss after birth, gestational age, sex, and the presence of any bruising. The method and frequency of feeding are assessed. Prevention of jaundice may be possible with early introduction of feedings and frequent nursing without supplementation. Every effort is made to provide an optimum thermal environment to reduce metabolic needs.
N u r s i n g A l e r t While blood is drawn, phototherapy lights are turned off. Blood is transported in a covered tube to avoid a false reading as a result of bilirubin destruction in the test tube.
Q u a l i t y Pa t i e n t O u t c o m e s Neonatal Hyperbilirubinemia
Total serum bilirubin level will be maintained below high-risk critical value (as determined on the hour-specific total serum bilirubin nomogram).
N u r s i n g A l e r t Evidence of jaundice that appears before the infant is 24 hours old is an indication for assessing bilirubin levels.
Phototherapy The infant who receives phototherapy is placed semi-nude (diaper may be left in place) under the light source and periodically evaluated to ensure tolerance to the procedure. After phototherapy has been initiated, frequent serum bilirubin levels (every 6 to 24 hours) are necessary because visual assessment of jaundice or transcutaneous bilirubin monitoring is no longer considered valid.
Several precautions are instituted to protect the infant during phototherapy. The infant's eyes are shielded by an opaque mask to prevent exposure to the light (see Fig. 8-17). The eye shield should
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be properly sized and correctly positioned to cover the eyes completely but prevent any occlusion of the nares. The infant's eyelids are closed before the mask is applied because the corneas may become excoriated if they come in contact with the dressing. On each nursing shift, the eyes are checked for evidence of discharge, excessive pressure on the eyelids, and corneal irritation. Eye shields are removed during feedings, which provide the opportunity for visual and sensory stimulation.
Infants who are in an open crib must have a protective Plexiglas shield between them and the overhead fluorescent lights to minimize the amount of undesirable ultraviolet light reaching their skin and to protect them from accidental bulb breakage. Their temperature is closely monitored to prevent hyperthermia or hypothermia. Maintaining the infant in a flexed position with rolled blankets along the sides of the body helps maintain heat and provides comfort.
Accurate documentation is another important nursing responsibility and includes (1) times that phototherapy is started and stopped, (2) proper shielding of the eyes, (3) type of light source (by manufacturer), (4) use of phototherapy in combination with an incubator or open bassinet, (5) photometer measurement of light intensity according to hospital protocol, (6) feeding and elimination pattern, (7) body temperature, and (8) serum bilirubin levels.
Minor side effects for which the nurse should be alert include loose, greenish stools; transient skin rashes; hyperthermia; increased metabolic rate; dehydration; electrolyte disturbances, such as hypocalcemia; and priapism. To prevent or minimize these effects, the temperature is monitored to detect early signs of hypothermia or hyperthermia, and the skin is observed for evidence of dehydration and drying, which can lead to excoriation and breakdown. Oily lubricants or lotions are not used on the skin while the infant is under phototherapy. Infants receiving phototherapy may require additional fluid volume to compensate for insensible and intestinal fluid loss. Breastfeeding or bottle feeding by the parent(s) and parental interaction (such as holding) is encouraged once phototherapy is initiated provided the infant receives adequate exposure to the treatment. Because phototherapy enhances the excretion of unconjugated bilirubin through the bowel, loose stools may indicate accelerated bilirubin removal. Frequent stooling can cause perianal irritation; therefore, meticulous skin care, especially keeping the skin clean and dry, is essential.
S a f e t y A l e r t Parents may be told by some practitioners to place the infant in the sunlight when the infant has jaundice; however, this practice is not recommended. If performed, the infant should only be placed in indirect sunlight (e.g., in a room where sunlight filters through a glass window), because direct sunlight may cause skin burns in a newborn.
After phototherapy is permanently discontinued, there is often a subsequent increase in the serum bilirubin level, often called the rebound effect. This is usually transient and resolves without resuming therapy; however, a follow-up serum bilirubin level should be checked.
Family Support Parents need reassurance concerning their infant's progress. All the procedures are explained to familiarize them with the benefits and risks. Parents need to be reassured that the naked infant under the bilirubin light is warm and comfortable. Eye shields are removed when the parents are visiting to facilitate the attachment process. The parents can be reassured that the neonate is accustomed to darkness after months of intrauterine existence and benefits a great deal from auditory and tactile stimulation (see Family-Centered Care box).
F a m i l y - C e n t e r e d C a r e Phototherapy and Parent–Infant Interaction
The traditional use of phototherapy has evoked concerns regarding a number of psychobehavioral issues, including parent–infant separation, potential social isolation, decreased sensorineural stimulation, altered biologic rhythms, altered feeding patterns, and activity changes. Parental anxiety is greatly increased, particularly at the sight of their newborn blindfolded and under special lights. The interruption of breastfeeding for phototherapy is a potential deterrent to
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successful mother–infant attachment and interaction. Because research has demonstrated that bilirubin catabolism occurs primarily within the first few hours of the initiation of phototherapy, there is increased support for the periodic removal of the infant from treatment for feeding and holding. The benefits of stopping phototherapy for parental feeding and holding outweigh concerns related to the clearance of bilirubin in healthy full-term newborns with mild hyperbilirubinemia. Home phototherapy offers an additional opportunity to foster parent–infant attachment.
The initiation of any treatment requires informed consent by the parents for the therapy prescribed; however, in the case of phototherapy, considerable anxiety may rightfully occur when words such as kernicterus and neurologic damage are used to describe possible effects of nontreatment. It is imperative that nurses remain sensitive to parents' feelings and information needs during this process; an important nursing intervention is assessment of the parents' understanding of the treatment involved and clarification of the nature of the therapy.
An important nursing intervention is recognition of breastfeeding jaundice. Lack of familiarity among health professionals has caused many newborns prolonged hospitalization, termination of breastfeeding, and unnecessary phototherapy. Care of the new mother may include supporting successful and frequent breastfeeding. Parents also need reassurance of the benign nature of the jaundice in a healthy infant and encouragement to resume breastfeeding if temporary cessation is prescribed. In some situations, jaundice may increase the risk of the parents' discontinuing breastfeeding and developing the vulnerable child syndrome—a belief that their child has experienced a “close call” and is vulnerable to serious injury (see Critical Thinking Case Study box).
C r i t i c a l T h i n k i n g C a s e S t u d y Jaundice
A full-term, 120-hour-old newborn is brought to the urgent care department late in the evening for evaluation of newborn jaundice. A serum bilirubin level was drawn earlier in the day at the birth hospital by heel stick; the results were total bilirubin 13.6 mg/dl and direct bilirubin 0.6 mg/dl. The father is concerned because he saw an online medical report saying that newborns could develop brain damage if the bilirubin levels were to increase to high levels. The mother is breastfeeding every 2 to 3 hours, and the newborn has had five wet diapers and three semiliquid stools over the past 18 hours. The newborn's birth weight was 2834 g (6.2 pounds), and her current weight (nude) is 2722 g (6 pounds). On examination, the infant is active and alert, with visibly jaundiced skin and sclerae, intact neurologic reflexes, and a strong suck reflex. The history reveals no prenatal or delivery complications. Apgar scores at 1 and 5 minutes were 8 and 9, respectively, and the initial assessment did not reveal any problems. The mother's blood type is A positive, and the direct Coombs test result is negative. The newborn was discharged from the birth hospital on the second day of life in apparent good health.
Questions
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1. Evidence: Is there sufficient evidence to draw any conclusions about the newborn's condition at
this time?
2. Assumptions: Describe some underlying assumptions about the following:
a. Newborn jaundice in a healthy full-term infant
b. Serum bilirubin levels and the newborn's age in hours; other pertinent laboratory values (may refer to Fig. 8-16, A) to determine the risk zone for the serum bilirubin
c. Nutritional and excretory function and relation to bilirubin metabolism
d. The physical status of the infant per assessment data
3. What implications and priorities for nursing care can be drawn at this time?
4. Does the evidence objectively support your argument (conclusion)?
Discharge Planning and Home Care With short hospital stays, mothers and infants may be discharged before evidence of jaundice is present. It is important for the nurse to discuss signs of jaundice with the mother because any clinical symptoms will probably appear at home. Home visits within 2 to 3 days after discharge to evaluate feeding and elimination patterns and jaundice are often routine for some health care organizations. Others may have an outpatient bilirubin clinic or laboratory where the infant can be evaluated by a nurse and weighed and a serum bilirubin can be drawn for evaluation. Assessment of breastfeeding is essential.
If home phototherapy is instituted, the hospital or home health care nurse or medical equipment company representative is usually responsible for teaching the family members and assessing their abilities to implement the treatment safely. General guidelines for home care preparation and education are discussed in Chapter 20. Written instructions and supervision of care—especially the application of eye shields if needed—are essential. The minor side effects of phototherapy are reviewed, and parents may need instruction in taking axillary temperatures and recording times and amounts of feedings and the number of wet diapers and stools. Regardless of how benign the disorder or the therapy, the parents need support and understanding. Measures should be taken to assist the mother in achieving successful breastfeeding, including consultation with a lactation specialist on an outpatient basis. Phenomenological research showed that mothers of infants who were receiving treatment for jaundice experienced physical and emotional exhaustion, loss of control, distress at the infant's appearance, and a feeling of having been robbed (Brethauer and Carey, 2010). Mothers in the study reported receiving a significant amount of conflicting information about jaundice and feeding from health care professionals. In jaundice associated with breastfeeding, follow-up blood studies are usually required to assess the progress of the jaundice. If temporary cessation of breastfeeding is prescribed, mothers should be taught to pump the breasts every 3 to 4 hours to maintain lactation; the expressed milk is frozen for use after breastfeeding is resumed.
Hemolytic Disease of the Newborn Hyperbilirubinemia in the first 24 hours of life is most often the result of HDN, an abnormally rapid rate of RBC destruction. Anemia caused by this destruction stimulates the production of RBCs,
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which in turn provides increasing numbers of cells for hemolysis. Major causes of increased erythrocyte destruction are isoimmunization (primarily Rh) and ABO incompatibility.
Blood Incompatibility The membranes of human blood cells contain a variety of antigens, also known as agglutinogens, substances capable of producing an immune response if recognized by the body as foreign. The reciprocal relationship between antigens on RBCs and antibodies in the plasma causes agglutination (clumping). In other words, antibodies in the plasma of one blood group (except the AB group, which contains no antibodies) produce agglutination when mixed with antigens of a different blood group. In the ABO blood group system, the antibodies occur naturally. In the Rh system, the person must be exposed to the Rh antigen before significant antibody formation takes place and causes a sensitivity response known as isoimmunization.
Rh Incompatibility (Isoimmunization) The Rh blood group consists of several antigens (with D being the most prevalent). For simplicity, only the terms Rh positive (presence of antigen) and Rh negative (absence of antigen) are used in this discussion. The presence or absence of the naturally occurring Rh factor determines the blood type.
Ordinarily, no problems are anticipated when the Rh blood types are the same in both the mother and the fetus or when the mother is Rh positive and the infant is Rh negative. Difficulty may arise when the mother is Rh negative and the infant is Rh positive. Although the maternal and fetal circulations are separate, there is evidence that fetal RBCs and cell-free DNA can enter the maternal circulation during pregnancy (Moise, 2012). More commonly, however, fetal RBCs enter into the maternal circulation at the time of delivery. The mother's natural defense mechanism responds to these alien cells by producing anti-Rh antibodies.
Under normal circumstances, this process of isoimmunization has no effect during the first pregnancy with an Rh-positive fetus, because the initial sensitization to Rh antigens rarely occurs before the onset of labor. However, with the increased risk of fetal blood being transferred to the maternal circulation during placental separation, maternal antibody production is stimulated. During a subsequent pregnancy with an Rh-positive fetus, these previously formed maternal antibodies to Rh-positive blood cells may enter the fetal circulation, where they attack and destroy fetal erythrocytes (Fig. 8-18). Multiple gestation, abruptio placentae, placenta previa, manual removal of the placenta, and cesarean delivery increase the incidence of transplacental hemorrhage and subsequent isoimmunization (Diehl-Jones and Fraser, 2014).
FIG 8-18 Development of maternal sensitization to Rh antigens. A, Fetal Rh-positive erythrocytes enter the maternal system. Maternal anti-Rh antibodies are formed. B, Anti-Rh antibodies cross the placenta
and attack fetal erythrocytes.
Because the condition begins in utero, the fetus attempts to compensate for the progressive hemolysis and anemia by accelerating the rate of erythropoiesis. As a result, immature RBCs
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(erythroblasts) appear in the fetal circulation, hence the term erythroblastosis fetalis. There is wide variability in the development of maternal sensitization to Rh-positive antigens.
Sensitization may occur during the first pregnancy if the woman had previously received an Rh- positive blood transfusion. No sensitization may occur in situations in which a strong placental barrier prevents transfer of fetal blood into the maternal circulation. In approximately 10% to 15% of sensitized mothers, there is no hemolytic reaction in the newborn. In addition, some Rh-negative women, even though exposed to Rh-positive fetal blood, are immunologically unable to produce antibodies to the foreign antigen (Hensley, Coughlin, and Klein, 2009).
In the most severe form of erythroblastosis fetalis, hydrops fetalis, the progressive hemolysis causes fetal hypoxia; cardiac failure; generalized edema (anasarca); and fluid effusions into the pericardial, pleural, and peritoneal spaces (hydrops). The fetus may be delivered stillborn or in severe respiratory distress. Maternal Rh immunoglobulin (RhIg) administration, early intrauterine detection of fetal anemia by ultrasonography (serial Doppler assessment of the peak velocity in the fetal middle cerebral artery), and subsequent treatment by fetal blood transfusions or high-dose IVIG have dramatically improved the outcome of affected fetuses (Bagwell, 2014).
ABO Incompatibility Hemolytic disease can also occur when the major blood group antigens of the fetus are different from those of the mother. The major blood groups are A, B, AB, and O. In the North American white population, 46% have type O blood, 42% have type A blood, 9% have type B blood, and 3% have type AB blood.
The presence or absence of antibodies and antigens determines whether agglutination will occur. Antibodies in the plasma of one blood group (except the AB group, which contains no antibodies) will produce agglutination (clumping) when mixed with antigens of a different blood group. Naturally occurring antibodies in the recipient's blood cause agglutination of a donor's RBCs. The agglutinated donor cells become trapped in peripheral blood vessels, where they hemolyze, releasing large amounts of bilirubin into the circulation.
The most common blood group incompatibility in the neonate is between a mother with O blood group and an infant with A or B blood group (see Table 8-3 for possible ABO incompatibilities). Naturally occurring anti-A or anti-B antibodies already present in the maternal circulation cross the placenta and attack the fetal RBCs, causing hemolysis. Usually, the hemolytic reaction is less severe than in Rh incompatibility; however, rare cases of hydrops have been reported (Black and Maheshwari, 2009). Unlike the Rh reaction, ABO incompatibility may occur in the first pregnancy. The risk of significant hemolysis in subsequent pregnancies is higher when the first pregnancy is complicated by significant hemolysis (Shamsi, Hossain, and Paidas, 2011).
TABLE 8-3 Potential Maternal–Fetal ABO Incompatibilities
Maternal Blood Group Incompatible Fetal Blood Group O A or B B A or AB A B or AB
Clinical Manifestations Jaundice may appear shortly after birth (during the first 24 hours) in newborns affected by HDN, and serum levels of unconjugated bilirubin rise rapidly. Anemia results from the hemolysis of large numbers of erythrocytes, and hyperbilirubinemia and jaundice result from the liver's inability to conjugate and excrete the excess bilirubin. Most newborns with HDN are not jaundiced at birth. However, hepatosplenomegaly and varying degrees of hydrops may be evident. If the infant is severely affected, signs of anemia (notably, marked pallor) and hypovolemic shock are apparent. Hypoglycemia may occur as a result of pancreatic cell hyperplasia.
Diagnostic Evaluation Early identification and diagnosis of RhD sensitization are important in the management and prevention of fetal complications. A maternal antibody titer (indirect Coombs test) should be drawn at the first prenatal visit. Genetic testing allows early identification of paternal zygosity at
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the RhD gene locus, thus allowing earlier detection of the potential for isoimmunization and avoiding further maternal or fetal testing (Liao, Gronowski, and Zhao, 2014). Amniocentesis can be used to test the fetal blood type of a woman whose antibody screen result is positive; the use of polymerase chain reaction may determine the fetal blood type and presence of maternal antibodies. The fetal hemoglobin and hematocrit can also be measured (Moise, 2012). Testing for the presence of cell-free fetal DNA in the maternal plasma of RhD-negative women to detect an RhD-positive fetus has been used successfully (Finning, Martin, and Daniels, 2009; Moise, 2012). Such testing negates the need for amniocentesis for fetal blood type.
Ultrasonography is considered an important adjunct in the detection of isoimmunization; alterations in the placenta, umbilical cord, and amniotic fluid volume, as well as the presence of fetal hydrops, can be detected with high-resolution ultrasonography and allow early treatment before the development of erythroblastosis. Doppler ultrasonography of fetal middle cerebral artery peak velocity has been used to detect and measure fetal hemoglobin and, subsequently, fetal anemia (Moise, 2012). Erythroblastosis fetalis caused by Rh incompatibility can also be monitored by evaluating rising anti-Rh antibody titers in the maternal circulation or by testing the optical density of amniotic fluid (ΔOD450 test) (Moise, 2012).
Hemolysis in the newborn is suspected on the basis of the timing and appearance of jaundice (see Table 8-2) and can be confirmed postnatally by detecting antibodies attached to the circulating erythrocytes of affected infants (direct Coombs test or direct antiglobulin test). The Coombs test may be performed on umbilical cord blood samples from infants born to Rh-negative mothers if there is a history of incompatibility or further investigation is warranted.
Therapeutic Management The primary aim of therapeutic management of isoimmunization is prevention. Postnatal therapy is usually phototherapy for mild cases of hemolysis and exchange transfusion for more severe forms. Although phototherapy may control bilirubin levels in mild cases, the hemolytic process may continue, causing significant anemia between 7 and 21 days of life. In some institutions, an IVIG is administered to decrease the formation of bilirubin in neonates with ABO incompatibility.
Prevention of Rh Isoimmunization The administration of RhIg, a human gamma globulin concentrate of anti-D, to all unsensitized Rh- negative mothers at 28 weeks of gestation and after delivery or abortion of an Rh-positive infant or fetus prevents the development of maternal sensitization to the Rh factor. The injected anti-Rh antibodies are thought to destroy (by subsequent phagocytosis and agglutination) fetal RBCs passing into the maternal circulation before they can be recognized by the mother's immune system. Because the immune response is blocked, anti-D antibodies and memory cells (which produce the primary and secondary immune responses, respectively) are not formed (Bagwell, 2014; Blackburn, 2011). The inhibition of memory cell formation is especially important because memory cells provide long-term immunity by initiating a rapid immune response after the antigen is reintroduced (McCance and Huether, 2010).
To be effective, RhIg (e.g., RhoGAM) must be administered to unsensitized mothers within 72 hours (but possibly as long as 3 to 4 weeks) after the first delivery or abortion and repeated after subsequent pregnancies or losses. The administration of RhIg at 26 to 28 weeks of gestation further reduces the risk of Rh isoimmunization. RhIg is not effective against existing Rh-positive antibodies in the maternal circulation.
Studies have demonstrated the effectiveness of IVIG at decreasing the severity of RBC destruction (hemolysis) in HDN and subsequent development of neonatal jaundice (Elalfy, Elbarbary, and Abaza, 2011; Demirel, Akar, Celik, et al, 2011). This therapy, often used in conjunction with phototherapy, may decrease the necessity for exchange transfusion. Maternal administration of high-dose IVIG, alone or in combination with plasmapheresis, decreases the fetal effects of RhD isoimmunization (Bellone and Boctor, 2014).
D r u g A l e r t RhIg is administered intramuscularly, not intravenously, and only to Rh-negative women with a negative Coombs test result—never to the newborn or father.
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Intrauterine Transfusion Infants of mothers already sensitized may be treated by intrauterine transfusion, which consists of infusing blood into the umbilical vein of the fetus. The need for therapy is based on the antenatal diagnosis of isoimmunization by determining the optical density of amniotic fluid (by amniocentesis) as an index of fetal hemolysis or by serial ultrasonography, which may detect the presence of fetal hydrops as early as 16 weeks of gestation. With the advance of ultrasound technology, fetal transfusion may be accomplished directly via the umbilical vein, infusing type O Rh-negative packed RBCs to raise the fetal hematocrit to 40% to 50%. The frequency of intrauterine transfusions may vary according to institution and fetal hydropic status but are most often done every 2 to 3 weeks until the fetus reaches pulmonary maturity at approximately 36 weeks of gestation (Sainio, Nupponen, Kuosmanen, et al, 2015). The use of intraperitoneal blood transfusions is used less commonly for isoimmunization because of higher associated fetal risks; however, it may be used when intravascular access is impossible.
Exchange Transfusion Exchange transfusion, in which the infant's blood is removed in small amounts (usually 5 to 10 ml at a time) and replaced with compatible blood (e.g., Rh-negative blood), is a standard mode of therapy for treatment of severe hyperbilirubinemia and is the treatment of choice for hyperbilirubinemia and hydrops caused by Rh incompatibility (Fig. 8-19). Exchange transfusion removes the sensitized erythrocytes, lowers the serum bilirubin level to prevent bilirubin encephalopathy, corrects the anemia, and prevents cardiac failure. Indications for exchange transfusion in full-term infants may include a rapidly increasing serum bilirubin level and hemolysis despite intensive phototherapy. The criteria for exchange transfusions in preterm infants vary according to associated illness factors. The American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia (2004) practice parameter guidelines provide recommendations for initiating phototherapy and for exchange transfusion in infants at 35 weeks of gestation or more. An infant born with hydrops fetalis or signs of cardiac failure is a candidate for immediate exchange transfusion with fresh whole blood.
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FIG 8-19 Prenatal development of the alveolar unit. (From McCance K, Huether S: Pathophysiology: the biologic basis for disease in adults and children, ed 7, St Louis, 2014, Mosby/Elsevier.)
For exchange transfusion, fresh whole blood is typed and crossmatched to the mother's serum. The amount of donor blood used is usually double the blood volume of the infant, which is approximately 85 ml/kg body weight but is limited to no more than 500 ml. The two-volume exchange transfusion replaces approximately 85% of the neonate's blood.
An exchange transfusion is a sterile surgical procedure. A catheter is inserted into the umbilical vein and threaded into the inferior vena cava. Depending on the infant's weight, 5 to 10 ml of blood is withdrawn within 15 to 20 seconds, and the same volume of donor blood is infused over 60 to 90 seconds. If the blood has been citrated (addition of citrate phosphate dextrose adenine to prevent coagulation), calcium gluconate may be given after the infusion of each 100 ml of donor's blood to prevent hypocalcemia.
Prognosis The severe anemia of isoimmunization may result in stillbirth, shock, congestive heart failure, or pulmonary or cerebral complications, such as cerebral palsy. As a result of early detection and intrauterine treatment, erythroblastotic newborns are seen less often and exchange transfusions for the condition are less common. Despite the availability of effective preventive measures, Rh HDN continues to cause significant fetal morbidity and mortality in the United States.
Nursing Care Management The initial nursing responsibility is recognizing newborn jaundice. The possibility of hemolytic disease can be anticipated from the prenatal and perinatal history. Prenatal evidence of
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incompatibility and a positive Coombs test result are cause for increased vigilance for early signs of jaundice in an infant. Data indicate that the use of the hour-specific bilirubin nomogram can be used in infants born at 35 weeks or more with ABO incompatibility and a positive Coombs test result to follow the infant's serum bilirubin to determine the need for additional follow-up after hospital discharge (Schutzman, Sekhon, and Hundalani, 2010).
If an exchange transfusion is required, the nurse prepares the infant and the family and assists the practitioner with the procedure. The infant receives nothing by mouth (NPO) during the procedure; therefore, a peripheral infusion of dextrose and electrolytes is established. The nurse documents the blood volume exchanged, including the amount of blood withdrawn and infused, the time of each procedure, and the cumulative record of the total volume exchanged. Vital signs, monitored electronically, are evaluated frequently and correlated with the removal and infusion of blood. If signs of cardiac or respiratory problems occur, the procedure is stopped temporarily and resumed after the infant's cardiorespiratory function stabilizes. The nurse also observes for signs of blood transfusion reaction and maintains the infant's blood glucose levels and fluid balance.
Throughout the procedure, attention must be given to the infant's thermoregulation. Hypothermia increases oxygen and glucose consumption, causing metabolic acidosis. Not only do these consequences hinder the infant's overall physical ability to withstand the long procedure, but they also inhibit the binding capacity of albumin and bilirubin and the hepatic enzymatic reactions, thus increasing the risk of kernicterus. Conversely, hyperthermia damages the donor erythrocytes, elevating the free potassium content and predisposing the infant to cardiac arrest.
The exchange transfusion is performed with the infant in a radiant warmer. However, the infant is usually covered with sterile drapes that may prevent the radiant heat from sufficiently warming the skin. The blood may also be warmed (using specially designed blood warming devices, never a microwave oven) before infusion.
After the procedure is completed, the nurse inspects the umbilical site for evidence of bleeding. The catheter may remain in place in case repeated exchanges are required.
N u r s i n g A l e r t Signs of blood exchange transfusion reaction include tachycardia or bradycardia, respiratory distress, dramatic change in blood pressure (BP), temperature instability, and generalized rash.
Metabolic Complications High-risk infants are subject to a variety of complications related to physiologic function and the transition to extrauterine life. Prominent among these are fluid and electrolyte derangements, hypoglycemia, and hypocalcemia. These complications often occur concurrently with or as a secondary result of other neonatal disorders and may therefore be difficult to differentiate from other conditions. The major characteristics of hypoglycemia and hypocalcemia are outlined in Table 8-4.
D r u g A l e r t Calcium preparations should never be administered by bolus rapid infusion in infants.
Q u a l i t y Pa t i e n t O u t c o m e s Neonatal Hypoglycemia
• Maintains serum blood glucose level above 45 mg/dl
• No clinical evidence of hypoglycemia or its effects
• Receives adequate carbohydrate intake
TABLE 8-4 Metabolic Complications
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Hypoglycemia Hypocalcemia Definition Blood glucose concentration significantly lower than that in the majority of infants of the same age and weight (usually <45 mg/dl) (see also Adamkin and American Academy of Pediatrics, Committee on Fetus and Newborn, 2011, for parameters for SGA, late preterm, and IDM or LGA infants)
Abnormally low levels of calcium in circulating blood (see values listed below)
Type Increased or impaired glucose utilization: Large or normal-size infants who appear to have
hyperinsulinism; infants born to women with diabetes; infants with increased metabolic demands, such as those with cold stress, sepsis, or after resuscitation; infants with enzymatic or metabolic endocrine defects
Decreased glucose stores: Small or growth-restricted infants, preterm infants
Early onset: Appears in first 48 hours; appears in preterm infants who experienced perinatal hypoxia or sometimes in IDM
Late onset: Cow's milk–induced hypocalcemia (neonatal tetany); apparent after first 3 to 4 days (high phosphorus-to-calcium ratio of cow's milk depresses parathyroid activity, reducing serum calcium levels); infants with intestinal malabsorption, hypoparathyroidism, or hypomagnesemia
Clinical Manifestations Vague, often indistinguishable from other newborn conditions Cerebral signs: Jitteriness, tremors, twitching, weak or high-pitched cry, lethargy, limpness,
apathy, convulsions, and coma Other: Cyanosis, apnea, rapid irregular respirations, sweating, eye rolling, poor feeding Signs often transient but recurrent
Early onset: Jitteriness, apnea, cyanotic episodes, edema, high-pitched cry, abdominal distention
Late onset: Twitching, tremors, seizures
Screening Bedside monitoring or serum blood glucose for all infants at risk At-risk infants or those who are symptomatic Laboratory Diagnosis Plasma glucose concentrations <47 to 50 mg/dl (2.6 to 2.8 mmol/L) (see also Adamkin and American Academy of Pediatrics, Committee on Fetus and Newborn, 2011, for parameters for SGA, late preterm, and IDM or LGA infants)
Serum calcium <7.8 to 8 mg/dl (1.95 to 2.0 mmol/L) in full-term infant or Ionized calcium <4.4 mg/dl (1.1 mmol/L)
Treatment Early feeding (within 1 hour) in normoglycemic and asymptomatic infants (preventive); IV glucose administration if breastfeeding or formula feedings not tolerated or glucose level extremely low (<25 mg/dL)
Early onset: Increased appropriate infant formula feedings; administration of calcium supplements (sometimes)
Late onset: Administration of calcium gluconate orally or intravenously (slowly); vitamin D
Correct hypoparathyroidism Nursing Identify infants at risk or with hypoglycemia (e.g., SGA, IUGR, LGA, IDM, late preterm). Reduce environmental factors that predispose to hypoglycemia (e.g., cold stress, respiratory
distress). Administer IV dextrose as prescribed. Initiate early breastfeeding or formula feedings in healthy infant. Ensure adequate intake of carbohydrate (breast milk or formula).
Identify infants at risk, or with hypocalcemia. Administer calcium as prescribed.* Observe for signs of acute hypercalcemia (e.g., vomiting, bradycardia). Manipulate environment to reduce stimuli that might precipitate a seizure or tremors
(e.g., picking up infant suddenly, sudden jarring of crib).
*See Drug Alert box. IDM, Infant of diabetic mother; IUGR, intrauterine growth restriction; IV, intravenous; LGA, large for gestational age; SGA, small for gestational age.
Respiratory Distress Syndrome Respiratory distress is a name applied to respiratory dysfunction in neonates and is primarily a disease related to developmental delay in lung maturation. The terms respiratory distress syndrome (RDS) and hyaline membrane disease are most often applied to this severe lung disorder, which not only is responsible for more infant deaths than any other disease but also carries the highest risk in terms of long-term respiratory and neurologic complications (see Chapter 21 for a discussion of acute RDS). It is seen almost exclusively in preterm infants. The disorder is rare in drug-exposed infants and infants who have been subjected to chronic intrauterine stress (e.g., maternal preeclampsia or hypertension). Respiratory distress of a nonpulmonary origin in neonates may also be caused by sepsis, cardiac defects (structural or functional), exposure to cold, airway obstruction (atresia), intraventricular hemorrhage, hypoglycemia, metabolic acidosis, acute blood loss, and drugs. Pneumonia in the neonatal period may result in respiratory distress caused by bacterial or viral agents and may occur alone or as a complication of RDS.
Pathophysiology Preterm infants are born before the lungs are fully prepared to serve as efficient organs for gas exchange. This appears to be a critical factor in the development of RDS. The effects of lung immaturity are compounded by the presence of more cartilage in the chest wall, leading to increased compliance of the chest wall, which collapses inward in response to less compliant (stiffer) lung tissue.
There is evidence of fetal respiratory activity before birth. The lungs make feeble respiratory movements, and fluid is excreted through the alveoli. Because the final unfolding of the alveolar septa, which increases the surface area of the lungs, occurs during the last trimester of pregnancy, preterm infants are born with numerous underdeveloped and many uninflatable alveoli. Pulmonary blood flow is limited as a result of the collapsed state of the fetal lungs, poor vascular development in general, and an immature capillary network. Because of increased pulmonary vascular resistance (PVR), the major portion of fetal blood is shunted from the lungs by way of the ductus arteriosus and foramen ovale.
At birth, infants must initiate breathing and keep the previously fluid-filled lungs inflated with air. At the same time, the pulmonary capillary blood flow increases by approximately tenfold to provide for adequate lung perfusion and to alter the intracardiac pressure that closes the fetal
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cardiac shunts. Most full-term infants successfully accomplish these adjustments, but preterm infants with respiratory distress are unable to do so. Although numerous factors are involved, a lack of stable surfactant plays a central role.
Surfactant is a surface-active phospholipid secreted by the alveolar epithelium. Acting much like a detergent, this substance reduces the surface tension of fluids that line the alveoli and respiratory passages, resulting in uniform expansion and maintenance of lung expansion at low intraalveolar pressure (Fig. 8-20). Deficient surfactant production causes unequal inflation of alveoli on inspiration and the collapse of alveoli on end expiration. Without surfactant, infants are unable to keep their lungs inflated and therefore exert a great deal of effort to reexpand the alveoli with each breath. With increasing exhaustion, infants are able to open fewer and fewer alveoli. This inability to maintain lung expansion produces widespread atelectasis.
FIG 8-20 Preterm infant who is Rh positive born to an Rh-negative mother who received intrauterine transfusions and is receiving postnatal transfusions.
Following birth the oxygen concentration in the blood normally increases, the ductus arteriosus constricts and the pulmonary vessels dilate to decrease PVR. In the absence of alveolar stability (normal functional residual capacity) and with progressive atelectasis, PVR increases as resistance to blood flow into the lungs increases hypoperfusion to the lung tissue occurs. With the increase in PVR, fetal shunts (ductus arteriosus and foramen ovale) remain open allowing right-to-left shunting of blood through the persisting fetal shunts.
Inadequate pulmonary perfusion and ventilation produce hypoxemia and hypercapnia. Pulmonary arterioles, with their thick muscular layer, constrict in response to hypoxia. Thus, a decrease in oxygen tension causes vasoconstriction in the pulmonary arterioles that is further enhanced by a decrease in blood pH. This vasoconstriction contributes to a further increase in PVR.
Prolonged hypoxemia activates anaerobic glycolysis, which produces increased amounts of lactic acid. An increase in lactic acid causes metabolic acidosis; an inability of the atelectatic lungs to blow off excess carbon dioxide produces respiratory acidosis. Acidosis causes further vasoconstriction. With deficient pulmonary circulation and alveolar perfusion, partial pressure of oxygen in arterial blood continues to fall, pH falls, and the materials needed for surfactant production are not circulated to the alveoli.
Diagnostic Evaluation The diagnosis of RDS is made on the basis of clinical signs (Box 8-4) and chest x-ray studies.
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Radiographic findings characteristic of RDS include (1) a diffuse granular pattern over both lung fields that closely resembles ground glass and represents alveolar atelectasis and (2) dark streaks, or bronchograms, within the ground glass areas that represent dilated, air-filled bronchioles. It is difficult to distinguish between RDS and pneumonia in infants with respiratory distress. The extent of respiratory compromise and acid–base status is determined by blood gas analysis. Criteria for visually evaluating the degree of respiratory distress are illustrated in Fig. 8-21. Pulse oximetry and carbon dioxide monitoring, as well as pulmonary function studies, assist in differentiating pulmonary and extrapulmonary illness and are used in the management of RDS.
Q u a l i t y Pa t i e n t O u t c o m e s Neonatal Respiratory Distress Syndrome
• Room air or oxygen saturation ≥88%
• Respiratory rate <60 breaths/min
• Blood pH ≥7.30
Box 8-4 C l i n i c a l M a n i f e s t a t i o n s o f R e s p i r a t o r y D i s t r e s s S y n d r o m e Tachypnea (>80 to 120 breaths/min) initially*
Dyspnea
Pronounced intercostal or substernal retractions (see Fig. 8-21)
Fine inspiratory crackles
Audible expiratory grunt
Flaring of the external nares
Cyanosis or pallor
*Not all infants born with respiratory distress syndrome (RDS) manifest these characteristics; very low birth weight (VLBW) and extremely low birth weight (ELBW) infants may have respiratory failure and shock at birth because of physiologic immaturity.
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FIG 8-21 Criteria for evaluating respiratory distress. (Modified from Silvermann WA, Anderson DH: A controlled clinical trial of effects of water mist on obstructive respiratory signs, death rate, and necropsy findings among premature infants, Pediatrics 17:1,
1956.)
Therapeutic Management The treatment of RDS involves immediate establishment of adequate oxygenation and ventilation and supportive care and measures required for any preterm infant, as well as those instituted to prevent further complications associated with preterm birth. The supportive measures most crucial to a favorable outcome are to: • Maintain adequate ventilation and oxygenation • Maintain acid–base balance • Maintain a neutral thermal environment • Maintain adequate tissue perfusion and oxygenation • Prevent hypotension • Maintain adequate hydration and electrolyte status
Nipple feedings are contraindicated in any situation that creates a marked increase in respiratory rate because of the greater hazards of aspiration. Nutrition is provided by parenteral therapy during the acute stage of the disease, and minimal enteral feeding is provided to enhance maturation of the neonate's gastrointestinal system.
The administration of exogenous surfactant to preterm neonates with RDS has become an accepted and common therapy in most neonatal centers worldwide. Numerous clinical trials involving the administration of exogenous surfactant to infants with or at high risk for RDS demonstrate improvements in blood gas values and ventilator settings, decreased incidence of pulmonary air leaks, intraventricular hemorrhage, decreased deaths from RDS, and an overall decreased infant mortality rate (Polin, Carlo, and American Academy of Pediatrics, Committee on Fetus and Newborn, 2014; Speer, Sweet, and Halliday, 2013). The overall rates of some associated comorbidities (bronchopulmonary dysplasia, NEC, patent ductus arteriosus) have not decreased with surfactant replacement. Currently, exogenous surfactant is derived from a natural source (e.g., porcine, bovine).
Surfactant therapy is also being used in infants with meconium aspiration, infectious pneumonia, sepsis, persistent pulmonary hypertension, and congenital diaphragmatic hernia (Polin, Carlo, and American Academy of Pediatrics, Committee on Fetus and Newborn, 2014). Surfactant may be administered at birth as a preventive or prophylactic treatment of RDS or later on in the course of RDS as a rescue treatment; however, research has demonstrated improved clinical outcomes and fewer adverse effects when surfactant is administered prophylactically to infants at risk for developing RDS (Polin, Carlo, and American Academy of Pediatrics, Committee on Fetus and Newborn, 2014). Surfactant is administered via an endotracheal (ET) tube directly into the infant's
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trachea. Complications seen with surfactant administration include pulmonary hemorrhage and mucous plugging. Nursing responsibilities with surfactant administration include assistance in the delivery of the product, collection and monitoring of blood gases, scrupulous monitoring of oxygenation with pulse oximetry, and assessment of the infant's tolerance of the procedure. After surfactant is absorbed, there is usually an increase in respiratory compliance that requires adjustment of ventilator settings to decrease mean airway pressure and prevent overinflation or hyperoxemia. Suctioning is usually delayed for an hour or so (depending on the type of surfactant and unit protocol) to allow maximum effects to occur. Studies have shown the benefit of administering surfactant early (prophylactic) in infants at risk for developing RDS, then extubating and placing on nasal continuous positive airway pressure (CPAP); this decreased the overall incidence of bronchopulmonary dysplasia, need for mechanical ventilation, and fewer air leak syndromes (Gardner, Enzman-Hines, and Dickey, 2011). Research is in progress to investigate the possibility of delivering an aerosolized surfactant (Pillow and Minocchieri, 2012). This method would decrease the problems associated with current delivery systems (contamination of the airway, interruption of mechanical ventilation, and loss of the drug in the ET tubing from reflux).
The goals of oxygen therapy are to provide adequate oxygen to the tissues, prevent lactic acid accumulation resulting from hypoxia, and at the same time avoid the potentially negative effects of oxygen and barotrauma. Numerous methods have been devised to improve oxygenation (Table 8- 5). All require that the gas be warmed and humidified before entering the respiratory tract. If the infant does not require mechanical ventilation, oxygen can be supplied by nasal cannula or via nasal prongs in conjunction with CPAP (see Oxygen Therapy, Chapter 20). If oxygen saturation of the blood cannot be maintained at a satisfactory level and the carbon dioxide level (PaCO2) rises, infants will require ventilatory assistance.
TABLE 8-5 Common Methods for Assisted Ventilation in Neonatal Respiratory Distress
Method Description How Provided Conventional Methods Continuous positive airway pressure (CPAP)
Provides constant distending pressure to airway in spontaneously breathing infant Nasal prongs ET tube Face mask
Intermittent mandatory ventilation (IMV)*
Allows infant to breathe spontaneously at own rate but provides mechanical cycled respirations and pressure at regular preset intervals
ET intubation and ventilator
Synchronized intermittent mandatory ventilation (SIMV)
Mechanically delivered breaths are synchronized to the onset of spontaneous patient breaths; assist/control mode facilitates full inspiratory synchrony; involves signal detection of onset of spontaneous respiration from abdominal movement, thoracic impedance, and airway pressure or flow changes
Patient-triggered infant ventilator with signal detector and assist/control mode; ET tube
Volume guarantee ventilation
Delivers a predetermined volume of gas using an inspiratory pressure that varies according to the infant's lung compliance (often used in conjunction with SIMV)
Volume guarantee ventilator with flow sensor; ET tube
Alternative Methods High-frequency oscillation (HFO)
Application of high-frequency, low-volume, sine-wave flow oscillations to airway at rates between 480 and 1200 breaths/min Variable-speed piston pump (or loudspeaker, fluidic oscillator); ET tube
High-frequency jet ventilation (HFJV)
Uses a separate, parallel, low-compliant circuit and injector port to deliver small pulses or jets of fresh gas deep into airway at rates between 250 and 900 breaths/min
May be used alone or with low-rate IMV; ET tube
*Also referred to as conventional ventilation (vs. high-frequency ventilation [HFV]). ET, Endotracheal tube.
Prevention The most successful approach to prevention of RDS is prevention of preterm delivery, especially in elective early delivery and cesarean section. Improved methods for assessing the maturity of the fetal lung by amniocentesis, although not a routine procedure, allow a reasonable prediction of adequate surfactant formation. Because estimation of a delivery date can be miscalculated by as much as 1 month, such tests are particularly valuable when scheduling an elective cesarean section. The combination of maternal steroid administration before delivery and surfactant administration postnatally seems to have a synergistic effect on neonatal lungs, with the net result being a decrease in infant mortality, decreased incidence of intraventricular hemorrhage, fewer pulmonary air leaks, and fewer problems with pulmonary interstitial emphysema and RDS (Warren and Anderson, 2009).
Prognosis RDS is a self-limiting disease. Before the use of surfactant, infants typically experienced a period of deterioration (≈48 hours) and, in the absence of complications, improved by 72 hours. Often
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heralded by the onset of diuresis, this improvement was attributed primarily to increased production and greater availability of surfactant. With the administration of surfactant, lung compliance begins to improve almost immediately, resulting in lower oxygen requirements and a decreased need for ventilatory support (Speer, Sweet, and Halliday, 2013).
Infants with RDS who survive the first 96 hours have a reasonable chance of recovery. However, complications of RDS include associated respiratory conditions and problems associated with prematurity, including patent ductus arteriosus and congestive heart failure, intraventricular hemorrhage, bronchopulmonary dysplasia, retinopathy of prematurity, pneumonia, air leak syndrome, sepsis, NEC, and neurologic sequelae.
Nursing Care Management Care of infants with RDS involves all of the observations and interventions previously described for high-risk infants. In addition, the nurse is concerned with the complex problems related to respiratory therapy and the constant threat of hypoxemia and acidosis that complicates the care of patients in respiratory difficulty.
The respiratory therapist, an important member of the NICU team, is often responsible for the maintenance of respiratory equipment. Although it may be the respiratory therapist's responsibility to regulate the apparatus, nurses should understand the equipment and be able to recognize when it is not functioning correctly. The most essential nursing function is to observe and assess the infant's response to therapy. Continuous monitoring and close observation are mandatory because an infant's status can change rapidly and because oxygen concentration and ventilation parameters are prescribed according to the infant's blood gas measurements and pulse oximetry readings.
Changes in oxygen concentration are based on these observations. The amount of oxygen administered, expressed as the fraction of inspired air (FiO2), is determined on an individual basis according to pulse oximetry or direct or indirect measurement of arterial oxygen concentration. Capillary samples collected from the heel (see Chapter 20 for procedure) are useful for pH and PaCO2 determinations but not for oxygenation status. Continuous transcutaneous or pulse oximetry readings are recorded at least hourly. Blood sampling is performed after ventilator changes for the acutely ill infant and thereafter when clinically indicated.
Mucus may collect in the respiratory tract as a result of the infant's pulmonary condition. Secretions interfere with gas flow and predispose the infant to obstruction of the passages, including the ET tube. Suctioning should be performed only when necessary and should be based on individual infant assessment, which includes auscultation of the chest, evidence of decreased oxygenation, excess moisture in the ET tube, or increased infant irritability. During suctioning, a variety of techniques can be used to minimize complications, including the use of a closed suctioning system (Gardner, Enzman-Hines, and Dickey, 2011).
N u r s i n g A l e r t Endotracheal (ET) suctioning is not an innocuous procedure (it may cause bronchospasm, bradycardia resulting from vagal nerve stimulation, hypoxia, or increased intracranial pressure [ICP], predisposing the infant to intraventricular hemorrhage) and should never be carried out on a routine basis. Improper suctioning technique can also cause infection, airway damage, or even pneumothoraces.
When nasopharyngeal passages, the trachea, or the ET tube is being suctioned, the catheter should be inserted gently but quickly; intermittent suction is applied as the catheter is withdrawn. Negative airway pressure should be applied for no more than 10 to 15 seconds because continuous suction removes air from the lungs along with the mucus. It is recommended that the “two-person” suctioning procedure be used on infants who are acutely ill and who do not tolerate any procedure without profound decreases in oxygen saturation, BP, and heart rate. The object of suctioning an artificial airway is to maintain patency of that airway, not the bronchi. Suction applied beyond the ET tube can cause traumatic lesions of the trachea. The use of in-line suction catheters may decrease airway contamination and hypoxia. Evidence-based guidelines for ET suctioning of neonates have been published (Gardner and Shirland, 2009).
The most advantageous positions for facilitating an infant's open airway are on the side with the head supported in alignment by a small folded blanket or, when on the back, positioned to keep the
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neck slightly extended. With the head in the “sniffing” position, the trachea is opened at its maximum; hyperextension reduces the tracheal diameter in neonates.
Inspection of the skin is part of routine infant assessment. Position changes and the use of water pillows are helpful in guarding against skin breakdown.
Mouth care is especially important when infants are receiving respiratory support. Thick oral secretions and dry mucous membranes may result from the drying effect of oxygen therapy. Drying and cracking can be prevented by good oral hygiene using sterile water. Irritation to the nares or mouth that occurs from appliances used to administer oxygen (e.g., nasal CPAP) may be reduced by the use of a water-soluble ointment. Routine oral hygiene care in intubated adults and older children has been shown to decrease the incidence of ventilator-associated pneumonia (see Chapter 21).
The nursing care of an infant with RDS is a demanding role; meticulous attention must be given to subtle changes in the infant's oxygenation status. The importance of attention to detail cannot be overemphasized, particularly in regard to medication administration.
Respiratory Complications Newborn infants are vulnerable to a variety of pulmonary complications, some requiring oxygen therapy (Table 8-6). For example, the preterm infant is subject to periods of apnea, and in term, late preterm, and postterm infants, intrauterine stress often causes fetuses to pass meconium, which may be aspirated before or during birth. Oxygen therapy, although lifesaving, is not without its hazards. Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia (chronic lung disease). The use of nasal CPAP decreases the incidence of adverse effects associated with intubation and positive-pressure ventilation in preterm infants with RDS. Retinopathy of prematurity is observed almost exclusively in preterm infants and is related primarily to prematurity and oxygen therapy (see Table 8-6). Evidence supports the resuscitation of asphyxiated newborns with 21% oxygen rather than 100% oxygen; preliminary studies reduced mortality and neurologic morbidities in newborns resuscitated with 21% oxygen (Chalkias, Xanthos, Syggelou, et al, 2013; Saugstad, 2010). Proponents for room air resuscitation suggest that fewer complications are associated with oxidative stress and hyperoxemia when room air is administered (Vento and Saugstad, 2011). The 2010 American Heart Association Neonatal Resuscitation Guidelines recommend the initiation of neonatal resuscitation using room air (no supplemental oxygen); if the neonate does not improve within 90 seconds, the use of supplemental oxygen is recommended (see Evidence-Based Practice box). Pulse oximetry is recommended to monitor the infant's oxygenation status during resuscitation and to prevent excessive use of oxygen in both term and preterm infants (Kattwinkel, Perlman, Aziz, et al, 2010).
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Use of Room Air or Low Oxygen for Newborn Stabilization and Resuscitation in the Delivery Room
Updated by Deb Fraser
Ask the Question PICOT Question Is room air or low oxygen better for newborn stabilization and resuscitation in the delivery room?
Search for Evidence Search Strategies Search selection included English publications on room air or low oxygen use for newborn stabilization and resuscitation in delivery room in past 3 years.
Database Used PubMed
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Critically Analyze the Evidence
• In infants younger than 32 weeks' gestation, initial oxygen supplementation of 30% oxygen is as safe as 65% oxygen with no differences in chronic lung disease or oxidative stress markers (Rook, Schierbeek, Vento, et al, 2014).
• Systematic review of 21% oxygen versus 100% oxygen use for stabilization or resuscitation of newborns found a significant reduction in risk for newborn mortality as well as hypoxic ischemic encephalopathy when 21% oxygen was used (Saugstad, Ramji, Soll, et al, 2008).
In moderately asphyxiated term infants, those resuscitated with 100% oxygen had elevated had oxidative stress markers in their blood at 28 days of age, whereas those resuscitated with 21% oxygen had levels similar to non-asphyxiated control infants (Vento, Escobar, Cernada, et al, 2012).
• In neonates 24 to 34 weeks' gestational age, a low oxygen strategy beginning with room air with a 10% increase in oxygen concentration every 30 seconds until satisfactory oxygen saturations were achieved resulted in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities compared to infants resuscitated with a high oxygen strategy (100% oxygen to start followed by 10% decreases in oxygen concentration every 30 seconds).
• In neonates 32 weeks' gestational age or younger, initiating resuscitation with 100% oxygen and titrating downward was more effective than initiating resuscitation with 21% oxygen (Rabi, Singhal, and Nettel-Aguirre, 2011).
• Use of heated and humidified air in neonates 32 weeks' gestational age or younger during resuscitation or stabilization in the delivery room minimized postnatal heat loss (te Pas, Lopriore, Dito, et al, 2010).
• Infants receiving 100% oxygen with positive-pressure ventilation and healthy infants transitioned in room air had similar increase in oxygen saturation, but a slower increase in oxygen saturation was observed in infants receiving 100% oxygen free flow (Rabi, Chen, Yee, et al, 2009).
• Newborns with spontaneous circulation (heart rate >60 beats/min) should be stabilized or resuscitated with room air, but asphyxiated newborns with depressed circulation (heart rate <60 beats/min) should be stabilized or resuscitated with 100% oxygen (Ten and Matsiukevich, 2009).
• In very preterm infants (<30 weeks' gestational age) stabilized or resuscitated with 100% oxygen, the majority (80%) had SpO2 95% in the first 10 minutes. Infants stabilized or resuscitated with room air followed a similar course as full-term and preterm newborns when 100% oxygen was administered along with titration against SpO2. Similar changes in heart rate were observed in both groups (Dawson, Kamlin, Wong, et al, 2009).
Apply the Evidence: Nursing Implications The International Liaison Committee on Resuscitation recommends that “in term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air rather than 100% oxygen” (Perlman, Wyllie, Kattwinkel, et al, 2010). Decisions to increase the oxygen concentration should be based on the oxygen saturation and the infant's clinical response.
When the oxygen saturation is below the recommended levels, increase fraction of inspired air (FiO2) by 10% every 30 seconds until the saturation level reaches the desired range. Rapid FiO2 changes may cause constriction of the pulmonary blood vessels (Ramji, Saugstad, and Jain, 2015).
Quality and Safety Competencies: Evidence-Based Practice* Knowledge Differentiate clinical opinion from research and evidence-based summaries.
Describe the various interventions for newborn stabilization and delivery room resuscitations with room air or low oxygen.
Skills
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Base individualized care plan on patient values, clinical expertise, and evidence. Integrate evidence into practice by using interventions for newborn stabilization and delivery
room resuscitations with room air or low oxygen.
Attitudes Value the concept of evidence-based practice as integral to determining best clinical practice.
Appreciate strengths and weakness of evidence for newborn stabilization and delivery room resuscitations with room air or low oxygen.
References Dawson JA, Kamlin CO, Wong C, et al. Oxygen saturation and heart rate during delivery
room resuscitation of infants <30 weeks' gestation with air or 100% oxygen. Arch Dis Child Fetal Neonatal Ed. 2009;94(2):F87–F91.
Perlman JM, Wyllie J, Kattwinkel J, et al. Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122(16 Suppl 2):S516–S538.
Rabi Y, Chen SY, Yee WH, et al. Relationship between oxygen saturation and the mode of oxygen delivery used in newborn resuscitation. J Perinatol. 2009;29(2):101–105.
Rabi Y, Singhal N, Nettel-Aguirre A. Room-air versus oxygen administration for resuscitation of preterm infants: the ROAR study. Pediatrics. 2011;128(2):e374–e381.
Ramji S, Saugstad OD, Jain A. Current concepts of oxygen therapy in neonates. Indian J Pediatr. 2015;82(1):46–52.
Rook D, Schierbeek H, Vento M, et al. Resuscitation of preterm infants with different inspired oxygen fractions. J Pediatr. 2014;164(6):1322–1326.
Saugstad OD, Ramji S, Soll RF, et al. Resuscitation of newborn infants with 21% or 100% oxygen: an updated systematic review and meta-analysis. Neonatology. 2008;94(3):176–182.
te Pas AB, Lopriore E, Dito I, et al. Humidified and heated air during stabilization at birth improves temperature in preterm infants. Pediatrics. 2010;125(6):e1427–e1432.
Ten VS, Matsiukevich D. Room air or 100% oxygen for resuscitation of infants with prenatal depression. Curr Opin Pediatr. 2009;21(2):188–193.
Vento M, Escobar J, Cernada M, et al. The use and misuse of oxygen during the neonatal period. Clin Perinatol. 2012;39(1):165–176.
*Adapted from the Quality and Safety Education for Nurses (QSEN) Institute.
Q u a l i t y Pa t i e n t O u t c o m e s Meconium Aspiration Syndrome
• Room air oxygen saturation ≥90%
• Maintains arterial/venous pH ≥7.35
TABLE 8-6 Respiratory Complications
Description ClinicalManifestations Therapeutic Management Nursing Care Management
Meconium Aspiration Syndrome Aspiration of amniotic fluid containing meconium into fetal or newborn trachea in utero or at first breath
Meconium stained at birth
Tachypnea Hypoxia Acidemia Hyperventilation
(early) Hypoventilation
(later)
Suction hypopharynx after delivery. Infants who are vigorous with strong, stable respiratory effort, good
muscle tone, and heart rate >100 beats/min should not undergo tracheal suctioning but should be closely monitored. Infants who demonstrate poor respiratory effort, low heart rate, and poor tone should be rapidly intubated, suctioned appropriately, and resuscitated according to clinical status after suctioning.
Monitor for respiratory distress; manage with supplemental oxygen. Prevent acidosis and hypoxemia. May use exogenous surfactant, INO, or ECMO.
See Respiratory Distress Syndrome, Nursing Care Management earlier in the chapter.
Apnea of Prematurity Lapse of spontaneous breathing for ≥20 seconds, which Persistent apneic Observe for apnea. Provide continuous electronic
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may or may not be followed by bradycardia, oxygen desaturation, and color change
spells Check for thermal stability and metabolic problem such as hypoglycemia.
Administer caffeine as prescribed. Administer nasal CPAP.
monitoring (respiratory and heart rates).
Observe for presence of respirations.
Observe color. Provide gentle tactile
stimulation. Suction nose and oropharynx
if still apneic. Apply positive pressure
ventilation with bag-valve- mask using the minimum of pressure needed to gently lift rib cage.
Assess for and manage any precipitating factors (e.g., temperature instability, abdominal distention, ambient oxygen).
Observe for signs of caffeine toxicity: tachycardia (rate ≥180 beats/min) and (later) vomiting, restlessness, irritability.
Assess skin (with use of nasal CPAP) for breakdown, irritation at nasal septum.
Pneumothorax Presence of extraneous air in pleural space as a result of alveolar rupture
Tachypnea or apnea
Systemic hypotension
Sudden or persistent oxygen desaturation
Grunting, nasal flaring
Retractions Absent or
diminished breath sounds
Shift in point of maximum impulse of heart sounds
Bradycardia, cyanosis
Evacuate trapped air in pleural space through needle aspiration or insertion of chest tube.
In otherwise healthy term infants who do not require high oxygen concentration or mechanical ventilation, supplemental oxygen to maintain normal saturation levels and close observation may be the only treatment required.
Maintain close vigilance of infants with respiratory distress and those on assisted ventilation.
Provide appropriate care of chest drainage apparatus.
Ensure emergency needle aspiration setup is available.
Bronchopulmonary Dysplasia Pathologic process related to alveolar damage from lung disease, prolonged exposure to mechanical ventilation, high peak inspiratory pressures and oxygen, and immature alveoli and respiratory tract
Dyspnea Barrel chest Inability to wean
from oxygen or mechanical ventilation after course of RDS (surfactant deficiency)
Wheezing
Prevention: Administer maternal steroids; administer exogenous surfactant
postnatally. Avoid intubation and mechanical ventilation when the infant's condition allows. Extubate mechanically ventilated infants as soon as medically indicated.
Provide early detection with pulmonary function tests. Use synchronized or volume guarantee ventilation, decreased
inspiratory pressures, or nasal CPAP. Prevent air leaks. Use high-frequency ventilation. Prevent or control respiratory or systemic infections. Minimize use of high oxygen concentrations in neonatal resuscitation
and on mechanical ventilation; monitor oxygen saturation and implement resuscitation according to neonate response to low oxygen administration.
Diagnosis established: Support respiratory efforts. Maintain adequate oxygenation and avoid hypoxemia. Administer bronchodilators and, in select cases, postnatal steroids. Provide supplemental oxygen in hospital or home.
Provide individualized developmental care and enhancement.
Monitor oxygen saturations closely in preterm infants and avoid hyperoxemia
Provide opportunities for additional rest during feedings.
Observe for signs of fluid overload or pulmonary edema.
Assist with home oxygen therapy as needed.
Assess susceptibility to upper respiratory tract infections and need for frequent hospitalization for respiratory dysfunction.
Provide increased caloric density (feedings) with human milk fortifier or protein supplements.
Persistent Pulmonary Hypertension of the Newborn Severe pulmonary hypertension and large right-to-left shunt through foramen ovale and ductus arteriosus
Hypoxia Marked cyanosis Tachypnea with
grunting and retractions
Decreased peripheral pulses and prolonged capillary refill (poor perfusion)
Shock
Regulate IV fluids. Provide supplemental oxygen and assisted ventilation. Administer systemic vasodilators, such as sildenafil. Maintain acid–base balance. Prevent hypoxemia and hypercarbia. Administer INO or ECMO.
See Nursing Care of the High- Risk Newborn and Family and Respiratory Distress Syndrome earlier in the chapter.
Provide nursing care to reduce stress to infant, especially noxious stimuli that cause increased oxygen demands.
Decrease physical manipulation and disturbance.
Retinopathy of Prematurity Severe vascular constriction in the immature retinal
vasculature followed by hypoxemia in the retina, which in turn stimulates abnormal vascular proliferation of retinal capillaries into the hypoxic area; as retinal veins dilate and multiply in the direction of the lens, retinal detachment may occur if untreated
Multifactorial etiology: Preterm birth is major risk factor
Progressive vascular growth of retina
Eventual blindness if not treated
Diagnosed by ophthalmologic examination
Prevent preterm birth. Provide early screening and detection in infants born at <30 weeks of
gestation and weight <1500 g (3.3 pounds). Decrease exposure to bright, direct lighting; although exposure to bright
light has not been proven to contribute to retinopathy of prematurity, such exposure is undesirable from a neurobehavioral developmental perspective.
Use supplemental oxygen judiciously and monitor oxygen blood levels carefully; prevent wide fluctuations in oxygen blood levels (hyperoxemia and hypoxemia).
Arrest vascular proliferation process—laser photocoagulation; surgical repair of detached retina.
Recently, there has been increased interest in the administration of an antivascular endothelial growth factor drug bevacizumab, which arrests the proliferation of vessels and prevents retinal detachment commonly seen in retinopathy of prematurity. If successful, this therapy may preclude the use of laser therapy (Hartnett, 2014).
See Nursing Care of the High- Risk Newborn and Family earlier in the chapter.
Provide preventive care by closely monitoring blood oxygen levels, responding promptly to saturation alarms, and preventing fluctuations in blood oxygen levels.
Provide postoperative pain management if surgery is performed.
Provide parental education and support.
Provide nursing care using principles of individualized developmental care.
CPAP, Continuous positive airway pressure; ECMO, extracorporeal membrane oxygenation; INO, inhaled nitric oxide; IV, intravenous; RDS, respiratory distress syndrome.
Inhaled nitric oxide (INO) and extracorporeal membrane oxygenation (ECMO) are additional therapies used in the treatment of respiratory distress and respiratory failure in neonates. INO is
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used in term and late preterm infants with conditions such as persistent pulmonary hypertension, meconium aspiration syndrome (see Table 8-6), pneumonia, sepsis, and congenital diaphragmatic hernia to decrease or reverse pulmonary hypertension, pulmonary vasoconstriction, acidosis, and hypoxemia. Nitric oxide is a colorless, highly diffusible gas that can be administered through the ventilator circuit blended with oxygen. INO therapy may be used in conjunction with surfactant replacement therapy, high-frequency ventilation, or ECMO. Although INO is used in preterm infants with respiratory distress and respiratory failure, its use has not proved to be significantly effective in decreasing rates of bronchopulmonary dysplasia or in improving survival rates in preterm infants (Keszler, 2012; Donohue, Gilmore, Cristofalo, et al, 2011).
ECMO may be used in the management of term infants with acute severe respiratory failure for the same conditions as those mentioned for INO. This therapy involves a modified heart–lung machine, although in ECMO the heart is not stopped and blood does not entirely bypass the lungs. Blood is shunted from a catheter in the right atrium or right internal jugular vein by gravity to a servo-regulated roller pump, pumped through a membrane lung where it is oxygenated and through a small heat exchanger and then returned to the systemic circulation via a major artery, such as the carotid artery, to the aortic arch. ECMO provides oxygen to the circulation; allows the lungs to “rest;” and decreases pulmonary hypertension and hypoxemia in such conditions as persistent pulmonary hypertension of the newborn, congenital diaphragmatic hernia, sepsis, meconium aspiration, and severe pneumonia.
Acid–Base Imbalance Many respiratory and metabolic conditions in infants and children may cause an acid–base imbalance. Disease states such as diarrhea (see Chapter 22), RDS, bronchopulmonary dysplasia, and respiratory failure may interfere with the body's ability to regulate and maintain acid–base balance. Simply stated, acidosis (acidemia) results from either accumulation of acid or loss of base, and alkalosis (alkalemia) results from either accumulation of base or loss of acid. Several laboratory tests are used to assess the nature and extent of acid–base disturbances; these are outlined in Table 8-7. To determine the acid–base status, three variables—the respiratory component (PCO2), the metabolic component (arterial bicarbonate or serum carbon dioxide [HCO3−]), and the serum pH— must be determined. In addition, the anion gap may be useful in determining the cause and extent of metabolic acidosis; therefore, serum chemistry is obtained as well. Measurement of any two variables (PCO2, pH, HCO3−) allows computation of the third using the Henderson-Hasselbalch equation. A summary of relationships between these and other variables is outlined in Table 8-8.
TABLE 8-7 Laboratory Tests Used in Assessment of Acid–Base Status
Abbreviation Test Normal Values* Description pH Partial pressure of hydrogen Birth: 7.11 to 7.36
1 day: 7.29 to 7.45 Child: 7.35 to 7.45
Expression of hydrogen ion concentration
PCO2 Partial pressure of carbon dioxide or carbon dioxide tension
Newborn: 27 to 40 mm Hg
Infant: 27 to 41 mm Hg
Measure of carbon dioxide tension; reflects carbonic acid (H2CO3) concentrations of plasma
HCO 3
− (serum) arterial
Carbon dioxide content or carbon dioxide combining power
Infant: 21 to 28 mEq/ml
Thereafter: 22 to 26 mEq/ml
Concentration of base bicarbonate
Base excess Base excess (whole blood) Newborn: −2 to −10
Infant: −1 to −7 Child: +2 to −4 Thereafter: +3 to
−3
Used to express extent of deviation from normal buffer base concentration; indicates quantity of blood buffers remaining after hydrogen ion is buffered
Anion gap Anion gap; using chemistry profile and serum bicarbonate
10 to 12,* (4 to 11)† Reflects difference between measured cation sodium and anions (also measured) of chloride and bicarbonate
*Huether SE: The cellular environment: fluids and electrolytes, acids and bases. In McCance KL, Huether SE, Brashers VL, et al, editors: Pathophysiology: the biologic basis for disease in adults and children, ed 6, St Louis, 2010, Mosby/Elsevier. †Data from Kliegman RM, Stanton BF, St. Geme JW, et al, editors: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders/Elsevier.
TABLE 8-8 Summary of Simple Acid–Base Disturbances (Partially Compensated)
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Disturbance Plasma pH Plasma PCO2 Plasma HCO3 −
Respiratory acidosis ↓ ↑ ↑ Respiratory alkalosis ↑ ↓ ↓ Metabolic acidosis ↓ ↓ ↓ Metabolic alkalosis ↑ ↑ ↑
The pH represents the concentration of hydrogen (H+) in solution and indicates only whether the imbalance is more acidic or more alkaline. It does not reflect the nature of the imbalance (i.e., whether it is of metabolic or respiratory origin). Body metabolism affects primarily the base bicarbonate (HCO3−); therefore, alterations in the concentration of bicarbonate are termed metabolic disturbances of acid–base balance. Also, because the amount of carbon dioxide (CO2) exhaled through the lungs affects the carbonic acid (H2CO3), changes in carbonic acid concentration are referred to as respiratory disturbances. Consequently, the simple disturbances (those with a single primary cause) are categorized as metabolic acidosis or alkalosis and respiratory acidosis or alkalosis.
When the fundamental acid–base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid–base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. For example, when the concentration of metabolic acids in the body increases they combine with bicarbonate (a buffer) to form carbonic acid. The lungs immediately attempt to compensate for the imbalance by eliminating the carbonic acid through exhaled carbon dioxide and water (compensation). The imbalance is corrected when the kidneys excrete hydrogen and ammonium ions in exchange for reabsorbed sodium bicarbonate.
When the secondary changes (the hyperventilation and renal excretion of hydrogen ions in the preceding example) succeed in preventing a distortion of the acid–base ratio and the pH is restored to normal, the disturbance is described as compensated. The uncompensated state exists when there is no compensatory effect and the pH remains uncorrected. The imbalance is said to be corrected when physiologic mechanisms fully correct the primary abnormality. Mixed acid–base imbalances may also occur in diseases states, and the patient will manifest two simultaneous acid– base imbalances rather than a single imbalance. It is not within the scope of this text to discuss the many variations of mixed acid–base imbalances; readers are referred to other published sources for such material (Fraser, 2012).
Cardiovascular Complications The most serious cardiovascular disorders of newborns are the congenital heart defects. Other conditions that occur in the newborn period are usually related to prematurity (e.g., anemia, patent ductus arteriosus) or other diseases (e.g., respiratory distress). Some of these disorders are outlined in Table 8-9.
TABLE 8-9 Cardiovascular and Hematologic Complications
Description ClinicalManifestations Therapeutic Management Nursing Care Management
Patent Ductus Arteriosus Failure of ductus arteriosus to close at birth, resulting in shunting of oxygenated blood from aorta through open ductus arteriosus into pulmonary artery, increasing workload on left side of heart and increasing pulmonary vascular congestion (see Chapter 23)
Decreased PaO2 Increased PCO2 Recurrent apnea Bounding peripheral
pulses Systolic or continuous
murmur
Regulate parenteral fluids. Provide respiratory support. Administer course of
indomethacin or ibuprofen or perform surgical ductal ligation.
See Nursing Care of the High-Risk Newborn and Family earlier in the chapter.
Anemia Hemoglobin (<14 mg/dl) inadequate to carry oxygenated blood to tissues Anemia commonly occurs in ill preterm infants as a result of increased blood sampling
and deficient erythropoiesis
Pallor Apnea Tachycardia Diminished activity Poor feeder Poor weight gain Respiratory distress—
grunting, nasal flaring, intercostal retractions
Respiratory difficulty
Administer volume expanders for acute hypovolemia at birth (e.g., normal saline).
Transfuse with packed RBCs or administer recombinant human erythropoietin.
Use microsamples for blood tests. Monitor amount of blood drawn for
tests. Administer recombinant human
erythropoietin as prescribed. Administer iron supplements as
prescribed.
Polycythemia or Hyperviscosity Syndrome Venous hematocrit ≥65% results in venous stasis in vital organs and risk for microthrombus development
High incidence of: Cardiovascular
symptoms (PPHN, cyanosis, apnea)
Seizures Hyperbilirubinemia Gastrointestinal
abnormalities
Implement partial exchange transfusion with blood product or appropriate volume expander.
Provide appropriate therapy for associated problems.
See Nursing Care of the High-Risk Newborn and Family and Hyperbilirubinemia earlier in the chapter.
Vitamin K Deficiency Bleeding (Formerly Hemorrhagic Disease of the Newborn) Bleeding disorder resulting from transient deficiency of vitamin K–dependent blood factors; newborn's sterile gut does not produce adequate amounts of vitamin K
Oozing blood from umbilicus or
Administer prophylactic vitamin K.
Administer prophylactic vitamin K via intramuscular route.
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circumcision Bloody or black stools Hematuria Petechiae
Observe for complications, such as bleeding umbilical cord, prolonged circumcision bleeding, and petechiae.
PPHN, Persistent pulmonary hypertension of the newborn; RBC, red blood cell.
Neurologic Complications Neurologic injury in newborn infants is common. Newborn infants are particularly vulnerable to ischemic injury caused by variable (both increased and decreased) cerebral blood flow subsequent to asphyxia; and preterm infants, with a fragile cerebrovascular network, are highly prone to periventricular or intraventricular hemorrhage. Fragility and increased permeability of capillaries and prolonged prothrombin time predispose preterm infants to trauma when delicate structures are subjected to the forces of labor. The more common neurologic complications are outlined in Table 8- 10.
TABLE 8-10 Neurologic Complications
Description Clinical Manifestations TherapeuticManagement Nursing Care Management
Hypoxic-Ischemic Brain Injury Nonprogressive neurologic (brain) impairment caused
by intrauterine or postnatal asphyxia resulting in hypoxemia or cerebral ischemia
Hypoxic-ischemic encephalopathy—the resultant cellular damage causes the clinical manifestations
Appears within first 6 to 12 hours after hypoxic episode
Seizures Abnormal muscle tone (usually
hypotonia) Disturbance of sucking and
swallowing Apneic episodes Stupor or coma Muscular weakness in hips and
shoulders (full term), lower limb weakness (preterm)
Prevent hypoxia. Provide supportive
care. Provide adequate
ventilation. Maintain cerebral
perfusion. Prevent cerebral
edema. Treat underlying
cause. Administer
antiseizure drugs. Initiate therapeutic
hypothermia if criteria met (see p. 280).
See Nursing Care of the High-Risk Newborn and Family earlier in the chapter.
Observe for signs that indicate cerebral hypoxia. Monitor ventilatory and IV therapy. Observe for and manage seizures. Support family. Provide guidelines for family management of potential mild to
severe neurologic damage.
Germinal Matrix or Intraventricular Hemorrhage Hemorrhage into and around ventricles caused by ruptured vessels as a result of an event that increases cerebral blood flow to area
Sudden deterioration in condition if bleed is large
Most bleeds initially asymptomatic
Tense, bulging anterior fontanel Neurologic signs: • Twitching • Stupor • Apnea • Seizures Evident on cranial
ultrasonography or MRI
Supportive care: Maintain oxygenation. Regulate fluid and
electrolytes, acid– base balance.
Suppress or prevent seizures.
Provide ventricular shunting or drainage.
See Nursing Care of the High-Risk Newborn and Family earlier in the chapter.
Prevent increased cerebral BP. Avoid events that may increase or decrease cerebral blood flow (e.g.,
pain, unnecessary stimulation, ET suctioning, hypoxia, hyperosmolar drugs, rapid volume expansion).
Elevate head of bed 20 to 30 degrees; keep head in midline for the first 72 hours after birth.
Support family. Monitor for posthemorrhagic hydrocephalus after diagnosis. Provide developmental care and enhancement.
Intracranial Hemorrhage Subdural Subarachnoid Intracerebellar
Sudden decrease in hematocrit Change in sensorium Poor feeding See Chapter 27
See Chapter 27. Same as for germinal matrix or intraventricular hemorrhage.
BP, Blood pressure; ET, endotracheal; IV, intravenous; MRI, magnetic resonance imaging.
The highest incidence of abnormal neurologic findings occurs in VLBW infants and those with intracranial hemorrhage. Major neurologic problems, such as cerebral palsy, seizures, and hydrocephalus, are usually diagnosed in the first 2 years of life. Less severe deficits, such as learning disorders, ADHD, and fine and gross motor incoordination, may not be diagnosed until preschool or even school age. Cerebral palsy is one of the most common neurologic deficits in survivors of prematurity (see Chapter 30).
Neonatal Seizures Seizures in the neonatal period are usually the clinical manifestation of a serious underlying disease. The most common cause of seizures for term and preterm neonates is hypoxic ischemic encephalopathy secondary to perinatal asphyxia (Verklan and Lopez, 2011). Although not life threatening as an isolated entity, seizures constitute a medical emergency because they signal a disease process that may produce irreversible cerebral damage. Consequently, it is imperative to recognize a seizure and its significance so that the cause, as well as the seizure, can be treated (Box 8-5).
Box 8-5
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C a u s e s o f N e o n a t a l S e i z u r e s Metabolic
Hypoglycemia, hyperglycemia
Hypocalcemia
Hypernatremia, hyponatremia
Hypomagnesemia
Pyridoxine deficiency
Aminoaciduria (e.g., phenylketonuria, maple syrup urine disease)
Hyperammonemia
Toxic
Uremia
Bilirubin encephalopathy (kernicterus)
Prenatal Infections
Toxoplasmosis
Syphilis
Cytomegalovirus
Herpes simplex
Postnatal Infections
Bacterial meningitis
Viral meningoencephalitis
Sepsis
Brain abscess
Trauma at Birth
Hypoxic brain injury
Subarachnoid, subdural hemorrhage
Intraventricular hemorrhage
Malformations
Central nervous system (CNS) agenesis
Hydranencephaly
Tuberous sclerosis
Miscellaneous
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Neonatal stroke
Narcotic withdrawal
Degenerative disease
Benign familial neonatal seizures
The features of neonatal seizures are different from those observed in older infants and children. For example, the well-organized, generalized tonic-clonic seizures seen in older children are rare in infants, especially preterm infants. The newborn brain, with its immature anatomic and physiologic status and less cortical organization, is unable to allow ready development and maintenance of a generalized seizure. Instead, signs of seizures in newborns, especially preterm neonates, are subtle and include findings such as lip smacking, tongue thrusting, eye rolling, and swimming movements (Verklan and Lopez, 2011).
Jitteriness or tremulousness in newborns is a repetitive shaking of an extremity or extremities that may be observed with crying, occur with changes in sleeping state, or is elicited with stimulation. Jitteriness is relatively common in newborns and in a mild degree may be considered normal during the first 4 days of life. Jitteriness can be distinguished from seizures by several characteristics: • Jitteriness is not accompanied by ocular movement as are seizures. • Whereas the dominant movement in jitteriness is tremor, seizure movement is clonic jerking that
cannot be stopped by flexion of the affected limb. • Jitteriness is highly sensitive to stimulation, but seizures are not.
Jitteriness may be a sign of hypoglycemia, and infants with jitteriness should have a blood glucose level evaluated.
A tremor is defined as repetitive movements of both hands (with or without movement of legs or jaws) at a frequency of two to five per second and lasting more than 10 minutes. It is common in newborn infants and has a variety of causes, including neurologic damage, hypoglycemia, and hypocalcemia. In most instances, tremors are of no pathologic significance.
Neonatal seizures can be divided into four major types. These classifications are outlined in order of frequency in Table 8-11 and consist of clonic, tonic, subtle, and myoclonic seizures (Verklan and Lopez, 2011). Clonic, multifocal clonic, and migratory clonic seizures are more common in term infants.
TABLE 8-11 Classifications of Neonatal Seizures
Type Characteristics Clonic Slow, rhythmic jerking movements
Approximately 1 to 3/second Focal Involves face, upper or lower extremities on one side of body
May involve neck or trunk Infant is conscious during event
Multifocal May migrate randomly from one part of the body to another Movements may start at different times
Tonic Extension, stiffening movements Generalized Extension of all four limbs (similar to decerebrate rigidity)
Upper limbs maintained in a stiffly flexed position (resembles decorticate rigidity) Focal Sustained posturing of a limb
Asymmetric posturing of trunk or neck Subtle May develop in either full-term or preterm infants but more common in preterm
Often overlooked by inexperienced observers Signs: • Horizontal eye deviation • Repetitive blinking or fluttering of the eyelids, staring • Sucking or other oral-buccal-lingual movements • Arm movements that resemble rowing or swimming • Leg movements described as pedaling or bicycling • Apnea (common)
Signs may appear alone or in combination Myoclonic Rapid jerks that involve flexor muscle groups Focal Involves upper extremity flexor muscle group
No EEG discharges observed Multifocal Asynchronous twitching of several parts of the body
No associated EEG discharges observed Generalized Bilateral jerks of upper and lower limbs
Associated with EEG discharges
EEG, Electroencephalogram. Adapted from Volpe J: Neonatal seizures. In Volpe J: Neurology of the newborn, ed 4, Philadelphia, 2008, Saunders.
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Diagnostic Evaluation Early evaluation and diagnosis of seizures are urgent. In addition to a careful physical examination, the pregnancy and family histories are investigated for familial and prenatal causes. Blood is drawn for glucose and electrolyte examination, and CSF may be obtained for testing of cell count and differential, protein, glucose, and culture. Electroencephalography (EEG) may help identify subtle seizures but is less helpful in establishing a diagnosis. Other diagnostic procedures, such as CT, MRI, and cerebral ultrasonography, may be indicated. A video EEG may be used to identify seizure activity in some newborns. More extensive metabolic testing may be needed when initial test results do not provide a diagnosis or the history is suggestive of an inherited metabolic disorder.
Therapeutic Management Treatment is directed toward prevention of neurologic damage and involves correction of metabolic derangements, respiratory and cardiovascular support, and suppression of the seizure activity. The underlying cause is treated (e.g., glucose infusion for hypoglycemia, calcium for hypocalcemia, antibiotics for infection). If needed, respiratory support is provided for hypoxia, and anticonvulsants may be administered, especially when the other measures fail to control the seizures. Phenobarbital, given intravenously or orally, has been the drug of choice and is used if seizures are severe and persistent. Other drugs that may be used are phenytoin (Dilantin) and lorazepam.
Fosphenytoin sodium is a water-soluble prodrug and may also be used for seizures. Fosphenytoin metabolizes to form phenytoin in the body yet can easily be diluted or mixed in dextrose and normal saline and may be given via IV or intramuscular routes. In addition, fosphenytoin does not cause pain during IV administration.
Recent research has shown that therapeutic hypothermia provided by cooling either the infant's head or the whole body reduces the severity of the neurologic damage in hypoxic ischemic encephalopathy when it is applied in the early stages of injury (first 6 hours after delivery) in infants with a gestational age of 35 to 36 weeks or more (Azzopardi, Strohm, Marlow, et al, 2014; Edwards, Brocklehurst, Gunn, et al, 2010; Shankaran, 2012).
Nursing Care Management The major nursing responsibilities in the care of infants with seizures are to recognize when the infant is having a seizure so that therapy can be instituted, to carry out the therapeutic regimen, and to observe the response to the therapy and any further evidence of seizures or other symptomatology. Assessment and other aspects of care are the same as for all high-risk infants. Parents need to be informed of their infant's status, and the nurse should reinforce and clarify the practitioner's explanations. The infant's behaviors need to be interpreted for the parents, and the infant's responses to the treatment must be anticipated and their significance explained. Parents are encouraged to visit their infant and perform the parenting activities consistent with the care plan. Seizures are a frightening phenomenon and generate a great deal of anxiety and fear, which is easily compounded by the justifiable concern of the staff. Providing support and guidance is an important nursing function.
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High Risk Related to Infectious Processes Sepsis Sepsis, or septicemia, refers to a generalized bacterial infection in the bloodstream. Neonates are highly susceptible to infection as a result of diminished nonspecific (inflammatory) and specific (humoral) immunity, such as impaired phagocytosis, delayed chemotactic response, minimal or absent IgA and immunoglobulin M (IgM), and decreased complement levels. Because of infants' poor response to pathogenic agents, there is usually no local inflammatory reaction at the portal of entry to signal an infection, and the resulting symptoms tend to be vague and nonspecific. Consequently, diagnosis and treatment may be delayed.
Breastfeeding has a protective benefit against infection and should be promoted for all newborns. It is of particular benefit to high-risk neonates. Colostrum contains immunoglobulins that are effective against gram-negative bacteria.
Sepsis in the neonatal period can be acquired prenatally across the placenta from the maternal bloodstream or during labor from ingestion or aspiration of infected amniotic fluid. Prolonged rupture of the membranes always presents a risk for this type from maternal–fetal transfer of pathogenic organisms. In utero transplacental transfer can occur with organisms and viruses such as cytomegalovirus, toxoplasmosis, and Treponema pallidum (syphilis), which cross the placental barrier during the latter half of pregnancy. Intrapartum infection may occur via contact with an infected mother; examples of such infections include herpesvirus and human immunodeficiency virus (HIV).
Early-onset sepsis (less than 3 days after birth) is acquired in the perinatal period; infection can occur from direct contact with organisms from the maternal gastrointestinal and genitourinary tracts. The most common infecting organism in term infants is group B streptococcus (GBS); in preterm infants, it is Escherichia coli (Sgro, Shah, Campbell, et al, 2011). Despite the development of maternal screening and prophylaxis, infection rates for early-onset GBS infection remain at approximately 0.3 per 1000 live births (Verani, McGee, and Schrag, 2010). E. coli, which may be present in the vagina, accounts for approximately half of all cases of sepsis caused by gram-negative organisms. GBS is an extremely virulent organism in neonates, with a high (50%) death rate in affected infants. Other bacteria noted to cause early-onset infection include Haemophilus influenzae, Neisseria meningitidis, coagulase-negative Staphylococcus (ConS), and Streptococcus pneumoniae (Venkatesh, Adams and Weisman, 2011). Other pathogens that are harbored in the vagina and may infect the infant include gonococci, C. albicans, HSV (type II), and Chlamydia.
Late-onset sepsis (1 to 3 weeks after birth) is primarily nosocomial, and the offending organisms are usually staphylococci, Klebsiella organisms, enterococci, E. coli, and Pseudomonas or Candida (Stoll, 2011). ConS, considered to be primarily a contaminant in older children and adults, is the most common cause of late-onset septicemia in ELBW and VLBW infants. Bacterial invasion can occur through sites such as the umbilical stump; the skin; mucous membranes of the eye, nose, pharynx, and ear; and internal systems, such as the respiratory, nervous, urinary, and gastrointestinal systems. Risk factors for ConS include low birth weight and early gestational age, poor hand hygiene, previous antibiotic exposure, and the presence of central IV lines (Downey, Smith, and Benjamin, 2010).
Postnatal infection is acquired by cross-contamination from other infants, personnel, or objects in the environment. Bacteria that are commonly called “water bugs” (because they are able to grow in water) are found in water supplies, humidifying apparatus, sink drains, suction machines, and most respiratory equipment. Organisms such as ConS, which usually colonize the skin, may infect indwelling venous and arterial catheters used for infusions, blood sampling, and monitoring of vital signs. Neonatal sepsis is most common in infants at risk, particularly preterm infants and infants born after a difficult or traumatic labor and delivery, who are least capable of resisting such bacterial invasion. These organisms are often transmitted by personnel from person to person or object to person by poor hand washing, crowded conditions, and inadequate housecleaning.
Diagnostic Evaluation Diagnosis of sepsis is often based on suspicion of presenting clinical signs and symptoms. Because sepsis is so easily confused with other neonatal disorders, the definitive diagnosis is established by
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laboratory and radiographic examination. Cultures of blood, urine, and CSF are collected to identify the causative organism. Blood studies may show signs of anemia, leukocytosis, or leukopenia. Leukopenia is usually an ominous sign because of its frequent association with high mortality. An elevated number of immature neutrophils (a left shift), decreased or increased total neutrophils, and changes in neutrophil morphology also suggest an infectious process in the neonate. Other diagnostic data may be helpful in the determination of neonatal sepsis and include C-reactive protein and other acute phase reactants, such as serum amyloid A; procalcitonin; and interleukins, specifically interleukin-6 (Ng and Lam, 2010).
Prevention Several measures are important in the prevention of both early- and late-onset infection. Programs to screen pregnant women for GBS colonization (culture-based) and treatment of those women in labor have dramatically reduced the incidence of GBS infection in neonates (Verani, McGee, and Schrag, 2010). Screening programs for other maternal infections, including hepatitis B and HIV, are also recommended. In developed countries, breastfeeding by mothers infected with HIV is not recommended because the virus may be transmitted in breast milk.
Nursery procedures aimed at minimizing the risk of nosocomial infections include the practice of good hand-washing techniques, appropriate isolation precautions where indicated, and the adoption of recommended standards for spacing of infant beds. Strategies such as the early introduction of enteral feeding aimed at reducing the indwelling time of central venous lines have been shown to reduce the risk of nosocomial infection (Toltzis and Walsh, 2010).
Therapeutic Management In addition to the institution of vigorous therapeutic measures, early recognition (Box 8-6) and diagnosis are essential to increase the infant's chance for survival and reduce the likelihood of permanent neurologic damage. Antibiotic therapy is initiated before laboratory results are available for confirmation and identification of the exact organism. Treatment consists of circulatory support, respiratory support, aggressive administration of antibiotics, and immunotherapy.
Box 8-6 M a n i f e s t a t i o n s o f N e o n a t a l S e p s i s General Signs
Infant generally “not doing well”
Poor temperature control—hypothermia, hyperthermia (rare in neonates)
Circulatory System
Pallor, cyanosis, or mottling
Cool, clammy skin
Hypotension
Edema
Irregular heartbeat—bradycardia, tachycardia
Respiratory System
Irregular respirations, apnea, or tachypnea
Cyanosis
Grunting
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Dyspnea
Retractions
Central Nervous System
Diminished activity—lethargy, hyporeflexia, coma
Increased activity—irritability, tremors, seizures
Full fontanel
Increased or decreased tone
Abnormal eye movements
Gastrointestinal System
Poor feeding
Vomiting
Diarrhea or decreased stooling
Abdominal distention
Hepatomegaly
Hemoccult-positive stools
Hematopoietic System
Jaundice
Pallor
Petechiae, ecchymosis
Splenomegaly
Supportive therapy usually involves administration of oxygen (if respiratory distress or hypoxia is evident), careful regulation of fluids, correction of electrolyte or acid–base imbalance, and temporary discontinuation of oral feedings. Blood transfusions may be needed to correct anemia and shock, and electronic monitoring of vital signs and regulation of the thermal environment are mandatory.
Antibiotic therapy, usually administered intravenously, is continued for 7 to 10 days if culture results are positive, discontinued in 48 to 72 hours if culture results are negative and the infant is asymptomatic. Antifungal and antiviral therapies are implemented as appropriate, depending on causative agents.
Prognosis The prognosis for neonatal sepsis is variable. Severe neurologic and respiratory sequelae may occur in ELBW and VLBW infants with early-onset sepsis. Late-onset sepsis and meningitis may also result in poor outcomes for immunocompromised neonates.
The introduction of new markers for neonatal sepsis such as acute phase reactants, cytokines, cell surface antigens, and bacterial genomes may prove to be particularly helpful in guidance for antibiotic therapy (Tripathi and Malik, 2010). Future experimental methods being explored to combat infection in neonates include monoclonal antibody therapy, fibronectin infusion, and lymphokine enhancement.
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Nursing Care Management Nursing care of infants with sepsis involves observation and assessment as outlined for any high- risk infant. Recognition of the existing problem is of paramount importance; it is usually the nurse who observes and assesses infants and identifies that “something is wrong” with them. Awareness of the potential modes of infection transmission also helps the nurse identify infants at risk for developing sepsis. Much of the care of infants with sepsis involves the medical treatment of the illness. Knowledge of the side effects of the specific antibiotic and proper regulation and administration of the drug are vital.
Prolonged antibiotic therapy poses additional hazards for affected infants. Antibiotics predispose infants to growth of resistant organisms and superinfection from fungal or mycotic agents, such as C. albicans. Nurses must be alert for evidence of such complications. Nystatin oral suspension is swabbed on the buccal mucosa for prophylaxis against oral candidiasis.
Part of the total care of infants with sepsis is to decrease any additional physiologic or environmental stress. This includes providing an optimum thermoregulated environment and anticipating potential problems such as dehydration or hypoxia. Precautions are implemented to prevent the spread of infection to other newborns, but to be effective, activities must be carried out by all caregivers. Proper hand washing, the use of disposable equipment (e.g., linens, catheters, feeding supplies, IV equipment), disposal of excretions (e.g., vomitus, stool), and adequate housekeeping of the environment and equipment are essential. Because nurses are the most consistent caregivers involved with sick infants, it is usually their responsibility to see that standard precautions are maintained by everyone.
In recent years, ventilator-associated pneumonia has received considerable attention in adult and pediatric intensive care units. Hand hygiene (staff) and oral hygiene (patient) have been shown to decrease the incidence of ventilator-associated pneumonia in children (see Chapter 21).
Another aspect of caring for infants with sepsis involves observation for signs of complications, including meningitis and septic shock, a severe complication caused by toxins in the bloodstream.
Necrotizing Enterocolitis NEC is an acute inflammatory disease of the bowel with increased incidence in preterm infants. The precise cause of NEC is still uncertain, but it appears to occur in infants whose gastrointestinal tracts have experienced vascular compromise. Intestinal ischemia of unknown etiology, immature gastrointestinal host defenses, bacterial proliferation, and feeding substrate are now believed to have a multifactorial role in the etiology of NEC. Prematurity remains the most prominent risk factor in the development of NEC (Lovvorn, Glenn, Pacetti, et al, 2011).
The damage to mucosal cells lining the bowel wall may be significant. Diminished blood supply to these cells causes their death in large numbers; they stop secreting protective, lubricating mucus; and the thin, unprotected bowel wall is attacked by proteolytic enzymes. Thus, the bowel wall continues to swell and break down; it is unable to synthesize protective IgM, and the mucosa is permeable to macromolecules (e.g., exotoxins), which further hampers intestinal defenses. Gas- forming bacteria invade the damaged areas to produce pneumatosis intestinalis, a radiologic finding reflecting the presence of gas in the submucosal or subserosal surfaces of the bowel.
A consistent relationship has been observed between the development of NEC and enteric feeding of hypertonic substances (e.g., formula, hyperosmolar medications). It is unclear whether this connection is a result of the formula imposing a stress on an ischemic bowel, serving as a substrate for bacterial growth, or both.
Diagnostic Evaluation Radiographic studies show a sausage-shaped dilation of the intestine that progresses to marked distention and the characteristic pneumatosis intestinalis—“soapsuds,” or the bubbly appearance of thickened bowel wall and ultra lumina. There may be air in the portal circulation or free air observed in the abdomen, indicating perforation. Laboratory findings may include anemia, leukopenia, leukocytosis, metabolic acidosis, and electrolyte imbalance. In severe cases, coagulopathy (DIC) or thrombocytopenia may be evident. Gram-negative organisms are often cultured from blood, although bacteremia or septicemia may not be prominent early in the course of the disease.
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Therapeutic Management Treatment of infants with NEC begins with prevention. Oral feedings may be withheld for at least 24 to 48 hours from infants who are believed to have experienced birth asphyxia. Breast milk is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes.
Minimal enteral feedings (trophic feeding, gastrointestinal priming) have gained acceptance with no evidence of increased incidence of NEC. In particular, the use of fresh human milk has been shown to decrease the risk of NEC (Corpeleijn, Kouwenhoven, Paap, et al, 2012). A systematic review of the role of probiotics such as Lactobacillus acidophilus and Bifidobacterium infantis administered with enteral feedings for the prevention of NEC has demonstrated a reduced incidence of severe NEC and mortality in preterm infants (Alfaleh, Anabrees, Bassler, et al, 2011). The preferred type and optimal dosing of probiotics remain to be determined.
Medical treatment of infants with confirmed NEC consists of discontinuation of all oral feedings; institution of abdominal decompression via nasogastric suction; administration of IV antibiotics; and correction of extravascular volume depletion, electrolyte abnormalities, acid–base imbalances, and hypoxia. Replacing oral feedings with parenteral fluids decreases the need for oxygen and circulation to the bowel. Serial abdominal radiographs (every 6 to 8 hours in the acute phase) are taken to monitor for possible progression of the disease to intestinal perforation.
Prognosis With early recognition and treatment, medical management is increasingly successful. If there is progressive deterioration under medical management or evidence of perforation, surgical resection and anastomosis are performed. Extensive involvement may necessitate surgical intervention and establishment of an ileostomy, jejunostomy, or colostomy. Sequelae in surviving infants include short-bowel syndrome (see Chapter 24), colonic stricture with obstruction, fat malabsorption, and growth failure secondary to intestinal dysfunction. A variety of surgical interventions for NEC is available and depends on the extent of bowel necrosis, associated illness factors, and infant stability. Intestinal transplantation has been successful in some former preterm infants with NEC-associated short-bowel syndrome who had already developed life-threatening total parenteral nutrition– related complications. Transplantation may be a lifesaving option for infants who previously faced high morbidity and mortality. Research is now underway to examine the use of tissue-engineered small intestine (Grant and Grikscheit, 2013).
Nursing Care Management Nursing responsibilities begin with the prompt recognition of the early warning signs of NEC. Because the signs are similar to those observed in many other disorders of newborns, nurses must constantly be aware of the possibility of this disease in infants who are at high risk for developing NEC (Box 8-7).
Box 8-7 C l i n i c a l M a n i f e s t a t i o n s o f N e c r o t i z i n g E n t e r o c o l i t i s Nonspecific Clinical Signs
Lethargy
Poor feeding
Hypotension
Vomiting
Apnea
Decreased urinary output
Unstable temperature
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Jaundice
Specific Signs
Distended (often shiny) abdomen
Blood in the stools or gastric contents
Gastric retention (undigested formula)
Localized abdominal wall erythema or induration
Bilious vomitus
When the disease is suspected, the nurse assists with diagnostic procedures and implements the therapeutic regimen. Vital signs, including BP, are monitored for changes that might indicate bowel perforation, septicemia, or cardiovascular shock, and measures are instituted to prevent possible transmission to other infants. It is especially important to avoid rectal temperatures because of the increased danger of perforation. To avoid pressure on the distended abdomen and to facilitate continuous observation, infants are often left undiapered and positioned supine or on the side.
Observe for indications of early development of NEC by checking the appearance of the abdomen for distention (measuring abdominal girth, measuring residual gastric contents before feedings, and listening for bowel sounds) and performing all routine assessments for high-risk neonates.
Conscientious attention to nutritional and hydration needs is essential, and antibiotics are administered as prescribed. The time at which oral feedings are reinstituted varies considerably but is usually at least 7 to 10 days after diagnosis and treatment. Feeding is usually reestablished using human milk, if available.
Because NEC is an infectious disease, one of the most important nursing functions is control of infection. Strict hand washing is the primary barrier to spread, and confirmed multiple cases are isolated. Persons with symptoms of a gastrointestinal disorder should not care for these or any other infants.
Infants who require surgery require the same careful attention and observation as any infant with abdominal surgery, including ostomy care (as applicable). This disorder is one of the most common reasons for performing ostomies on newborns. Throughout the medical and surgical management of infants with NEC, the nurse should be continually alert to signs of complications, such as septicemia, DIC, hypoglycemia, and other metabolic derangements.
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High Risk Related to Maternal Conditions The health of fetuses and newborns may be affected by a number of maternal conditions; essentially, any condition affecting the mother also has the potential for negatively affecting the health of the newborn. Pregnancy-induced hypertension or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome may cause preterm delivery, intrauterine growth restriction (IUGR), asphyxia, and death if it is not detected early and appropriate interventions implemented. It is not within the scope of this text to elaborate on the pathophysiology and treatment of these conditions; however, readers are referred to any one of the excellent maternity texts available for a detailed discussion of these conditions.
Infants of Diabetic Mothers Before insulin therapy, few women with diabetes were able to conceive; for those who did, the mortality rate for both the mother and the infant was high. The morbidity and mortality of infants of diabetic mothers (IDMs) have been significantly reduced as a result of effective control of maternal diabetes and an increased understanding of fetal disorders. Because infants born to women with gestational diabetes mellitus are at risk for the same complications as IDMs, the following discussion of IDMs includes infants born to women with gestational diabetes mellitus.
The severity of the maternal diabetes affects infant survival. The severity of maternal diabetes is determined by the duration of the disease before pregnancy; age of onset; extent of vascular complications; and abnormalities of the current pregnancy, such as pyelonephritis, diabetic ketoacidosis, pregnancy-induced hypertension, and noncompliance. The single most important factor influencing fetal well-being is the euglycemic status of the mother. It has been found that reasonable metabolic control that begins before conception and continues during the first weeks of pregnancy can prevent malformation in an IDM. Elevated levels of hemoglobin A1c during the periconceptional period appear to be associated with a higher incidence of congenital malformations. In the case of gestational diabetes, macrosomia is the most common finding; serious complications are rare (Mitanchez, 2010).
Hypoglycemia may appear a short time after birth and in IDMs is associated with increased insulin activity in the blood (see also Table 8-4). The serum glucose level that corresponds to clinical hypoglycemia has not been well defined. Because some infants experience metabolic complications at higher levels than previously thought, some researchers recommend that serum glucose levels be maintained above 45 mg/dl (2.5 mmol/L) in infants with abnormal clinical symptoms and as high as 50 mg/dl in other infants (Rozance and Hay, 2010; Sperling, 2011). The American Academy of Pediatrics recommends that symptomatic infants receive treatment if their blood glucose is less than 40 mg/dl (Adamkin and American Academy of Pediatrics, Committee on Fetus and Newborn, 2011).
Hypoglycemia in IDMs is related to hypertrophy and hyperplasia of the pancreatic islet cells and thus is a transient state of hyperinsulinism. High maternal blood glucose levels during fetal life provide a continual stimulus to the fetal islet cells for insulin production (glucose easily passes the placental barrier from maternal to fetal side; insulin, however, does not cross the placental barrier). This sustained state of hyperglycemia promotes fetal insulin secretion that ultimately leads to excessive growth and deposition of fat, which probably accounts for the infants who are large for gestational age, or macrosomic (Ogata, 2010). When the neonate's glucose supply is removed abruptly at the time of birth, the continued production of insulin soon depletes the blood of circulating glucose, creating a state of hyperinsulinism and hypoglycemia within 0.5 to 4 hours, especially in infants of mothers with poorly controlled diabetes (formerly class C diabetes or beyond [class D through R]). Precipitous drops in blood glucose levels can cause serious neurologic damage or death.
IDMs have a characteristic appearance (Box 8-8 and Fig. 8-22). IDMs are more likely to have disproportionately large abdominal circumferences and shoulders, leading to an increased risk of shoulder dystocia and birth injury (Dailey and Coustan, 2010). Infants of mothers with advanced diabetes may be small for gestational age, may have IUGR, or may be the appropriate size for gestational age because of the maternal vascular (placental) involvement. There is an increase in congenital anomalies in IDMs in addition to a high susceptibility to hypoglycemia, hypocalcemia,
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hypomagnesemia, polycythemia, hyperbilirubinemia, cardiomyopathy, and RDS (Dailey and Coustan, 2010). Hyperinsulinemia and hyperglycemia in the diabetic mother may be factors in reducing fetal surfactant synthesis, thus contributing to the development of RDS. Although large, these infants may be delivered before term as a result of maternal complications or increased fetal size.
Box 8-8 C l i n i c a l M a n i f e s t a t i o n s o f I n f a n t s o f D i a b e t i c M o t h e r s • Large for gestational age
• Very plump and full faced
• Abundant vernix caseosa
• Plethora (polycythemia)
• Listless and lethargic
• Jitteriness
FIG 8-22 Large-for-gestational age infant. This infant of a diabetic mother (IDM) weighed 5 kg at birth and exhibits the typical round facies. (From Zitelli BJ, McIntire SC, Nowalk AJ: Zitelli and Davis' atlas of pediatric physical
diagnosis, ed 6, St Louis, 2012, Saunders/Elsevier.)
Congenital hyperinsulinism, a condition which causes neonatal macrosomia and profound hypoglycemia, is often present in the neonatal period. However, this condition is usually not associated with maternal diabetes mellitus but appears to have a genetic etiology; the condition is also associated with syndromes, such as Beckwith-Wiedemann syndrome (Sperling, 2011).
Therapeutic Management The most important management of IDMs is careful monitoring of serum glucose levels and observation for accompanying complications such as RDS. The infants are examined for the presence of any anomalies or birth injuries, and blood studies for determination of glucose, calcium, hematocrit, and bilirubin are obtained on a regular basis.
Because the hypertrophied pancreas is so sensitive to blood glucose concentrations, the administration of oral glucose may trigger a massive insulin release, resulting in rebound hypoglycemia. Therefore, feedings of breast milk or formula begin within the first hour after birth, provided that the infant's cardiorespiratory condition is stable. Approximately half of these infants do well and adjust without complications. Infants born to mothers with poorly controlled diabetes may require IV dextrose infusions. Treatment with 10% dextrose and water (IV) is initiated with the goal of maintaining serum blood glucose levels above 45 mg/dl (Adamkin and American Academy of Pediatrics, Committee on Fetus and Newborn, 2011). Oral and IV intake may be titrated to
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maintain adequate blood glucose levels. Frequent blood glucose determinations are needed for the first 2 to 4 days of life to assess the degree of hypoglycemia present at any given time. Testing blood taken from the heel with calibrated portable reflectance meters (e.g., glucometers) is a simple and effective screening evaluation that can then be confirmed by laboratory examination.
Nursing Care Management The nursing care of IDMs involves early examination for congenital anomalies, signs of possible respiratory or cardiac problems, maintenance of adequate thermoregulation, early introduction of carbohydrate feedings as appropriate, and monitoring of serum blood glucose levels. The latter is of particular importance because many infants with hypoglycemia may remain asymptomatic. IV glucose infusion requires careful monitoring of the site and the neonate's reaction to therapy; high glucose concentrations (≥12.5%) should be infused via a central line instead of a peripheral site.
Because macrosomic infants are at risk for problems associated with a difficult delivery, they are monitored for birth injuries, such as brachial plexus injury and palsy, fractured clavicle, and phrenic nerve palsy. Additional monitoring of the infant for problems associated with this condition (polycythemia, hypocalcemia, poor feeding, and hyperbilirubinemia) is also a vital nursing function.
Some evidence indicates that IDMs have an increased risk of acquiring type 2 diabetes and metabolic syndrome in childhood or early adulthood (Ogata, 2010); therefore, nursing care should also focus on healthy lifestyle and prevention later in life with IDMs.
Drug-Exposed Infants* Maternal habits hazardous to the fetus and neonate include drug addiction, smoking, and alcohol abuse. Occasional withdrawal reactions have been reported in neonates of mothers who use excessive amounts of drugs, such as barbiturates, alcohol, amphetamines, or antidepressants. Serious reactions are seen in neonates whose mothers abuse psychoactive drugs or are treated with methadone.
Narcotics, which have a low molecular weight, readily cross the placental membrane and enter the fetal system. Illicit substances may also be transmitted to the newborn through breast milk. When the mother is a habitual user of opiates, especially oxycodone (OxyContin), heroin, or methadone, the unborn child may also become chemically dependent or passively addicted to the drug, which places such infants at risk during the perinatal and early neonatal periods. Neonatal abstinence syndrome (NAS) is the term used to describe the set of behaviors exhibited by infants exposed to narcotics in utero.
Clinical Manifestations The adverse effects of exposure of a fetus to drugs are varied. They include transient behavioral changes such as alterations in fetal breathing movements and irreversible effects such as fetal death, IUGR, structural malformations, or cognitive impairment. Determining the specific effects of individual drugs on an individual fetus is made difficult by polydrug use, which is common; errors or omissions in reporting drug use; and variations in the strength, purity, and types of additives found in street drugs. Maternal conditions such as poverty, malnutrition, and comorbid conditions (such as sexually transmitted infections) further compound the difficulty in identifying the presence and consequences of intrauterine drug exposure. Most infants who are exposed to drugs in utero may demonstrate no immediate untoward effects and appear normal at birth. Infants exposed only to heroin may begin to exhibit signs of drug withdrawal within 12 to 24 hours. If mothers have been taking methadone, the signs appear somewhat later—anywhere from 1 or 2 days to 2 to 3 weeks or more after birth. The clinical manifestations may fall into any one or all of the following categories: CNS, gastrointestinal, respiratory, and autonomic nervous system signs (Weiner and Finnegan, 2011). The manifestations become most pronounced between 48 and 72 hours of age and may last from 6 days to 8 weeks, depending on the severity of the withdrawal (Box 8-9). Although these infants suck avidly on fists and display an exaggerated rooting reflex, they are poor feeders with uncoordinated and ineffectual sucking and swallowing reflexes.
Box 8-9
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S i g n s o f Wi t h d r a wa l i n N e o n a t e s Neurologic
Irritability
Seizures
Hyperactivity
High-pitched cry
Tremors
Exaggerated Moro reflex
Hypertonicity of muscles
Gastrointestinal
Poor feeding
Diarrhea
Dehydration
Vomiting
Frantic, uncoordinated sucking
Gastric residuals
Autonomic
Diaphoresis
Fever
Mottled skin
Nasal stuffiness
Miscellaneous
Disrupted sleep patterns
Tachypnea (>60 breaths/min)
Excoriations (knees, face, perianal)
Temperature instability
About 55% to 94% of infants born to narcotic-addicted mothers show signs of withdrawal (Burgos and Burke, 2009). Because of irregular and varying degrees of drug use, quality of drug, and mixed- drug usage by the mother, some infants display mild or variable manifestations. Most manifestations are the vague, nonspecific signs characteristic of all infants in general; therefore, it is important to differentiate between drug withdrawal and other disorders before specific therapy is instituted. Other conditions (e.g., hypocalcemia, hypoglycemia, sepsis) often coexist with the drug withdrawal. Additional signs seen in drug-exposed newborns include loose stools; tachycardia; fever; projectile vomiting; crying; nasal stuffiness; and generalized perspiration, which is unusual in newborns.
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Diagnostic Evaluation Newborn urine, hair, or meconium sampling may be required to identify drug exposure and implement appropriate early interventional therapies aimed at minimizing the consequences of intrauterine drug exposure. Meconium sampling for fetal drug exposure is reported to provide more screening accuracy than urine screening because drug metabolites accumulate in meconium (Weiner and Finnegan, 2011). Urine toxicology screening may be less accurate because it reflects only recent substance intake by the mother (Soni and Singh, 2012). Meconium and hair testing for drug metabolites has the advantages of being noninvasive, more accurate, and easy to collect.
Therapeutic Management The treatment of drug-exposed infants initially consists of early identification through maternal history, presenting symptoms of NAS, or toxicology screening when substance abuse is strongly suspected. Early identification and intervention are essential to prevent further adverse effects; early discharge from the birth institution should be postponed until further assessment of the maternal situation and establishment of a treatment plan for the mother and infant. Drug therapies to decrease withdrawal effects include parenteral or oral administration of phenobarbital, buprenorphine, clonidine, methadone, and morphine. A combination of these drugs may be necessary to treat infants exposed to multiple drugs in utero, and careful attention should be given to possible adverse effects of the treatment drugs (Burgos and Burke, 2009).
Prognosis The prognosis for drug-exposed infants depends on the type and amount of drug(s) taken by the mother and the stage(s) of fetal development in which the drug was taken. The overall mortality rate of infants born to narcotic-addicted mothers is increased, but with early recognition, proper treatment, and long-term follow-up, the morbidity and mortality associated with drug exposure are decreased.
Often, drug-exposed infants exhibit poor brain and body growth at birth; however, at times, infants do not exhibit any signs that indicate exposure to harmful agents, and their condition may therefore be overlooked until symptoms appear later in life. Drug-exposed infants may have chronic feeding problems; irritability; abnormal neurologic responses; abnormal parent–infant interactions; developmental and cognitive delays; learning disabilities in childhood; and behavioral problems, including ADHD.
Nursing Care Management One of the key factors in the treatment of drug-exposed neonates is early identification of substance abuse in the pregnant woman so that treatment can be initiated and side effects minimized. This is especially problematic from a social and legal standpoint because the pregnant woman is often aware of the consequences of admitting to substance abuse and may therefore be less likely to readily admit to the problem for fear of social and legal repercussions. If the mother has had good prenatal care, the practitioner is aware of the problem and may have instituted therapy before delivery. However, a number of mothers deliver their infants without the benefit of adequate care, and the condition is unknown to health care personnel at the time of delivery.
The degree of withdrawal is closely related to the amount of drug the mother has habitually taken, the length of time she has been taking the drug, and her drug level at the time of delivery. The most severe symptoms are observed in the infants of mothers who have taken large amounts of drugs over a long period. In addition, the nearer to the time of delivery that the mother takes the drug, the longer it takes the child to develop withdrawal and the more severe the manifestations. The infant may not exhibit withdrawal symptoms until 7 to 10 days after delivery, by which time most newborns have been discharged from the birth center and caregivers are less likely to recognize signs of irritability and poor feeding as withdrawal, thus predisposing the newborn to abuse or neglect and growth failure (failure to thrive). The infant may be at further risk for subsequent abuse or neglect because of home conditions that preclude adequate newborn care and follow-up.
After the presence of NAS is identified in an infant, nursing care is directed toward treatment of the presenting signs, decreasing stimuli that may precipitate hyperactivity and irritability (e.g., dimming the lights, decreasing noise levels), providing adequate nutrition and hydration, and
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promoting the mother–infant relationship. Appropriate individualized developmental care is implemented to facilitate self-consoling and self-regulating behaviors. Irritable and hyperactive infants have been found to respond to physical comforting, movement, and close contact. Wrapping infants snugly and rocking and holding them tightly limit their ability to self-stimulate. Arranging nursing activities to reduce the amount of disturbance helps decrease exogenous stimulation.
Breastfeeding is encouraged in mothers who are not using illicit substances, do not have HIV infection, and are compliant with a methadone program; breastfeeding promotes mother–infant bonding, and small quantities of methadone passed through breast milk have not proven to be harmful.
The Neonatal Abstinence Scoring System was developed to monitor infants in an objective manner and evaluate their response to clinical and pharmacologic interventions (Finnegan, 1985). This system is also designed to assist nurses and other health care workers in evaluating the severity of infants' withdrawal symptoms. Another tool that may be used to evaluate withdrawal behavior and treatment in newborns is the Neonatal Withdrawal Inventory developed by Zahorodny, Rom, Whitney, and others (1998).
The Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a comprehensive neurologic and behavioral assessment tool that may be used to identify newborns at risk as a result of intrauterine drug exposure. The tool measures stress or abstinence, state, neurologic status, and muscle tone in the context of the newborn's medical condition at the time of examination. The NNNS may be used for medically stable newborns who are at least 30 weeks of gestation and up to 48 weeks of corrected or conceptional age (Lester, Tronick, and Brazelton, 2004).
Loose stools, poor intake, and regurgitation after feeding predispose these infants to malnutrition, dehydration, skin breakdown, and electrolyte imbalance. In addition, these infants burn up energy with continual activity and increased oxygen consumption at the cellular level. Frequent weighing, careful monitoring of intake and output and electrolytes, and additional caloric supplementation may be necessary. Hyperactive infants must be protected from skin abrasions on the knees, toes, and cheeks that are caused by rubbing on bed linens while in a prone position (awake). Monitoring and recording the activity level and its relationship to other activities, such as feeding and preventing complications, are important nursing functions.
A valuable aid to anticipating problems in the newborn is recognizing substance abuse in the mother. Unless the mother is enrolled in a methadone rehabilitation program, she seldom risks calling attention to her habit by seeking prenatal care. Consequently, infants and mothers are exposed to the additional hazards of obstetric and medical complications. Moreover, the nature of substance use and addiction makes the user susceptible to disorders, such as infection (hepatitis B, HIV), foreign body reaction, and the hazards of inadequate nutrition and preterm birth. Methadone treatment does not prevent withdrawal reaction in neonates, but the clinical course may be modified. Also, the intensive psychological support of mothers is a factor in the treatment and reduction of perinatal mortality. Experience has indicated that these mothers are usually anxious and depressed, lack confidence, have a poor self-image, and have difficulty with interpersonal relationships. They may have a psychological need for the pregnancy and an infant.
Initial symptoms or the recurrence of withdrawal symptoms may develop after discharge from the hospital; therefore, it is important to establish rapport and maintain contact with the family so they will return for treatment if this occurs. The demands of the drug-exposed infant on the caregiver are enormous and unrewarding in terms of positive feedback. The infants are difficult to comfort, and they cry for long periods, which can be especially trying for the caregiver after the infant's discharge from the hospital. Long-term follow-up to evaluate the status of the infant and family is very important. Sudden infant death syndrome (SIDS) and HIV infection are observed more commonly in infants born to users of methadone and heroin.
Many problems arise in relation to the disposition of infants of drug-dependent mothers. Those who advocate separation of mothers and children argue that the mothers are not capable of assuming responsibility for their infant's care, that child care is frustrating to them, and that their existence is too disorganized and chaotic. Others encourage the mother–infant bond and recommend a protected environment, such as a therapeutic community; a halfway house; or continuous ongoing, supportive services in the home after discharge. Careful evaluation and the cooperative efforts of a variety of health professionals are required whether the choice is foster home placement or supportive follow-up care of mothers who keep their infants.
Alcohol Exposure
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Alcohol ingestion during pregnancy is associated with both short- and long-term effects on the fetus and newborn. The quantity of alcohol required to produce fetal effects is unclear, but it is known that infants born to heavy drinkers have twice the risk of congenital abnormalities than those born to moderate drinkers (Carlo, 2011). Alcohol withdrawal can occur in neonates, particularly when maternal ingestion occurs near the time of delivery. Signs and symptoms include jitteriness, increased tone and reflex responses, and irritability. Seizures are also common. Fetal effects of alcohol exposure vary from subtle learning disabilities to obvious facial features and growth abnormalities. In 2004, the National Organization on Fetal Alcohol Syndrome clarified terminology for fetal alcohol exposure by adopting the term fetal alcohol spectrum disorder (FASD) as an umbrella term to describe the range of clinical effects. Fetal alcohol syndrome (FAS) falls within this spectrum but is reserved for individuals who display the triad of characteristic facial features, growth restriction, and neurodevelopmental deficits with a confirmed history of maternal alcohol consumption (Pruett, Waterman and Caughey, 2013). Craniofacial features include microcephaly, small eyes or short palpebral fissures, a thin upper lip, a flat midface, and an indistinct philtrum. Neurologic problems in FAS children include some degree of intelligence quotient (IQ) deficit, ADHD, diminished fine motor skills, and poor speech. These children have been shown to lack inhibition, have no stranger anxiety, and lack appropriate judgment skills.
Infants who do not display the signs of FAS but are born to mothers who are also heavy alcohol drinkers have significantly more tremors, hypertonia, restlessness, excessive mouthing movements, crying, and inconsolability than infants of substance-abusive mothers who do not consume alcohol during pregnancy. An added concern regarding substance abuse is that many of the mothers often use several drugs, such as tranquilizers, sedatives, amphetamines, phencyclidine, marijuana, and other psychotropic agents.
Cocaine Exposure Cocaine is a CNS stimulant and peripheral sympathomimetic. Legally, it is classified as a narcotic, but it is not an opioid. The effects on fetuses are secondary to maternal effects, which include increased BP, decreased uterine blood flow, and increased vascular resistance. Consequently, the fetus experiences decreased blood flow and oxygenation because of placental and fetal vasoconstriction. Researchers have concluded that variables such as the mother's lack of prenatal care; poor nutrition; and use of tobacco, alcohol, and other drugs during pregnancy compound the effects of cocaine exposure in the infant (Bandstra, Morrow, Mansoor, et al, 2010).
Infants may appear normal or may show neurologic problems at birth that may continue during the neonatal period. In much of the research literature, these findings were transient, and there has been variable evidence demonstrating permanent sequelae. Either of two types of behavior may emerge as a result of cocaine's effects on fetal development: neurobehavioral depression or excitability. The behaviors of a depressed infant include lethargy, hypotonia, a weak cry, and difficulty in arousing. The behaviors of an excitable neonate may include a high-pitched cry, hypertonicity, jitteriness, irritability, and an inability to be consoled (Bandstra, Morrow, Mansoor, et al, 2010).
Sequelae of prenatal cocaine exposure include preterm birth, a smaller head circumference, decreased birth length, and decreased weight. The areas of the brain that appear to be particularly vulnerable to the effects of prenatal cocaine exposure include those that regulate attention and executive functioning. Early studies of cocaine exposure identified an increased incidence of gastroschisis, genitourinary anomalies, and periventricular and intraventricular hemorrhage; however, meta-analyses have not confirmed these complications (Bandstra, Morrow, Mansoor, et al, 2010). Heavy cocaine exposure has been shown to result in elevated heart rate after birth (Meyer and Zhang, 2009).
Some studies found that long-term sequelae for newborns exposed to cocaine include lower language, motor, and cognitive scores and an increased risk for learning disabilities; however, one study revealed no significant differences in the total or verbal IQ scores but did note an increased risk of specific cognitive impairments (Bandstra and Accornero, 2011). In a study that controlled for other prenatal drug exposures, a dose-related effect of cocaine was found on expressive, receptive, and total language scores at 3, 5, and 12 years old (Bandstra, Morrow, Accornero, et al, 2011). Other investigators have found that the subtle effects of cocaine on school performance are moderated by the child's environment (Ackerman, Riggins, and Black, 2010). Studies using the Brazelton Neonatal Assessment Scale have again shown inconsistent results with subtle abnormalities in
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neurobehavioral clusters varying in severity timing and according to levels of exposure (Bandstra, Morrow, Mansoor, et al, 2010).
Therapeutic Management Treatment of these infants is similar to that for other drug-exposed infants, including reduction of external stimuli; supportive treatment aimed at alleviating symptoms; and, at times, mild sedation.
Nursing Care Management Nursing care of cocaine-exposed infants is the same as that for other drug-exposed infants. Because they have increased flexor tone, these infants respond to swaddling (Pitts, 2010). Positioning, infant massage, and limited tactile stimulation have been shown to be effective interventions. Significant amounts of cocaine have been found in breast milk (D'Apolito, 2013); therefore, mothers should be cautioned regarding this hazard to their infants.
Referral to early intervention programs, including child health care, parental drug treatment, individualized developmental care, and parenting education, is essential in promoting optimum outcome for these children. Because these children often live in impoverished environments, they are at high risk for cognitive delays, lack of child health care, and inadequate nutrition and benefit from early intervention programs.
Methamphetamine Exposure The fetal and neonatal effects of maternal use of methamphetamines in pregnancy are not well known, and findings are often confounded by polydrug use and the effects of the newborn or child's environment. LBW, preterm birth, and anomalies such as cleft lip and palate and cardiac defects have been reported in infants exposed to methamphetamines in utero (Pitts, 2010).
Methamphetamine use has increased significantly in the past 10 years in certain regions of the United States. In a report by Terplan, Smith, Kozloski, and others (2009), 24% of pregnant women admitted to federally funded treatment centers in the United States used methamphetamines in 2006, which was up from 8% in 1994; 63% of pregnant women using methamphetamines reported using the drug throughout the pregnancy. A higher incidence of preterm delivery and placental abruption was associated with methamphetamine use. In addition, fetal growth restriction (small for gestational age) was slightly higher in methamphetamine-exposed offspring; however, 80% of these neonates' mothers also had significant alcohol and tobacco use.
Study reports vary in the time of clinical manifestations of withdrawal from this drug. A study of infants exposed to methamphetamine in utero showed that such infants exhibited withdrawal signs of stress, low tone, and poorer quality of movement, which were not observed in the unexposed infants (LaGasse, Wouldes, Newman, et al, 2011). After birth, infants may experience abnormal sleep patterns, agitation, poor feeding, and state disorganization (Pitts, 2010).
The long-term effects of methamphetamine exposure on children remains unclear; however, some studies have shown problems with math and language skills. It is postulated that similar to cocaine, methamphetamine exposure may affect areas of the brain responsible for higher order functioning with effects more likely to be manifest when the child reaches school age (Lester and LaGasse, 2010).
Marijuana Exposure Marijuana has replaced cocaine as the most common illicit drug used by women ages 18 to 44 years (nonpregnant and pregnant) in the United States (McCabe and Arndt, 2012). Marijuana crosses the placenta; however, specific effects on the fetus have been difficult to determine. Some studies have reported an association between the chronic use of marijuana and a decrease in infant birth weight and length (Gray, Eiden, Leonard, et al, 2010); however, this finding is confounded by cigarette smoking (Bandstra and Accornero, 2011). More subtle effects of major exposure, such as an increase in attention problems, have also been identified (Marroun, Hudziak, Tiemeier, et al, 2011). Compounding the issue of the effects of marijuana is multidrug use, which combines the harmful effects of marijuana, tobacco, alcohol, opiates, and cocaine. Long-term follow-up studies on exposed infants are needed.
Selective Serotonin Reuptake Inhibitors
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Studies estimate that between 8% and 13% of pregnant women experience major depression (Grote, Bridge, Gavin, et al, 2010). For many of these women, selective serotonin reuptake inhibitors (SSRIs) provide an important therapeutic benefit; however, these drugs may result in side effects in their newborns. Signs of withdrawal are present in up to one third of infants exposed to SSRIs in utero (Burgos and Burke, 2009). Findings include hypertonia, tremulousness, wakefulness, high-pitched crying, and feeding problems. An increased risk of persistent pulmonary hypertension has been reported in neonates exposed to SSRIs early in pregnancy (Galbally, Gentile, and Lewis, 2012); however, this finding has not been consistently reported (Wilson, Zelig, Harvey, et al, 2011). Some SSRIs are transferred into breast milk. Breastfeeding infants whose mothers are taking SSRIs should be monitored for sleep disturbances, irritability, and poor feeding.
Maternal Infections The range of pathologic conditions produced by infectious agents is large, and the difference between the maternal and fetal effects caused by any one agent is also great. Some maternal infections, especially during early gestation, can result in fetal loss or malformations because the fetus's ability to handle infectious organisms is limited and the fetal immunologic system is unable to prevent the dissemination of infectious organisms to the various tissues.
Not all prenatal infections produce teratogenic effects. Furthermore, the clinical picture of disorders caused by transplacental transfer of infectious agents is not always well defined. Some viral agents can cause remarkably similar manifestations, and it is common to test for all of them when a prenatal infection is suspected. This is the so-called TORCH complex, an acronym for:
Toxoplasmosis
Other (e.g., hepatitis B, parvovirus, HIV, West Nile)
Rubella
Cytomegalovirus infection
Herpes simplex
To determine the causative agent in a symptomatic infant, tests are performed to rule out each of these infections. The O category may involve testing for several viral infections (e.g., hepatitis B, varicella zoster, measles, mumps, HIV, syphilis, and human parvovirus). Bacterial infections are not included in the TORCH workup, because they are usually identified by clinical manifestations and readily available laboratory tests. Gonococcal conjunctivitis (ophthalmia neonatorum) and chlamydial conjunctivitis have been significantly reduced by prophylactic measures at birth (see Chapter 7). The major maternal infections, their possible effects, and specific nursing considerations are outlined in Table 8-12.
TABLE 8-12 Infections Acquired from the Mother Before, During, or After Birth*
Fetal or Newborn Effect Transmission Nursing Considerations† Human Immunodeficiency Virus No significant difference between infected and uninfected infants at birth
in some instances Embryopathy reported by some observers: • Depressed nasal bridge • Mild upward or downward obliquity of eyes • Long palpebral fissures with blue sclerae • Patulous lips • Ocular hypertelorism • Prominent upper vermilion border (See also Chapter 24)
Transplacental; during vaginal delivery; potentially in breast milk
Administer antiviral prophylaxis to the HIV-positive mother. The time of initiation (if not already on treatment) and the choice of regimens is determined by examining a number of factors, including the mother's current treatment. Detailed recommendations can be obtained from Office of AIDS Research Advisory Council (2014).
During labor, ZDV is recommended for all HIV-infected pregnant women, regardless of the antepartum treatment regimen.
Cesarean section in HIV-positive mothers is recommended to reduce transmission. HIV-exposed neonates should receive a 6-week course of ZDV (consider addition of
another antiretroviral drug based on maternal treatment and exposure). Avoid breastfeeding in HIV-positive mother. Documented routine HIV education and routine testing with consent for all pregnant
women in United States are recommended. Chickenpox (Varicella-Zoster Virus) Intrauterine exposure—congenital varicella syndrome: limb dysplasia,
microcephaly, cortical atrophy, chorioretinitis, cataracts, cutaneous scars, other anomalies, auditory nerve palsy, motor and cognitive delays
Severe symptoms (rash, fever) and higher mortality in infant whose mother develops varicella 5 days before to 2 days after delivery
First trimester (fetal varicella syndrome); perinatal period (infection)
Use varicella zoster immunoglobulin (VariZIG) or IVIG to treat infants born to mothers with onset of disease within 5 days before or 2 days after delivery.
Institute isolation precautions in newborn born to mother with varicella up to 21 to 28 days (latter time if newborn received VariZIG or IVIG after birth) if hospitalized.
Prevention: Universal immunization of all children with varicella vaccine.
Chlamydia Infection (Chlamydia Trachomatis) Conjunctivitis, pneumonia Last trimester or
perinatal period Standard ophthalmic prophylaxis for gonococcal ophthalmia neonatorum (topical
antibiotics, silver nitrate, or povidone iodine) is not effective in treatment or prevention of chlamydial ophthalmia.
Treat with oral erythromycin for 14 days.
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Coxsackievirus (Group B Enterovirus–Nonpolio) Poor feeding, vomiting, diarrhea, fever; cardiac enlargement,
arrhythmias, congestive heart failure; lethargy, seizures, meningeal involvement
Mimics bacterial sepsis
Peripartum Treatment is supportive. Provide IVIG in neonatal infections.
Cytomegalovirus Variable manifestation from asymptomatic to severe Microcephaly, cerebral calcifications, chorioretinitis Jaundice, hepatosplenomegaly Petechial or purpuric rash Neurologic sequelae—seizure disorders, sensorimotor deafness,
cognitive impairment
Throughout pregnancy
Infection acquired at birth, shortly thereafter, or via human milk is not associated with clinical illness.
Affected individuals excrete virus. Virus is detected in urine or tissue by electron microscopy. Pregnant women should avoid close contact with known cases. To treat infection, administer IV antivirals such as ganciclovir to newborn.
Parvovirus B19 (Erythema Infectiosum) Fetal hydrops and death from anemia and heart failure with early
exposure Anemia with later exposure No teratogenic effects established Ordinarily, low risk of adverse effect to fetus
Transplacental First trimester infection has most serious effects. Pregnant health care workers should not care for patients who might be highly
contagious (e.g., child with sickle cell anemia, aplastic crisis). Routine exclusion of pregnant women from workplace where disease is occurring is not
recommended. Gonococcal Disease (Neisseria Gonorrhoeae) Ophthalmitis Neonatal gonococcal arthritis, septicemia, meningitis
Last trimester or perinatal period
Apply prophylactic medication to eyes at time of birth. Obtain smears for culture. To treat infection, administer penicillin.
Hepatitis B Virus May be asymptomatic at birth Acute hepatitis, changes in liver function
Transplacental; contaminated maternal fluids or secretions during delivery
Administer HBIg to all infants of HBsAG-positive mothers within 12 hours of birth; in addition, administer hepatitis B vaccine at separate site.
Prevention: Universal immunization of all infants with hepatitis B vaccine (see Immunizations, Chapter 6).
Listeriosis (Listeria Monocytogenes) Maternal infection associated with abortion, preterm delivery, and fetal
death Preterm birth, sepsis, and pneumonia seen in early-onset disease; late-
onset disease usually manifests as meningitis
Transplacental by ascending infection or exposure at delivery
Hand washing is essential to prevent nosocomial spread. Treat infected newborn with antibiotics—ampicillin and gentamicin.
Rubella, Congenital (Rubella Virus) Eye defects—cataracts (unilateral or bilateral), microphthalmia, retinitis,
glaucoma CNS signs—microcephaly, seizures, severe cognitive impairment Congenital heart defects—patent ductus arteriosus Auditory—high incidence of delayed hearing loss IUGR Hyperbilirubinemia, meningitis, thrombocytopenia, hepatomegaly
First trimester; early second trimester
Pregnant women should avoid contact with all affected persons, including infants with rubella syndrome.
Emphasize vaccination of all unimmunized prepubertal children, susceptible adolescents, and women of childbearing age (nonpregnant).
Caution women against pregnancy for at least 3 months after vaccination.
Syphilis, Congenital (Treponema Pallidum) Stillbirth, prematurity, hydrops fetalis May be asymptomatic at birth and in first few weeks of life or may have
multisystem manifestations: hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia
Copper-colored maculopapular cutaneous lesions (usually after first few weeks of life), mucous membrane patches, hair loss, nail exfoliation, snuffles (syphilitic rhinitis), profound anemia, poor feeding, pseudoparalysis of one or more limbs, dysmorphic teeth (older child)
Transplacental; can be anytime during pregnancy or at birth
This is most severe form of syphilis. Treatment consists of IV penicillin. Diagnostic evaluation depends on maternal serology testing and infant symptoms
(American Academy of Pediatrics, Committee on Infectious Diseases, 2012).
Toxoplasmosis (Toxoplasma Gondii) May be asymptomatic at birth (70% to 90% of cases) or have
maculopapular rash, lymphadenopathy, hepatosplenomegaly, jaundice, thrombocytopenia
Hydrocephaly, cerebral calcifications, chorioretinitis (classic triad) Microcephaly, seizures, cognitive impairment, deafness Encephalitis, myocarditis, hepatosplenomegaly, anemia, jaundice,
diarrhea, vomiting, purpura
Throughout pregnancy
Predominant host for organism is cats
May be transmitted through cat feces or poorly cooked or raw infected meats
Caution pregnant women to avoid contact with cat feces (e.g., emptying cat litter boxes). Administer a combination of sulfadiazine and pyrimethamine (Daraprim) along with
supplemental folinic acid.
*This table is not an exhaustive representation of all perinatally transmitted infections. For further information regarding specific diseases or treatment not listed here, refer to American Academy of Pediatrics, Committee on Infectious Diseases, Pickering L, editor: 2012 red book: report of the Committee on Infectious Diseases, ed 29, Elk Grove Village, IL, 2012, American Academy of Pediatrics. †Isolation precautions depend on institutional policy (see Infection Control, Chapter 20). AIDS, Acquired immune deficiency syndrome; CNS, Central nervous system; HBsAG, hepatitis B surface antigen; HBIg, hepatitis B immunoglobulin; HIV, human immunodeficiency virus; IUGR, intrauterine growth restriction; IV, intravenous; IVIG, intravenous immunoglobulin; ZDV, zidovudine. From Nussbaum RL, McInnes RR, Willard HF: Thompson and Thompson genetics in medicine, ed 6 (rev reprint), Philadelphia, 2007, Saunders/Elsevier.
Nursing Care Management One of the major goals in care of infants suspected of having an infectious disease is identification of the causative organism. Standard precautions are implemented according to institutional policy. In suspected cytomegalovirus and rubella infections, pregnant health care personnel are cautioned to avoid contact with these infants. HSV is easily transmitted from one infant to another; therefore, the risk of cross-contamination is reduced or eliminated by wearing gloves for patient contact. The American Academy of Pediatrics' Red Book: 2012 Report of the Committee on Infectious Diseases provides guidelines for the type and duration of precautions for most bacterial and viral exposures (American Academy of Pediatrics, Committee on Infectious Diseases and Pickering, 2012). Careful hand washing is the most important nursing intervention in reducing the spread of any infection.
Specimens need to be obtained for laboratory examinations, and the infant and parents need to be prepared for diagnostic procedures. When possible, long-term disabilities are prevented by early evaluation and implementation of therapy. The family is taught any special handling techniques needed for the care of their infant and signs of complications or possible sequelae. If sequelae are inevitable, the family will need assistance in determining how they can best cope with the problems, such as assistance with home care, referral to appropriate agencies, or placement in an
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institution for care. The major goal of nursing care is prevention of these disorders with provision of adequate prenatal care for the expectant mother and precautions regarding exposure to teratogenic infections.
Defects Caused by Chemical Agents Prenatal environmental influences from chemicals such as alcohol, medications, or drugs of abuse; infectious disease; or radiation or other environmental influences may be regarded as nongenetic causes of congenital anomalies because these effects can produce congenital structural, functional, or growth defects. An agent that produces congenital malformations or increases their incidence is called a teratogen.
The relationship of the fetal and maternal circulations allows for the interchange of chemical substances across the placental membrane. Many drugs have been suspected of producing congenital malformations, and some have been definitely implicated. Some of the most recognized teratogenic drugs include alcohol, tobacco, antiepileptic medications, isotretinoin (Accutane), lithium, cocaine, and diethylstilbestrol (Table 8-13).
TABLE 8-13 Congenital Effects of Maternal Alcohol Ingestion and Tobacco Smoking
Fetal or Newborn Effects Comments and Nursing Care Management Alcohol (Fetal Alcohol Spectrum Disorder) Features vary—infant may not display physical
features; involves three main categories: • Growth failure in utero and after birth,
including microcephaly • Midfacial dysmorphic features • CNS involvement, including cognitive
impairment, irritability, hyperactivity, hypertonia, and behavioral problems
Facial features include hypoplastic maxilla; micrognathia; short palpebral fissures; thinned upper lip; hypoplastic philtrum; short, upturned nose.
One or a combination of these features present in infancy or later (may not appear until later in life).
Children or adults who demonstrate cognitive, behavioral, and psychosocial problems without physical features and growth delay are referred to as having ARND.
Affected infants may display nonspecific signs, such as irritability, lethargy, difficulty establishing respirations, seizures, tremors, poor suck reflex, and abdominal distention. Birth defects may occur but are less common.
Diagnosis is made more difficult by a lack of a single biologic marker and may be made based on maternal history of alcohol ingestion.
A number of terms (including ARND and FASD) have been proposed to describe the combination of findings.
Quantity of alcohol consumed is not the determinant; rather, it is the amount consumed in excess of the liver's ability to detoxify the alcohol. Free alcohol has an affinity for brain tissue, hence the CNS symptoms. Ethanol byproducts also contribute to toxicity, as do other substances consumed in addition to alcohol and poor maternal self-care. The effects of alcohol on the fetus occur across a continuum ranging from subtle neurological deficits to full-blown FAS. The term FASD is used to describe the range of clinical presentations ascribed to fetal alcohol exposure.
Early gestation is considered the most vulnerable period; however, exposure at any period may cause subtle damage to the developing fetus.
Effects of alcohol on CNS are not reversible. FASD is the leading cause of preventable cognitive impairment in the United States. Early intervention with mothers is aimed at minimizing fetal effects, education, and involvement in prevention and treatment
counseling. Early intervention with newborns focuses on reducing the effects of alcohol exposure on growing child, especially in relation to
cognitive deficits and learning disabilities. Treatment in the neonatal period is similar to that of drug-exposed infants and should involve extensive assessment and
individualized developmental care. Provide resources to help decrease or eliminate alcohol intake. During Your Pregnancy: Alcohol During Pregnancy is available at the
March of Dimes' website.* Further information is available from the National Organization on Fetal Alcohol Syndrome† and Centers for Disease Control and
Prevention.‡
Maternal Tobacco Smoking Smoking is associated with significant birth
weight deficits; positive dose-response relationship is related to size of fetus.
Two active substances—nicotine and cotinine—are higher in newborns of mothers who smoke than in mothers who do not.
Postnatal growth deficits occur, as do deficits in emotional and behavioral development in the growing child.
Maternal smoking is associated with an increased risk of SIDS, respiratory tract illnesses in childhood, and childhood learning deficits.
There is evidence that even secondhand smoke can be deleterious to unborn fetuses and growing children.
Counseling regarding fetal and postnatal effects should be made available to all pregnant women, and they are encouraged to stop smoking. Smoking cessation during pregnancy decreases the chance of fetal complications.
Encourage pregnant women to enroll in smoking cessation programs. Evaluate polydrug use in conjunction with smoking. An increased incidence of perinatal complications leading to preterm birth includes abruptio placentae, placenta previa, and
premature rupture of membranes. Provide resources to help eliminate smoking. During Your Pregnancy: Smoking During Pregnancy is available from the March of
Dimes.*
*http://www.marchofdimes.com. †1200 Eton Court NW, Third Floor, Washington, DC 20007; 202-785-4585; 800 66 NOFAS; http://www.nofas.org. ‡Fetal Alcohol Syndrome Branch, Division of Birth Defects, Child Development and Disability and Health, Centers for Disease Control and Prevention, Atlanta, http://www.cdc.gov/ncbddd/fas/default.htm. ARND, Alcohol-related neurodevelopmental disorder; CNS, central nervous system; FAS, fetal alcohol syndrome; FASD, fetal alcohol spectrum disorder; SIDS, sudden infant death syndrome.
The extent to which chemical agents affect the unborn child depends on the interplay of several factors, including the nature of the agent and its accessibility to the fetus, the gestational age at which exposure occurred, the level and duration of the dosage, and the genetic makeup of the fetus. For example, fetal exposure to valproic acid in the first 3 months of pregnancy may result in congenital anomalies such as neural tube defects, congenital heart defects, and distinctive facial features. The limited metabolic capabilities of the fetal liver and its immature enzyme and transport systems render the unborn child ill equipped for maintaining homeostasis when chemical
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disturbances are imposed by the mother or the environment. This includes both substances produced by the mother in response to a disease state (e.g., diabetes) and exogenous substances ingested or inhaled by the mother.
The teratogenic effect of drugs is not believed to have an effect on developing tissue until day 15 of gestation, when tissue differentiation begins to take place. Before that time, drugs usually have little effect because they are believed to have an insignificant affinity for undifferentiated tissue. Also, until implantation takes place, at approximately 7 days after conception, the embryo is not exposed to maternal blood that contains the drug. However, some drugs may affect the uterine lining, making it unsuitable for implantation. Drugs administered between days 15 and 90 may produce an effect if the tissue for which the drug has an affinity is in the process of differentiation at that time. After 90 days, when differentiation is complete, most fetal tissues are believed to be relatively resistant to teratogenic effects of drugs. However, the impact on ongoing neurologic development is not known.
Nursing Care Management Expectant mothers are cautioned against ingesting any medication without first consulting a practitioner. To help ensure that fewer women will inadvertently take some chemical that might be harmful to their fetuses, labels on medications are now required to include information regarding the possible teratogenic effects of each drug. All women of childbearing age should be educated regarding the effects of chemicals, especially alcohol, on unborn fetuses. FAS is an irreversible condition but is completely preventable. The March of Dimes* and Centers for Disease Control and Prevention† have information about prevention tips, and the Genetic Alliance‡ has information about support groups for families of children with FAS. Genetic counseling is recommended for women who have a concern about a possible teratogen during pregnancy.
N u r s i n g A l e r t One drug recognized for its carcinogenic effect is diethylstilbestrol. Large doses of this hormone, given to pregnant women in the United States between 1938 and 1971 to prevent abortion, caused adenocarcinoma of the vagina in a significant proportion of the female offspring when they reach adolescence and early adulthood.
Congenital Hypothyroidism Congenital hypothyroidism (CH) may have a number of causes and can be either permanent or transient. Transient CH is frequently associated with maternal Graves disease that was treated with antithyroid drugs. The majority of cases are sporadic (nonhereditary), but approximately 15% of all cases are transmitted as an autosomal dominant trait. The most common pathogenesis is thyroid dysgenesis, mostly with unknown causes. Worldwide, the most common cause of CH resulting in hypothyroidism is iodine deficiency. However, no matter what the cause, the manifestations and management are similar. In some conditions, the thyroid deficiency is severe, and manifestations develop early; in others, the symptoms may be delayed for months or years. Early detection and prompt initiation of treatment are essential because their delay will result in various degrees of cognitive impairment, in which the IQ loss has a direct relationship to the time treatment is initiated. If treatment is implemented from 0 to 3 months of age, the mean IQ attained is 89 (range, 64 to 107); if treatment begins at 3 to 6 months, mean IQ will reach 71 (range, 36 to 96); treatment initiated after 6 months of age will result in a mean IQ of 54 (range, 25 to 80).
Results of screening tests indicate that CH occurs in approximately 1 in 4000 to 1 in 3000 newborns (Langham, Hindmarsh, Krywawych, et al, 2013). It affects all races and ethnicities, but it is more prevalent among Hispanic and American Indian or Alaskan Native people (1 in 2000 to 1 in 700 newborns) and less prevalent among African Americans (1 in 3200 to 1 in 17,000 newborns). Also, a higher incidence of other congenital abnormalities has been observed in infants with CH. Many preterm infants have transient hypothyroidism (hypothyroxinemia) at birth as a result of hypothalamic and pituitary immaturity. Infants born before 28 weeks of gestation may require temporary thyroid hormone replacement. Some screening programs target both primary (thyroid- based) and secondary (pituitary-based) hypothyroidism.
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Diagnostic Evaluation Because CH is one of the most common preventable causes of cognitive impairment, early diagnosis and treatment of this disease are essential interventions. Neonatal screening consists of an initial filter paper blood spot T4 measurement followed by measurement of thyroid-stimulating hormone (TSH) in specimens with low T4 values.
Tests are mandatory in all US states and territories. Although a blood sample obtained by heel stick for the spot test is best obtained between 2 and 6 days of age, specimens are usually taken within the first 24 to 48 hours or before discharge as part of a concurrent screen for other metabolic defects. Early screening can result in overdiagnosis (false-positives) but is preferable to missing the diagnosis.
For screening results that show a low level of T4 (<10%), obtain TSH levels, and if these are elevated (>40 mU/L), further tests to determine the cause of the disease should be carried out (Stokowski, 2014). Additional tests include serum measurement of T4, triiodothyronine (T3), resin uptake, free T4, and thyroid-bound globulin. Tests of thyroid gland function (thyroid scan and uptake) usually involve oral administration of a radioactive isotope of iodine (131I) and measurement of iodine uptake by the thyroid, usually within 24 hours. In CH, protein-bound iodine, T4, T3, and free T4 levels are low, and thyroid uptake of 131I is decreased. Skeletal radiography is used to assess age.
In newborns, thyroid function studies are elevated in comparison with values in older children; therefore, it is important to document the timing of the tests. In preterm and sick full-term infants, thyroid function tests are usually lower than in healthy full-term infants; a repeat T4 and TSH may be evaluated after 30 weeks (corrected age) in newborns born before that time and after resolution of the acute illness in sick full-term infants.
Therapeutic Management Treatment involves lifelong thyroid hormone replacement therapy as soon as possible after diagnosis to abolish all signs of hypothyroidism and reestablish normal physical and mental development. The drug of choice is synthetic levothyroxine sodium (Synthroid, Levothroid). Optimum dosage of L-thyroxine should be able to maintain blood TSH concentration between 0.5 and 4.0 mU/L during the first 3 years of life (Stokowski, 2014). Regular measurement of T4 levels is important in ensuring optimum treatment. Bone age surveys are also performed to ensure optimum growth.
Prognosis If treatment is started shortly after birth, normal physical growth and intelligence are possible. The most significant factor adversely affecting eventual intellectual development appears to be inadequate treatment, which may be related to noncompliance. An appropriate approach to treatment remains a subject of debate. Some studies have shown that overtreatment of CH may also lead to lower cognitive scores in later childhood (Bongers-Schokking, Resing, de Rijke, et al, 2013).
Nursing Care Management The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in infants who are preterm, discharged early, or born at home. Approximately 10% of cases are detected only by a second screening at 2 to 6 weeks old. Nurses in community health need to be aware of the earliest signs of the disorder. Parental remarks about an unusually “quiet and good” baby and demonstrated symptoms (such as prolonged jaundice, constipation, and umbilical hernia) should lead to a suspicion of hypothyroidism, which requires a referral for specific tests.
After the diagnosis is confirmed, parents need an explanation of the disorder and the necessity of lifelong treatment. The child should be referred to a pediatric endocrinologist for care. The importance of compliance with the drug regimen for the child to achieve normal growth and development must be stressed (Stokowski, 2014). Because the drug is tasteless, it can be crushed and added to formula, water, or food. If a dose is missed, twice the dose should be given the next day. Unless there are maternal contraindicative factors, breastfeeding is acceptable and encouraged in infants with hypothyroidism (Lawrence and Lawrence, 2011). Parents also need to be aware of
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signs indicating overdose, such as a rapid pulse, dyspnea, irritability, insomnia, fever, sweating, and weight loss. Ideally, they should know how to count the pulse and be instructed to withhold a dose and consult their practitioner if the pulse rate is above a certain value. Signs of inadequate treatment are fatigue, sleepiness, decreased appetite, and constipation.
If the diagnosis was delayed past early infancy, the chance of permanent cognitive impairment is great. Parents need the same guidance in caring for their child as others who have an offspring with cognitive impairment (see Chapter 18). They need an opportunity to discuss their feelings regarding late recognition of the disorder. Although treatment will not reverse the intellectual deficit, it may prevent further damage. Genetic counseling is important for the rare families in which the etiology of CH is thyroid dyshormonogenesis, which is inherited in an autosomal recessive manner (see Genetic Evaluation and Counseling later in this chapter).
Phenylketonuria Phenylketonuria, an inborn error of metabolism inherited as an autosomal recessive trait (the PAH gene is located on chromosome 12q24), is caused by a deficiency or absence of the enzyme needed to metabolize the essential amino acid phenylalanine. Classic PKU is at one end of a spectrum of conditions known as hyperphenylalaninemia. Within the spectrum of hyperphenylalaninemia are conditions with varying degrees of severity depending on the degree of enzyme deficiency. Because rarer forms are a result of a deficiency in other enzymes and are diagnosed and treated differently, the following discussion of PKU is limited to the severe, classic form.
In PKU, the hepatic enzyme phenylalanine hydroxylase, which normally controls the conversion of phenylalanine to tyrosine, is deficient. This results in the accumulation of phenylalanine in the bloodstream and urinary excretion of abnormal amounts of its metabolites, the phenyl acids (Fig. 8- 23). One of these phenylketones, phenylacetic acid, gives urine the characteristic musty odor associated with the disease. Another is phenylpyruvic acid, which is responsible for the term phenylketonuria.
FIG 8-23 Metabolic error and consequences in phenylketonuria.
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Tyrosine, the amino acid produced by the metabolism of phenylalanine, is absent in PKU. Tyrosine is needed to form the pigment melanin and the hormones epinephrine and T4. Decreased melanin production results in similar phenotypes of most individuals with PKU, which is blond hair, blue eyes, and fair skin that is particularly susceptible to eczema and other dermatologic problems. Children with a genetically darker skin color may be red haired or brunette.
The prevalence of PKU varies widely in the United States because different states have different definition criteria for what constitutes hyperphenylalaninemia and PKU. The reported figures for PKU in the United States is 1 case per 15,000 live births. The disease has a wide variation of incidence by ethnic groups. In Europe, the incidence is 1 in 10,000 births; in Asia and Africa, the prevalence is quite low (Blau, van Spronsen, and Levy, 2010).
Clinical manifestations in untreated PKU include failure to thrive (growth failure); frequent vomiting; irritability; hyperactivity; and unpredictable, erratic behavior. Cognitive impairment is thought to be caused by the accumulation of phenylalanine and presumably by decreased levels of the neurotransmitters dopamine and tryptophan, which affect the normal development of the brain and CNS, resulting in defective myelinization, cystic degeneration of the gray and white matter, and disturbances in cortical lamination. Older children commonly display bizarre or schizoid behavior patterns such as fright reactions, screaming episodes, head banging, arm biting, disorientation, failure to respond to strong stimuli, and catatonia-like positions.
Diagnostic Evaluation* The objective in diagnosing and treating the disorder is to prevent cognitive impairment. Every newborn should be screened for PKU. The most commonly used test for screening newborns is the Guthrie blood test, a bacterial inhibition assay for phenylalanine in the blood. Bacillus subtilis, present in the culture medium, grows if the blood contains an excessive amount of phenylalanine. If performed properly, this test detects serum phenylalanine levels greater than 4 mg/dl (normal value, 1.6 mg/dl), but it will not quantify the results. Other methods for testing include quantitative fluorometric assay and tandem mass spectrometry, which will give an absolute value. Only fresh heel blood, not cord blood, can be used for the test.
Avoid “layering” the blood specimen on the special Guthrie paper. Layering is placing one drop of blood on top of the other or overlapping the specimen. This practice results in a falsely high reading, or false positive, which will lead the newborn screening department to call the family and physician to arrange for a diagnostic blood phenylalanine test to determine whether the newborn truly has PKU. Best results are obtained by collecting the specimen with a pipette from the heel stick and spreading the blood uniformly over the blot paper.
Because of the possibility of variant forms of hyperphenylalaninemia, PKU cofactor variant screen should be performed in all children diagnosed with PKU. A major concern is that a significant number of infants are not rescreened for PKU after early discharge and are at risk for a missed or delayed diagnosis. Give special consideration to screening infants born at home who have no hospital contact and infants adopted internationally.
Therapeutic Management* Treatment of PKU involves restricting phenylalanine in the diet. Because the genetic enzyme is intracellular, systemic administration of phenylalanine hydroxylase is of no value. Phenylalanine cannot be eliminated because it is an essential amino acid in tissue growth. Therefore, dietary management must meet two criteria: (1) meet the child's nutritional need for optimum growth and (2) maintain phenylalanine levels within a safe range (2 to 6 mg/dl in neonates and children up to 12 years old, and 2 to 10 mg/dl through adolescence) (Soltanizadeh and Mirmoghtadaie, 2014).
Professionals agree that infants with PKU who have blood phenylalanine levels higher than 10 mg/dl should be started on treatment to establish metabolic control as soon as possible, ideally by 7 to 10 days of age (Kaye, Committee on Genetics, Accurso, et al, 2006). The daily amounts of phenylalanine are individualized for each child and require frequent changes on the basis of appetite, growth and development, and blood phenylalanine and tyrosine levels.
Because all natural food proteins contain phenylalanine and will be limited, the diet must be supplemented with a specially prepared phenylalanine-free formula (e.g., Phenex-1 for infants or Phenex-2 for children and adults).* The phenylalanine-free formula is an amino acid–modified formula essential in the low phenylalanine diet to provide the appropriate protein, vitamins, minerals, and calories for optimal growth and development. Because tyrosine becomes an essential
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amino acid, the phenylalanine-free formula supplies an adequate amount, but in some cases, additional supplementation may be needed. The phenylalanine-free amino acid–modified formula for infants has all the nutrients necessary for adequate infant growth. Because of the low phenylalanine content of breast milk, total or partial breastfeeding may be possible with close monitoring of phenylalanine levels (Lawrence and Lawrence, 2011).
When treatment for PKU was first instituted, it was believed that phenylalanine withdrawal during only the first 3 years of age would suffice to avoid cognitive impairment and other deleterious manifestations of PKU. However, most clinicians now agree that to achieve optimal metabolic control and outcome, a restricted phenylalanine diet, including medical foods and low- protein products, most likely will be medically required for virtually all individuals with classic PKU for their entire lives (Soltanizadeh and Mirmoghtadaie, 2014). Such lifetime reduction of phenylalanine intake is necessary to prevent neuropsychological and cognitive deficits because even mild hyperphenylalaninemia (20 mg/dl) would produce such effects. To evaluate the effectiveness of dietary treatment, frequent monitoring of blood phenylalanine and tyrosine levels is necessary.
Phenylalanine levels greater than 6 mg/dl in mothers with PKU affect the normal embryologic development of the fetus, including cognitive impairment, cardiac defects, and LBW. It is recommended that phenylalanine levels below 6 mg/dl be achieved at least 3 months before conception in women with PKU (Koch, Trefz, and Waisbren, 2010).
Prognosis Although many individuals with treated PKU manifest no cognitive and behavioral deficits, many comparisons of individuals with PKU with control participants show lower performance on IQ tests, with larger differences in other cognitive domains; however, their performance is still in the average range. Evidence for differences in behavioral adjustment is inconsistent despite anecdotal reports suggesting greater risk for internalizing psychopathology and attention disorders. In addition, insufficient data are available on the effects of phenylalanine restriction over many decades of life (Kaye, Committee on Genetics, Accurso, et al, 2006). Recent data suggest that treatment with tetrahydrobiopterin in addition to the phenylalanine-restricted diet may be beneficial to PKU patients (Blau, van Spronsen, and Levy, 2010). Total bone mineral density is considerably lower in children who are on a low-phenylalanine diet even though calcium, phosphorus, and magnesium intakes are higher than normal.
Nursing Care Management The principal nursing considerations involve teaching the family regarding the dietary restrictions. Although the treatment may sound simple, the task of maintaining such a strict dietary regimen is demanding, especially for older children and adolescents. In addition, mothers of children with PKU may have to spend many hours preparing special foods, such as low-phenylalanine snacks. Foods with low phenylalanine levels (e.g., vegetables, fruits, juices, and some cereals, breads, and starches) must be measured to provide the prescribed amount of phenylalanine. High-protein foods, such as meat and dairy products, are eliminated from the diet. The sweetener aspartame (NutraSweet) should be avoided because it is composed of two amino acids, aspartic acid and phenylalanine, and if used will decrease the amount of natural phenylalanine that is prescribed for the day. However, medications that use aspartame as the sweetener may be used if no other nonaspartame medications are available because the content of the artificial sweetener is minimal or can be counted in the total daily phenylalanine allowance.
Maintaining the diet during infancy presents few problems. Solid foods such as cereal, fruits, and vegetables are introduced as usual to the infant. Difficulties arise as the child gets older. Studies show a gradual decline in diet compliance with consequent increases in blood phenylalanine levels during early adolescence and young adulthood (Channon, Goodman, Zlotowitz, et al, 2007).
A decreased appetite and refusal to eat may reduce intake of the calculated phenylalanine requirement. The child's increasing independence may also inhibit absolute control of what he or she eats. Either factor can result in decreased or increased phenylalanine levels. During the school years, peer pressure becomes a major force in deterring the child from eating the prescribed foods or abstaining from high-protein foods, such as milkshakes and ice cream. Limitations of this diet are best illustrated by an example: a quarter-pound hamburger may provide a 2-day phenylalanine allowance for a school-age child.
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The assistance of a registered dietitian is essential. Parents need a basic understanding of the disorder and practical suggestions regarding food selection and preparation.* Meal planning is based on weighing the food on a gram scale; a less accurate method is the exchange list. As soon as children are old enough, usually by early preschool, they should be involved in the daily calculation, menu planning, and formula preparation. Using a computer, voice-activated calculator, cards, or colored beads can help children keep track of the daily allowance of phenylalanine foods. A system of goal setting, self-monitoring, contracts, and rewards can promote compliance in adolescents.
Preparation of the phenylalanine-free formula can present some challenges. The formula tends to be lumpy; mixing the powder with a small amount of water to make a paste and then adding the rest of the required liquid, helps alleviate this problem. A blender or mixer dissolves the powder more easily; a rechargeable hand mixer can be used when traveling. Although the taste is virtually impossible to camouflage, many new products are on the market today. Some of the complete formulas are chocolate, vanilla, strawberry, and orange flavored. Incomplete formulas are also available that do not contain the vitamins and minerals and are plain tasting; these can be added to cold foods instead of mixing them as a formula. Formula bars are convenient for active adolescents. Formula capsules are also available, but the patient would need to take 20 or more capsules per day.
Family Support† In addition to the problem related to a child with a chronic disorder (see Chapter 17), the parents have the burden of knowing that they are carriers of the defect. Genetic counseling is especially important to inform the parents that prenatal testing is now available to detect the presence of the defective gene in heterozygotes. Counseling is also important for adults with PKU to inform them that all of their offspring will be carriers for PKU (see Genetic Evaluation and Counseling).
Galactosemia Galactosemia is a rare autosomal recessive disorder that results from various gene mutations leading to three distinct enzymatic deficiencies. The most common type of galactosemia (classic galactosemia) results from a deficiency of a hepatic enzyme, galactose 1-phosphate uridyltransferase (GALT), and affects approximately 1 in 50,000 births. The other two varieties of galactosemia involve deficiencies in the enzymes galactokinase (GALK) and galactose 4′-epimerase (GALE); these are extremely rare disorders. All three enzymes (GALT, GALK, and GALE) are involved in the conversion of galactose into glucose.
As galactose accumulates in the blood, several organs are affected. Hepatic dysfunction leads to cirrhosis, resulting in jaundice in the infant by the second week of life. The spleen subsequently becomes enlarged as a result of portal hypertension. Cataracts are usually recognizable by 1 or 2 months of age; cerebral damage, manifested by the symptoms of lethargy and hypotonia, is evident soon afterward. Infants with galactosemia appear normal at birth, but within a few days of ingesting milk (which has a high lactose content), they begin to experience vomiting and diarrhea, leading to weight loss. E. coli sepsis is also a common presenting clinical sign. Death during the first month of life is frequent in untreated infants. Occasionally classic galactosemia is seen with milder, chronic manifestations, such as growth failure, feeding difficulty, and developmental delay. This presentation is more frequent among African-American children with galactosemia (Kaye, Committee on Genetics, Accurso, et al, 2006).
Diagnostic Evaluation Diagnosis is made on the basis of the infant's history, physical examination, galactosuria, increased levels of galactose in the blood, and decreased levels of GALT activity in erythrocytes. The infant may display characteristics of malnutrition; hypoglycemia, jaundice, hepatosplenomegaly, sepsis, cataracts, and decreased muscle tone (Bosch, 2006). Newborn screening for this disease is required in most states. Heterozygotes can also be identified because heterozygotic individuals have significantly lower levels of the essential enzyme.
Therapeutic Management During infancy, treatment consists of eliminating all milk and lactose-containing formula, including
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breast milk. Traditionally, lactose-free formulas are used, with soy-protein formula being the feeding of choice; however, some research suggests that elemental formula (galactose-free) may be more beneficial than soy formulas (Zlatunich and Packman, 2005). However, the American Academy of Pediatrics recommends the use of soy protein–based formula for infants with galactosemia, and it is considerably less expensive than elemental formula (Bhatia, Greer, and Committee on Nutrition, 2008). As the infant progresses to solids, only foods low in galactose should be consumed. Certain fruits are high in galactose, and some dietitians recommend that they be avoided. Food lists should be given to the family to ensure that appropriate foods are chosen.
If galactosemia is suspected, supportive treatment and care are implemented, including monitoring for hypoglycemia, liver failure, bleeding disorders, and E. coli sepsis.
Prognosis Follow-up studies of children treated from birth or within the first 2 months of life after symptoms appear have found long-term complications, such as hypogonadism, cognitive impairment, growth restriction, and verbal and motor delays (Bosch, 2006). These findings have revealed that eliminating sources of galactose does not significantly improve the outcome. New therapeutic strategies, such as enhancing residual transferase activity, replacing depleted metabolites, and using gene replacement therapy, are needed to improve the prognosis for these children.
Nursing Care Management* Nursing interventions are similar to those for PKU except that dietary restrictions are easier to maintain because many more foods are allowed. However, reading food labels carefully for the presence of any form of lactose, especially dairy products, is mandatory. Many drugs, such as some of the penicillin preparations, contain lactose as filler and also must be avoided. Unfortunately, lactose is an unlabeled ingredient in many pharmaceuticals. Therefore, instruct parents to ask their local pharmacist about galactose content of any over-the-counter or prescription medication.
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Genetic Evaluation and Counseling Genetic counseling is a communication process concerned with the human problems associated with the occurrence, or risk of occurrence, of a genetic disorder in a family. It involves relaying information about the diagnosis, treatment options, recurrence risk, and availability of prenatal diagnosis. With the completion of the Human Genome Project, the international project to determine the total genetic information in humans, a new era of human genetics is unfolding (International Human Genome Sequencing Consortium, 2004), and it will lead to a better understanding of specifically how genetic variation contributes to health and disease. It is essential that nurses master the basic principles of heredity, understand how heredity contributes to disorders, and be aware of the types of genetic testing available (Table 8-14).
TABLE 8-14 Types of Genetic Testing
Test and Method Specimen Indication Comments Chromosome analysis (karyotyping) Blood, skin,
amniocytes, bone marrow
Detection of chromosomal abnormality, sex determination, cancer classification
Almost 100% accuracy for whole or partial chromosomal abnormality; will not detect microdeletions or duplication (submicroscopic chromosome segments), single-gene defects, or multifactorial disorders
Fluorescence in situ hybridization (FISH)
Blood, skin, amniocytes, bone marrow
Detection of microdeletion or duplications of chromosome segments (not visible by chromosome analysis)
A technique that is a cross between chromosome analysis and single-gene DNA tests
Direct DNA mutation detection (polymerase chain reaction, Southern blot, gene sequencing)
Blood, skin, amniocytes
Detection of gene mutation(s) in affected individual for diagnosis, in unaffected carrier, or for presymptomatic diagnosis
Gene location must be mapped, and disease-producing mutations must be characterized; can test single individual
Indirect DNA linkage studies (restriction length fragment polymorphisms, microsatellites, genetic markers)
Blood Prediction of carrier or presymptomatic status based on inheritance of same chromosome segment as in known affected individual
Must test several family members, including one or two confirmed affected individuals, for testing to be valid
Biochemical Blood, skin, amniotic fluid, muscle biopsy, urine, stool, CSF
Detection of metabolic pathway errors, enzyme defects, prenatal neural tube or ventral wall defect
Results may be difficult to interpret if partial pathway error or modified substrate is present
Maternal serum α-fetoprotein levels screen for neural tube and ventral wall defects
CSF, Cerebrospinal fluid; DNA, deoxyribonucleic acid.
Nurses frequently encounter children with genetic diseases and families in which there is a risk that a disorder may be transmitted to or occur in an offspring. It is a responsibility of nurses to be alert to situations in which persons could benefit from a genetic evaluation and counseling (see Nursing Care Guidelines box), to be aware of the local genetic resources, to aid families in finding services, and to offer support and care for children and families affected by genetic conditions. Local genetic clinics can be located through several sites; for example, GeneTests,* a publicly funded medical genetics information resource developed for physicians and other health care providers, is available at no cost to all interested persons. Another resource is the National Society of Genetic Counselors,† which lists genetic counselors by states in the United States.
N u r s i n g C a r e G u i d e l i n e s Common Indications for Referral
Previous child with multiple congenital anomalies; cognitive impairment; or an isolated birth defect, such as neural tube defect, cleft lip, or cleft palate
Family history of a hereditary condition, such as cystic fibrosis, fragile X syndrome, or diabetes
Prenatal diagnosis of advanced maternal age or other indication
Consanguinity
Teratogen exposure, such as to occupational chemicals, medications, or alcohol
Repeated pregnancy loss or infertility
Newly diagnosed abnormality or genetic condition
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Before undertaking genetic testing and after receiving results, particularly when testing for susceptibility to late-onset disorders, such as cancer or neurologic disease
As follow-up for a positive newborn test, as with phenylketonuria, or a heterozygote screening test, such as Tay-Sachs disease
From Nussbaum R, McInnes R, Willard H: Thompson and Thompson genetics in medicine, ed 6, Philadelphia, 2007, Saunders/Elsevier.
Maintaining contact with the family or referring the family to an agency that can provide a sustained relationship, usually the public health agency in their locality, is one of the most important aspects in the care of the patient and family. In a disorder that requires conscientious diet management, such as PKU or galactosemia, it is important to make certain that the family understands and follows the advice. A vital role for nurses is to advocate for the child and family as they make their way through the various specialty clinics. This is especially important for families that are more vulnerable because of cognitive, hearing, language, or financial issues and those who otherwise may have difficulty accessing health services. Nurses can reinforce the genetic information or arrange for additional genetic counseling if a family has additional questions or misunderstandings.
One of the current ethical concerns is the testing of healthy children for carrier status of a genetic condition that either will not have adverse consequences until adulthood or only has reproductive implications. The American Academy of Pediatrics, Committee on Bioethics (2001, reaffirmed 2008) policy statement does not support the broad use of carrier testing or screening in children or adolescents. When there is no clear medical benefit to testing in childhood, the child should be permitted to wait until adulthood to choose whether or not to be tested. Genetic counseling is recommended to help the family weigh all of the issues.
Psychological Aspects of Genetic Disease The diagnosis of a genetic disorder in a child can be a life-altering experience for families. They may have to reassess their perception of “self” and the loss of the dream of the perfect infant. Parents may change educational, employment, and reproductive plans after the diagnosis of a genetic disorder in their child.
Families may need to have the genetic information repeated several times. Families may also encounter ethical or moral dilemmas regarding genetic evaluation and testing options, as well as potential involvement of other family members. Nurses are pivotal caregivers in assessing the family's understanding of the genetic disorder, psychological responses, and coping mechanisms. Nurses may help families by providing support and attempting to alleviate possible feelings of guilt and by helping the family make the best possible adjustment to the disorder.
It is important to stress that there is nothing shameful about an inherited or congenital defect and to emphasize any appropriate remedy. The thought of a hereditary disorder often creates intrafamily strife, hostility, and marital disharmony, sometimes to the point of family disintegration. Relatives may change their reproductive plans after the diagnosis of a genetic disorder in a member, or the decision to reproduce may be postponed indefinitely on the basis of a disorder in a relative, even a remote one. Although people may understand the information on an intellectual level, they may still harbor fears on an emotional level. Nurses can help the family identify their personal strengths and offer them information about local and national support groups. (The Genetic Alliance* is a nonprofit organization that has a database of support groups for genetic conditions.) Finally, it is important to keep in mind that the infant or child has the same basic needs after the diagnosis of a genetic disorder as he or she had before the diagnosis.
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NCLEX Review Questions 1. Identify the anatomic changes that occur shortly after birth that affect the newborn's adaptation to
extrauterine existence. Select all that apply. a. Closure of the foramen ovale b. Closure of the ductus arteriosus c. Increase in pulmonary vascular resistance d. Closure of the ductus venosus e. Decrease in pulmonary vascular resistance
2. In the newly born infant, thermogenesis is achieved by: a. Shivering b. Brown fat metabolism c. Overhead warming unit d. Skin-to-skin contact with mother
3. What does the Apgar scoring system assess? Select all that apply. a. Respiratory effort b. Heart rate c. Core temperature d. Reflex irritability e. Muscle tone f. Color
4. A newborn whose mother is positive for Chlamydia trachomatis should be optimally treated with which of these to prevent ophthalmia? a. Silver nitrate solution (1%) b. Tetracycline ophthalmic ointment (1%) c. Oral erythromycin d. Erythromycin ophthalmic solution (0.5%)
5. A healthy infant is born to a mother with known high-risk behaviors whose HIV status is undetermined. The mother states that she wishes to breastfeed her infant. The nurse's response to the mother's request should be based on which of the following information? a. HIV is rarely transmitted to the newborn through maternal milk. b. Breastfeeding should be withheld until HIV status (maternal) is determined. c. Breastfeeding should be avoided completely in mothers with high-risk behaviors. d. In such infants, antiretroviral medication should be started within 12 hours of birth.
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Correct Answers 1. a, b, d, e; 2. b;
3. a, b, d, e, f; 4. c;
5. b
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*Information is available from Vascular Birthmarks Foundation, http://www.birthmark.org. *http://www.hmbana.org. *Information is available from the National Institute of Child Health and Human Development's Safe to Sleep Public Education Campaign, http://www.nichd.nih.gov/sts. *http://www.safercar.gov/parents/CarSeats/Right-Seat-Age-And-Size-Recommendations.htm. *PO Box 3696, Oakbrook, IL 60522-3696; 630-990-0010, 877-969-0010; http://www.compassionatefriends.org/home.aspx. †Contact Maureen Connelly, 4324 Berrywick Terrace, St. Louis, MO 63128; 314-487-7582; or Martha Eise, [email protected]; http://www.amendgroup.com.
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‡National Share Office, 402 Jackson Street, St. Charles, MO, 63301; 800-821-6819. *Note that the term addiction is often associated with behaviors whereby the person seeks the drug(s) to experience a high or euphoria, escape from reality, or satisfy a personal need. Newborns who have been exposed to drugs in utero are not addicted in a behavioral sense, yet they may experience mild to strong physiologic signs as a result of the exposure. Therefore, to say that an infant born to a mother who uses substances is addicted is incorrect; drug-exposed newborn is a better term, which implies intrauterine drug exposure. *1275 Mamaroneck Ave., White Plains, NY 10605; 914-997-4488; http://www.marchofdimes.com. †http://www.cdc.gov/. ‡4301 Connecticut Ave. NW, Suite 404, Washington, DC 20008; http://www.geneticalliance.org. *Always refer patient to a genetic metabolic specialist. For a reference list, visit the American Society of Human Genetics' website, http://www.ashg.org. *For more information, contact American Society of Human Genetics, 9650 Rockville Pike, Bethesda, MD 20814; 301-634-7300, 866- HUM-GENE; http://www.ashg.org. *A resource for dietary management is Acosta PB, Yannicelli S: The Ross metabolic formula system nutrition support protocols, ed 4, Columbus, OH, 2001, Abbott Nutrition; 800-227-5767; http://abbottnutrition.com. *A helpful resource is Schuett V, editor: Low protein cookery for phenylketonuria, ed 3, Madison, WI, 1997, University of Wisconsin Press. †National support groups include the Children's PKU Network, which offers a variety of support services; contact 3790 Via de la Valle, Suite 120, Del Mar, CA 92014; 800-377-6677; email: [email protected]; http://www.pkunetwork.org, and the National PKU Alliance, contact Christine Brown, Executive Director, PO Box 501, Tomahawk, WI 54487; 715-437-0477; http://www.npkua.org. *Information and support for parents can be found at the American Liver Foundation, http://www.liverfoundation.org; and at Parents of Galactosemic Children, Inc., PO Box 2401, Mandeville, LA 74070-2401; 866-900-PGC1; http://www.galactosemia.org. *http://www.ncbi.nlm.nih.gov/sites/GeneTests. †http://www.nsgc.org. *http://www.geneticalliance.org.
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U N I T 4 Family-Centered Care of the Infant
OUTLINE 9 Health Promotion of the Infant and Family 10 Health Problems of Infants
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Health Promotion of the Infant and Family Cheryl C. Rodgers
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Promoting Optimal Growth and Development Biologic Development At no other time in life are physical changes and developmental achievements as dramatic as during infancy. All major body systems undergo progressive maturation, and there is concurrent development of skills that increasingly allow infants to respond to and cope with the environment. Acquisition of these fine and gross motor skills occurs in an orderly head-to-toe and center-to- periphery (cephalocaudal-proximodistal) sequence.
Proportional Changes During the first year of life, especially the initial 6 months, growth is very rapid. Infants gain 150 to 210 g (≈5 to 7 oz) weekly until they are approximately 5 to 6 months old, which is when the birth weight has at least doubled. An average weight for a 6-month-old child is 7.3 kg (16 pounds). Weight gain slows during the second 6 months. By 1 year old, the infant's birth weight has tripled, for an average weight of 9.75 kg (21.5 pounds). Infants who are breastfed beyond 4 to 6 months old typically gain less weight than those who are bottle fed, yet their head circumference is more than adequate. There is evidence that breastfed infants tend to self-regulate energy intake. This self- regulation of intake with breastfeeding (vs. formula [bottle] feeding) is believed to have further significance in the development of childhood obesity and subsequent cardiovascular disease (Fewtrell, 2011). Researchers also found that infants who were breastfed in early infancy were more likely to regulate their appetite in late infancy and childhood than infants who were bottle fed (DiSantis, Collins, Fisher, et al, 2011).
Height increases by 2.5 cm (1 inch) a month during the first 6 months of life and also slows during the second 6 months. Increases in length occur in sudden spurts, rather than in a slow, gradual pattern. The average height is 65 cm (25.5 inches) at 6 months old and 74 cm (29 inches) at 12 months old. By 1 year old, the birth length has increased by almost 50%. This increase occurs mainly in the trunk rather than in the legs and contributes to the characteristic physique of the infant.
Head growth is also rapid. Head circumference increases approximately 2 cm (0.75 inch) per month for the first 3 months, 1 cm (0.4 inch) per month from 4 to 6 months, then the rate of growth declines to only 0.5 cm (0.2 inch) monthly during the second 6 months. The average size is 43 cm (17 inches) at 6 months and 46 cm (18 inches) at 12 months. By 1 year, head size has increased by almost 33%. Closure of the cranial sutures occurs, with the posterior fontanel fusing by 6 to 8 weeks old and the anterior fontanel closing by 12 to 18 months old (average, 14 months old).
Expanding head size reflects the growth and differentiation of the nervous system. By the end of the first year, the brain has increased in weight about 2.5 times. Maturation of the brain is exhibited in the dramatic developmental achievements of infancy (Table 9-1). Primitive reflexes are replaced by voluntary, purposeful movement, and new reflexes that influence motor development appear.
TABLE 9-1 Growth and Development During Infancy
Physical Gross Motor Fine Motor Sensory Vocalization Socialization and Cognition 1 Month Old Weight gain of 150 to 210
g (5 to 7 oz) weekly for first 6 months
Height gain of 2.5 cm (1 inch) monthly for first 6 months
Head circumference increases by 1.5 cm (0.5 inch) monthly for first 6 months
Primitive reflexes present and strong
Doll's eye reflex and dance reflex fading
Obligatory nose breathing (most infants)
•Assumes flexed position with pelvis high but knees not under abdomen when prone (at birth, knees flexed under abdomen)
•Can turn head from side to side when prone; lifts head momentarily from bed (see Fig. 9-3, A)
Has marked head lag, especially when pulled from lying to sitting position (see Fig. 9-2, A)
Holds head momentarily parallel and in midline when suspended in prone position
Assumes asymmetric tonic neck flex position when supine
When held in standing position, body is limp at knees and hips
In sitting position, back is uniformly rounded, with absence of head control
Hands predominantly closed
Grasp reflex strong Hand clenches on
contact with rattle
•Able to fixate on moving object in range of 45 degrees when held at a distance of 20 to 25 cm (8 to 10 inches)
Visual acuity approaches 20/100*
Follows light to midline Quiets when hears a voice
Cries to express displeasure
Makes small, throaty sounds
Makes comfort sounds during feeding
Is in sensorimotor phase—stage I, use of reflexes (birth to 1 month old), and stage II, primary circular reactions (1 to 4 months old)
Watches parent's face intently as she or he talks to infant
2 Months Old
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Posterior fontanel closed Crawling reflex
disappears
•Assumes less flexed position when prone—hips flat, legs extended, arms flexed, head to side
Less head lag when pulled to sitting position (see Fig. 9-2, B)
Can maintain head in same plane as rest of body when held in ventral suspension
When prone, can lift head almost 45 degrees off table
When moved to sitting position, head is held up but bends forward (see Fig. 9-5, B)
Assumes symmetric tonic neck position intermittently
Hands often open Grasp reflex fading
Binocular fixation and convergence to near objects beginning
When supine, follows dangling toy from side to point beyond midline
Visually searches to locate sounds
Turns head to side when sound is made at level of ear
•Vocalizes, distinct from crying
Crying becomes differentiated
Coos Vocalizes to familiar
voice
•Demonstrates social smile in response to various stimuli
3 Months Old Primitive reflexes fading Able to hold head more erect
when sitting but still bobs forward
Has only slight head lag when pulled to sitting position
Assumes symmetric body positioning
Able to raise head and shoulders from prone position to a 45- to 90-degree angle from table; bears weight on forearms
When held in standing position, able to bear slight fraction of weight on legs
Regards own hand
•Actively holds rattle but will not reach for it
Grasp reflex absent Hands kept loosely
open Clutches own hand;
pulls at blankets and clothes
•Follows objects to periphery (180 degrees)
•Locates sound by turning head to side and looking in same direction
Begins to have ability to coordinate stimuli from various sense organs
•Squeals aloud to show pleasure
Coos, babbles, chuckles
Vocalizes when smiling
“Talks” a great deal when spoken to
Less crying during periods of wakefulness
Displays considerable interest in surroundings
Ceases crying when parent enters room Can recognize familiar faces and objects,
such as feeding bottle Shows awareness of strange situations
4 Months Old Drooling begins Moro, tonic neck, and
rooting reflexes have disappeared
•Has almost no head lag when pulled to sitting position (see Fig. 9-2, C)
•Balances head well in sitting position (see Fig. 9-5, C)
Back less rounded, curved only in lumbar area
Able to sit erect if propped up Able to raise head and chest off
surface to angle of 90 degrees (see Fig. 9-3, B)
Assumes predominant symmetric position
•Rolls from back to side
•Inspects and plays with hands; pulls clothing or blanket over face in play
Tries to reach objects with hand but overshoots
Grasps object with both hands
Plays with rattle placed in hand and shakes it but cannot pick it up if dropped
Can carry objects to mouth
Able to accommodate to near objects
Binocular vision fairly well established
Can focus on a 1.25-cm (0.5- inch) block
Beginning eye–hand coordination
Makes consonant sounds n, k, g, p, b
•Laughs aloud Vocalization changes
according to mood
Is in stage III, secondary circular reactions
Demands attention by fussing; becomes bored if left alone
Enjoys social interaction with people Anticipates feeding when sees bottle or
mother if breastfeeding Shows excitement with whole body,
squeals, breathes heavily Shows interest in strange stimuli Begins to show memory
5 Months Old Beginning signs of tooth
eruption Birth weight doubles
No head lag when pulled to sitting position
When sitting, able to hold head erect and steady
Able to sit for longer periods when back is well supported
Back straight When prone, assumes symmetric
positioning with arms extended
•Can turn over from abdomen to back
When supine, puts feet to mouth
•Able to grasp objects voluntarily
Uses palmar grasp, bi- dextrous approach
Plays with toes Takes objects directly to
mouth Holds one cube while
regarding a second one
Visually pursues a dropped object
Is able to sustain visual inspection of an object
Can localize sounds made below ear
Squeals Makes cooing vowel
sounds interspersed with consonant sounds (e.g., ah-goo)
Smiles at mirror image Pats bottle or breast with both hands More enthusiastically playful but may
have rapid mood swings Is able to discriminate strangers from
family Vocalizes displeasure when object is
taken away Discovers parts of body
6 Months Old Growth rate may begin to
decline Weight gain of 90 to 150 g
(3 to 5 oz) weekly for next 6 months
Height gain of 1.25 cm (0.5 inch) monthly for next 6 months
•Teething may begin with eruption of two lower central incisors
•Chewing and biting occur
When prone, can lift chest and upper abdomen off surface, bearing weight on hands (see Fig. 9-3, C)
When about to be pulled to a sitting position, lifts head
Sits in high chair with back straight
Rolls from back to abdomen When held in standing position,
bears almost all of weight Hand regard absent
Re-secures a dropped object
Drops one cube when another is given
Grasps and manipulates small objects
Holds bottle Grasps feet and pulls to
mouth
Adjusts posture to see an object
Prefers more complex visual stimuli
Can localize sounds made above ear
Will turn head to the side and then look up or down
•Begins to imitate sounds
•Babbling resembles one-syllable utterances—ma, mu, da, di, hi
Vocalizes to toys, mirror image
Takes pleasure in hearing own sounds (self-reinforcement)
Recognizes parents; begins to fear strangers
Holds arms out to be picked up Has definite likes and dislikes Begins to imitate (cough, protrusion of
tongue) Excites on hearing footsteps •Briefly searches for a dropped object
(object permanence beginning) Frequent mood swings, from crying to
laughing, with little or no provocation
7 Months Old Eruption of upper central incisors
When supine, spontaneously lifts head off surface
•Sits, leaning forward on both hands (see Fig. 9-5, D)
When prone, bears weight on one hand
Sits erect momentarily Bears full weight on feet (see Fig.
9-6, A) When held in standing position,
bounces actively
•Transfers objects from one hand to the other (see Fig. 9-5, E)
Has uni-dextrous approach and grasp
Holds two cubes more than momentarily
Bangs cubes on table Rakes at a small object
•Can fixate on very small objects
Responds to own name Localizes sound by turning
head in a curving arch Beginning awareness of
depth and space Has taste preferences
•Produces vowel sounds and chained syllables—baba, dada, kaka
Vocalizes four distinct vowel sounds
“Talks” when others are talking
•Increasing fear of strangers; shows signs of fretfulness when parent disappears
Imitates simple acts and noises Tries to attract attention by coughing or
snorting Plays peek-a-boo Demonstrates dislike of food by keeping
lips closed Exhibits oral aggressiveness in biting and
mouthing Demonstrates expectation in response to
repetition of stimuli 8 Months Old Begins to show regular
patterns in bladder and bowel elimination
Parachute reflex appears (see Fig. 9-4)
•Sits steadily unsupported (see Fig. 9-5, E)
Readily bears weight on legs when supported; may stand holding onto furniture
Adjusts posture to reach an object
Has beginning pincer grasp using index, fourth, and fifth fingers against lower part of thumb
Releases objects at will Rings bell purposely Retains two cubes while
regarding third cube Secures an object by
pulling on a string Reaches persistently for
toys out of reach
Makes consonant sounds t, d, w
Listens selectively to familiar words
Utterances signal emphasis and emotion
Combines syllables, such as dada, but does not ascribe meaning to them
Increasing anxiety over loss of parent, particularly mother, and fear of strangers
Responds to word “no” Dislikes dressing, diaper change
9 Months Old Eruption of upper lateral incisor may begin
Creeps on hands and knees Sits steadily on floor for
prolonged time (10 minutes) Recovers balance when leaning
forward but cannot do so when leaning sideways
•Pulls self to standing position and stands holding on to furniture (see Fig. 9-6, B and C)
•Uses thumb and index finger in crude pincer grasp (see Fig. 9-1)
Preference for use of dominant hand now evident
Grasps third cube Compares two cubes by
bringing them
Localizes sounds by turning head diagonally and directly toward sound
Depth perception increasing
Responds to simple verbal commands
Comprehends “no-no”
Parent (mother) is increasingly important for own sake
Shows increasing interest in pleasing parent
Begins to show fears of going to bed and being left alone
Puts arms in front of face to avoid having it washed
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together 10 Months Old Labyrinth-righting reflex is strongest when infant is in prone or supine position; is able to raise head
Can change from prone to sitting position
Stands while holding on to furniture; sits by falling down
Recovers balance easily while sitting
While standing, lifts one foot to take a step (see Fig. 9-6, D)
Crude release of an object beginning
Grasps bell by handle
•Says “dada,” “mama” with meaning
Comprehends “bye- bye”
May say one word (e.g., “hi,” “bye,” “no”)
Inhibits behavior to verbal command of “no-no” or own name
Imitates facial expressions; waves bye- bye
Extends toy to another person but will not release it
•Develops object permanence Repeats actions that attract attention and
cause laughter Pulls clothes of another to attract
attention Plays interactive games, such as pat-a-
cake Reacts to adult anger; cries when scolded Demonstrates independence in dressing,
feeding, locomotive skills, and testing of parents
Looks at and follows picture in a book 11 Months Old Eruption of lower lateral incisor may begin
When sitting, pivots to reach toward back to pick up an object
•Cruises or walks holding on to furniture or with both hands held
Explores objects more thoroughly (e.g., clapper inside bell)
Has neat pincer grasp Drops object
deliberately for it to be picked up
Puts one object after another into a container (sequential play)
Able to manipulate an object to remove it from tight-fitting enclosure
Imitates definite speech sounds
Experiences joy and satisfaction when a task is mastered
Reacts to restrictions with frustration Rolls ball to another on request Anticipates body gestures when a
familiar nursery rhyme or story is being told (e.g., holds toes and feet in response to “This little piggy went to market”)
Plays games up-down, “so big,” or peek- a-boo
Shakes head for “no”
12 Months Old •Birth weight tripled •Birth length increased
by 50% Head and chest
circumference equal (head circumference 46 cm [18 inches])
Has six to eight deciduous teeth
Anterior fontanel almost closed
Landau reflex fading Babinski reflex
disappears Lumbar curve develops;
lordosis evident during walking
•Walks with one hand held Cruises well •May attempt to stand alone
momentarily; may attempt first step alone
Can sit down from standing position without help
Releases cube in cup Attempts to build two-
block tower but fails Tries to insert a pellet
into a narrow-necked bottle but fails
Can turn pages in a book, many at a time
Discriminates simple geometric forms (e.g., circle)
Amblyopia may develop with lack of binocularity
Can follow rapidly moving object
Controls and adjusts response to sound; listens for sound to recur
•Says three to five words besides “dada,” “mama”
Comprehends meaning of several words (comprehension always precedes verbalization)
Recognizes objects by name
Imitates animal sounds
Understands simple verbal commands (e.g., “Give it to me,” “Show me your eyes”)
Shows emotions, such as jealousy, affection (may hug or kiss on request), anger, fear
Enjoys familiar surroundings and explores away from parent
Is fearful in strange situation; clings to parent
May develop habit of “security blanket” or favorite toy
Has increasing determination to practice locomotor skills
•Searches for an object even if it has not been hidden but searches only where object was last seen
•Milestones that represent essential integrative aspects of development that lay the foundation for the achievement of more advanced skills. *Degree of visual acuity varies according to vision measurement procedure used.
The chest assumes a more adult contour, with the lateral diameter becoming larger than the anteroposterior diameter. The chest circumference approximately equals the head circumference by the end of the first year. The heart grows less rapidly than does the rest of the body. Its weight is usually doubled by 1 year old in comparison with body weight, which triples during the same period. The size of the heart is still large in relation to the chest cavity; its width is approximately 55% of the chest width.
It is important to note that genetic, metabolic, environmental, and nutritional factors strongly influence infant growth; thus, the previous statements are general guidelines only. Use the appropriate infant growth charts reflecting weight for length and head circumference in each case to determine appropriate growth parameters. The World Health Organization growth charts released in 2006 are now recommended as reference growth charts in children 0 to 59 months old (Turck, Michaelsen, Shamir, et al, 2013).
Maturation of Systems Other organ systems also change and grow during infancy. The respiratory rate slows somewhat and is relatively stable. Respiratory movements continue to be abdominal. Several factors predispose infants to more severe and acute respiratory problems than older children. The close proximity of the trachea to the bronchi and its branching structures rapidly transmits infectious agents from one anatomic location to another. The short, straight eustachian tube closely communicates with the ear, allowing infection to ascend from the pharynx to the middle ear. In addition, the inability of the immune system to produce immunoglobulin A (IgA) in the mucosal lining provides less protection against infection in infancy than during later childhood.
The heart rate slows, and the rhythm is often sinus arrhythmia (rate increases with inspiration and decreases with expiration). Blood pressure also changes during infancy. Systolic pressure rises during the first 2 months as a result of the increasing ability of the left ventricle to pump blood into the systemic circulation. Diastolic pressure decreases during the first 3 months and then gradually
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rises to values close to those at birth. Fluctuations in blood pressure occur during varying states of activity and emotion.
Significant hematopoietic changes occur during the first year of life. Fetal hemoglobin (HgbF) is present for the first 5 months, with adult hemoglobin steadily increasing through the first half of infancy. Fetal hemoglobin results in a shortened survival of red blood cells (RBCs) and thus a decreased number of RBCs. A common result at 3 to 6 months old is physiologic anemia. High levels of fetal hemoglobin depress the production of erythropoietin, a hormone released by the kidneys that stimulates RBC production.
Maternally derived iron stores are present for the first 5 to 6 months of life and gradually diminish, which also accounts for lowered hemoglobin levels toward the end of the first 6 months. The occurrence of physiologic anemia is not affected by an adequate supply of iron. However, when erythropoiesis is stimulated, iron stores are necessary for the formation of hemoglobin.
The digestive processes are relatively immature at birth. Although term newborn infants have some limitations in digestive function, human milk has properties that partially compensate for decreased digestive enzymatic activity, thus enabling breastfed infants to receive optimal nutrition during the first several months of life. The enzyme amylase (also called ptyalin) is present in small amounts but usually has little effect on the foodstuffs because of the small amount of time the food stays in the mouth. Gastric digestion in the stomach consists primarily of the action of hydrochloric acid and rennin, an enzyme that acts specifically on the casein in milk to cause the formation of curds—coagulated semisolid particles of milk. The curds cause the milk to be retained in the stomach long enough for digestion to occur.
Digestion also takes place in the duodenum, where pancreatic enzymes and bile begin to break down protein and fat. Secretion of the pancreatic enzyme amylase, which is needed for digestion of complex carbohydrates, is deficient until about the fourth to sixth month of life. Lipase is also limited, and infants do not achieve adult levels of fat absorption until 4 to 5 months old. Trypsin is secreted in sufficient quantities to catabolize protein into polypeptides and some amino acids.
The immaturity of the digestive processes is evident in the appearance of stools. During infancy, solid foods (e.g., peas, carrots, corn, raisins) are passed incompletely broken down in the feces. An excess quantity of fiber easily disposes infants to loose, bulky stools.
During infancy, the stomach enlarges to accommodate a greater volume of food. By the end of the first year, infants are able to tolerate three meals a day and an evening bottle and may have one or two bowel movements daily. However, with any type of gastric irritation, infants are vulnerable to diarrhea, vomiting, and dehydration (see Chapter 22).
The liver is the most immature of all the gastrointestinal organs throughout infancy. The ability to conjugate bilirubin and secrete bile is achieved after the first couple of weeks of life. However, the capacities for gluconeogenesis, formation of plasma protein and ketones, storage of vitamins, and deaminization of amino acids remain relatively immature for the first year of life.
Maturation of the sucking, swallowing, and breathing reflexes and the eruption of teeth (see Teething later in chapter) parallel the changes in the gastrointestinal tract and prepare infants for the introduction of solid foods.
The immunologic system undergoes numerous changes during the first year. Full-term newborns receive significant amounts of maternal immunoglobulin G (IgG), which, for approximately 3 months, confers immunity against antigens to which their mothers were exposed. During this time, infants begin to synthesize IgG but in limited amounts. Approximately 40% of adult levels are reached by 1 year old; therefore, infants are at higher risk for infection during the first 12 months of life. Significant amounts of immunoglobulin M (IgM) are produced at birth, and adult levels are reached by 9 months old. Prebiotic oligosaccharides found in breast milk produce probiotic bacteria such as bifidobacteria and lactobacilli, which in turn stimulate synthesis and secretion of secretory IgA. Secretory IgA is present in large amounts in colostrum; IgA confers protection to the mucous membranes of the gastrointestinal tract (Durand, Ochoa, Bellomo, et al, 2013) against many bacteria, such as Escherichia coli, and viruses such as rubella, poliovirus, and the enteroviruses. The development of the mucosa-associated lymphoid tissue occurs during infancy; in part, this system is believed to prevent colonization and passage of bacteria across the infant's mucosal barrier. The function and quantity of T-lymphocytes, lymphokines, interferon-γ, interleukins, tumor necrosis factor-α, and complement are reduced in early infancy, thus preventing optimal response to certain bacteria and viruses. The production of IgA and immunoglobulins D and E (IgD and IgE) is much more gradual, and maximum levels are not attained until early childhood. Probiotics may have a significant role in helping the gastrointestinal tract establish a “good” bacterial colonization in the
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gut to prevent many illnesses, including antibiotic-induced diarrhea and possibly Helicobacter pylori gastritis (Vitetta, Briskey, Alford, et al, 2014).
Evidence indicates that vernix caseosa, a white oily substance that coats term infants' bodies and is often found in abundance in creases of the axilla and groin, has innate immunologic properties that serve to protect newborns from infection (Visscher and Narendran, 2014). Vernix also appears to have a role in maintaining the integrity of the stratum corneum and facilitating acid mantle development (Visscher and Narendran, 2014). The epidermis of a full-term infant undergoes maturation during the first month of life; the newborn's skin acts as a barrier to infection, assists in thermal regulation, and prevents transepidermal water loss in term infants.
During infancy, thermoregulation becomes more efficient; the ability of the skin to contract and of muscles to shiver in response to cold increases. The peripheral capillaries respond to changes in ambient temperature to regulate heat loss. The capillaries constrict in response to cold, conserving core body temperature and decreasing potential evaporative heat loss from the skin surface. The capillaries dilate in response to heat, decreasing internal body temperature through evaporation, conduction, and convection. Shivering (thermogenesis) causes the muscles and muscle fibers to contract, generating metabolic heat, which is distributed throughout the body. Increased adipose tissue during the first 6 months insulates the body against heat loss.
A shift in the total body fluid occurs; at birth, 78% of a term infant's body weight is water, and there is an abundance of extracellular fluid (ECF). As the percentage of body water decreases, so does the amount of ECF—from 44% at term to 20% in adulthood. The high proportion of ECF, which is composed of blood plasma, interstitial fluid, and lymph, predisposes the infant to a more rapid loss of total body fluid and, consequently, dehydration. The loss of 5% to 10% of term newborns' initial birth weight in the first 5 days of life is attributed to ECF compartment contraction, enhanced renal tubular function, and rapidly increasing glomerular filtration rate (Blackburn, 2013).
The immaturity of the renal structures also predisposes infants to dehydration and electrolyte imbalance. Complete maturity of the kidneys occurs during the latter half of the second year, which is when the cuboidal epithelium of the glomeruli becomes flattened. Before this time, the filtration capacity of the glomeruli is reduced. Urine is voided frequently and has a low specific gravity (1.008 to 1.012). At term, most infants produce and excrete approximately 15 to 60 ml/kg/24 hours, and an output of less than 0.5 ml/kg/hour after 48 hours of age is considered to be oliguria (Blackburn, 2013).
Auditory acuity is at adult levels during infancy. Visual acuity begins to improve, and binocular fixation is established. Binocularity, or the fixation of two ocular images into one cerebral picture (fusion), begins to develop by 6 weeks old and should be established by 4 months old. Depth perception (stereopsis) begins to develop by age 7 to 9 months old but may not be fully mature until 2 or 3 years old, thus increasing infants' and younger toddlers' risk of falling.
Fine Motor Development Fine motor behavior includes the use of the hands and fingers in the prehension (grasp) of objects. Grasping occurs during the first 2 to 3 months as a reflex and gradually becomes voluntary. At 1 month old, the hands are predominantly closed; and by 3 months old, they are mostly open. By this time, infants demonstrate a desire to grasp objects, but they “grasp” objects more with the eyes than with the hands. If a rattle is placed in the hand, infants will actively hold on to it. By 4 months old, infants regard both a small pellet and the hands and then look from the object to the hands and back again. By 5 months old, infants are able to voluntarily grasp objects.
By 6 months old, infants have increased manipulative skill. They hold their bottles, grasp their feet and pull them to their mouths, and feed themselves crackers. By 7 months old, they transfer objects from one hand to the other, use one hand for grasping, and hold a cube in each hand simultaneously. They enjoy banging objects and explore the movable parts of toys.
Gradually, the palmar grasp (using the whole hand) is replaced by a pincer grasp (using the thumb and index finger). By 8 to 9 months old, infants use a crude pincer grasp; and by 10 months old, they have progressed to a neat pincer grasp sufficient to pick up raisins and other finger foods (Fig. 9-1). They can deliberately let go of an object and offer it to someone. By 11 months old, they put objects into containers and like to remove them. By 1 year old, infants try to build towers of two blocks but fail.
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FIG 9-1 Crude pincer grasp at 8 to 10 months old. (Photo by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Gross Motor Development
Head Control Full-term newborns can momentarily hold their heads in midline and parallel when their bodies are suspended ventrally and can lift and turn their heads from side to side when they are prone (see Fig. 7-7). This is not the case when infants are lying prone on a pillow or soft surface; infants do not have the head control to lift their heads out of the depression of the object and therefore risk suffocation in the prone position early in infancy (see Sudden Infant Death Syndrome, Chapter 10). Marked head lag is evident when infants are pulled from a lying to a sitting position. By 3 months old, infants can hold their heads well beyond the plane of their bodies. By 4 months old, infants can lift their heads and front portion of their chests approximately 90 degrees above the table, bearing their weight on the forearms. Only slight head lag is evident when infants are pulled from a lying to a sitting position; and by 4 to 6 months old, head control is well established (Figs. 9-2 and 9-3).
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FIG 9-2 Head control while pulled to sitting position. A, Complete head lag at 1 month old. B, Partial head lag at 2 months old. C, Almost no head lag at 4 months old.
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FIG 9-3 Head control while prone. A, The infant momentarily lifts the head at 1 month old. B, The infant lifts the head and chest 90 degrees and bears weight on the forearms at 4 months old. C, The infant lifts
head, chest, and upper abdomen and can bear weight on the hands at 6 months old. Note how this position facilitates turning from the abdomen to the back.
Rolling Over Newborns may roll over accidentally because of their rounded backs. The ability to willfully turn from the abdomen to the back occurs around 5 months old, and the ability to turn from the back to the abdomen occurs at approximately 6 months old. Infants put to sleep on their sides may easily roll over to a prone (face-down) position, thus placing them at higher risk for sudden infant death syndrome (SIDS). It is therefore important to place infants in a supine position for sleep. While infants are awake, a prone position (tummy time) is acceptable to enhance achievement of milestones, such as head control, crawling, creeping, and turning over. It is noteworthy that the parachute reflex (Fig. 9-4), a protective response to falling, appears at approximately 7 months old.
N u r s i n g A l e r t In the first several months, before the infant can roll over, the head should be positioned on alternating sides to prevent positional plagiocephaly (when asleep or awake in the supine position) (see Chapter 10).
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FIG 9-4 Parachute reflex. (Photo by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Sitting The ability to sit follows progressive head control and straightening of the back (Fig. 9-5). For the first 2 to 3 months, the back is uniformly rounded. The convex cervical curve forms at approximately 3 to 4 months old, when head control is established. The convex lumbar curve appears when the child begins to sit, at about 4 months old. As the spinal column straightens, infants can be propped in a sitting position. By 7 months old, infants can sit alone, leaning forward on their hands for support. By 8 months old, they can sit well while unsupported and begin to explore their surroundings in this position rather than in a lying position. By 10 months old, they can maneuver from a prone to a sitting position.
FIG 9-5 Development of sitting. A, The back is completely rounded, and the infant has no ability to sit
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upright at 1 month old. B, At 2 months old, the infant exhibits more control; the back is still rounded, but the infant can try to pull up with some head control. C, The back is rounded only in the lumbar area, and
the infant is able to sit erect with good head control at 4 months old. D, The infant can sit alone, leaning on the hands for support, at 7 months old. E, The infant sits without support at 8 months old. Note the
transferring of objects that occurs at 7 months old. (B, D, and E, Photos by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Locomotion Locomotion involves acquiring the ability to bear weight; propel forward on all four extremities; stand upright with support; cruise by holding on to furniture; and finally, walk alone (Fig. 9-6). Following a cephalocaudal pattern, infants who are 4 to 6 months old have increasing coordination in their arms. Initial locomotion results in infants propelling themselves backward by pushing with their arms. By 6 to 7 months old, they are able to bear all of their weight on their legs with assistance. Crawling (propelling forward with the belly on the floor) progresses to creeping on hands and knees (with the belly off the floor) by 9 months old. At this time, they stand while holding on to furniture and can pull themselves to the standing position, but they are unable to maneuver back down except by falling. By 11 months old, they walk while holding on to furniture or with both hands held; and by 1 year old, they may be able to walk with one hand held. A number of infants attempt their first independent steps by their first birthday.
N u r s i n g A l e r t An infant who does not pull to a standing position by 11 to 12 months old should be further evaluated for possible developmental dysplasia of the hip (see Chapter 29).
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FIG 9-6 Development of locomotion. A, The infant bears full weight on the feet by 7 months old. B, The infant can maneuver from a sitting to a kneeling position. C, The infant can stand holding on to furniture at
9 months old. D, While standing, the infant takes deliberate step at 10 months old. E, The infant crawls with the abdomen on the floor and pulls self forward at about 7 months old and then creeps on hands and
knees at 9 months old (F). (Photos by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
Psychosocial Development: Developing a Sense of Trust (Erikson) Erikson's phase I (birth to 1 year old) is concerned with acquiring a sense of trust while overcoming a sense of mistrust. The trust that develops is a trust of self, of others, and of the world. Infants “trust” that their feeding, comfort, stimulation, and caring needs will be met. The crucial element for the achievement of this task is the quality of both the parent (caregiver)–child relationship and the care the infant receives. The provision of food, warmth, and shelter by itself is inadequate for the development of a strong sense of self. The infant and parent must jointly learn to satisfactorily meet their needs for mutual regulation of frustration to occur. When this synchrony fails to develop, mistrust is the eventual outcome.
Failure to learn delayed gratification leads to mistrust. Mistrust can result from either too much
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or too little frustration. If parents always meet their children's needs before the children signal their readiness, infants will never learn to test their ability to control the environment. If the delay is prolonged, infants will experience constant frustration and eventually mistrust others in their efforts to satisfy them. Therefore, consistency of care is essential.
The trust acquired in infancy provides the foundation for all succeeding phases. Trust allows infants a feeling of physical comfort and security, which assists them in experiencing unfamiliar, unknown situations with a minimum of fear. Erikson has divided the first year of life into two oral– social stages. During the first 3 to 4 months, food intake is the most important social activity in which the infant engages. Newborns can tolerate little frustration or delay of gratification. Primary narcissism (total concern for oneself) is at its height. However, as bodily processes (such as vision, motor movements, and vocalization) become better controlled, infants use more advanced behaviors to interact with others. For example, rather than cry, infants may put their arms up to signify a desire to be held.
The next social modality involves a mode of reaching out to others through grasping. Grasping is initially reflexive, but even as a reflex, it has a powerful social meaning for the parents. The reciprocal response to the infant's grasping is the parents' holding on and touching. There is pleasurable tactile stimulation for both the child and the parents.
Tactile stimulation is extremely important in the total process of acquiring trust. The degree of mothering skill, the quantity of food, or the length of sucking does not determine the quality of the experience. Rather, the total nature of the quality of the interpersonal relationship influences the infant's formulation of trust.
During the second stage, the more active and aggressive modality of biting occurs. Infants learn that they can hold on to what is their own and can more fully control their environment. During this stage, infants may be confronted with one of their first conflicts. If they are breastfeeding, they quickly learn that biting causes the mother to become upset and withdraw the breast. Yet biting also brings internal relief from teething discomfort and a sense of power or control.
This conflict may be solved in a variety of ways. The mother may wean the infant from the breast and begin bottle feeding, or the infant may learn to bite substitute nipples, such as a pacifier, and retain pleasurable breastfeeding. The successful resolution of this conflict strengthens the mother– child relationship because it occurs at a time when infants are recognizing the mother as the most significant person in their life.
Cognitive Development: Sensorimotor Phase (Piaget) The theory most commonly used to explain cognition, or the ability to know, is that of Piaget. The period from birth to 24 months old is termed the sensorimotor phase and is composed of six stages; however, because this discussion is concerned with ages birth to 12 months old, only the first four stages are discussed. The last two stages occur during the toddler period of 12 to 24 months old and are discussed in Chapter 11.
During the sensorimotor phase, infants progress from reflexive behaviors to simple repetitive acts to imitative activity. Three crucial events take place during this phase. The first event involves separation, in which infants learn to separate themselves from other objects in the environment. They realize that others besides themselves control the environment and that certain readjustments must take place for mutual satisfaction to occur. This coincides with Erikson's concept of the formation of trust.
The second major accomplishment is achieving the concept of object permanence, or the realization that objects that leave the visual field still exist. A typical example of the development of object permanence is when infants are able to pursue objects they observe being hidden under a pillow or behind a chair (Fig. 9-7). This skill develops at approximately 9 to 10 months old, which corresponds to the time of increased locomotion skills.
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FIG 9-7 A 9-month-old infant is able to find hidden objects under a pillow. (Photo by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
The last major intellectual achievement of this period is the ability to use symbols, or mental representation. The use of symbols allows infants to think of an object or situation without actually experiencing it. The recognition of symbols is the beginning of the understanding of time and space.
The first stage, from birth to 1 month old, is identified by infants' use of reflexes. At birth, infants' individuality and temperament are expressed through the physiologic reflexes of sucking, rooting, grasping, and crying. The repetitious nature of the reflexes is the beginning of associations between an act and a sequential response. When infants cry because they are hungry, a nipple is put in the mouth, and they suck, feel satisfaction, and sleep. They are assimilating this experience while perceiving auditory, tactile, and visual cues. This experience of perceiving certain patterns, or “ordering,” provides a foundation for the subsequent stages.
The second stage, primary circular reactions, marks the beginning of the replacement of reflexive behavior with voluntary acts. During the period from 1 to 4 months old, activities such as sucking and grasping become deliberate acts that elicit certain responses. The beginning of accommodation is evident. Infants incorporate and adapt their reactions to the environment and recognize the stimulus that produced a response. Previously, they cried until the nipple was brought to the mouth. Now they associate the nipple with the sound of the parent's voice. They accommodate this new piece of information and adapt by ceasing to cry when they hear the voice—before receiving the nipple. What is taking place is realization of causality and recognition of an orderly sequence of events. The environment is taken in with all of the senses and with whatever motor ability is present.
The secondary circular reactions stage is a continuation of primary circular reactions and lasts until 8 months old. In this stage, the primary circular reactions are repeated and prolonged for the response that results. Grasping and holding now become shaking, banging, and pulling. Shaking is performed to hear a noise, not solely for the pleasure of shaking. The quality and quantity of an act become evident. “More” or “less” shaking produces different responses. Causality, time, deliberate intention, and separateness from the environment begin to develop.
Three new processes of human behavior occur. Imitation requires the differentiation of selected acts from several events. By the second half of the first year, infants can imitate sounds and simple gestures. Play becomes evident as they take pleasure in performing an act after they have mastered it. Much of infants' waking hours are absorbed in sensorimotor play. Affect (outward manifestation of emotion and feeling) is seen as infants begin to develop a sense of permanence. During the first 6 months, infants believe that an object exists only for as long as they can visually perceive it. In other words, out of sight, out of mind. Affect to external objects is evident when the object continues to be present or remembered even though it is beyond the range of perception. Object permanence is a critical component of parent–child attachment and is seen in the development of stranger anxiety at 6 to 8 months old.
During the fourth sensorimotor stage, coordination of secondary schemas and their application to new situations, infants use previous behavioral achievements primarily as the foundation for
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adding new intellectual skills to their expanding repertoire. This stage is largely transitional. Increasing motor skills allow for greater exploration of the environment. They begin to discover that hiding an object does not mean that it is gone but that removing an obstacle will reveal the object. This marks the beginning of intellectual reasoning. Furthermore, they can experience an event by observing it, and they begin to associate symbols with events (e.g., “bye-bye” with “Mommy or Daddy goes to work”), but the classification is purely their own. In this stage, they learn from the object itself; this is in contrast to the second stage, in which infants learn from the type of interaction between objects or individuals. Intentionality is further developed in that infants now actively attempt to remove a barrier to the desired (or undesired) action (see Fig. 9-7). If something is in their way, they attempt to climb over it or push it away. Previously, an obstacle would cause them to give up any further attempt to achieve the desired goal.
Development of Body Image The development of body image parallels sensorimotor development. Infants' kinesthetic and tactile experiences are the first perceptions of their bodies, and the mouth is the principal area of pleasurable sensations. Other parts of their bodies are primarily objects of pleasure—the hands and fingers to suck and the feet to play with. As their physical needs are met, they feel comfort and satisfaction with their bodies. Messages conveyed by their caregivers reinforce these feelings. For example, when infants smile, they receive emotional satisfaction from others who smile back.
Achieving the concept of object permanence is basic to the development of self-image. By the end of the first year, infants recognize that they are distinct from their parents. At the same time, they have increasing interest in their image, especially in the mirror (Fig. 9-8). As motor skills develop, they learn that parts of their bodies are useful; for example, their hands bring objects to their mouths, and their legs help them move to different locations. All of these achievements transmit messages to them about themselves. Therefore, it is important to transmit positive messages to infants about their bodies.
FIG 9-8 A 9-month-old infant enjoying own image in mirror.
Social Development Infants' social development is initially influenced by their reflexive behavior, such as the grasp, and eventually depends primarily on the interaction between them and their principal caregivers. Attachment to their parents is increasingly evident during the second half of the first year. In addition, tremendous strides are made in communication and personal–social behavior. Whereas crying and reflexive behavior are methods to meet one's needs in early infancy, the social smile is an
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early step in social communication. This has a profound effect on family members and is a tremendous stimulus for evoking continued responses from others. By 4 months old, infants laugh aloud.
Play is a major socializing agent and provides stimulation needed to learn from and interact with the environment. By 6 months old, infants are very personable. They play games such as peek-a-boo when their heads are hidden in a towel, they signal their desire to be picked up by extending their arms, and they show displeasure when a toy is removed or their faces are washed.
Attachment The importance of human physical contact to infants cannot be overemphasized. Parenting is not an instinctual ability but a learned, acquired process. The attachment of parent and child, which often begins before birth and assumes even more importance at birth (see Chapter 7), continues during the first year (Fig. 9-9). In the following discussion of attachment, the term mother is used in the broad context of the consistent caregiver with whom the child relates more than anyone else. However, with society's changing social climate and sex-role stereotypes, this person may well be the father or a grandparent. Studies on father–infant attachment demonstrate that stages similar to maternal attachment occur and that fathers are more involved in child care when mothers are employed (although mothers continue to do the majority of infant care). Additional research has shown that inexperienced, first-time fathers are as capable as experienced fathers of developing a close attachment with their infants. Fathers verbalized more positive feelings of love and affection toward their newborns when they were able to have close physical contact, such as holding their infant (Feeley, Sherrard, Waitzer, et al, 2013). Fathers have also been reported to have a significant role in supporting mothers in the perinatal period. Studies of high-risk infants demonstrate the need for a father's involvement in the infant's care because of high demands of the infant and/or restrictions of the mother (Feeley, Sherrard, Waitzer, et al, 2013). Research demonstrates that fathers develop feelings of attachment with their offspring and that their relationship with the infant is an important factor in the mother's emotional well-being. With many single-parent families in existence, a grandmother (or other significant caretaker) may become the primary caretaker. It is important for nurses to recognize that infant–parent attachments may be present or absent in situations where caretaker roles are less well defined by those involved.
FIG 9-9 Infancy is an important time for attachment to significant others. (Photo by Paul Vincent Kuntz, Texas Children's Hospital, Houston, TX.)
When infants are not provided a safe haven and consistent and loving care, an insecure attachment develops; such infants do not feel they can trust the world in which they live. This insecure attachment may result in psychosocial difficulties as the child grows and may persist even into adulthood. Insecure attachment may also exist in homes where there is domestic violence and maternal postnatal depression.
Attachment progresses during infancy, with the infant assuming an increasingly significant role
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in the family. Two components of cognitive development are required for attachment: (1) the ability to discriminate the mother from other individuals and (2) the achievement of object permanence. Both of these processes prepare infants for an equally important aspect of attachment—separation from the parent. Separation-individuation should occur as a harmonious, parallel process with emotional attachment.
During the formation of attachment to the parent, the infant progresses through four distinct but overlapping stages. For the first few weeks of life, infants respond indiscriminately to anyone. Beginning at approximately 8 to 12 weeks old, they cry, smile, and vocalize more to the mother than to anyone else but continue to respond to others, whether familiar or not. At approximately 6 months old, infants show a distinct preference for the mother. They follow her more, cry when she leaves, enjoy playing with her more, and feel most secure in her arms. About 1 month after showing attachment to the mother, many infants begin attaching to other members of the family, most often the father.
Infants acquire other developmental behaviors that influence the attachment process. These include • Differential crying, smiling, and vocalization (more to the mother than to anyone else) • Visual-motor orientation (looking more at the mother, even if she is not close) • Crying when the mother leaves the room • Approaching through locomotion (crawling, creeping, or walking) • Clinging (especially in the presence of a stranger) • Exploring away from the mother while using her as a secure base
Severe attachment disorders are psychological and developmental problems that stems from maladaptive or absent attachment between the infant and parent (Zeanah and Gleason, 2015). There are two different patterns of attachment disorders: the emotionally withdrawn–inhibited pattern and an indiscriminate-disinhibited pattern (Zeanah and Gleason, 2015). These two subtypes have been classified into separate disorders: reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) of infancy or early childhood. Infants at risk for severe attachment disorders include those who have been victims of physical or sexual abuse or neglect; infants exposed to parental alcoholism, mental illness, and substance abuse; and infants who have experienced the absence of a consistent primary caregiver as a result of foster care, institutionalization, parental abandonment, or parental incarceration (Zeanah and Gleason, 2015). Children with RAD may manifest behaviors such as not being cuddly with parents, failing to seek and respond to comfort when distressed, minimal social and emotional reciprocity, and emotional deregulation such as unexplained fearfulness or irritability (Zeanah and Gleason, 2015). Children with DSED may exhibit behaviors such as inappropriate approach to unfamiliar adults, lack of suspicion of strangers, and poor impulse control (Zeanah and Gleason, 2015). Either or both of these complex disorders are diagnosed with maltreated and orphaned children. Without early intervention, some of these children fail to develop a conscience and develop an antisocial personality disorder that may lead to criminal acts. Children with autism or other pervasive developmental disorders have behaviors that are categorically different from those with RAD (Zeanah and Gleason, 2015).
Separation Anxiety Between 4 and 8 months old, infants progress through the first stage of separation-individuation and begin to have some awareness of themselves and their mothers as separate beings. At the same time, object permanence is developing, and infants are aware that their parents can be absent. Therefore, separation anxiety develops and is manifested through a predictable sequence of behaviors.
During the early second half of the first year, infants protest when placed in their cribs, and a short time later, they object when their mothers leave the room. Infants may not notice the mother's absence if they are absorbed in an activity. However, when they realize her absence, they protest. From this point on, they become alert to her activities and whereabouts. By 11 to 12 months old, they are able to anticipate her imminent departure by watching her behaviors, and they begin to protest before she leaves. At this point, many parents learn to postpone alerting the child to their departure until just before leaving.
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Stranger Fear As infants demonstrate attachment to one person, they correspondingly exhibit less friendliness to others. Between 6 and 8 months old, fear of strangers and stranger anxiety become prominent and are related to infants' ability to discriminate between familiar and unfamiliar people. Behaviors such as clinging to the parent, crying, and turning away from the stranger are common.
Language Development Infants' first means of verbal communication is crying. Crying as a biologic sign conveys a message of urgency and signals displeasure, such as hunger. However, crying is also a social event that affects the development of the parent–infant relationship—either by its absence, which usually has a positive effect on parents, or by its presence, which may evoke a negative response or persuade parents to minister to the child's physical or emotional needs.
In the first few weeks of life, crying has a reflexive quality and is mostly related to physiologic needs. Infants cry for 1 to 1.5 hours a day up to 3 weeks old and then build up to 2 to 4 hours by 6 weeks old. Crying tends to decrease by 12 weeks old. It is thought that the increase in crying for no apparent reason during the first few months may be related to the discharge of energy and the maturational changes in the central nervous system. At the end of the first year, infants cry for attention; from fear (especially stranger fear); and from frustration, usually in response to their developing but inadequate motor skills.
Vocalizations heard during crying eventually become syllables and words (e.g., the “mama” heard during vigorous crying). Infants vocalize as early as 5 to 6 weeks old by making small throaty sounds. By 2 months old, they make single vowel sounds, such as ah, eh, and uh. By 3 to 4 months old, the consonants n, k, g, p, and b are added, and infants coo, gurgle, and laugh aloud. By 6 months old, they imitate sounds; add the consonants t, d, and w; and combine syllables (e.g., “dada”), but they do not ascribe meaning to the word until 10 to 11 months old. By 9 to 10 months old, they comprehend the meaning of the word “no” and obey simple commands. By 1 year old, they can say 3 to 5 words with meaning and may understand as many as 100 words. Because language development is based on expressive skills (ability to make thoughts, ideas, and desires known to others) and receptive skills (ability to understand the words being spoken), it is important that infants are exposed to expressive speech and that infants with delays in achieving milestones are carefully evaluated for potential hearing loss (see Universal Newborn Hearing Screening, Chapter 7).
Play Play during infancy represents the various social modalities observed during cognitive development. The activity of infants is primarily narcissistic and revolves around their own bodies. As discussed under Development of Body Image (earlier in this chapter), body parts are primarily objects of play and pleasure.
During the first year, play becomes more sophisticated and interdependent. From birth to 3 months old, infants' responses to the environment are global and largely undifferentiated. Play is dependent; pleasure is demonstrated by a quieting attitude (1 month old), a smile (2 months old), or a squeal (3 months old). From 3 to 6 months old, infants show more discriminate interest in stimuli and begin to play alone with rattles or soft stuffed toys or with someone else. There is much more interaction during play. By 4 months old, they laugh aloud, show preference for certain toys, and become excited when food or a favorite object is brought to them. They recognize images in a mirror, smile at them, and vocalize to them.
By 6 months to 1 year old, play involves sensorimotor skills. Games such as peek-a-boo and pat- a-cake are played. Verbal repetition and imitation of simple gestures occur in response to demonstration. Play is much more selective, not only in terms of specific toys, but also in terms of “playmates.” Although play is solitary or one sided, infants choose with whom they will interact. At 6 to 8 months old, they usually refuse to play with strangers. Parents are definite favorites, and infants know how to attract their attention. At 6 months old, they extend their arms to be picked up; at 7 months old, they cough to make their presence known; at 10 months old, they pull their parents' clothing; and at 12 months old, they call their parents by name. This represents a tremendous advance from the newborn who signaled biologic needs by crying to express displeasure.
Stimulation is as important for psychosocial growth as food is for physical growth. Knowledge of
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developmental milestones allows nurses to guide parents regarding proper play for infants. It is not sufficient to place a mobile over a crib and toys in a play yard for a child's optimum social, emotional, and intellectual development. Play must provide interpersonal contact and recreational and educational stimulation. Infants need to be played with, not merely allowed to play. Although the type of play infants engage in is called solitary, this is a figurative, not literal, term to denote one- sided play. The type of toys given to children is much less important than the quality of personal interaction that occurs.
Temperament An infant's temperament or behavioral style influences the type of interaction that occurs between the child and parents, especially the mother, and other family members (see Temperament, Chapter 3). In assessing a child's temperament, the parents' perception of the child and the degree of fit between their expectations and the child's actual temperament are important. The more dissonance or lack of harmony, between the child's temperament and the parent's ability to accept and deal with the behavior, the greater risk for subsequent parent–child conflicts.
Although most behavioral researchers agree that there is a strong biologic component to temperament, researchers also suggest that the environment, particularly the family, may modify temperament (Gallitto, 2015). Family interaction with the infant is perceived as a circular process wherein each family member affects the others and the family as a unit. With these concepts in mind, the nurse has an important role in helping the family understand the infant's temperament as it relates to family dynamics and the eventual well-being of the child and family unit.
Some researchers speculate that infant temperament may contribute to depression. Depressed mothers and fathers (vs. nondepressed mothers and fathers) rate their infant's temperament as more difficult at 3 and 18 months old (Kerstis, Engström, Edlund, et al, 2013). The researchers stress that depressed parents need to be identified early and provided with supportive programs to enhance the parent-infant relationship. When there is a lack of reciprocity between the infant and parents or when the infant's behavior does not meet parental expectations, there is increased risk for discord. Researchers have correlated fussy infant temperament with the introduction of complementary feedings at 3 months old (Wasser, Bentley, Borja, et al, 2011) and feeding infants foods that may contribute to obesity (Vollrath, Tonstadt, Rothbart, et al, 2011).
Several instruments can measure infant temperament. These instruments include the Revised Infant Temperament Questionnaire (Carey and McDevitt, 1978), the Infant Behavior Questionnaire (Gartstein and Rothbart, 2003), and the Early Infancy Temperament Questionnaire (Medoff-Cooper, Carey, and McDevitt, 1993). In discussing test results to parents, it is best to avoid descriptors (such as “difficult”); instead, infants can be described in terms of characteristics (such as “intense” or “less predictable”).
Childrearing Practices Related to Temperament With knowledge of the infant's temperament, nurses are better able to (1) provide parents with background information that will help them see their child in a better perspective, (2) offer a more organized picture of their child's behavior and possibly reveal distortions in their perceptions of the behavior, and (3) guide parents regarding appropriate childrearing techniques.
Knowledge of the developmental sequence allows the nurse to assess normal growth and minor or abnormal deviations. It also helps parents gain realistic expectations of their child's ability and provides guidelines for suitable play and stimulation. Parents who lack knowledge of child growth and development may set inappropriate behavioral expectations for their child. Emphasizing the child's developmental rather than chronologic age strengthens the parent–child relationship by fostering trust and lessening frustration. Therefore, thorough understanding and appreciation of children's growth and development are essential.
Because of the complexity of the developmental process during the first 12 months, Table 9-1 is presented to help organize and clarify the data already discussed. Although all milestones are important, some represent essential integrative aspects of development that lay the foundation for achievement of more advanced skills. These essential milestones are designated by a black dot (•) in the table. The table represents the average monthly age at which various skills are attained. It must be remembered that although the sequence is the same, the rate will vary among children.
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Coping with Concerns Related to Normal Growth and Development Separation and Stranger Fear A number of fears can appear during infancy. However, the fear that causes parents the most concern is fear related to strangers and separation. Although erroneously interpreted by some as a sign of undesirable, antisocial behavior, stranger fear and separation anxiety are important components of a strong, healthy parent–child attachment. Nevertheless, this period can present difficulties for the parent and child. Parents may be more confined to the home because the infant violently protests having babysitters. To accustom the infant to new people, parents are encouraged to have close friends or relatives visit often. This provides other persons with whom the child is comfortable and can give parents time for themselves.
Infants also need opportunities to safely experience strangers. Usually toward the end of the first year, infants begin to venture away from the parent and demonstrate curiosity about strangers. If allowed to explore at their own rate, many infants eventually “warm up.” If parents hold the child away from their face, the infant can observe while maintaining close physical contact.
The best approach for the stranger (including nurses) is to talk softly; meet the child at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding out the arms and smiling broadly.
Parents also may wonder whether they should encourage the child's clinging, dependent behavior, especially if there is pressure from others who view this as “spoiling” (see following discussion). Parents need to be reassured that such behavior is healthy, desirable, and necessary for the child's optimal emotional development. If parents can reassure the infant of their presence, the infant will learn to realize that they are still there even if not physically present. Talking to infants when leaving the room, allowing them to hear one's voice on the telephone, and using transitional objects (e.g., a favorite blanket or toy) reassure the continued presence of the parent.
Alternate Child Care Arrangements For many parents, especially working mothers, locating safe and competent child care facilities for infants is an increasingly difficult problem, one that is compounded by the number of mothers working outside the home. Over the past 40 years, there have been variable shifts in child care arrangements; whereas the majority of children are cared for in group centers or other settings, increasingly more children are being cared for in home settings.
The basic types of care are in-home care, either in the parents' or caregivers' home (family daycare), and center-based care, usually in a daycare center. In-home care may consist of a full-time babysitter who lives in the home, a full-time babysitter who comes to the home, cooperative arrangements such as exchange babysitting, or family daycare. A licensed small family child care home typically provides care and protection for up to six children for part of a 24-hour day and does not include informal arrangements, such as exchange babysitting or caregivers in the child's own home. The six children may include the family daycare provider's own children younger than 5 years old living in the home. Large family child care homes may provide care for 8 to 12 children. Unfortunately, many family daycare homes operate without a license and may care for large numbers of infants without adequate staff and facilities.
Child center–based care usually refers to a licensed daycare facility that provides care for six or more children for 6 or more hours in a 24-hour day. Work-based group care is another option that is becoming increasingly popular as employers recognize the benefit of providing high-quality and convenient child care to their employees. Sick-child care may also be available for times when children are ill. Such programs are often located in community hospitals or in work settings.
Nurses may fulfill a unique role in guiding parents in locating suitable facilities that have a well- qualified staff. State licensing agencies can help parents identify daycare centers that accept children of specific age groups and are convenient to home and work. Their records are available to the public and provide reports from the health, safety, and fire departments; periodic evaluations from the licensing agency; complaints filed against the center; and qualification of the center's employees. State-licensed programs are supposed to abide by established standards, which represent the minimum requirements and safeguards. However, enforcement of the standards is sometimes inadequate.
Early childhood programs may also belong to a voluntary accreditation system sponsored by
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National Association for the Education of Young Children, which serves as a model for optimum care. References from other parents are also helpful, provided that they have investigated the center carefully and have remained involved with the agency's activities.
The same conscientious attention should be applied to locating competent babysitters. References from other employers are essential, and there is no substitute for observing the interaction between the individual and the child.
Important areas for parents to evaluate are the center's daily program, teacher qualifications, the nurturing qualities of caregivers, student-to-staff ratio, discipline policy, environmental safety precautions, provision of meals, sanitary conditions, adequate indoor and outdoor space per child, and fee schedule. Although fees vary considerably, a program that charges a minimum fee may also be providing minimum services. Parents should arrange to meet the director and some of the employees, especially those who would be caring for the child. Resources to familiarize parents with characteristics of quality child care and checklists to systematically evaluate the center and compare it with other facilities can help parents make successful choices. At all times, the parent should have the right to visit the child, and regular conferences should occur to review the child's progress.
One of the areas that is increasingly important in selecting child care is the center's health practices; however, parents often do not check the center for health and safety features. Evidence shows that children, especially those younger than 6 years old in daycare centers, have more illnesses—especially diarrhea, otitis media, respiratory tract infections (especially if the caregiver smokes), hepatitis A, meningitis, and cytomegalovirus—than children cared for in their homes. The strongest predictor of risk of illness is the number of unrelated children in the room. Proactive infection control measures and education of staff have been effective in reducing the incidence of upper respiratory tract infections, diarrhea, and rotavirus. It has been reported that families that have children in out-of-home child care lose an estimated 6 to 29 days of work per year as a result of children's illnesses (Shope and Hashikawa, 2012). Parents should inquire about the center's policy regarding the attendance and care of sick children.
Limit Setting and Discipline As infants' motor skills advance and mobility increases, parents are faced with the need to set safe limits to protect the child and establish a positive and supportive parent–child relationship (see Safety Promotion and Injury Prevention later in this chapter). Although there are numerous disciplinary techniques, some are more appropriate for this age than others. An effective approach used in disciplining a child is the use of time-out. The basic principles are the same as those discussed in Chapter 14 except that the place for time-out needs to be commensurate with the child's abilities. For example, a play yard is better for most infants than a chair. Although parents may be concerned about instituting discipline during infancy, it is important to stress that the earlier effective disciplinary methods are used, the easier it is to continue these approaches.
Parents must recognize the infant's cognitive and behavioral limitations; adequate protection from hazards must be implemented because infants and toddlers do not understand a cause-and- effect relationship between dangerous objects and physical harm. Additionally, parents may need reassurance that their infant's behavior is exploratory in nature, not oppositional (at this age) and primarily centered on the infant's basic needs of warmth, love, food, security, and comfort. Parents may verbalize that comforting the infant too much or meeting his or her needs will result in a spoiled child; there is no substantial evidence that meeting the infant's basic needs will result in such behaviors later in life. Children innately test limits and explore during the exploratory phase of growth; instead of discouraging exploration, parents should provide safe alternatives, put dangerous household items away, and give children consistent discipline and nurturing.
Effective teaching for injury prevention optimally begins in infancy by helping parents understand the nature of their child's normal development. It must be reiterated continually that infants cry because a need is not being met, not to intentionally irritate an adult. A fussy or irritable infant is a potential victim of shaken baby syndrome (or other bodily harm) because adults and caretakers may not understand the nature of the infant's crying.
Thumb Sucking and Use of a Pacifier Sucking is infants' chief pleasure and may not be satisfied by breastfeeding or bottle feeding. It is such a strong need that infants who are deprived of sucking, such as those with a cleft lip repair,
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suck on their tongues. Some newborns are born with sucking blisters on their hands from in utero sucking activity.
Problems arise when parents are overly concerned about the sucking of the fingers, thumb, or pacifier and attempt to restrain this natural tendency. Before giving advice, nurses should investigate the parents' feelings and base guidance on this information.
Pacifier use, particularly in the early days after birth and in the birth hospital, has gained considerable attention in the scientific literature. Nelson (2012) suggests that it cannot be stated with absolute certainty that pacifier use is bad in every situation. Health care workers must be informed on potential harm and benefits in pacifier use and provide parents with the highest level of evidence in order to make an informed decision on usage. Researchers and breastfeeding experts recommend that pacifiers are not introduced to breastfed infants unless medically necessary (Lawrence and Lawrence, 2011) (see Research Focus box).
R e s e a r c h F o c u s Pacifier Use and Breastfeeding
A recent systematic review found mixed results of pacifier use and breastfeeding outcomes (Nelson, 2012). The association of pacifier use and deceased breastfeeding duration was only found in observational studies, while no effect of pacifier use on breastfeeding duration was noted in randomized control trials (Nelson, 2012). They further concluded that the greatest impact on pacifier use and breastfeeding occurred early in the infant's life when learning effective sucking and stimulating the mother's milk.
Pacifier use has been associated with an increased risk of otitis media in several studies (Salah, Abdel-Aziz, Al-Farok, et al, 2013). Because of this, the American Academy of Pediatrics Subcommittee on the Management of Acute Otitis Media recommended that parents reduce pacifier usage in the second 6 months of life (Nelson, 2012). However, the American Academy of Pediatrics' Task Force on Sudden Infant Death Syndrome (2011) cites strong evidence for a protective effect in SIDS reduction when pacifiers are used at bedtime and nap time. The exact mechanism involved in the protection for SIDS is not known. Still, pacifiers should be cleaned and replaced regularly, and there should be an emphasis on allowing the infant to control the pace, frequency, and termination of feeding rather than allowing the pacifier (or anything else) to become the focus of the interaction. Pacifier use during painful procedures in neonates has been shown to produce an analgesic effect (see Chapter 5).
A systematic review found an association between pacifier use in infancy and a reduction in breastfeeding and exclusive breastfeeding (Nelson, 2012). However, the authors concluded that pacifier use and poor breastfeeding outcomes may not have a causal effect; rather, it may be related to a marker for socioeconomic, demographic, psychosocial, and cultural factors that determine pacifier use and breastfeeding. A recent Cochrane review found that pacifier use in full-term healthy infants started from birth or after lactation did not significantly affect the prevalence of duration of exclusive and partial breastfeeding up to 4 months old (Jaafar, Jahanafar, Angolkar, et al, 2011). At the time of this writing, there is no evidence that pacifier use and nonnutritive sucking in preterm infants has any effect on the initiation and length of breastfeeding. Nonnutritive sucking should not be withheld from preterm infants, especially when used in conjunction with concentrated sucrose for pain management.
To decrease dependence on nonnutritive sucking in young infants, sucking pleasure can be increased by prolonging feeding time. Also, the parent's excessive use of the pacifier to calm the child should be explored. It is not unusual for parents to place a pacifier in the infant's mouth as soon as crying begins, thus reinforcing a pattern of distress–relief.
If the child uses a pacifier, stress safety considerations in purchasing one. During infancy and early childhood, there is no need to restrain nonnutritive sucking of the fingers. Malocclusion may occur if thumb sucking persists past approximately 4 years old or when the permanent teeth erupt. Some parents may perceive pacifiers as less damaging because they are discarded by 2 to 3 years old, but thumb sucking may persist well into the school-age years. Because of the limited number of studies correlating pacifier use and increased risk of infections or dental malocclusion, there are no recommendations for or against pacifier use related to oral health (Nelson, 2012). Both pacifier use
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and thumb sucking may also have significant cultural variations. Thumb sucking reaches its peak at age 18 to 20 months old and is most prevalent when children are hungry, tired, or feeling insecure. Persistent thumb sucking in a listless, apathetic child always warrants investigation. It may be a sign of an emotional problem between the parent and child or of boredom, isolation, and lack of stimulation.
Teething One of the more difficult periods in infants' (and parents') lives is the eruption of the deciduous (primary) teeth, often referred to as teething. The age of tooth eruption shows considerable variation among children, but the order of their appearance is fairly regular and predictable (Fig. 9-10). The first primary teeth to erupt are the lower central incisors, which appear at approximately 6 to 10 months old (average, 8 months old). These are followed closely by the upper central incisors. A quick guide to assessment of deciduous teeth during the first 2 years is: Age of the child in months − 6 = Number of teeth. For example: 8 months of age − 6 = 2 teeth at this time.
FIG 9-10 Sequence of eruption of primary teeth. *Range represents ±1 standard deviation, or 67% of subjects studied. (Data from American Dental Association, Eruption charts, 2014, http://www.ada.org/2930.aspx?currentTab=1.)
Teething is a physiologic process; some discomfort is common as the crown of the tooth breaks through the periodontal membrane. Some children show minimum evidence of teething, such as drooling, increased finger sucking, or biting on hard objects. Others are irritable, have difficulty sleeping, ear rubbing, and decreased interest in solid foods. Generally, signs of illness such as fever (>39° C), vomiting, or diarrhea are not symptoms of teething but of illness and may warrant further investigation. Because teething pain is a result of inflammation, cold is soothing. Giving the child a frozen teething ring helps relieve the inflammation, but do not freeze teething rings filled with gels or non-sterile water because they may crack and leak into the infant's mouth. Several nonprescription topical anesthetic ointments are available, although the active ingredient in most of them is benzocaine, which may cause a rare but serious disorder called methemoglobinemia. Therefore, the US Food and Drug Administration recommends use of such products only under the advice and supervision of a health care provider (US Food and Drug Administration, 2014). In the event of persistent irritability that affects sleeping and feeding, systemic analgesics (such as, acetaminophen or ibuprofen) can be given (if age appropriate) for no more than 3 days; however, parents should know that this is a temporary measure, and they should contact the practitioner if symptoms persist or if the child's condition changes.
The use of teething powders or procedures such as cutting or rubbing the gums with salicylates (aspirin) is discouraged because ingestion of the powder, infection or irritation of the tissue, and ingestion or aspiration of the aspirin can occur. Hard candy may cause accidental choking or aspiration and should be avoided at this age.
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Promoting Optimal Health During Infancy Nutrition Ideally, discussion of optimal nutrition should begin prenatally with a discussion regarding maternal intake of adequate nutrition in the form of a balanced diet and adequate amounts of protein, vitamins, and minerals—all of which have an impact on the growing fetus. Nurses should encourage and provide information for parents to discuss the options of breastfeeding or bottle feeding the infant well in advance of the delivery date. The choice for either is highly individual and is discussed in Chapter 7. This section is primarily concerned with infant nutrition during the months when growth needs and developmental milestones ready the child for the introduction of solid foods.
Despite adequate availability of optimum nutrient sources, experts are concerned that infants are not fed appropriately. Infants may be given solid foods when their digestive systems are not ready to completely absorb such foods. In addition, drinks that are inappropriate for growing infants may be given in place of enriched infant milk and may only provide “empty” calories and contribute to childhood and adult obesity and place infants at risk for iron-deficiency anemia, vitamin D deficiency, and rickets. A survey of infant feeding practices found that about 20% of infants had consumed solid foods before 4 months old despite recommendations that such foods not be introduced until 4 to 6 months old (Aronsson, Uusitalo, Vehik, et al, 2015). Infant health practices, including nutrition, may have a far-reaching, long-term impact on the child's life. Growth and development could be negatively affected, and so could the risk of acquiring certain chronic health conditions. There is some evidence that childhood obesity is significantly decreased when breastfeeding is continued and solid food introduction is delayed until at least 4 months old (Moss and Yeaton, 2014). Nurses must be proactive in teaching parents what constitutes appropriate infant nutrition and nutritional habits, which provide the child with an optimum opportunity to grow and develop into a healthy child and adult.
Health care professionals have recently become more aware of the use of complementary and alternative medical therapies in children that may not be as beneficial as touted in various media sources. One concern is children's intake of megavitamins and herbs; parents may assume that the word natural in reference to ingredients means the product is safe when this may not be the case. It is important for nurses to be aware of the effects, availability, and practice of complementary therapies and to be able to cogently discuss their use with parents.
The First 6 Months Human milk is the most desirable complete diet for infants during the first 6 months. A healthy term infant receiving breast milk from a well-nourished mother usually requires no specific vitamin and mineral supplements with a few exceptions. Daily supplements of vitamin D and vitamin B12 may be indicated if the mother's intake of these vitamins is inadequate. The American Academy of Pediatrics (Wagner, Greer, American Academy of Pediatrics Section on Breastfeeding, et al, 2008) recommends that all infants (including those exclusively breastfed) receive a daily supplement of 400 IU of vitamin D beginning in the first few days of life to prevent rickets and vitamin D deficiency. Vitamin D supplementation should occur until the infant is consuming at least 1 L/day (or 1 qt/day) of vitamin D–fortified formula (Wagner, Greer, American Academy of Pediatrics Section on Breastfeeding, et al, 2008). Non-breastfed infants who are taking less than 1 L/day of vitamin D–fortified formula should also receive a daily vitamin D supplement of 400 IU (see Safety Alert). If the infant is being exclusively breastfed after 4 months old (when fetal iron stores are depleted), iron supplementation (1 mg/kg/day) is recommended until appropriate iron-containing complementary foods (such as, iron-fortified cereal) are introduced (Baker, Greer, and American Academy of Pediatrics Committee on Nutrition, 2010) (see Community Focus box). Infants, whether breastfed or bottle fed, do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water in infants may result in water intoxication and hyponatremia.
C o m m u n i t y F o c u s
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Administration of Iron Supplements
• Ideally, iron supplements should be administered between meals for greater absorption.
• Liquid iron supplements may stain the teeth; therefore, administer them with a dropper toward the back of the mouth (side). In older children, administer liquid iron supplements through a straw or rinse the mouth thoroughly after ingestion.
• Avoid administration of liquid iron supplements with whole cow's milk or milk products, because they bind free iron and prevent absorption.
• Educate parents that iron supplements will turn stools black or tarry green.
• Iron supplements may cause transient constipation. Caution parents not to switch to a low-iron containing formula or whole milk, which are poor sources of iron and may lead to iron-deficiency anemia (see Iron-Deficiency Anemia, Chapter 24).
• In older children, follow liquid iron supplement with a citrus fruit or juice drink (no more than 3 to 4 oz).
• Avoid administration of iron supplements with foods or drinks that bind iron and prevent absorption (see Iron-Deficiency Anemia, Chapter 24).
S a f e t y A l e r t There are reports of accidental overdoses of liquid vitamin D in infants caused by packaging errors; the syringe for liquid administration may not be labeled clearly for 400 IU. Nurses should educate parents to read syringes and to avoid administering more than 400 IU of vitamin D (US Food and Drug Administration Consumer Health Information, 2010).
Fluoride supplementation in exclusively breastfed children is not required for the first 6 months because of the risk of dental fluorosis. However, fluoride supplementation may be necessary if the breastfeeding mother's water supply does not contain the required amount of fluoridation (see later in this chapter). Employed mothers can continue breastfeeding with guidance and encouragement.* Mothers are encouraged to set realistic goals for employment and breastfeeding, with accurate information regarding the costs, risks, and benefits of available feeding options. Barriers encountered by working breastfeeding mothers include lack of employer or coworker support, unavailable or inadequate facilities for pumping and storing milk, lack of time to express milk while at work, real or perceived low milk supply, and insufficient time allowed to pump during work. Many mothers may find that a program of breast pumping when away from home and bottle feeding the infant the expressed milk with or without formula supplementation is successful. Expressed breast milk may be stored in the refrigerator (4° C [39° F]) without danger of bacterial contamination for up to 5 days (Lawrence and Lawrence, 2011). Although feeding the infant at home may occur on a demand basis, pumping milk away from home may be needed every 3 to 4 hours to maintain adequate supply. Breast milk may be expressed by hand or pump (manual or electric) and stored in an appropriate air-tight glass or plastic container. Expressed breast milk may be frozen (−18° C [0° F] or lower) for up to 6 months (depending on the type of freezer used) but care should be taken to prevent freezer burn (see Breastfeeding: A Guide for the Medical Profession [Lawrence and Lawrence, 2011] for further guidelines on storing and freezing human milk).
In addition to efficient breast pumping, mothers also need child care by a trusted individual or agency and support and assistance from significant others. As with all breastfeeding mothers, these women must have proper nutrition and rest for adequate lactation. Maternal fatigue is considered the biggest threat to successful breastfeeding in employed mothers.
N u r s i n g A l e r t Warming expressed milk in a microwave decreases the availability of anti-infective properties and nutrients (Labiner-Wolfe and Fein, 2013). To prevent oral burns from uneven warming of the milk,
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breast milk should never be thawed or rewarmed in a microwave oven. To thaw the frozen milk, either place the container under a lukewarm water bath (<40.5° C [105° F]) or place it in a refrigerator overnight.
There are reports of an increase in the use of herbs by lactating mothers to increase breast milk supply. The galactogogues, including fenugreek, blessed thistle, fennel, and chaste tree, have been purported to increase maternal milk supply, but a recent systematic review found insufficient evidence for the use of any type of galactogogues (Mortel and Mehta, 2013). For a discussion of galactogogues, including those mentioned here, see Appendix P, Protocol 9, in Breastfeeding: A Guide for the Medical Profession (Lawrence and Lawrence, 2011).
An acceptable alternative to breastfeeding is commercial iron-fortified formula. Similar to human milk, it supplies all nutrients needed by infants for the first 6 months. Unmodified whole cow's milk, low-fat cow's milk, skim milk, other animal milks, and imitation milk drinks are not acceptable as major sources of nutrition for infants because of their limited digestibility, increased risk of contamination, and lack of components needed for appropriate growth. Whole milk can cause iron-deficiency anemia in infants, possibly as a result of occult gastrointestinal blood loss. Pasteurized whole cow's milk is deficient in iron, zinc, and vitamin C and has a high renal solute load, which makes it undesirable for infants younger than 12 months old (American Academy of Pediatrics, Committee on Nutrition, 2014).
N u r s i n g A l e r t Dietary fat in infants younger than 6 months old should not be restricted unless on specific medical advice. Substituting skim or low-fat milk is unacceptable because the essential fatty acids are inadequate, and the solute concentration of protein and electrolytes, such as sodium, is too high.
The amount of formula per feeding and the number of feedings per day vary among infants. Infants being fed on demand usually determine their own feeding schedule, but some infants may need a more planned schedule based on average feeding patterns to ensure sufficient nutrients. In general, the number of feedings decreases from six at 1 month old to four or five at 6 months old. Regardless of the number of feedings, the total amount of formula ingested will usually level off at about 32 ounces (946 ml) per day.
Honey should be avoided in the first 12 months because of the risk of botulism (see Chapter 30); pacifiers should not be coated with honey to encourage the infant to take it. Socializing the infant to food flavors of the family's culture is common in addition to continuing breastfeeding for 2 to 4 years (see Cultural Considerations box).
C u l t u r a l C o n s i d e r a t i o n s Multicultural Feeding Practices
Cultural beliefs and values often influence infant-feeding practices. Health care professionals may benefit from understanding the multicultural feeding practices that parents choose for their infants. Traditional feeding practices include offering a variety of liquids or foods (such as sugared wine, water, or honey) during the first few days of life and thereafter.
Bottled water for mixing powdered or concentrated formula is a relatively safe alternative to tap water if available. Tap water has a high content of contaminants, such as lead. Do not assume, however, that bottled water is sterile unless specifically stated on the container. Fluoridated bottled water is not necessary for mixing powdered formula unless the local water source is low in fluoride, in which case fluoride supplementation is recommended after 6 months old (see Dental Health later in this chapter).
The addition of solid foods before 4 to 6 months old is not recommended. During the early months, solid foods are not compatible with the ability of the gastrointestinal tract and infant's nutritional needs. Feeding solids to young infants exposes them to food antigens that may produce food protein allergy. Ample evidence indicates that early introduction of foods other than maternal milk in the first 6 months of life predisposes children to an increased risk for food allergy
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development; foods known to be allergenic (e.g., peanuts, eggs, fish, seafood) should be introduced later than 9 months old according to the child's risk for atopy (Heinrich, Koletzko, and Koletzko, 2014).
Developmentally, infants are not ready for solid food. The extrusion (protrusion) reflex is strong and often causes them to push food out of the mouth. Infants instinctively suck when given food. Because of their limited motor abilities, infants are unable to deliberately push food away or avoid feeding. Therefore, early introduction of solids is a type of forced feeding that may lead to excessive weight gain and increased predisposition to allergies and iron-deficiency anemia. Parents should be cautioned concerning the use of juices and nonnutritive drinks such as fruit-flavored drinks or carbonated beverages (soda or pop) during this period. Many juices and nonnutritive drinks, although readily available to consumers, do not provide sufficient and appropriate caloric intake for infants younger than 12 months old; such drinks may replace the nutrients in breast milk or formula and lead to growth or health problems. Fruit juices are not required in the first 6 months; no studies have demonstrated benefits of giving fruit juice to infants.
The Second 6 Months During the second half of the first year, human milk or formula should continue to be the primary source of nutrition. The use of fluoride supplementation depends on the infant's intake of fluoride tap water (see Dental Health later in this chapter). If breastfeeding is discontinued, a commercial iron-fortified formula should be substituted. Follow-up or transition formulas marketed for older infants offer no special advantages over other infant formulas and provide excessive protein (American Academy of Pediatrics, Committee on Nutrition, 2014).
The major change in feeding habits is the addition of solid foods to the infant's diet. Physiologically and developmentally, infants 4 to 6 months old are in a transition period. By this time, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic foods. Tooth eruption is beginning and facilitates biting and chewing. The extrusion reflex has disappeared, and swallowing is more coordinated to allow infants to accept solids easily. Head control is well developed, which permits infants to sit with support and purposely turn their heads away to communicate lack of interest in food. Voluntary grasping and improved eye–hand coordination gradually allow infants to pick up finger foods and feed themselves. Their increasing sense of independence is evident in their desire to hold their bottles and try to “help” during feeding.
Selection and Preparation of Solid Foods The choice of solid foods to introduce first is variable but should meet the reasons for feeding solids, such as supplying nutrients not found in formula or breast milk. Iron-fortified infant cereal is generally introduced first because of its high iron content (7 mg/3 Tbsp. of prepared dry cereal). Commercially prepared ready-to-serve dry cereals for infants include rice, barley, oatmeal, and high-protein cereals; rice is usually suggested as an initial food because of its easy digestibility and low allergenic potential. Cereals (such as cream of farina) are not used because infant commercial cereals are a better source of iron. Some of the commercial baby cereals are combined with fruit. There is little nutritional benefit from these preparations, and they are more expensive. New foods should be added one at a time; therefore, parents should avoid cereal combinations when beginning a new grain.
Infant cereal (iron fortified) may be mixed with expressed breast milk or water until whole milk is given. After 6 months old, small amounts of 100% fruit juices can be mixed with the dry cereal; the vitamin C content of the juice enhances the absorption of iron in the cereal. Because of their benefit as a source of iron, infant cereals should be continued until the child is 18 months old.
Fruit juice can be offered from a cup for its rich source of vitamin C and as a substitute for milk for one feeding a day. Large quantities of certain juices (e.g., apple, pear, prune, sweet cherry, peach, and grape) are avoided, because they may cause abdominal pain, diarrhea, or bloating in some children. Avoid fruit-flavored drinks, which may be marketed as juices but contain high concentrations of complex sugars. White grape juice (no more than 5 oz/day) may be better absorbed and safe for infants this age without causing gastrointestinal distress. The American Academy of Pediatrics, Committee on Nutrition (2014) recommends that fruit juice intake not exceed 4 to 6 ounces per day and that juices not be given to infants younger than 4 to 6 months old. Because vitamin C is naturally destroyed by heat, juice is not warmed. Juice containers are always
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kept covered and refrigerated to prevent further vitamin loss. The addition of other foods is arbitrary. A common sequence is to introduce strained fruits
followed by vegetables and, finally, meats; however, some clinicians prefer to add vegetables before fruit. If foods are introduced early, citrus fruits, meats, and eggs are delayed until after 6 months old because of their potential to result in allergy. At 6 months old, foods such as a cracker or zwieback can be offered as finger and teething foods. By 8 to 9 months old, junior foods and nutritious finger foods such as firmly cooked vegetable, raw pieces of fruit, or cheese can be given. By 1 year old, well-cooked table foods are served.
The introduction of solid foods into the infant's diet at this age is primarily for taste and chewing experience, not for growth. The majority of infants' caloric needs are derived from the primary milk source (human or formula); therefore, solids should not be perceived as a substitute for milk until the child is older than 12 months old. Portion sizes may vary according to the infant's taste. In general, 1 Tbsp. per year of age (i.e., to Tbsp. for most infants under 12 months old) is adequate for most infants. In most cases, 2 Tbsp. may be served, but because of infants' focus on the texture and feel of the food, smaller amounts will be consumed. Another reason for smaller portions is the concern over feeding habits in early childhood and obesity; early feeding of smaller portions may help prevent the “clean your plate” or “eat all your food or you can't get down from the table” concepts, which are known to contribute to overeating in later life. The addition of solid foods to exclusively breastfed infants' diet does not significantly increase overall caloric intake or weight gain.
Commercially prepared baby foods are the most common type of food served to infants in the United States. They are convenient and usually contain no added salt or sugar but can be relatively expensive. An alternative is to prepare baby foods at home, which is a simple and inexpensive process.
In general, low-calorie milk and foods should be avoided in infants and toddlers unless a strict medically prescribed diet is required. Infants' growth during this phase is crucial to future development, and dietary fat should be curtailed with great caution. At the same time, it is important to recognize that certain types of dietary fat are unacceptable for infants; fried potatoes, candy, ice cream, cake, soda pop and other sweetened drinks, and other such items do not constitute an appropriate amount of fat intake and may contribute to childhood obesity. One suggestion is to limit the amount (serving size) of dietary fat in foods provided rather than eliminate them altogether, especially during infancy.
Parents are cautioned to avoid reliance on foods and supplements marketed as iron- or vitamin- fortified as primary sources of minerals. Instead, encourage parents to offer the child a variety of fruits, vegetables, and whole grains, including those known to naturally be rich in iron.
Introduction of Solid Foods When the spoon is first introduced, infants often push it away and appear dissatisfied. Food that is placed on the front of the tongue and pushed out is simply scooped up and refed. As infants become accustomed to the spoon, they will more eagerly accept the food and eventually open the mouth in anticipation (or keep it closed in dislike).
One food item is introduced at intervals of 4 to 7 days to allow for identification of food allergies. New foods are fed in small amounts. As the amount of solid food increases, the quantity of milk is decreased to less than 1 L/day to prevent overfeeding.
Because feeding is a learning process, as well as a means of nutrition, new foods are given alone to allow the child to learn new tastes and textures. Food should not be mixed in the bottle and fed through a nipple with a large hole. This deprives the child of the pleasure of learning new tastes and developing a discriminating palate. It can also cause problems with poor chewing of food later in life because of lack of experience. Guidelines for the introduction of new foods are given in the Family-Centered Care box.
F a m i l y - C e n t e r e d C a r e Feeding During the First Year
Birth to 6 Months Old (Breastfeeding or Bottle Feeding)
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Breastfeeding
• Most desirable complete diet for the first half of the first year.*
• A recommended supplement is oral vitamin D (400 IU/day).
• In exclusively breastfed infants 4 months old and older, recommend an iron supplement of 1 mg/kg/day until iron-rich complementary foods are introduced.
Formula
• Iron-fortified commercial formula is a complete food for the first half of the first year.*
• Requires fluoride supplements (0.25 mg) when the concentration of fluoride in the drinking water is below 0.3 ppm after 6 months old.
• Evaporated milk formula requires supplements of vitamin C, iron, and fluoride (in accordance with the fluoride content of the local water supply after 6 months old).
4 to 12 Months Old (Solid Foods)
• May begin to add solids by 4 to 6 months old.
• First foods are strained, pureed, or finely mashed.
• Finger foods such as teething crackers, raw fruit, or vegetables can be introduced by 6 to 7 months old.
• Chopped table food or commercially prepared junior foods can be started by 9 to 12 months old.
• With the exception of cereal, the order of introducing foods is variable; a recommended sequence is fruit, then vegetables, and then meat.
• Introduce one food at a time, usually at intervals of 4 to 7 days, to identify food allergies.
• Introduce solids when the infant is hungry.
• Begin spoon feeding by pushing food to back of tongue because of infants' natural tendency to thrust the tongue forward.
• Use a small spoon with a straight handle; begin with 1 or 2 tsp. of food; gradually increase to 2 to 3 Tbsp. per feeding.
• As the quantity of solids increases, decrease the quantity of milk to prevent overfeeding. Limit formula or milk to approximately 960 ml (32 oz) daily and fruit juice to less than 180 ml (6 oz) daily.
• Never introduce foods by mixing them with the formula in the bottle.
Cereal—Start at 4 to 6 Months Old
• Introduce commercially prepared iron-fortified infant cereals and administer daily until 18 months old.
• Rice cereal is usually introduced first because of its low allergenic potential.
• Parents can discontinue supplemental iron when iron-fortified cereal is given.
Fruits and Vegetables—Start at 6 to 8 Months Old
• Applesauce, bananas, and pears are usually well tolerated.
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• Avoid fruits and vegetables marketed in cans that are not specifically designed for infants because of variable and sometimes high lead content and addition of salt, sugar, or preservatives.
• Offer fruit juice only from a cup, not a bottle, to reduce the development of early childhood caries. Limit to 4 ounces per day or less.
Meat, Fish, and Poultry—Start at 8 to 10 Months Old
• Avoid fatty meats.
• Prepare by baking, broiling, steaming, or poaching.
• Include organ meats such as liver, which has a high iron, vitamin A, and vitamin B complex content.
• If soup is given, be certain all ingredients are familiar to child's diet.
• Avoid commercial meat and vegetable combinations because their protein content is low.
Eggs and Cheese—Start at 12 Months Old
• Serve egg yolk hard boiled and mashed, soft cooked, or poached.
• Introduce egg white in small quantities (1 tsp.) toward the end of the first year to detect an allergy.
• Use cheese as a substitute for meat and as finger food.
*Breastfeeding or commercial formula feeding for up to 12 months old is recommended. After 1 year, whole cow's milk can be given.
Weaning Defined as the process of giving up one method of feeding for another, weaning usually refers to relinquishing the breast or bottle for a cup. In Western societies, this is generally regarded as a major task for infants and is often seen as a potentially traumatic experience. It is psychologically significant because infants are required to give up a major source of oral pleasure and gratification.
Other cultural groups define weaning in relation to significant life events (e.g., teething) or reaching a specific age. No one time for weaning is best for every child, but generally, most infants show signs of readiness during the second half of the first year. It is recommended that weaning occur with the infant's needs as a guide (Lawrence and Lawrence, 2011). Their increasing desire for freedom of movement may lessen their desire to be held close for feedings. They are acquiring more control over their actions and can easily manipulate a cup to their lips (even if it is held upside down!). Imitation becomes a powerful motivator by 8 or 9 months old, and they enjoy using a cup or glass like others do.
Weaning should be gradual by replacing one bottle or breastfeeding session at a time. The nighttime feeding is usually the last feeding to be discontinued. It is advisable to never allow a child to take a bottle of milk to bed; this is a major cause of caries in deciduous teeth. If breastfeeding is terminated before 5 or 6 months old, weaning should be to a bottle (not in bed) to provide for the infant's continued sucking needs. If discontinued later, weaning can be directly to a cup, especially by 12 to 14 months old. Any sweet liquid, such as fruit juice, should be given in a cup and should not be given at bedtime.
Sleep and Activity Sleep patterns vary among infants, with active infants typically sleeping less than placid children. The total daily sleep for 2-month-old infants is approximately 15 hours (range 10 to 20 hours); whereas the total daily sleep for 6- to 12-month-old infants is approximately 13 hours (range 9 to 17
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hours) (Galland, Taylor, Elder, et al, 2012). Consolidation of nocturnal sleep hours occurred during the first 12 months with decreasing daytime sleep and increasing nighttime sleep. Generally, by 12 months old, most infants have developed a nocturnal pattern of sleep that lasts at least 8 hours. The number of naps per day varies, but infants typically take two naps by the end of the first year. Breastfed infants usually sleep for shorter periods, especially during the night, compared with bottle-fed infants (Middlemiss, Yaure, and Huey, 2015). A discussion of sleep problems is found in Chapter 10.
Most infants are naturally active and need no encouragement to be mobile. Problems can arise when devices such as play yards, strollers, commercial swings, and mobile walkers are used excessively. These items restrict movement and prevent infants from exploring and developing gross motor skills. Contrary to popular belief, mobile walkers do not enhance coordination and are dangerous if tipped over or placed near the top of stairs, porches, in-ground pools, furnaces, and other hazardous surfaces.
Dental Health Good dental hygiene begins with appropriate maternal dental health before and during the pregnancy and counseling during early infancy regarding dietary intake for the promotion of optimum oral hygiene. Counsel parents early regarding the risk of feeding practices that increase the risk of poor dental health. Some of these, as previously mentioned, include avoiding propping the milk bottle; giving the milk bottle in the bed; or giving fruit juices in a bottle, especially before 6 months old. These contribute to enamel erosion and early childhood caries (previously called baby bottle tooth decay).
When the primary teeth erupt, cleaning should begin. The teeth and gums are initially cleaned by wiping with a damp cloth; toothbrushing is too harsh for the tender gingiva. The caregiver can stabilize the infant by cradling the child with one arm and using the free hand to cleanse the teeth. Oral hygiene can be made pleasant by singing or talking to the infant. It is recommended that the infant have a brief oral health examination by 6 months old from a qualified pediatric health practitioner; infants at high risk for caries are identified and oral health counseling is implemented. It is also recommended that the infant have an established dental home by 1 year old (American Academy of Pediatric Dentistry, 2014). It is generally recommended that a small, soft-bristled toothbrush be used as more teeth erupt and the infant adjusts to the routine of cleaning. Water is preferred to toothpaste, which the infant will swallow (and if the toothpaste is fluoridated, the infant may ingest excessive amounts of fluoride). The American Academy of Pediatric Dentistry (2014) recommends a “smear” of toothpaste for children younger than 3 years old and a pea-size amount for those 3 to 6 years old.
Fluoride, an essential mineral for building caries-resistant teeth, is needed beginning at 6 months old if the infant does not receive water with adequate fluoride content. The American Academy of Pediatric Dentistry (2014) recommends the determination of fluoride administration be based on individual needs of each child. Systemic fluoride administration should be considered for all children at risk for dental caries who drink fluoride deficient water (<0.6 ppm) but only after determining all dietary sources of fluoride.
Dietary considerations are also important because habits begun during infancy tend to continue into later years. Avoid foods with concentrated sugar (sucrose) in the infant's diet. Dietary considerations are also important because habits begun during infancy tend to continue into later years. Foods with concentrated sugar are used sparingly (if at all) in the infant's diet. The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey also may cause infant botulism, and parts of the candy pacifier can be aspirated (Box 9-1). Parents need to be counseled regarding the detrimental effects of frequent and prolonged bottle feeding or breastfeeding during sleep, when the sweet milk or other fluid (such as juice) bathes the teeth, producing early childhood caries. In addition, carbonated beverages should be avoided in infancy. (See Chapter 11 for a more extensive discussion of dental health, including early childhood caries.)
Box 9-1 S a f e t y P r o m o t i o n a n d I n j u r y P r e ve n t i o n D u r i n g I n f a n c y
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Birth to 4 Months Old Major Developmental Accomplishments
Exhibits involuntary reflexes (e.g., crawling reflex may propel infant forward or backward; startle reflex may cause the body to jerk)
May roll over
Has increasing eye–hand coordination and voluntary grasp reflex
Injury Prevention Aspiration
Aspiration is not as great a danger to this age group, but parents should begin practicing safeguarding early (see 4 to 7 Months Old later in this box).
Never shake baby powder directly on infant; place powder in hand and then on infant's skin; store container closed and out of the infant's reach.
Hold infant for feeding; do not prop bottle.
Know emergency procedures for choking.
Use pacifier with one-piece construction and loop handle.
Burns
Install smoke detectors in home.
Do not use microwave oven to warm formula; always check temperature of liquid before feeding.
Check bathwater.
Do not pour hot liquids when infant is close by, such as sitting on lap.
Beware of cigarette ashes that may fall on infant.
Do not leave infant in sun for more than a few minutes; keep exposed areas covered.
Wash flame-retardant clothes according to label directions.
Use cool-mist vaporizers.
Do not leave child in parked car.
Check surface heat of car restraint before placing child in seat.
Suffocation and Drowning
Keep all plastic bags stored out of infant's reach; discard large plastic garment bags after tying in a knot.
Do not cover mattress with plastic.
Use firm mattress and loose blankets with no pillows.
Make certain crib design follows federal regulations and mattress fits snugly—crib slats 2.375 inches (6 cm) apart.*
Position crib away from other furniture and away from radiators.
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Do not tie pacifier on a string around infant's neck.
Remove bibs at bedtime.
Never leave infant alone in bath.
Do not leave infant younger than 12 months old alone on adult or youth mattress or beanbag-type seats.
Motor Vehicles
Transport infant in federally approved, rear-facing car seat, preferably in back seat.
Do not place infant on seat (of car) or in lap.
Do not place child in a carriage or stroller behind a parked car.
Do not place infant or child in front passenger seat with an air bag.
Do not leave infant unattended in car.
Falls
Use crib with fixed, raised rails.
Never leave infant alone on a raised, unguarded surface.
When in doubt as to where to place child, use floor.
Restrain child in infant seat, and never leave child unattended while the seat is resting on a raised surface.
Avoid using a high chair until child can sit well with support.
Accidental Poisoning
Poisoning is not as great a danger to this age group, but parents should begin practicing safeguards early (see 4 to 7 Months Old later in this box).
Bodily Damage
Keep sharp or jagged objects, such as knives and broken glass, out of child's reach.
Keep diaper pins closed and away from infant.
4 to 7 Months Old Major Developmental Accomplishments
Rolls over
Sits momentarily
Grasps and manipulates small objects
Re-secures a dropped object
Has well-developed eye–hand coordination
Can focus on and locate small objects
Has prominent mouthing (oral fixation)
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Can push up on hands and knees
Crawls backward
Injury Prevention Aspiration
Keep buttons, beads, syringe caps, and other small objects out of infant's reach.
Keep floor free of any small objects.
Do not feed infant hard candy, nuts, food with pits or seeds, or whole or circular pieces of hot dog.
Exercise caution when giving teething biscuits because large chunks may be broken off and aspirated.
Do not feed infant while he or she is lying down.
Inspect toys for removable parts.
Keep baby powder, if used, out of reach.
Avoid storing cleaning fluid, paints, pesticides, and other toxic substances within infant's reach.
Know telephone number of local poison control center (800-222-1222) (usually listed in front of telephone directory).
Suffocation
Keep all latex balloons out of reach.
Remove all crib toys that are strung across crib or play yard when child begins to push up on hands or knees or is 5 months old.
Burns
Keep water faucets out of reach.
Place hot objects (cigarettes, candles, incense) on high surface out of child's reach.
Limit exposure to sun; apply sunscreen.
Falls
Restrain in a high chair.
Keep crib rails raised to full height.
Motor Vehicles
See Birth to 4 Months Old earlier in this box.
Accidental Poisoning
Make certain that paint for furniture or toys does not contain lead.
Place toxic substances on a high shelf or in locked cabinet.
Hang plants or place on high surface rather than on floor.
Know telephone number of local poison control center (800-222-1222) (usually listed in front of telephone directory).
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Bodily Damage
Give toys that are smooth and rounded, preferably made of wood or plastic.
Avoid long, pointed objects as toys.
Avoid toys that are excessively loud.
Keep sharp objects out of infant's reach.
8 to 12 Months Old Major Developmental Accomplishments
Crawls or creeps
Stands holding on to furniture
Stands alone
Cruises around furniture
Walks
Climbs
Pulls on objects
Throws objects
Picks up small objects; has pincer grasp
Explores by putting objects in mouth
Dislikes being restrained
Explores away from parent
Increasingly understands simple commands and phrases
Injury Prevention Aspiration
Keep small objects off floor, off furniture, and out of reach of children.
Take care when feeding solid table food to give very small pieces.
Do not use beanbag toys or allow child to play with dried beans.
See also 4 to 7 Months Old earlier in this box.
Bodily Damage
See 4 to 7 Months Old earlier in this box.
Avoid placing televisions or other large objects on top of furniture, which may be overturned when infant pulls self to standing position.
Falls
Avoid walkers, especially near stairs.*
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Ensure that furniture is sturdy enough for child to pull self to standing position and cruise.
Fence stairways at top and bottom if child has access to either end.*
Dress infant in safe shoes and clothing (soles that do not “catch” on floor, tied shoelaces, pant legs that do not touch floor).
Suffocation and Drowning
Keep doors of ovens, dishwashers, refrigerators, coolers, and front-loading clothes washers and dryers closed at all times.
If storing an unused large appliance, such as a refrigerator, remove the door.
Supervise contact with inflated balloons; immediately discard popped balloons and keep uninflated balloons out of reach.
Fence swimming pools and other bodies of standing water, such as decorative fountains; lock gate to swimming pools so that only adult can access.
Always supervise when near any source of water, such as cleaning buckets, drainage areas, toilets.
Keep bathroom doors closed.
Eliminate unnecessary pools of water.
Keep one hand on child at all times when in tub.
Accidental Poisoning
Administer medications as a drug, not as a candy.
Do not administer medications unless prescribed by a practitioner.
Return medications and poisons to safe storage area immediately after use; replace caps properly if a child-protector cap is used.
Have poison control center number (800-222-1222) on telephone and refrigerator.
Burns
Place guards in front of or around any heating appliance, fireplace, or furnace.
Keep electrical wires hidden or out of reach.
Place plastic guards over electrical outlets; place furniture in front of outlets.
Keep hanging tablecloths out of reach (child may pull down hot liquids or heavy or sharp objects).
*Information on many items such as cribs or walkers is available from US Consumer Product Safety Commission, 800-638-2772; http://www.cpsc.gov/.
Safety Promotion and Injury Prevention Injuries are a major cause of death during infancy, especially for children 6 to 12 months old. The three leading cause of accidental death injury in infants were suffocation, motor vehicle–related injuries, and drowning (Centers for Disease Control and Prevention, 2012a). During the years 2000 to 2009, unintentional infant suffocation death rates increased by 54% (Centers for Disease Control and Prevention, 2012a). For the years 2010 to 2011, unintentional injuries (accidents) were the leading cause of death in children 1 to 4 years old, whereas accidents were the fifth leading cause of
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death in infants from birth to 12 months old (Hamilton, Hoyert, Martin, et al, 2013). Fall-related injuries were the most common cause of unintentional injuries resulting in emergency department visits among infants 0 to 12 months old with 59% of the emergency department visits attributed to this cause (Centers for Disease Control and Prevention, 2012b). In a study of infants treated for accidents, causes of injuries included beds, car seats, and stairs (Mack, Gilchrist, and Ballesteros, 2008). According to a recent Cochrane study, one third of all injuries occur in the home, yet there is insufficient evidence to demonstrate that modification of the home environment has an impact on the rate of injuries (Turner, Arthur, Lyons, et al, 2011). Constant vigilance, awareness, and supervision are essential as children gain increased locomotor and manipulative skills that are coupled with an insatiable curiosity about the environment. Box 9-1 lists the major developmental achievements of each period during infancy and the appropriate injury prevention plan. Table 9-2 lists common types of injuries and associated objects that predispose to such injuries. Suggestions for promoting safety in the home environment are given for specific types of injuries. The acronym SAFE PAD, described in Table 9-2, may be used to identify common types of injuries to infants and older children.
TABLE 9-2 Common Infant Injuries, Associated Risk Factors, and Safety Promotion
SAFE PAD Acronym Risk Factors Suggested Safety Interventions
Suffocation, Sleep position
Latex balloons Avoid latex balloons except with close adult supervision. Plastic bags Tie unused plastic bags in a knot and dispose of in a safe container. Bed surface (non-infant), such as sofa or adult bed
Avoid placing infants to sleep on sofas, soft bedding, or adult bed.
Pillows Avoid use of pillows for sleep. Soft cushions and blankets Clear bedding of soft cushions and blankets. Prone sleeping Place infant to sleep on back at all times.
Asphyxia, animal bites
Food items: Cylindrical items, such as hot dogs, hard candy, peanuts, almonds
Cut hot dogs lengthwise; avoid hard candy in infants and toddlers. Infants should completely chew up each food item in mouth; do not feed more until item is swallowed.
Toys: Small toys, such as Legos As a general rule of thumb, if the toy fits into a toilet paper cardboard roll, it can be swallowed by a small child. Small objects: Batteries, buttons, beads, dried beans, syringe caps, safety pins
Keep out of reach of infants, who are naturally inquisitive.
Pacifiers Pacifiers should be one piece. Baby (talc) powder Avoid shaking powder over infant; if used, place on adult's hand and then place on infant's skin. Domestic dogs, cats Supervise child around domestic animals; teach not to approach dog that is eating, has puppies, or is not feeling well. Animals
that are “tame” can be unpredictable. Small children are the right size for most domesticated animals to come face to face. Closely supervise child around visiting pets. (See Pet and Wild Animal Bites, Chapter 13.)
Falls Stairs Infants like to climb; place childproof gate at top and bottom of stairs. Diaper changing table Infants do not have depth perception and cannot perceive a dangerous height from one that is safe. Never leave infants
unattended on a flat surface even if not rolling over. Crib, bed-crib sides can fall when infant leans on them
In 2011, a mandate was made to stop selling drop-side infant cribs.*
Infant carriers Never leave infant unattended in a carrier on top of a surface, such as a shopping cart, clothes dryer, washer, kitchen cabinet; place carrier on floor.
Car seat restraints Secure infant in car seat restraint securely and never leave unattended if unrestrained. High chair Restrain infant in high chair; avoid using high chair except for feeding and only if adult supervision is adequate; even restrained
infants can squirm out of some restraints and fall. Infant walkers Use only stationary walkers. There is no evidence that walkers help infants “walk” any sooner. Wheeled walkers can easily be
propelled off stairs and other platforms, such as porches or decks, causing significant injury. Windows, screens Avoid placing furniture next to a window. Infants learn to climb and can fall out of open windows, even with screens. Television, stereos, sound systems These must be secured to the stand; infants can pull the stand over, causing the TV or sound system to land on their heads,
causing significant injury. Electrical burns or burns
Electrical outlets Place safety cap over electrical outlets; infants may be burned by placing conductive object into outlet. Hot hair combs, curlers Keep out of reach of infant and keep turned off when not in use. Water Infants may turn on tap or faucet in bathtub and burn self. Lower the water heater to a safe temperature of 49° C (120° F). Before
placing infant in tub, check temperature of water and completely turn off faucet so child cannot alter temperature of water. Never leave infant unattended in tub or sink of water.
Fireplace Place a childproof screen in front of fireplace. Stove, hot liquids Keep top front burners off and keep pot handles turned toward back to avoid infant pulling hot pot onto self and causing burn
injuries. Cigarettes Avoid smoking and holding infant on lap while smoking cigar or cigarette.
Poisoning, ingestions
Medication, ointments, cream, lotions Medications left in purses or handbags or on a table top can often be ingested by the curious infant. Keep Poison Control Center number readily available (800-222-1222).
Plants: Household plants may be a source of accidental poisoning
Keep plants out of child's reach.
Cleaning solutions Store in locked cabinet or in top cabinet where there are no drawers or shelves for infant to climb on. Avoid storing cleaning and caustic solutions in containers such as a soda bottle or jar—infants and toddlers cannot differentiate a soda from a caustic drain cleaner.
Inhalation or oral or nasal ingestion of poisonous or harmful chemicals such as methamphetamine, gasoline, turpentine
Keep gasoline and turpentine stored in a locked cabinet or closet out of child's reach. Avoid storing in containers that are also used to keep drinks or food.
Automobile safety
Car or truck and hot weather An automobile-related hazard for infants is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>26.4° C [80° F]). Infants dissipate heat poorly, and an increase in body temperature may cause death in a few hours. Caution parents against leaving infants in a vehicle alone for any reason.
Air bags Avoid placing infant in a car restraint behind an air bag. Deactivate the air bag (available in certain models) or place the infant in the back seat in a proper car seat restraint.
Car seat restraint See discussion earlier in this chapter. Drowning Bath tub Never leave infant unattended in tub or sink of water.
Swimming pools, bird baths, decorative ponds of water, splash pads
Place fence around pools with gate lock that is out of child's reach. Supervise infants in water at all times; an infant may drown in as little as 2 inches of water. Swimming lessons are encouraged but are not foolproof for drowning if infant or child hits head on hard object and becomes unconscious as falling into the water.
5-gallon buckets Keep 5-gallon buckets empty of water or elevated out of child's reach.
*A number of parent education pamphlets (such as Crib Safety Tips and Is Your Used Crib Safe?) are available in English and Spanish from the US Consumer Product Safety Commission, 4330 East West Highway, Bethesda, MD 20814; 800-638-2772; http://www.cpsc.gov.
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Motor Vehicle Injuries A significant number of infants are injured or die from improper restraint within vehicles, most often from riding on the lap of another occupant. Desapriya, Joshi, Subwarzi, et al, (2008) found that falls accounted for a significant proportion of injuries (98%) in infants from birth to 4 months old as a result of inappropriate use of a car restraint system. Reports indicate that child restraint use decreases with increasing age of children and increasing number of occupants. Lack of proper child restraint continues to be a major factor in fatal accidents involving children. One observational report of newborns being placed in a car seat restraint by their family found a 52% incidence of newborn infants placed incorrectly in car seat restraints and a 48% incidence of errors in the placement of infant car seat restraints with 29% of the car seat restraints not attached to the vehicle (Rogers, Gallo, Saleheen, et al, 2012). All infants must be secured in federally-approved restraints rather than held or placed on the seat of the car. There is no safe alternative. Car seat restraints have an expiration date on the seat or in the owner's manual, which indicates the date when it should be destroyed and a new model purchased. If the car seat is in a motor vehicle accident, it may need to be replaced.
Infant restraints are designed either as an infant-only model or as a convertible infant–toddler model. Either restraint is a semi-reclined seat that faces the rear of the car. A rear-facing car seat provides the best protection for the disproportionately heavy head and weak neck of an infant. This position minimizes the stress on the neck by spreading the forces of a frontal crash over the entire back, neck, and head; the spine is supported by the back of the car seat. If the seat were faced forward, the head would whip forward because of the force of the crash, creating enormous stress on the neck (Fig. 9-11). It is now recommended that all infants and toddlers ride in rear-facing car safety seats until they reach 2 years old or until they surpass the maximum height and weight recommended for the car seat (American Academy of Pediatrics, 2011).* Studies indicate that toddlers up to 24 months old are safer riding in car seats in the rear-facing position (Bull and Durbin, 2008; Truong, Hill, and Cole, 2013).
FIG 9-11 Rear-facing infant seat in rear seat of car. The infant is placed in the seat when going home from the hospital. (Courtesy of Brian and Mayannyn Sallee, Anchorage, AK.)
The restraint is anchored to the vehicle with the vehicle's seat belt, and the restraint has a harness system for securing the infant. Some harness systems require a clip to keep the shoulder straps correctly positioned. Newer vehicles (manufactured after 1999) have tether straps that attach to anchors in the car seat to better secure the seat and minimize forward movement of the forward- facing convertible seats in the event of an accident. The LATCH (lower anchor and tether for children) system provides car seat anchors between the front cushion and backrest so that the seat belt does not have to be used. Some automobiles have tether straps for rear-facing infant-only seats as well (see Fig 12-11). Although many infant restraints can be recliners, they are used in the car only in the position specified by the manufacturer. In 2014, the National Highway Traffic Safety Administration changed the LATCH system rule, which now states if the combined weight of the child and the car seat is more than 65 pounds, parents will be instructed to use the shoulder-lap belt restraint to restrain the child in the car seat instead of relying on the LATCH system for maximum protection.
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Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat. The back seat is the safest area of the car for children. For restraints to be effective, they must be used properly. Dressing the infant in an outfit with sleeves and legs allows the harness to hold the child securely in the seat. A small blanket or towel rolled tightly can be placed on either side of the head to minimize movement and keep the infant's hips against the back of the seat. Padding between the infant's legs and crotch is added to prevent slouching. Thick, soft padding is not placed under the infant or behind the back because during the impact, the padding will compress, leaving the harness straps loose. Preterm infants being discharged home from the hospital should be placed in appropriate car seat restraints as they would be placed in the car prior to discharge, and their heart rate and oxygen saturation should be monitored for 90 to 120 minutes to detect any potential problems with airway occlusion. (For further discussion of car seat restraints, see Chapter 11.)
N u r s i n g A l e r t Rear-facing infant safety seats must not be placed in the front seats of cars equipped with an air bag on the passenger side. If an infant safety seat is placed in the passenger seat with an air bag, the child could be seriously injured if the air bag is released because rear-facing infant seats extend closer to the dashboard.
Nurse's Role in Injury Prevention The task of injury prevention begins to be appreciated only when the potential environmental dangers to which infants are vulnerable are considered. Injury prevention and parent education should be handled on a growth and developmental basis. It is simply impossible to completely protect infants and small children from all potential dangers without placing them in a sterile, impractical environment. However, many childhood deaths continue to occur as a result of preventable injuries. Nurses must be aware of the possible causes of injury in each age group to provide anticipatory, preventive teaching. For example, the nurse should discuss guidelines for injury prevention during infancy (see Box 9-1) before the child reaches the susceptible age group. Preventive teaching ideally begins during pregnancy.
One third of all injuries to children occur in the home, and therefore the importance of safety cannot be overemphasized. The Family-Centered Care box summarizes a home safety checklist that can be presented to parents to increase their awareness of danger areas in the home and assist them in implementing safety devices and practices before their absence can inflict injury on infants. Hands-on displays (such as cabinet latches or toilet seat locks) can familiarize parents with inexpensive, commercial devices that can be used in the home to prevent injuries.
F a m i l y - C e n t e r e d C a r e Child Safety Home Checklist
Safety: Fire, Electrical, Burns
• Guards in front of or around any heating appliance, fireplace, or furnace (including floor furnace)*
• Electrical wires hidden or out of reach*
• No frayed or broken wires; no overloaded sockets
• Plastic guards or caps over electrical outlets; furniture in front of outlets*
• Hanging tablecloths out of reach away from open fires*
• Smoke detectors tested and operating properly
• Kitchen matches stored out of child's reach*
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• Large, deep ashtrays throughout house (if used)
• Small stoves, heaters, and other hot objects (cigarettes, candles, coffee pots, slow cookers) placed where they cannot be tipped over or reached by children
• Hot water heater set at 49° C (120° F) or lower
• Pot handles turned toward back of stove and the center of table
• No loose clothing worn near stove
• No cooking or eating hot foods or liquids with child standing nearby or sitting in lap
• All small appliances, such as iron, turned off, disconnected, and placed out of reach when not in use
• Cool, not hot, mist vaporizer used
• Fire extinguisher available on each floor and checked periodically
• Electrical fuse box and gas shutoff accessible
• Family escape plan in case of a fire practiced periodically; fire escape ladder available on upper- level floors
• Telephone number of fire or rescue squad and address of home with nearest cross street posted near phone
Safety: Suffocation and Aspiration
• Small objects stored out of reach*
• Toys inspected for small removable parts or long strings*
• Hanging crib toys and mobiles placed out of reach
• Plastic bags stored away from young child's reach; large plastic garment bags discarded after tying in knots*
• Mattress or pillow not covered with plastic or in manner accessible to child*
• Crib design according to federal regulations (crib slats <2.375 inches [6 cm] apart) with snug- fitting mattress*†
• Crib positioned away from other furniture or windows*
• Portable play yard sides up and locked at all times while in use*
• Accordion-style gates not used*
• Bathroom doors kept closed and toilet seats down*
• Faucets turned off firmly*
• Pool fenced with locked gate
• Proper safety equipment at poolside
• Electronic garage door openers stored safely and garage door adjusted to rise when door strikes object
• Doors of ovens, trunks, dishwashers, refrigerators, and front-loading clothes washers and dryers
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kept closed*
• Unused appliance, such as a refrigerator, securely closed with lock or doors removed*
• Food served in small, non-cylindric pieces*
• Toy chests without lids or with lids that securely lock in open position*
• Buckets and wading pools kept empty when not in use*
• Clothesline above head level
• At least one member of household trained in basic life support (cardiopulmonary resuscitation [CPR]), including first aid for choking
Safety: Poisoning
• Toxic substances, including batteries, placed on a high shelf, preferably in locked cabinet
• Toxic plants hung or placed out of reach*
• Excess quantities of cleaning fluid, paints, pesticides, drugs, and other toxic substances not stored in home
• Used containers of poisonous substances discarded where child cannot obtain access
• Telephone number of local poison control center (800-222-1222) and home address with nearest cross street posted near phone
• Medicines clearly labeled in childproof containers and stored out of reach
• Household cleaners, disinfectants, and insecticides kept in their original containers separate from food and out of reach
• Smoking in areas away from children
Safety: Falls
• Nonskid mats, strips, or surfaces in tubs and showers
• Exits, halls, and passageways in rooms kept clear of toys, furniture, boxes, and other items that could be obstructive
• Stairs and halls well lighted with switches at both top and bottom
• Sturdy handrails for all steps and stairways
• Nothing stored on stairways
• Treads, risers, and carpeting in good repair
• Glass doors and walls marked with decals
• Safety glass used in doors, windows, and walls
• Gates on top and bottom of staircases and elevated areas, such as porch, fire escape*
• Guardrails on upstairs windows with locks that limit height of window opening and access to areas such as fire escape*
• Crib side rails raised to full height; mattress lowered as child grows*
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• Restraints used in high chairs, walkers, or other baby furniture; preferably, walkers not used*
• Scatter rugs secured in place or used with nonskid backing
• Walks, patios, and driveways in good repair
Safety: Bodily Injury
• Knives, power tools, and unloaded firearms stored safely or placed in locked cabinet
• Garden tools returned to storage racks after use
• Pets properly restrained and immunized for rabies
• Swings, slides, and other outdoor play equipment kept in safe condition
• Yard free of broken glass, nail-studded boards, and other litter
• Cement birdbaths placed where young child cannot tip them over*
• Furniture anchored so child cannot pull down on top of self when climbing or pulling to stand
*Safety measures are specific for homes with young children. All safety measures should be implemented in homes where children reside and visit frequently, such as those of grandparents and babysitters.
†Federal regulations are available from the US Consumer Product Safety Commission, 800-638-2772; http://www.cpsc.gov.
Injury prevention requires protection of the child and education of the caregiver. Nurses in ambulatory care settings, health maintenance centers, and visiting nurse agencies are in a most favorable position for injury education. Although early postpartum discharge may be restrictive for parent teaching, this is an excellent opportunity to introduce the family to infant safety and safety for other children as well. One approach to teaching injury prevention is to relate why children in various age groups are prone to specific types of injuries. However, injury prevention must also be practical. For instance, parents are taught bathroom cleaning agents, cosmetics, and personal care items can be placed on a top shelf in the linen closet, and towels or sheets can be stored on the lower shelves and floor. In addition, parents should be encouraged to take an infant cardiopulmonary resuscitation (CPR) class to deal effectively with potential problems.
Parents need to remember that infants and young children cannot anticipate danger or understand when it is or is not present. When small children are in the home, dangerous objects must be removed or placed out of reach. Additionally, infants have no cognitive concept of cause and effect and therefore cannot relate meaning to experiences or potential dangers. A dead electrical wire may present no actual harm, but if the child is allowed to play with it, a poor behavior is enforced and will be practiced when the child encounters a live wire. Although it is always wise to explain why something is dangerous, it must be remembered that small children need to be physically removed from the situation.
It is not easy to teach safety, supervise closely, and refrain from saying “no” a hundred times a day. Parents become acutely aware of this dilemma as soon as their infants learn to crawl. When children are taught the meaning of “no,” they should also be taught what “yes” means. Children should be praised for playing with suitable toys, their efforts at behaving or listening should be reinforced, and innovative and creative recreational toys should be provided for them. Infants love to tear paper and avidly pursue books, magazines, or newspapers left on the floor. Instead of always scolding them for destroying a valued book, parents should provide child-safe books (e.g., those constructed of fabric) for them to play with. If they enjoy pots and pans, a cabinet can be arranged with safe utensils for them to explore.
One additional factor must be stressed concerning injury prevention and education. Children are imitators; they copy what they see and hear. Practicing safety teaches safety, which applies to parents and their children and to nurses and their clients. Saying one thing but doing another confuses children and can lead to difficulties as the child grows older.
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Anticipatory Guidance—Care of Families Childrearing is no easy task; it presents challenges to both new parents and seasoned parents. With society's changing roles, combined with a highly mobile population, traditional role models and time-honored methods of raising children are declining. As a result, parents look to professionals for guidance. Nurses are in an advantageous position to render assistance and suggestions. Every phase of a child's life has its particular traumas—toilet training for toddlers, unexplained fears for preschoolers, and identity crises for adolescents. For parents of infants, some challenges center around dependency, discipline, increased mobility, and safety. Major areas for parental guidance during the first year are listed in the Family-Centered Care box.
F a m i l y - C e n t e r e d C a r e Guidance During Infant's First Year
First 6 Months
• Teach parents car safety with use of federally approved restraint, facing rearward, in the middle of the back seat—not in a seat with an air bag.
• Understand each parent's adjustment to newborn, especially mother's postpartum emotional needs.
• Teach care of infant and help parents understand his or her individual needs and temperament and that the infant expresses wants through crying.
• Reassure parents that infant cannot be spoiled by too much attention during the first 4 to 6 months.
• Encourage parents to establish a schedule that meets needs of child and themselves.
• Help parents understand infant's need for stimulation in environment.
• Support parents' pleasure in seeing child's growing friendliness and social response, especially smiling.
• Plan anticipatory guidance for safety.
• Stress need for immunizations.
• Prepare for introduction of solid foods.
Second 6 Months
• Prepare parents for child's “stranger anxiety.”
• Encourage parents to allow child to cling to them and avoid long separation from either parent.
• Guide parents concerning discipline because of infant's increasing mobility.
• Encourage use of negative voice and eye contact rather than physical punishment as a means of discipline.
• Encourage showing most attention when infant is behaving well, rather than when infant is crying.
• Teach injury prevention because of child's advancing motor skills and curiosity.
• Encourage parents to leave child with suitable caregiver to allow some free time.
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• Discuss readiness for weaning.
• Explore parents' feelings regarding infant's sleep patterns.
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NCLEX Review Questions 1. In relation to developmental milestones, the infant can be expected to roll over from back to
abdomen at approximately: a. 2 months old b. 4 months old c. 6 months old d. 8 months old
2. An important milestone in the infant's life is the development of object permanence. This milestone is represented by which of these statements? a. The infant smiles at the mother when she talks to him. b. The infant repeatedly flexes and extends his arms and legs when the mother picks him up. c. The infant turns and looks for the mother when she walks out of his view. d. The infant cries when the mother hands him to a babysitter.
3. An important nutritional supplement recommended to prevent rickets in infants who are exclusively breastfeeding is: a. Vitamin A b. Fluoride c. Vitamin D d. Folic acid
4. A 4-month-old infant is brought to the well-child clinic for immunizations. The mother indicates that the infant often strains to have a bowel movement, so she has been giving him honey and has stopped feeding him iron-fortified formula, based on her sister's recommendations. The nurse recognizes that the infant is at risk for the development of which of the following? Select all that apply. a. Obesity b. Iron-deficiency anemia c. Rickets d. Infant botulism e. Cow's milk allergy
5. The type of play in which infants engage is called: a. Solitary b. Parallel c. Associative d. Cooperative
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Correct Answers 1. c; 2. c;
3. c; 4. b, d;
5. a
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Blackburn ST. Maternal, fetal, and neonatal physiology: a clinical perspective. ed 4. Saunders/Elsevier: Philadelphia; 2013.
Bull MJ, Durbin DR. Rear-facing car safety seats: getting the message right. Pediatrics. 2008;121(3):619–620.
Carey WB, McDevitt SC. Revision of the Infant Temperament Questionnaire. Pediatrics. 1978;61(5):735–739.
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Desapriya EB, Joshi P, Subwarzi S, et al. Infant injuries from child restraint safety seat misuse at British Columbia Children's Hospital. Pediatr Int. 2008;50(5):674–678.
DiSantis KI, Collins BN, Fisher JO, et al. Do infants fed directly from the breast have improved appetite regulation and slower growth during early childhood compared with infants fed from a bottle? Int J Behav Nutr Phys Act. 2011;8:89.
Durand D, Ochoa TJ, Bellomo SME, et al. Detection of secretory immunoglobulin A in human colostrum as mucosal immune response against proteins of the type III secretion system of Salmonella, Shigella and enteropathogenic Escherichia coli. Pediatr Infect Dis J. 2013;32(10):1122–1126.
Feeley N, Sherrard K, Waitzer E, et al. The father at the bedside: patterns of involvement in the NICU. J Perinat Neonat Nurs. 2013;27(1):72–80.
Fewtrell MS. Breastfeeding and later risk of CVD and obesity: evidence from randomized trials. Proc Nutr Soc. 2011;70(4):472–477.
Galland BC, Taylor BJ, Elder DE, et al. Normal sleep patterns in infants and children: a systematic review of observational studies. Sleep Med Rev. 2012;16(3):213–222.
Gallitto E. Temperament as a moderator of the effects of parenting on children's behavior. Dev Psychopathol. 2015;27(3):757–773.
Gartstein MA, Rothbart MK. Studying infant temperament via the Revised Infant Behavior Questionnaire. Infant Behav Dev. 2003;26(1):64–86.
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2013;29(2):154–162. Moss BG, Yeaton WH. Early childhood healthy and obese weight status: potentially protective
benefits of breastfeeding and delaying solid foods. Matern Child Health J. 2014;18(5):1224– 1232.
Nelson AM. A comprehensive review of evidence and current recommendations related to pacifier usage. J Pediatr Nurs. 2012;27(6):690–699.
Rogers SC, Gallo K, Saleheen H, et al. Wishful thinking: safe transportation of newborns at hospital discharge. J Trauma Acute Care Surg. 2012;73(4 Suppl 3):S262–S264.
Salah M, Abdel-Aziz M, Al-Farok A, et al. Recurrent acute otitis media in infants: analysis of risk factors. Int J Pediatr Otorhinolaryngol. 2013;77(10):1665–1669.
Shope TR, Hashikawa AN. Exclusion of mildly ill children from childcare. Pediatric Ann. 2012;41(5):204–208.
Truong WH, Hill BW, Cole PA. Automobile safety in children: a review of North American evidence and recommendations. J Am Acad Orthop Surg. 2013;21(6):323–331.
Turck D, Michaelsen KF, Shamir R, et al. World Health Organization 2006 child growth standards and 2007 growth reference charts: a discussion paper by the committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2013;57(2):258–264.
Turner S, Arthur G, Lyons RA, et al. Modification of the home environment for the reduction of injuries. Cochrane Database Syst Rev. 2011;(2) [CD003600].
US Food and Drug Administration. Do teething babies need medicine on their gums? No. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm385817.htm; 2014.
US Food and Drug Administration Consumer Health Information. Infant overdose risk with liquid vitamin D. http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM215586.pdf; 2010.
Visscher M, Narendran V. The ontogeny of skin. Adv Wound Care. 2014;3(4):291–303. Vitetta L, Briskey D, Alford H, et al. Probiotics, prebiotics and the gastrointestinal tract in
health and disease. Inflammopharmacology. 2014;22(3):135–154. Vollrath ME, Tonstad S, Rothbart MK, et al. Infant temperament is associated with potentially
obesogenic diet at 18 months. Int J Obes. 2011;6(2–2):e408–e414. Wagner CL, Greer FR, American Academy of Pediatrics, Section on Breastfeeding, et al.
Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142–1152.
Wasser H, Bentley M, Borja J, et al. Infants perceived as “fussy” are more likely to receive complementary foods before 4 months. Pediatrics. 2011;127(2):229–237.
Zeanah CH, Gleason MM. Attachment disorders in early childhood—clinical presentation, causes, correlates, and treatment. J Child Psychol Psychiatry. 2015;56(3):207–222.
*See also The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies, which includes information for breastfeeding in the workplace. This guide was updated in 2013 and can be downloaded at http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.PDF. *Car seat information is available from the American Academy of Pediatrics at https://healthychildren.org/English/safety- prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx; and from the Insurance Institute for Highway Safety, 1005 N. Glebe Road, Suite 800, Arlington, VA 22201; 703-247-1500; http://www.iihs.org. The National Highway Traffic Safety Administration, http://www.nhtsa.gov, also provides child passenger safety and air bag safety information for parents.
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Health Problems of Infants Cheryl C. Rodgers
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Nutritional Imbalances Reports of severe nutritional disorders in childhood in most developed countries are uncommon, yet there often exist small numbers of children who may experience a nutritional deficiency of some kind. The 2008 Feeding Infants and Toddlers Study (FITS) found that usual nutrient intake of infants, toddlers, and preschoolers (0 to 47 months old) met or exceeded energy and protein requirements based on the Dietary Reference Intakes (DRIs) and the 2005 Dietary Guidelines for Americans (Butte, Fox, Briefel, et al, 2010). According to the study, a small but significant number of infants were at risk for inadequate intake of iron and zinc. Dietary fiber intakes in toddlers and preschoolers were low, and saturated fat intakes exceeded recommendations for the majority of preschoolers (Butte, Fox, Briefel, et al, 2010). Foods to complement breast milk through the first 2 years of life should be based on local foods appropriate to the infant's dentition and ability to chew (Solomons and Vossenaar, 2013). Foods may need to include home fortification but should not rely on processed complementary foods (Solomons and Vossenaar, 2013).
The findings of these studies and other similar reports are important for nurses who work with infants and children. Nurses must work to promote healthy nutrition habits early in children's lives through proper education of families and children about healthy lifestyle habits, including diet and exercise for health promotion and prevention of morbidities associated with poor micronutrient intake and sedentary lifestyle.
Vitamin Imbalances Although true vitamin deficiencies are rare in the United States, subclinical deficiencies are commonly seen in population subgroups in which either maternal or child dietary intake is imbalanced and contains inadequate amounts of vitamins. Vitamin D–deficiency rickets, once rarely seen because of the widespread commercial availability of vitamin D–fortified milk, increased before the turn of the century. Populations at risk include: • Children who are exclusively breastfed by mothers with an inadequate intake of vitamin D or are
exclusively breastfed longer than 6 months without adequate maternal vitamin D intake or supplementation
• Children with dark skin pigmentation who are exposed to minimal sunlight because of socioeconomic, religious, or cultural beliefs or housing in urban areas with high levels of pollution, or who live above or below a latitude of 33 degrees north and south where sunlight does not produce vitamin D (Wacker and Holick, 2013)
• Children with diets that are low in sources of vitamin D and calcium • Individuals who use milk products not supplemented with vitamin D (e.g., yogurt,* raw cow's
milk) as the primary source of milk • Children who are overweight or obese (Turer, Lin, and Flores, 2013)
The American Academy of Pediatrics (2008) recommends that infants who are exclusively breastfed receive 400 IU of vitamin D beginning shortly after birth to prevent rickets and vitamin D deficiency. Vitamin D supplementation should continue until the infant is consuming at least 1 L/day (or 1 quart/day) of vitamin D–fortified formula (American Academy of Pediatrics, 2008). Non-breastfed infants who are taking less than 1 L/day of vitamin D–fortified formula should also receive a daily vitamin D supplement of 400 IU. Inadequate maternal ingestion of cobalamin (vitamin B12) may contribute to infant neurologic impairment when exclusive breastfeeding (past 6 months) is the only source of the infant's nutrition. A correlation between the incidence of childhood upper respiratory infections and vitamin D deficiency has been found, but the implications of the findings have yet to be completely understood (Taylor and Camargo, 2011; Walker and Modlin, 2009).
Children may also be at risk for vitamin deficiencies secondary to disorders or their treatment. For example, vitamin deficiencies of the fat-soluble vitamins A and D may occur in malabsorptive disorders, such as cystic fibrosis and short bowel syndrome. Preterm infants may develop rickets in the second month of life as a result of inadequate intake of vitamin D, calcium, and phosphorus. Children receiving high doses of salicylates may have impaired vitamin C storage. Environmental tobacco smoke exposure has been implicated in decreased concentrations of vitamin A, E, and C in
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infants (Yilmaz, Agras, Hizli, et al, 2009). Children with chronic illnesses resulting in anorexia, decreased food intake, or possible nutrient malabsorption as a result of multiple medications should be carefully evaluated for adequate vitamin and mineral intake in some form (parenteral or enteral).
Children with thalassemia are reported to have suboptimal intakes (according to DRI recommendations) of vitamins A, D, E, and K, folate, calcium, and magnesium, and the inadequacies continue to increase with advanced age (Fung, Xu, Trachtenberg, et al, 2012). One study found that children with intestinal failure who were being transitioned from parenteral nutrition to enteral nutrition had at least one vitamin and mineral deficiency; vitamin D was the most common deficiency identified, and zinc and iron were the most common minerals identified as being deficient (Yang, Duro, Zurakowski, et al, 2011).
Vitamin A deficiency has been reported with increased risk of blindness in children with measles. However, a recent Cochrane review of studies assessing the efficacy of vitamin A in children with measles found no information specifically related to ocular morbidities (Bello, Meremikwu, Ejemot- Nwadiaro, et al, 2014). Despite the lack of evidence, vitamin A supplementation has minimal side effects and should be administered to children with measles (Bello, Meremikwu, Ejemot-Nwadiaro, et al, 2014). Complications from diarrhea and infections are often increased in infants and children with vitamin A deficiency. Although scurvy (caused by a deficiency of vitamin C) is rare in developed countries, cases have been reported in infants who have poor intake of vitamin C due to poor oral intake, oral motor dysfunction, or feeding problems (Besbes, Haddad, Meriem, et al, 2010).
An excessive dose of a vitamin is generally defined as 10 or more times the Recommended Dietary Allowance (RDA), although the fat-soluble vitamins, especially vitamins A and D, tend to cause toxic reactions at lower doses. With the addition of vitamins to commercially prepared foods, the potential for hypervitaminosis has increased, especially when combined with the excessive use of vitamin supplements. Hypervitaminosis of A and D presents the greatest problems because these fat-soluble vitamins are stored in the body. High intakes of vitamin A initially present with dry, scaly skin that progresses to desquamation and fissures, and include anorexia, vomiting, and bulging fontanelle (Hayman and Dalziel, 2012). Vitamin D is the most likely of all vitamins to cause toxic reactions in relatively small overdoses. The water-soluble vitamins, primarily niacin, B6, and C, can also cause toxicity. Poor outcomes in infants (e.g., fatal hypermagnesemia) have been associated with megavitamin therapy with high doses of magnesium oxide.
One vitamin supplement that is recommended for all women of childbearing age is a daily dose of 0.4 mg of folic acid, the usual RDA. Folic acid taken before conception and during early pregnancy can reduce the risk of neural tube defects such as spina bifida by as much as 79% (Czeizel, Dudas, Paput, et al, 2011). Drugs such as oral contraceptives and antidepressants may decrease folic acid absorption; thus, adolescent girls taking such medications should consider supplementation (see Spina Bifida, Chapter 30).
Mineral Imbalances A number of minerals are essential nutrients. The macrominerals refer to those with daily requirements greater than 100 mg and include calcium, phosphorus, magnesium, sodium, potassium, chloride, and sulfur. Microminerals, or trace elements, have daily requirements of less than 100 mg and include several essential minerals and those whose exact role in nutrition is still unclear. The greatest concern with minerals is deficiency, especially iron-deficiency anemia (see Chapter 24). However, other minerals that may be inadequate in children's diets, even with supplementation, include calcium, phosphorus, magnesium, and zinc. Low levels of zinc can cause nutritional failure to thrive (FTT). Some of the macrominerals may be inadvertently overlooked when a child with intestinal failure or recent surgery is making the transition from total parenteral intake to enteral intake.
An imbalance in the intake of calcium and phosphorous may occur in infants who are given whole cow's milk instead of infant formula; neonatal tetany may be observed in such cases (see Chapter 8). Whole cow's milk is also a poor source of iron, and inadequate intake of iron from other food sources (such as iron-fortified cereal) may cause iron-deficiency anemia.
The regulation of mineral balance in the body is a complex process. Dietary extremes of mineral intake can cause a number of mineral–mineral interactions that could result in unexpected deficiencies or excesses. For example, excessive amounts of one mineral, such as zinc, can result in a
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deficiency of another mineral, such as copper, even if sufficient amounts of copper are ingested. Thus, megadose intake of one mineral may cause an inadvertent deficiency of another essential mineral by blocking its absorption in the blood or intestinal wall or by competing with binding sites on protein carriers needed for metabolism.
Deficiencies can also occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods (such as soy) are high in phytates. Contrary to popular opinion, spinach is not an ideal source of iron or calcium because of its high oxalate content.
Children with certain illnesses are at greater risk for growth failure, especially in relation to bone mineral deficiency as a result of the treatment of the disease, decreased nutrient intake, or decreased absorption of necessary minerals. Those at risk for such deficiencies include children who are receiving or have received radiation and chemotherapy for cancer; children with human immunodeficiency virus (HIV), sickle cell disease, cystic fibrosis, gastrointestinal (GI) malabsorption, or nephrosis; and extremely low birth weight (ELBW) and very low birth weight (VLBW) preterm infants.
Nursing Care Management Identification of adequacy of nutrient intake is the initial nursing goal and requires assessment based on a dietary history and physical examination for signs of deficiency or excess (see Nutritional Assessment, Chapter 7). After assessment data are collected, this information is evaluated against standard intakes to identify areas of concern. One source of standard nutrient intakes is the DRIs (see Chapter 4).
Standardized growth reference charts are used in infants, children, and adolescents to compare and assess growth parameters such as height and head circumference with the percentile distribution of other children at the same ages. The World Health Organization growth charts represent standardized growth reference now recommended for infants and toddlers up to 24 months old. This growth chart includes head circumference, height, and weight references, which were derived from healthy children in six different countries around the world. These growth standards are based on the growth of healthy breastfed infants throughout the first year of life. The Centers for Disease Control and Prevention's growth charts are now recommended for children 2 to 19 years old (Grummer-Strawn, Reinold, Krebs, et al, 2010).
Infants should be breastfed for the first 6 months and preferably for 1 year, be introduced to some solid foods after about 4 to 6 months, and receive iron-fortified cereal for at least 18 months (see Chapter 9). Vitamin B12 supplementation is recommended if the breastfeeding mother's intake of the vitamin is inadequate or if she is not taking vitamin supplements (Roumeliotis, Dix, and Lipson, 2012). If the infant is being exclusively breastfed after 4 months (when fetal iron stores are depleted), iron supplementation (1 mg/kg/day) is recommended until appropriate iron-containing complementary foods (such as iron-fortified cereal) are introduced (Baker, Greer, and American Academy of Pediatrics Committee on Nutrition, 2010). The introduction of solids for vegetarian infants may occur using the same guidelines as for other children (see Nutrition, Chapter 11). A variety of foods should be introduced during the early years to ensure a well-balanced intake. Infants who have particular nutritional deficits should be identified; a multidisciplinary approach should be taken to identify the deficit and the etiology, and to establish a plan with the caregiver to promote adequate growth and development.
Severe Acute Malnutrition (Protein-Energy Malnutrition) Malnutrition continues to be a major health problem in the world today, particularly in children younger than 5 years old. However, lack of food is not always the primary cause of malnutrition. In many developing and underdeveloped nations, diarrhea (gastroenteritis) is a major factor. Additional factors are bottle feeding (in poor sanitary conditions), inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, climate conditions, and cultural and religious food preferences. Poverty is an underlying cause of malnutrition due to the association of poor environmental conditions and lack of adequate food (Imdad, Sadiq, and Bhutta, 2011). The most extreme forms of malnutrition, or protein-energy malnutrition (PEM), are
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kwashiorkor and marasmus. Some authorities, including the World Health Organization, suggest that severe malnutrition encompasses more than protein energy deficits and thus prefer the term severe acute malnutrition (SAM). SAM may be subdivided into edematous (kwashiorkor), severe wasting (marasmus) types, or marasmic kwashiorkor, which has features of both marasmus and kwashiorkor.
In the United States, milder forms of SAM are seen as a result of primary malnutrition, although the classic cases of marasmus and kwashiorkor may also occur. Unlike in developing countries, where the main reason for SAM is inadequate food, in the United States, SAM occurs despite ample dietary supplies (see Failure to Thrive later in this chapter). SAM may also be seen in people with chronic health problems, such as cystic fibrosis, cancer, chronic diarrhea syndromes, HIV, burns, inborn errors of metabolism, and GI malabsorption. Kwashiorkor has been reported in the United States in children fed only a rice beverage diet and also in children whose families are following a fad diet (Ashworth, 2016). The rice drink contains 0.13 g of protein per ounce (compared with the 0.5 g found in human milk and infant formulas) and is an inadequate source of nutrition for children. Other reported cases of kwashiorkor in developed countries involved infants who were fed extremely restricted diets due to perceived or actual reactions to foods or food allergies (Tierney, Sage, and Shwayder, 2010). Kwashiorkor has also been reported in the United States when infants have been fed inappropriate food as a result of parental (caretaker) nutritional ignorance, a perceived cow's milk–based formula intolerance, or cow's milk intolerance (Tierney, Sage, and Shwayder, 2010). Therefore, it is important that health care workers not assume that SAM cannot occur in developed countries; a comprehensive dietary history should be obtained in any child with clinical features resembling SAM.
Kwashiorkor Kwashiorkor has been defined as primarily a deficiency of protein with an adequate supply of calories. A diet consisting mainly of starch grains or tubers provides adequate calories in the form of carbohydrates but an inadequate amount of high-quality proteins. Some evidence, however, supports a multifactorial etiology, including cultural, psychologic, and infective factors that may interact to place the child at risk for kwashiorkor. Kwashiorkor may result from the interplay of nutrient deprivation and infectious or environmental stresses, which produces an imbalanced response to such insults (Trehan and Manary, 2015). Kwashiorkor often occurs subsequent to an infectious outbreak of measles and dysentery. There is further evidence that oxidative stress occurs in children with kwashiorkor, resulting in free radical damage, which may precipitate cellular changes, resulting in edema and muscle wasting (Bandsma, Spoelstra, Mari, et al, 2011).
Taken from the Ga language (Ghana), the word kwashiorkor means “the sickness the older child gets when the next baby is born” and aptly describes the syndrome that develops in the first child, usually between 1 and 4 years old, when weaned from the breast after the second child is born.
The child with kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). The edema often masks severe muscular atrophy, making the child appear less debilitated than he or she actually is. The skin is scaly and dry and has areas of depigmentation. Several dermatoses may be evident, partly resulting from the vitamin deficiencies. Permanent blindness often results from the severe lack of vitamin A. Mineral deficiencies are common, especially iron, calcium, and zinc. Acute zinc deficiency is a common complication of severe SAM and results in skin rashes, loss of hair, impaired immune response and susceptibility to infections, digestive problems, night blindness, changes in affective behavior, defective wound healing, and impaired growth. Its depressant effect on appetite further limits food intake. The hair is thin, dry, coarse, and dull. Depigmentation is common, and patchy alopecia may occur.
Diarrhea (persistent diarrhea malnutrition syndrome) commonly occurs from a lowered resistance to infection and further complicates the electrolyte imbalance. Low levels of cytokines (protein cells involved in the primary response to infection) have been reported in children with kwashiorkor, suggesting that such children have a blunted immune response to infection. A large number of deaths in children with kwashiorkor occur in those who develop HIV infection. GI disturbances such as fatty infiltration of the liver and atrophy of the acini cells of the pancreas occur. Anemia is also a common finding in malnourished children. Protein deficiency increases the child's susceptibility to infection, which eventually results in death. Fatal deterioration may be caused by diarrhea and infection or by circulatory failure.
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Marasmus Marasmus results from general malnutrition of both calories and protein. It is common in underdeveloped countries during times of drought, especially in cultures where adults eat first; the remaining food is often insufficient in quality and quantity for the children.
Marasmus is usually a syndrome of physical and emotional deprivation and is not confined to geographic areas where food supplies are inadequate. It may be seen in children with growth failure in whom the cause is not solely nutritional but primarily emotional. Marasmus may be seen in infants as young as 3 months old if breastfeeding is not successful and there are no suitable alternatives. Marasmic kwashiorkor is a form of SAM in which clinical findings of both kwashiorkor and marasmus are evident; the child has edema, severe wasting, and stunted growth. In marasmic kwashiorkor, the child has inadequate nutrient intake and superimposed infection. Fluid and electrolyte disturbances, hypothermia, and hypoglycemia are associated with a poor prognosis.
Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the child with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor; thus, deficiency of fat-soluble vitamins is usually minimal or absent. In general, the clinical manifestations of marasmus are similar to those seen in kwashiorkor, except with marasmus, there is no edema from hypoalbuminemia or sodium retention, which contributes to a severely emaciated appearance; no dermatoses caused by vitamin deficiencies; little or no depigmentation of hair or skin; moderately normal fat metabolism and lipid absorption; and a smaller head size and slower recovery after treatment.
The child is fretful, apathetic, withdrawn, and so lethargic that prostration frequently occurs. Intercurrent infection with debilitating diseases such as tuberculosis, parasitosis, HIV, and dysentery is common.
Therapeutic Management The treatment of SAM includes providing a diet with high-quality proteins, carbohydrates, vitamins, and minerals. When SAM occurs as a result of persistent diarrhea, three management goals are identified:
1. Rehydration with an oral rehydration solution that also replaces electrolytes
2. Administration of antibiotics to prevent intercurrent infections
3. Provision of adequate (energy intake) nutrition by either breastfeeding or a proper weaning diet
Local protocols are used in developing countries to deal with SAM. Experts recommend a three- phase treatment protocol: (1) acute or initial phase in the first 2 to 10 days involving initiation of treatment for oral rehydration, diarrhea, and intestinal parasites; prevention of hypoglycemia and hypothermia; and subsequent dietary management; (2) recovery or rehabilitation (2 to 6 weeks) focusing on increasing dietary intake and weight gain; and (3) follow-up phase, focusing on care after discharge in an outpatient setting to prevent relapse and promote weight gain, provide developmental stimulation, and evaluate cognitive and motor deficits. In the acute phase, care is taken to prevent fluid overload; the child is observed closely for signs of food or fluid intolerance. Refeeding syndrome may occur when carbohydrates are administered too rapidly causing severe hypophosphatemia that may cause sudden death in a child who has been malnourished (Kliegman, 2016).
Vitamin and mineral supplementation are required in most cases of SAM. Vitamin A, zinc, and copper are recommended; iron supplementation is not recommended until the child is able to tolerate a steady food source. In addition, the child is observed for signs of skin breakdown, which should be treated to prevent infection. Breastfeeding is encouraged if the mother and child are able to do so effectively; in some cases, partial supplementation with a modified cow's milk–based formula may be necessary.
The World Health Organization issued a statement recognizing the importance of breastfeeding for the first 6 months in developing countries where HIV is prevalent among childbearing women and children (Lawrence, 2013). The World Health Organization recognizes that appropriate sources of food and water for infants may not be available after the 6 months are concluded and that the
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risk for malnutrition is greater among such children than the theoretical risk of HIV. Furthermore, the organization recommends that breastfeeding continue after 6 months with the introduction of complementary foods, provided they are safe for child consumption. In severely malnourished children, a modest energy food source is given initially followed by a high-protein and energy food source; severely malnourished children will not tolerate a high-energy and high-protein source initially. A number of food sources may be provided to treat SAM. They include oral rehydration solutions (ReSoMal), amino acid–based elemental food, and ready-to-feed foods that do not require the addition of water (to minimize contaminated water consumption); parenteral and oral antibiotics are often part of the standard treatment for PEM (Jones and Berkley, 2014).
Nursing Care Management Because SAM appears early in childhood, primarily in children 6 months to 2 years old, and is associated with early weaning, a low-protein diet, delayed introduction of complementary foods, and frequent infections (Grover and Ee, 2009), it is essential that nursing care focus on prevention of SAM through parent education about feeding practices during this crucial period. Prevention should also focus on the nutritional health of pregnant women because this will directly affect the health of their unborn children. Breastfeeding is the optimal method of feeding for the first 6 months. The immune properties naturally found in breast milk not only nourish infants but also help prevent opportunistic infections, which may contribute to SAM. Providing for essential physiologic needs, such as appropriate nutrient intake, protection from infection, adequate hydration, skin care, and restoration of physiologic integrity, is paramount. Additional nursing care focuses on education about and administration of childhood vaccinations to prevent illness, promotion of nutrition and well-being for the lactating mother, encouragement and participation in well-child visits for infants and toddlers, appropriate food sources for children being weaned from breastfeeding, and education regarding sanitation practices to prevent childhood GI diseases.
Poor skin integrity further increases the chance of infections, hypothermia, water loss, and skin breakdown. Tube feedings may be required for infants too weak to breastfeed or bottle feed. Oral rehydration with an approved oral rehydration solution is commonly used in cases of SAM in which diarrhea and infection are not immediately life threatening.
One approach that has gained acceptance for treating childhood malnutrition in developing countries is the use of ready-to-use therapeutic food (RUTF). RUTF is a paste based on peanuts, powdered milk, sugar, and vegetable oil; it requires no mixing with water or milk. The packaged RUTF can be stored without refrigeration. Studies have demonstrated improved survival rates in malnourished children (Amthor, Cole, and Manary, 2009; Park, Kim, Ouma, et al, 2012). Some of the reported advantages of home-based (community-based) treatment include that children are not exposed to hospital-acquired infections and may receive the RUTF from village health aides (Park, Kim, Ouma, et al, 2012).
It is imperative that nurses be at the forefront in educating and reinforcing healthy nutrition habits in parents of small children to prevent malnutrition. Because children with marasmus may experience emotional starvation as well, care should be consistent with care of children with failure to thrive (later in this chapter).
The World Health Organization has published guidelines for the dietary treatment and management of children with severe malnutrition; these guidelines are available at http://apps.who.int/iris/bitstream/10665/95584/1/9789241506328_eng.pdf?ua=1. These guidelines provide a summary of the evidence along with specific recommendations regarding the care of infants and children with SAM.
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Health Problems Related to Nutrition Food Sensitivity In 2010, the National Institute of Allergy and Infectious Diseases, working with 34 other professional organizations, published new evidence-based guidelines for the diagnosis and management of food allergy. A food allergy is defined by the National Institute of Allergy and Infectious Diseases as “an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food” (Boyce, Assa'ad, Burks, et al, 2010, p. 1108). Food allergens are defined as specific components of food or ingredients in food (such as a protein) that are recognized by allergen-specific immune cells eliciting an immune reaction that results in the characteristic symptoms (Boyce, Assa'ad, Burks, et al, 2010). Food intolerance is said to exist when a food or food component elicits a reproducible adverse reaction but does not have an established or likely immunologic mechanism (Boyce, Assa'ad, Burks, et al, 2010). A person may have an immune- mediated allergy to cow's milk protein, but the person who is unable to digest the lactose in cow's milk is considered to be intolerant to cow's milk, not allergic as is the first person described. The National Institute of Allergy and Infectious Diseases guidelines classify food allergy according to the following: food-induced anaphylaxis, GI food allergies, and specific syndromes; cutaneous reactions to foods; respiratory manifestation; and Heiner syndrome (Boyce, Assa'ad, Burks, et al, 2010). The exact prevalence of food allergies in children is reported to be much lower than what parents report. Approximately 6% of children may experience food allergic reactions in the first 2 to 3 years of life; 1.5% will have an allergy to eggs, 2.5% to cow's milk, and 1% to peanuts (Sampson, Wang, Sicherer, 2016). Seafood allergies in children are reported to be low in the United States: 0.2% for fish and 0.5% for crustaceans (Boyce, Assa'ad, Burks, et al, 2010). The National Institute of Allergy and Infectious Diseases report further points out that most children will eventually be able to tolerate milk, eggs, soy, and wheat, but far fewer will ever tolerate tree nut and peanuts (Boyce, Assa'ad, Burks, et al, 2010). The National Institute of Allergy and Infectious Diseases report indicates that 50% to 90% of all presumed food allergies are not actually allergies. The National Institute of Allergy and Infectious Diseases guidelines also recommend the following (Boyce, Assa'ad, Burks, et al, 2010; Burks, Jones, Boyce, et al, 2011): • Infants should be exclusively breastfed until 4 to 6 months old. • Soy formula is not recommended to prevent the development of food allergy. • Introduction of complementary foods should not be delayed beyond 6 months old. • Hydrolyzed formula (vs. cow's milk) may be used in at-risk infants to prevent or modify food
allergy. • Maternal diet during pregnancy or lactation should not be restricted to prevent food allergy. • Children should be vaccinated with the measles, mumps, and rubella (MMR) and measles,
mumps, rubella, and varicella (MMRV) vaccines (even with an egg allergy). • Patients with severe egg allergy reactions should not receive the influenza vaccine without
consulting the primary practitioner for an analysis of the risks vs. benefits (see also Chapter 6, Immunizations).
A summary of the National Institute of Allergy and Infectious Diseases guidelines is provided by McBride (2011) and Burks, Jones, Boyce, et al, (2011).
The clinical manifestations of food allergy may be divided as follows (American Academy of Pediatrics, 2014):
Systemic: Anaphylactic, growth failure
GI: Abdominal pain, vomiting, cramping, diarrhea
Respiratory: Cough, wheezing, rhinitis, infiltrates
Cutaneous: Urticaria, rash, atopic dermatitis
Food allergies usually occur either as an immunoglobulin E (IgE)–mediated or non–IgE-mediated immune response; some toxic reactions may occur as a result of a toxin found within the food. Food
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allergy is caused by exposure to allergens, usually proteins (but not the smaller amino acids), that are capable of inducing IgE antibody formation (sensitization) when ingested. Sensitization refers to the initial exposure of an individual to an allergen, resulting in an immune response; subsequent exposure induces a much stronger response that is clinically apparent. Consequently, food allergy typically occurs after the food has been ingested one or more times. The National Institute of Allergy and Infectious Diseases report indicates that sensitization alone is not sufficient to classify as a food allergy; rather, an immune-mediated response and manifestation of specific signs and symptoms are necessary to categorize an individual as having a food allergy (Boyce, Assa'ad, Burks, et al, 2010). The most common food allergens are listed in Box 10-1.
Box 10-1 C o m m o n A l l e r g e n i c F o o d s a n d S o u r c e s Nuts*: Some chocolates, candy, baked goods, cherry soda (may be flavored with a nut extract),
walnut oil
Eggs*: Mayonnaise, creamy salad dressing, baked goods, egg noodles, some cake icing, meringue, custard, pancakes, French toast, root beer
Wheat*: Almost all baked goods, wieners, bologna, pressed or chopped cold cuts, gravy, pasta, malt, soy sauce, some canned soups
Legumes: Peanuts,* peanut butter or oil, beans, peas, lentils
Fish or shellfish*: Cod liver oil, pizza with anchovies, Caesar salad dressing, any food fried in same oil as fish
Soy*: Soy sauce, teriyaki or Worcestershire sauce, tofu, baked goods using soy flour or oil, soy nuts, soy infant formulas or milk, soybean paste, tuna packed in vegetable oil, many margarines
Chocolate: Cola beverages, cocoa, chocolate-flavored drinks
Milk: Ice cream, butter, margarine (if it contains dairy products), yogurt, cheese, pudding, baked goods, wieners, bologna, canned creamed soups, instant breakfast drinks, powdered milk drinks, milk chocolate
Buckwheat: Some cereals, pancakes
Pork, chicken: Bacon, wieners, sausage, pork fat, chicken broth
Strawberries, melon, pineapple: Gelatin, syrups
Corn: Popcorn, cereal, muffins, cornstarch, corn meal, corn bread, corn tortillas, corn syrup
Citrus fruits: Orange, lemon, lime, grapefruit; any of these in drinks, gelatin, juice, or medicines
Tomatoes: Juice, some vegetable soups, spaghetti, pizza sauce, catsup
Spices: Chili, pepper, vinegar, cinnamon
*Most common allergens.
Oral allergy syndrome occurs when a food allergen (commonly fruits and vegetables) is ingested and there is subsequent edema and pruritus involving the lips, tongue, palate, and throat. Recovery from symptoms is usually rapid. Immediate GI hypersensitivity is an IgE-mediated reaction to a food allergen; reactions include nausea, abdominal pain, cramping, diarrhea, vomiting, anaphylaxis, or all of these. Additional food allergies seen in young children include allergic
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eosinophilic esophagitis, allergic eosinophilic gastroenteritis, food protein–induced proctocolitis, and food protein–induced enterocolitis.
Food allergy or hypersensitivity may also be classified according to the interval between ingestion and the manifestation of symptoms: immediate (within minutes to hours) or delayed (2 to 48 hours) (American Academy of Pediatrics, 2014).
Food allergies can occur at any time but are common during infancy because the immature intestinal tract is more permeable to proteins than the mature intestinal tract, thus increasing the likelihood of an immune response. Allergies in general demonstrate a genetic component: Children who have one parent with allergy have a 50% or greater risk of developing allergy; children who have both parents with allergy have up to a 100% risk of developing allergy. Allergy with a hereditary tendency is referred to as atopy. Some infants with atopy can be identified at birth from elevated levels of IgE in umbilical cord blood.
Deaths have been reported in children who experienced an anaphylactic reaction to food. Onset of the reactions occurred shortly after ingestion (5 to 30 minutes). In most of the children, the reactions did not begin with skin signs, such as hives, red rash, and flushing, but rather mimicked an acute asthma attack (wheezing, decreased air movement in airways, dyspnea). Watch children with food anaphylaxis closely, because a biphasic response has been recorded in a number of cases in which there is an immediate response, apparent recovery, and then acute recurrence of symptoms (Simons, 2009). Children with extremely sensitive food allergies should wear a medical identification bracelet and have an injectable epinephrine cartridge (EpiPen) readily available (see Anaphylaxis, Chapter 23). Any child with a history of food allergy or previous severe reaction to food should have a written emergency treatment plan, as well as an EpiPen. Note that diphenhydramine and cetirizine are effective for cutaneous and nasal manifestations but not for airway manifestations (Keet, 2011).
Although the reason is unknown, many children “outgrow” their food allergies (Nowak- Wegrzyn, Sampson and Sicherer, 2016). Children who are allergic to more than one food may develop tolerance to each food at a different time. The most common allergens, such as peanuts, are outgrown less readily than other food allergens. Because of the tendency to lose the hypersensitivity, allergenic foods should be reintroduced into the diet after a period of abstinence (usually ≥1 year) to evaluate whether the food can be safely added to the diet. Foods that are associated with severe anaphylactic reactions (e.g., peanuts) continue to present a lifelong risk and must be avoided.
N u r s i n g A l e r t Indications for the administration of intramuscular epinephrine in a child with a life-threatening anaphylactic reaction or one who is experiencing severe symptoms include any one of the following (Simons, Ardusso, Bilò, et al, 2011):
• Itching sensation or tightness in throat; hoarseness
• “Barky” cough
• Difficulty swallowing; dyspnea
• Wheezing or stridor
• Itching, flushing, urticarial, angioedema
• Syncope, bradycardia, dysrhythmia, or hypotension
• Anxiety, confusion, sense of impending doom
D r u g A l e r t Emergency Management of Anaphylaxis
Drug: Epinephrine 0.01 mg/kg up to maximum of 0.5 mg
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Dosage: EpiPen Jr 0.15 mg intramuscularly (IM) for child weighing 8 to 25 kg (17.5 to 55 pounds)
EpiPen 0.3 mg IM for child weighing 25 kg (55 pounds) or more
Observe for adverse reactions: Tachycardia, hypertension, irritability, headache, nausea, and tremors
Data from Sampson HA, Wang J, Sicherer SH: Anaphylaxis. In Kliegman RM, Stanton BF, St. Geme JW, et al, editors: Nelson textbook of pediatrics, ed 20, Philadelphia, 2016, Saunders/Elsevier.
Diagnosis and Therapeutic Management The diagnosis of food allergy is made based on a number of factors, including the occurrence of anaphylaxis or any combination of 37 symptoms listed in the National Institute of Allergy and Infectious Diseases guidelines within minutes to hours of ingesting food or if such symptoms have occurred after the ingestion of a specific food on one or more occasions. The gold standard is the double-blind, placebo-controlled food challenge; the skin prick test and serum IgE measurements may be used as an adjunct to diagnose food allergy but singly should not be used for the diagnosis. The atopy patch test, intradermal test, and serum IgE test are not recommended for establishing a diagnosis. A single oral food challenge may be used in certain circumstances (Boyce, Assa'ad, Burks, et al, 2010). The traditional management of food allergy consists of avoiding the specific food or ingredient that causes the manifestations. Because children with food allergies (usually two or more) are at risk for inadequate nutrient intake and growth failure, it is recommended that they have an annual nutritional assessment to prevent such problems.
Nursing Care Management Nursing care of children with potential food allergy consists of assisting in collecting vital health assessment data for the establishment of a diagnosis and assisting with diagnostic tests. It is important for nurses to be informed about food allergy and provide parents and caregivers, as well as older children, with accurate information regarding food allergy.
Educate parents, teachers, and daycare workers regarding signs and symptoms of food allergy and reactions. People with food allergy should avoid unfamiliar foods and restaurants that do not disclose food ingredients. Labeling guidelines require that food additives (such as spices and flavoring) be clearly labeled on commercially-sold, store-bought foods. Hidden ingredients in prepared foods are also potential sources of food allergy.
Children with a history of food allergy may spend a considerable amount of time in daycare; therefore, persons working in daycare centers and other children's settings need to be properly educated regarding recognition and management of severe anaphylactic reactions (see Critical Thinking Exercises box).
C r i t i c a l T h i n k i n g E x e r c i s e s Food Allergy Anaphylaxis
A group of nursing students is holding a health promotion fair at a local elementary school for first, second, and third graders. The nursing students have several booths set up in the school cafeteria. Three second-grade boys are engaging in horseplay in front of one of the booths when one of the boys, Jason, an 8-year-old child, suddenly starts coughing and clutching his throat. The students also observe that he is developing red splotches on his face, neck, and throat and that he is scratching. Jason says, “I'm having trouble breathing!” The school nurse is nearby and comes over to see what the commotion is about. One of the boys with Jason says, “We didn't mean any harm! We were just goofing around when we put peanuts in his trail mix.” One of the student nurses says, “He's in obvious distress. What should we do?”
1. Evidence: Is there sufficient evidence to draw any conclusions at this time about Jason's condition?
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2. Assumptions: Describe some underlying assumptions about the following:
a. Clinical manifestations of food allergy.
b. The emergency treatment of a food allergy “reaction,” or anaphylaxis.
c. Which one of the following interventions would have highest immediate priority?
1. Call Jason's parents and ask them to come pick him up from school.
2. Call Jason's family practitioner to obtain orders for medication.
3. Promptly administer an intramuscular dose of epinephrine.
4. Call 911, and wait for the emergency response personnel to arrive.
d. Based on your answer to item 2c, identify the appropriate medication dosage for this child.
3. What implications for nursing care exist in this situation after an intervention in item 2c has been chosen and implemented?
4. Describe the potential results of taking a “let's observe Jason for a few minutes before we do anything” stance in this scenario.
5. Is there evidence to support your immediate and secondary nursing interventions? Provide objective evidence to support your decisions for action.
Exclusive breastfeeding is now considered a primary strategy for avoiding atopy in families with known food allergies; however, there is no evidence that maternal avoidance (during pregnancy or lactation) of cow's milk protein or other dietary products known to cause food allergy will prevent food allergy in children (American Academy of Pediatrics, 2014; Boyce, Assa'ad, Burks, et al, 2010). Researchers indicate that delaying the introduction of highly allergenic foods past 4 to 6 months old may not be as protective for food allergy as previously believed (Fleischer, Spergel, Assa'ad, et al, 2013). Likewise, studies have shown that soy formula does not prevent allergic disease in infants and children (Fleischer, Spergel, Assa'ad, et al, 2013).*
Cow's Milk Allergy Cow's milk allergy (CMA) is a multifaceted disorder representing adverse systemic and local GI reactions to cow's milk protein. Approximately 2.5% of infants develop cow's milk hypersensitivity, with 60% being IgE mediated. Some studies suggest that milk allergy may persist, and some children may not be able to tolerate milk until they are 16 years old (American Academy of Pediatrics, 2014). (This discussion centers on cow's milk protein contained in commercial infant formulas; whole milk is not recommended for infants younger than 12 months old.) The allergy may be manifested within the first 4 months of life through a variety of signs and symptoms that may appear within 45 minutes of milk ingestion or after several days (Box 10-2). The diagnosis may initially be made from the history, although the history alone is not diagnostic. The timing and diversity of clinical manifestations vary greatly. For example, CMA may be manifested as colic, diarrhea, vomiting, GI bleeding, gastroesophageal reflux, chronic constipation, or sleeplessness in
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an otherwise healthy infant.
Box 10-2 C o m m o n C l i n i c a l M a n i f e s t a t i o n s o f C o w ' s M i l k A l l e r g y Gastrointestinal
Diarrhea
Vomiting
Colic
Wheezing
Gastroesophageal reflux
Blood streaked, mucous, loose stools
Respiratory
Rhinitis
Bronchitis
Asthma
Sneezing
Coughing
Chronic nasal discharge
Asthma exacerbation
Cutaneous
Urticaria
Atopic dermatitis (AD)
Systemic
Anaphylaxis
Other Signs and Symptoms
Eczema
Excessive crying
Pallor (from anemia secondary to chronic blood loss in gastrointestinal [GI] tract)
Fussiness, irritability
Diagnostic Evaluation A number of diagnostic tests may be performed, including stool analysis for blood, eosinophils, and leukocytes (both frank and occult bleeding can occur from the colitis); serum IgE levels; skin-prick or scratch testing; and radioallergosorbent test (RAST) (measures IgE antibodies to specific
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allergens in serum by radioimmunoassay). Both skin testing and RAST may help identity the offending food, but the results are not always conclusive. No single diagnostic test is considered definitive for the diagnosis (American Academy of Pediatrics, 2014). Cow's milk protein products should be eliminated to improve the diagnostic results (Kattan, Cocco, and Järvinen, 2011).
The most definitive diagnostic strategy is elimination of milk in the diet followed by challenge testing after improvement of symptoms. A clinical diagnosis is made when symptoms improve after removal of milk from the diet and two or more challenge tests produce symptoms (Kattan, Cocco, and Järvinen, 2011). Challenge testing involves reintroducing small quantities of milk in the diet to detect resurgence of symptoms; at times it involves the use of a placebo so that the parent is unaware of (or “blind” to) the timing of allergen ingestion. A double-blind, placebo-controlled food challenge is the gold standard for diagnosing food allergies such as CMA, yet it may not be used often for diagnosing CMA because of the expense, time involved, and risk for further exposure and anaphylactic reaction (Dupont, 2014). Careful observation of the child is required during a challenge test because of the possibility of anaphylactic reaction.
Therapeutic Management Treatment of CMA is elimination of cow's milk–based formula and all other dairy products. For infants fed cow's milk formula, this primarily involves changing the formula to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum) in which the protein has been broken down into its amino acids through enzymatic hydrolysis. Although the American Academy of Pediatrics (2014) recommends the use of extensively hydrolyzed formulas for CMA, many practitioners may start a soy formula instead because of the expense of the hydrolyzed formulas. Approximately 50% of infants who are sensitive to cow's milk protein also demonstrate sensitivity to soy, but soy is less expensive than protein hydrolysate formula. Other choices for children who are intolerant to cow's milk–based formula are the amino acid–based formulas Neocate or EleCare, but their cost is a major consideration. Goat's milk (raw) is not an acceptable substitute because it cross-reacts with cow's milk protein, is deficient in folic acid, has a high sodium and protein content, and is unsuitable as the only source of calories. Some suggest that goat's milk infant formula may be a suitable substitute for CMA; however, anaphylactic reaction to goat's milk has been noted in infants who are also allergic to cow's milk (Ehlayel, Bener, Hazeima, et al, 2011). Infants usually remain on the milk- free diet for 12 months, after which time small quantities of milk are reintroduced.
Children who have CMA may tolerate extensively heated cow's milk (Dupont, 2014). One study reports that children with CMA became tolerant to uncooked milk products over time after consuming baked milk products (Kim, Nowak-Wegrzyn, Sicherer, et al, 2011).
Nursing Care Management The principal nursing objectives are identification of potential CMA and appropriate counseling of parents regarding substitute formulas. Parents often interpret GI symptoms such as spitting up and loose stools or fussiness as indications that the infant is allergic to cow's milk and switch the infant to a variety of formulas in an attempt to resolve the problem.
Parents need much reassurance regarding the needs of nonverbal infants with such an array of symptoms. Endless nights of lost sleep and a crying infant may promote feelings of parenting inadequacy and role conflict, thus aggravating the situation. Nurses can reassure parents that many of these symptoms are common and the reasons are often never found, yet the child does achieve appropriate growth and development. Report acute symptoms to the practitioner for further evaluation. Parents need reassurance that the infant will receive complete nutrition from the new formula and will have no ill effects from the absence of cow's milk.
When solid foods are started, parents need guidance in avoiding milk product. Carefully reading all food labels helps avoid exposure to prepared foods containing milk products. Although labeled as nondairy, milk, cream, and butter substitutes may contain cow's milk protein (Kattan, Cocco, and Järvinen, 2011).
Failure to Thrive Failure to thrive (FTT), or growth failure, is a sign of inadequate growth resulting from an inability to obtain or use calories required for growth. FTT has no universal definition, although one of the more common criteria is a weight (and sometimes height) that falls below the fifth percentile for the
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child's age. Another definition of FTT includes a weight for age (height) z value of less than −2.0 (a z value is a standard deviation value that represents anthropometric data normalizing for sex and age with greater precision than growth percentile curves [Atalay and McCord, 2012]). A third way to define FTT is a weight curve that crosses more than two percentile lines on a standardized growth chart after previous achievement of a stable growth pattern. Weight for length is reported to be a better indicator of acute undernutrition (Becker, Carney, Corkins, et al, 2015). Growth measurements alone are not used to diagnose children with FTT. Rather, the finding of a pattern of persistent deviation from established growth parameters is cause for concern. In addition to lack of consensus on the precise definition of FTT, some advocate for a change in terminology; thus, terms such as growth failure and pediatric undernutrition are used in the literature for FTT. According to Cole and Lanham (2011), approximately 5% to 10% of children in primary care in the United States have FTT with the majority presenting before 18 months old.
Some experts suggest that the previously used classifications of organic FTT and nonorganic FTT are too simplistic because most cases of growth failure have mixed causes; they suggest that FTT be classified according to pathophysiology in the following categories (Cole and Lanham, 2011):
Inadequate caloric intake: Incorrect formula preparation, neglect, food fads, lack of food availability, breastfeeding problems, behavioral problems affecting eating, or central nervous system problems affecting intake
Inadequate caloric absorption: Food allergy, malabsorption, pyloric stenosis, GI atresia, inborn errors of metabolism
Excessive caloric expenditure: Hyperthyroidism, malignancy, congenital heart disease, chronic pulmonary disease or chronic immunodeficiency
The cause of FTT is often multifactorial and involves a combination of infant organic disease, dysfunctional parenting behaviors, and/or poor parent-infant bonding (Cole and Lanham, 2011). However, the primary etiology is inadequate caloric intake, regardless of the cause.
Infants who are born preterm and with VLBW or ELBW, as well as those with intrauterine growth restriction (IUGR), are often referred for growth failure within the first 2 years of life because they typically do not grow physically at the same rate as term cohorts even after discharge from the acute care facility. Catch-up growth has been shown to be much more difficult to achieve in ELBW and VLBW infants. As young adults, former VLBW infants are more likely to have small stature (both height and weight) and lower rates of tertiary education than term cohorts (Darlow, Horwood, Pere-Bracken, et al, 2013).
Other factors that can lead to inadequate caloric intake in infancy include poverty, health or childrearing beliefs such as fad diets, inadequate nutritional knowledge, family stress, feeding resistance, and insufficient breast milk intake. In infants younger than 8 weeks old, breastfeeding problems as a result of inadequate latch or uncoordinated sucking and swallowing may occur (Cole and Lanham, 2011). One account reports a 6-month-old term infant with FTT as a result of severe ankyloglossia (tongue tie) (Forlenza, Paradise Black, McNamara, et al, 2010).
Diagnostic Evaluation Diagnosis is initially made from evidence of growth failure. If FTT is recent, the weight, but not the height, is below accepted standards (usually the fifth percentile); if FTT is longstanding, both weight and height are low, indicating chronic malnutrition. Perhaps as important as anthropometric measurements are a complete health and dietary history (including perinatal history), physical examination for evidence of organic causes, developmental assessment, and family assessment. A dietary intake history, either a 24-hour food intake or a history of food consumed over a 3- to 5-day period, is also essential. In addition, explore the child's activity level, perceived food allergies, and dietary restrictions. An assessment of household organization and mealtime behaviors and rituals is important in the collection of pertinent data. It is often helpful to obtain the growth patterns of the affected child's parents and siblings; these can be compared with norm-referenced standards to evaluate the child's growth. An assessment of the home environment and child–parent interaction may be helpful as well. Other tests (lead toxicity, anemia, stool- reducing substances, occult blood, ova and parasites, alkaline phosphatase, and zinc levels) are selected only as indicated to rule out organic problems. In most cases, laboratory studies are of little
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diagnostic value (Cole and Lanham, 2011). To prevent the overuse of diagnostic procedures, consider FTT early in the differential diagnosis. To avoid the social stigma of FTT during the early investigative phase, some health care workers use the term growth delay until the actual cause is established.
Therapeutic Management The primary management of FTT is aimed at reversing the cause of the growth failure. If malnutrition is severe, the initial treatment is directed at reversing the malnutrition. The goal is to provide sufficient calories to support “catch-up” growth—a rate of growth greater than the expected rate for age.
In addition to adding caloric density to feedings, the child may require multivitamin supplements and dietary supplementation with high-calorie foods and drinks. Any coexisting medical problems are treated.
In most cases of FTT, an interdisciplinary team of physician, nurse, dietitian, child life specialist, occupational therapist, pediatric feeding specialist, and social worker or mental health professional is needed to deal with the multiple problems. Make efforts to relieve any additional stresses on the family by offering referrals to welfare agencies or supplemental food programs. In some cases, family therapy may be required. Temporary placement in a foster home may relieve the family's stress, protect the child, and allow the child some stability if insurmountable obstacles are preventing appropriate family function. Behavior modification aimed at mealtime rituals (or lack thereof) and family social time may be required. Hospitalization admission is indicated for (1) evidence (anthropometric) of SAM, (2) child abuse or neglect, (3) significant dehydration, (4) caretaker substance abuse or psychosis, (5) outpatient management that does not result in weight gain, and (6) serious intercurrent infection (American Academy of Pediatrics, 2014).
Prognosis The prognosis for FTT is related to the cause. If the parents have simply not understood the infant's needs, teaching may remedy the child's limited caloric intake and permanently reverse the growth failure. Inadequate or infrequent feeding periods by the infant's primary caretaker, in conjunction with family disorganization, are often observed to be the cause of FTT.
Few long-term studies provide data on the prognosis for children with FTT; however, experts indicate that children who had FTT as infants are at risk for shorter heights, and delayed development (Nangia and Tiwari, 2013). Factors related to poor prognosis are severe feeding resistance, lack of awareness in and cooperation from the parent(s), low family income, low maternal educational level, adolescent mother, preterm birth, IUGR, and early age of onset of FTT. Because later cognitive and motor function is affected by malnourishment in infancy, many of these children are below normal in intellectual development with childhood IQ scores significantly lower than peers without a history of malnourishment (Romano, Hartman, Privitera, et al, 2015). In addition, there is a higher likelihood of eating and behavioral issues among children with a history of malnutrition when compared to peers (Romano, Hartman, Privitera, et al, 2015). Such findings indicate that a long-term plan and follow-up care are needed for the optimum development of these children.
Nursing Care Management Nurses play a critical role in the diagnosis of FTT through their assessment of the child, parents, and family interactions. Knowledge of the characteristics of children with FTT and their families is essential in helping identify these children and hastening the confirmation of a diagnosis (Box 10-3). Accurate assessment of initial weight and height and daily weight, as well as recording of all food intake, is imperative. The nurse documents the child's feeding behavior and the parent–child interaction during feeding, other caregiving activities, and play. Children with growth failure may have a history of difficult feeding, vomiting, sleep disturbance, and excessive irritability. Patterns such as crying during feedings; vomiting; hoarding food in the mouth; ruminating after feeding; refusing to switch from liquids to solids; and displaying aversion behavior, such as turning from food or spitting food, become attention-seeking mechanisms to prolong the attention received at mealtime. In some cases, the child may use feeding as a control mechanism in a poorly organized or chaotic family situation; parents may allow the child to dictate the norms for behavior and feeding because of inexperience with parenting or poor parenting role models. Thus, refusing to eat or only
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eating high-sugar foods may be the child's norm. In such cases, family therapy is essential to reverse the trend and assist the parents and child in understanding each other's roles.
Box 10-3 C l i n i c a l M a n i f e s t a t i o n s o f F a i l u r e t o T h r i ve • Growth failure (see earlier in chapter for definitions)
• Developmental delays—social, motor, adaptive, language
• Undernutrition
• Apathy
• Withdrawn behavior
• Feeding or eating disorders, such as vomiting, feeding resistance, anorexia, pica, rumination
• No fear of strangers (at age when stranger anxiety is normal)
• Avoidance of eye contact
• Wide-eyed gaze and continual scan of the environment (“radar gaze”)
• Stiff and unyielding or flaccid and unresponsive
• Minimal smiling
Some parents are at increased risk for attachment problems because of isolation and social crisis; inadequate support systems, such as teenage and single mothers; and poor parenting role models as a child. Other factors that should be considered are lack of education; physical and mental health problems, such as physical and sexual abuse, depression, or drug dependence; immaturity, especially in adolescent parents; and lack of commitment to parenting, such as giving priority to entertainment or employment. Often these parents and their families are under stress and in multiple chronic emotional, social, and financial crises.
Because part of the difficulty between parent and child is dissatisfaction and frustration, the child should have a primary core of nurses (Fig. 10-1). The nurses caring for the child can learn to perceive the child's cues and reverse the cycle of dissatisfaction, especially in the area of feeding.
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FIG 10-1 A consistent nurse is important in developing trust in infants with failure to thrive (FTT).
Because many of these children are responding to stimuli that have led to the negative feeding patterns, the first goal is to structure the feeding environment to encourage eating. Initially, staff members and a feeding specialist may need to feed these children to thoroughly assess the difficulties encountered during the feeding process and to devise strategies that eliminate or minimize such problems.
Four primary goals in the nutritional management of children with FTT are to correct nutritional deficiencies and achieve ideal weight for height, allow for catch-up growth, restore optimum body composition, and educate the parents or primary caregivers regarding the child's nutritional requirements and appropriate feeding methods. For infants, 24 kcal/oz formulas may be provided to increase caloric intake; older children (1 to 6 years old) may benefit from a 30 kcal/oz formula (American Academy of Pediatrics, 2014). Other carbohydrate additives include fortified rice cereal and vegetable oil. Because vitamin and mineral deficiencies may occur, multivitamin supplementation, including zinc and iron, is recommended. For toddlers, a high-calorie milk drink (such as, PediaSure) may be used to increase caloric intake. Carefully monitor for signs of intolerance to the formula. Usually only in extreme cases of malnourishment are tube feedings or intravenous therapy required.
Because maladaptive feeding practices often contribute to growth failure, give parents specific step-by-step directions for formula preparation, as well as a written schedule of feeding times. Restrict juice intake in children with FTT until adequate weight gain has been achieved with appropriate milk sources; thereafter give no more than 4 oz/day of juice.
Behavior modification techniques may be used with older infants and toddlers to interrupt poor feeding patterns. Feeding times may actually involve “struggles of will” in cases of maladaptive feedings that result in FTT. These behaviors are different from the occasional toddler behavior of food refusal, which is primarily developmental, not pathologic. The association of appropriate food with good or bad behaviors and consequent rewards may be part of the complex problem. In severe cases of malnourishment, tube feedings or intravenous therapy may be required.
In addition to attending to the child's physical needs, the interdisciplinary team must plan care for appropriate developmental stimulation. After an approximate developmental age is established, a planned program of play is begun. Ideally, a child life specialist is involved to implement and supervise the stimulation program. Every effort is made to teach the parent how to play and interact with the child.
Nursing care of these children involves a “family systems” approach. In other words, for the entire family to become healthy, each member must be helped to change. Care of the parents is aimed at helping them improve their self-esteem by acquiring positive, successful parenting skills. Initially, this necessitates providing an environment in which they feel welcomed and accepted. Depending on the cause of FTT, many children are treated on an outpatient basis.
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Skin Disorders Diaper Dermatitis Diaper dermatitis is common in infants and one of several acute inflammatory skin disorders caused either directly or indirectly by wearing diapers. The peak age of occurrence is 9 to 12 months old, and the incidence is greater in bottle-fed infants than in breastfed infants.
Pathophysiology and Clinical Manifestations Diaper dermatitis is caused by prolonged and repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Although the irritant in the majority of cases is urine and feces, a combination of factors contributes to irritation.
Prolonged contact of the skin with diaper wetness produces higher friction, greater abrasion damage, increased transepidermal permeability, and increased microbial counts. Healthy skin is less resistant to potential irritants.
Although ammonia was once thought to cause diaper rash because of the association between the strong odor on diapers and dermatitis, ammonia alone is not sufficient. The irritant quality of urine is related to an increase in pH from the breakdown of urea in the presence of fecal urease. The increased pH promotes the activity of fecal enzymes, principally the proteases and lipases, which act as irritants. Fecal enzymes also increase the permeability of skin to bile salts, another potential irritant in feces.
The eruption of diaper dermatitis is manifested primarily on convex surfaces or in folds. The lesions represent a variety of types and configurations. Eruptions involving the skin in most intimate contact with the diaper (e.g., the convex surfaces of buttocks, inner thighs, mons pubis, scrotum) but sparing the folds are likely to be caused by chemical irritants, especially from urine and feces (Fig. 10-2). Other causes are detergents or soaps from inadequately rinsed cloth diapers or the chemicals in disposable wipes. Perianal involvement is usually the result of chemical irritation from feces, especially diarrheal stools. Candida albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal fold (Fig. 10-3). It is seen in up to 90% of infants with chronic diaper dermatitis and should be considered in diaper rashes that are recalcitrant to treatment.
FIG 10-2 Irritant diaper dermatitis. Note the sharply demarcated edges. (From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 5, St Louis, 2010, Mosby/Elsevier.)
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FIG 10-3 Candidiasis of diaper area. Note the beefy red central erythema with satellite pustules. (From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology, ed 4, St Louis, 2011, Saunders/Elsevier.)
Nursing Care Management Nursing interventions are aimed at altering the three factors that produce dermatitis: wetness, pH, and fecal irritants. The most significant factor amenable to intervention is the moist environment created in the diaper area. Changing the diaper as soon as it becomes wet eliminates a large part of the problem, and removing the diaper to expose healthy skin to air facilitates drying. The use of a hair dryer or heat lamp is not recommended because these devices can cause burns.
Diaper construction has a significant impact on the incidence and severity of diaper dermatitis. Superabsorbent disposable paper diapers reduce diaper dermatitis. They contain an absorbent gelling material that binds water tightly to decrease skin wetness, maintains pH control by providing a buffering capacity, and decreases skin irritation by preventing mixing of urine and feces in the diaper.
Guidelines for controlling diaper rash are presented in the Family-Centered Care box. A common misconception about using cornstarch on skin is that it promotes the growth of C. albicans. Neither cornstarch nor talc promotes the growth of fungi under conditions normally found in the diaper area. Cornstarch is more effective in reducing friction and tends to cake less than talc when the skin is wet. On the basis of these properties and its safety in terms of inhalation injury, cornstarch is the preferred product. Talc should not be used.
F a m i l y - C e n t e r e d C a r e Controlling Diaper Rash
Keep skin dry.*
Use superabsorbent disposable diapers to reduce skin wetness.
Change diapers as soon as soiled—especially with stool—whenever possible, preferably once during the night.
Expose healthy or only slightly irritated skin to air, not heat, to dry completely.
Apply ointment, such as zinc oxide or petrolatum, to protect skin, especially if skin is very red or
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has moist, open areas.
Avoid removing skin barrier cream with each diaper change; remove waste material and reapply skin barrier cream.
To completely remove ointment, especially zinc oxide, use mineral oil; do not wash vigorously.
Avoid over washing the skin, especially with perfumed soaps or commercial wipes, which may be irritating.
May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin.
Gently wipe stool from skin using a soft cloth and warm water.
Use disposable diaper wipes that are detergent- and alcohol-free.
*Powder helps keep the skin dry, but talc is dangerous if breathed into the lungs. Plain cornstarch or cornstarch-based powder is safer. When using any powder product, first shake it into your hand and then apply it to the diaper area. Store the container away from the infant's reach; keep the container closed when not in use.
Atopic Dermatitis (Eczema) Eczema or eczematous inflammation of the skin refers to a descriptive category of dermatologic diseases and not to a specific etiology. Atopic dermatitis (AD) is a type of pruritic eczema that usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency (atopy) (Jacob, Yang, Herro, et al, 2010). AD manifests in three forms based on the child's age and the distribution of lesions:
Infantile (infantile eczema): Usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age
Childhood: May follow the infantile form; occurs at 2 to 3 years of age; 90% of children have manifestations by 5 years of age
Preadolescent and adolescent: Begins at about 12 years of age; may continue into the early adult years or indefinitely
The diagnosis of AD is based on a combination of history, clinical manifestations, and in some cases, morphologic findings (Box 10-4). Children with AD have a lower threshold compared with children who do not have AD for cutaneous itching, and many authorities believe the dermatologic manifestations appear subsequent to scratching from the intense pruritus (Alanne, Nermes, Soderlund, et al, 2011). For example, infants rub their faces against bed linen, and their crawling (a form of scratching) results in irritation of knees and elbows. Lesions disappear if the scratching is stopped.
Box 10-4 C l i n i c a l M a n i f e s t a t i o n s o f At o p i c D e r m a t i t i s Distribution of Lesions
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Infantile form: Generalized, especially cheeks, scalp, trunk, and extensor surfaces of extremities
Childhood form: Flexural areas (antecubital and popliteal fossae, neck), wrists, ankles, and feet
Preadolescent and adolescent form: Face, sides of neck, hands, feet, face, and antecubital and popliteal fossae (to a lesser extent)
Appearance of Lesions Infantile Form
Erythema
Vesicles
Papules
Weeping
Oozing
Crusting
Scaling
Often symmetric
Childhood Form
Symmetric involvement
Clusters of small erythematous or flesh-colored papules or minimally scaling patches
Dry and may be hyperpigmented
Lichenification (thickened skin with accentuation of creases)
Keratosis pilaris (follicular hyperkeratosis) common
Adolescent or Adult Form
Same as childhood manifestations
Dry, thick lesions (lichenified plaques) common
Confluent papules
Other Physical Manifestations
Intense itching
Unaffected skin dry and rough
African-American children likely to exhibit more papular or follicular lesions than are white children
May exhibit one or more of the following:
• Lymphadenopathy, especially near affected sites
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• Increased palmar creases (many cases)
• Atopic pleats (extra line or groove of lower eyelid)
• Prone to cold hands
• Pityriasis alba (small, poorly defined areas of hypopigmentation)
• Facial pallor (especially around nose, mouth, and ears)
• Bluish discoloration beneath eyes (“allergic shiners”)
• Increased susceptibility to unusual cutaneous infections (especially viral)
The majority of children with infantile AD have a family history of eczema, asthma, food allergies, or allergic rhinitis, which strongly supports a genetic predisposition. The cause is unknown but appears to be related to abnormal function of the skin, including alterations in perspiration, peripheral vascular function, and heat tolerance. Manifestations of the chronic disease improve in humid climates and get worse in the fall and winter, when homes are heated and environmental humidity is lower. The disorder can be controlled but not cured. A study of 134 infants with AD showed that itching, scratching, and sleep disturbance were specific features detracting from quality of life in these young children (Alanne, Nermes, Soderlund, et al, 2011).
Therapeutic Management The major goals of management are to hydrate the skin, relieve pruritus, prevent and minimize flare-ups or inflammation, and prevent and control secondary infection. The general measures for managing AD focus on reducing pruritus and other aspects of the disease. Management strategies include avoiding exposure to skin irritants or allergens; avoiding overheating; and administrating medications such as antihistamines, topical immunomodulators, topical steroids, and (sometimes) mild sedatives, as indicated.
Enhancing skin hydration and preventing dry, flaky skin are accomplished in a number of ways, depending on the child's skin characteristics and individual needs. A tepid bath with a mild soap (Dove or Neutrogena), no soap, or an emulsifying oil followed immediately by application of an emollient (within 3 minutes) assists in trapping moisture and preventing its loss. Bubble baths and harsh soaps should be avoided. The bath may need to be repeated once or twice daily, depending on the child's status; excessive bathing without emollient application only dries out the skin. Some lotions are not effective, and emollients should be chosen carefully to prevent excessive skin drying. Aquaphor, Cetaphil, and Eucerin are acceptable lotions for skin hydration. A nighttime bath followed by emollient application and dressing in soft cotton pajamas may help alleviate most nighttime pruritus.
Sometimes colloid baths, such as the addition of 2 cups of cornstarch to a tub of warm water, provide temporary relief of itching and may help the child sleep if given before bedtime. Cool wet compresses are soothing to the skin and provide antiseptic protection.
Oral antihistamine drugs (such as, hydroxyzine or diphenhydramine) usually relieve moderate or severe pruritus. Nonsedating antihistamines, such as loratadine (Claritin) or fexofenadine (Allegra), may be preferred for daytime pruritus relief. Occasional flare-ups require the use of topical steroids to diminish inflammation. Low-, moderate-, or high-potency topical corticosteroids are prescribed, depending on the degree of involvement, the area of the body to be treated, the child's age, the potential for local side effects (striae, skin atrophy, and pigment changes), and the type of vehicle to be used (e.g., cream, lotion, ointment). Patients receiving topical corticosteroid therapy for chronic conditions should be evaluated for risk factors for suboptimal linear growth and reduced bone density. Topical immunomodulators, a new nonsteroidal treatment for AD, are best used at the
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beginning of a “flare-up” just as the skin becomes red and itches. Two immunomodulator medications used in children with AD are tacrolimus and pimecrolimus (Schneider, Tilles, Lio, et al, 2013). Tacrolimus is available in two ointment strengths (0.03% and 0.1%); the 0.03% concentration has been approved for use in children 2 years old and older (Schneider, Tilles, Lio, et al, 2013). Pimecrolimus is available in a 1% cream that has no systemic accumulation or effects. This drug is approved for use in children with mild to moderate AD. Both drugs can be used freely on the face without worrying about steroid side effects.
If secondary skin infections occur in children with AD, these infections are managed with appropriate antibiotics. Topical and oral antibiotics are used; however, areas of active infection are first cultured to ensure appropriate therapy (Wolter and Price, 2014).
Nursing Care Management Assessment of the child with AD includes a family history for evidence of atopy, a history of previous involvement, and any environmental or dietary factors associated with the present and previous exacerbations. The skin lesions are examined for type, distribution, and evidence of secondary infection. Parents are interviewed regarding the child's behavior, especially in relation to scratching, irritability, and sleeping patterns. Exploration of the family's feelings and methods of coping is also important.
The nursing care of the child with AD is challenging. Controlling the intense pruritus is imperative if the disorder is to be successfully managed because scratching leads to new lesions and may cause secondary infection. In addition to the medical regimen, other measures can be taken to prevent or minimize the scratching. Fingernails and toenails are cut short, kept clean, and filed frequently to prevent sharp edges. Gloves or cotton stockings can be placed over the hands and pinned to shirtsleeves. One-piece outfits with long sleeves and long pants also decrease direct contact with the skin. If gloves or socks are used, the child needs time to be free from such restrictions. An excellent time to remove gloves, socks, or other protective devices is during the bath or after receiving sedative or antipruritic medication.
Conditions that increase itching are eliminated when possible. Woolen clothes or blankets, rough fabrics, and furry stuffed animals are removed from the child's environment. Because heat and humidity cause perspiration (which intensifies itching), proper dress for climatic conditions is essential. Pruritus is often precipitated by exposure to the irritant effects of certain components of common products, such as soaps, detergents, fabric softeners, perfumes, and powders. During cold months, synthetic fabrics (not wool) should be used for overcoats, hats, gloves, and snowsuits. Exposure to latex products, such as gloves and balloons, should also be avoided.
Clothes and sheets are laundered in a mild detergent and rinsed thoroughly in clear water (without fabric softeners or antistatic chemicals). Putting the clothes through a second complete wash cycle without using detergent reduces the amount of residue remaining in the fabric.
Preventing infection is usually accomplished by preventing scratching. Baths are given as prescribed; the water is kept tepid; and soaps (except as indicated), bubble baths, oils, and powders are avoided. Skinfolds and diaper areas need frequent cleansing with plain water. A room humidifier or vaporizer may benefit children with extremely dry skin. Skin lesions are examined for signs of infection—usually honey-colored crusts or pustules with surrounding erythema. Any signs of infection are reported to the practitioner.
N u r s i n g A l e r t If the child is being treated with baths, it is imperative that the emollient preparation be applied immediately after bathing (while the skin is still slightly moist) to prevent drying.
Wet soaks and compresses are applied and medications for pruritus or infection are administered as directed. The family is given explicit instructions on the preparation and use of soaks, special baths, and topical medications, including the order of application if more than one is prescribed. It is important to emphasize that one thick application of topical medication is not equivalent to several thin applications and that excessive use of an agent (particularly steroids) can be hazardous. If children have difficulty remaining still for a 10- or 15-minute soak, bath, or dressing application, these can be carried out at naptime or when the child is engrossed in watching television, listening to a story, or playing with tub toys.
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Diet modification is another source of frustration to parents. When a hypoallergenic diet is prescribed, parents need help to understand the reason for the diet and the guidelines for avoiding hyperallergenic foods. Because hypoallergenic diets take time before visible effects are apparent, parents need reassurance that results may not be seen immediately. If airborne allergens make eczema worse, the family is counseled about “allergy proofing” the home (see Asthma, Chapter 21).
Parents are assured that the lesions will not produce scarring (unless secondarily infected) and that the disease is not contagious. However, the child may have repeated exacerbations and remissions. Spontaneous and permanent remission takes place at approximately 2 to 3 years old in most children with the infantile disorder.
During acute phases, emotional stress can become intense for the family. They need time to discuss negative feelings and to be reassured that these feelings are normal. Stress tends to aggravate the severity of the condition. Therefore, efforts to relieve as much anxiety as possible in both the parents and the child have a beneficial emotional and physical effect.
Seborrheic Dermatitis Seborrheic dermatitis is a chronic, recurrent, inflammatory reaction of the skin that occurs most commonly on the scalp (cradle cap) but may involve the eyelids (blepharitis), external ear canal (otitis externa), nasolabial folds, and inguinal region. The cause is unknown, although it is more common in early infancy, when sebum production is increased. The lesions are characteristically thick, adherent, yellowish, scaly, oily patches that may or may not be mildly pruritic. Unlike AD, seborrheic dermatitis is not associated with a positive family history for allergy, is common in infants shortly after birth, and is common after puberty. Diagnosis is made primarily by the appearance and the location of the crusts or scales.
Nursing Care Management Cradle cap may be prevented with adequate scalp hygiene. Frequently, parents omit shampooing the infant's hair for fear of damaging the “soft spots,” or fontanels. The nurse should discuss how to shampoo the infant's hair and emphasize that the fontanel is similar to skin anywhere else on the body; it does not puncture or tear with mild pressure.
When seborrheic lesions are present, direct the treatment at removing the scales or crusts. Education may need to include a demonstration. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine- tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.
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Special Health Problems Colic (Paroxysmal Abdominal Pain) Colic is reported to occur in 5% to 20% of all infants and is more prevalent in preterm and small for gestational age infants (Savino, Ceratto, Poggi, et al, 2015; Milidou, Sondergaard, Jensen, et al, 2014). An organic cause may be identified in fewer than 5% of infants seen by physicians because of excessive crying (Akhnikh, Engelberts, van Sleuwen, et al, 2014). The condition is defined by the rule of threes: crying and fussing for more than 3 hours a day occurring more than 3 days per week and for more than 3 weeks in a healthy infant (Kim, 2011). Some studies report an increase in symptoms (fussiness and crying) in the late afternoon or evening (Morin, 2009); however, in some infants, the onset of symptoms occurs at another time. Colic is more common in infants younger than 3 months old than in older infants, and infants with difficult temperaments are more likely to be colicky.
Despite the obvious behavioral indications of pain, the infant with colic gains weight and usually thrives. There is no evidence of a residual effect of colic on older children except perhaps a strained parent–child relationship in some cases. In other words, infants who are colicky grow up to be normal children and adults. Colic is self-limiting and in most cases resolves as infants mature, generally around 12 to 16 weeks old (Akhnikh, Engelberts, van Sleuwen, et al, 2014).
Among the theories investigated as potential causes are too rapid feeding, overeating, swallowing excessive air, improper feeding technique (especially in positioning and burping), and emotional stress or tension between the parent and child. Although all of these may occur, there is no evidence that one factor is consistently present. Infants with CMA symptoms have a high rate of colic (44%), and eliminating cow's milk products from the infant's diet can reduce the symptoms.
The exact cause of colic is not fully understood but some experts believe maternal smoking, inadequate parent–infant interaction, firstborn status, lactase deficiency, difficult infant temperament, difficulty regulating emotions, and abnormal GI motility are potential causes of colic (Drug and Therapeutics Bulletin, 2013). Some experts have suggested that inadequate amounts of lactobacilli in the GI tract influences gut motor function and gas production (Drug and Therapeutics Bulletin, 2013). The consensus of many experts who study colic is that it is multifactorial and that no single treatment for every colicky infant will be effective in alleviating the symptoms.
Therapeutic Management Management of colic should begin with an investigation of possible organic causes, such as CMA, intussusception, or other GI problem. If a sensitivity to cow's milk is strongly suspected, a trial substitution of another formula such as an extensively hydrolyzed (Nutramigen, Alimentum, Pregestimil), whey hydrolysate, or amino acid (Neocate, EleCare) formula is warranted. Soy formulas are usually avoided because of the possibility of sensitivity to soy protein as well (Drug and Therapeutics Bulletin, 2013). Oral administration of Lactobacillus reuteri to colicky breastfed infants decreased crying symptoms within 21 days of initiation (Savino, Cordisco, Tarasco, et al, 2010; Szajewska, Gyrczuk, and Horvath, 2013). When no specific inciting agent can be found, the supportive measures discussed in the Nursing Care Management section are used.
The use of drugs, including sedatives, antispasmodics, antihistamines, and antiflatulents, is sometimes recommended. Simethicone (Mylicon) may also help allay the symptoms of colic. However, in most controlled studies, none of these drugs completely reduced the symptoms of colic. Behavioral interventions have not proved effective at reducing the symptoms of colic but have helped parents deal with their crying infants in a more positive manner. The addition of lactase to infant formula has produced mixed results as far as abatement of overall symptoms.
An extensive review of a wide variety of interventions for colic indicates no specific safe remedies are available to alleviate symptoms of colic in every infant. Dietary changes including the elimination of cow's milk protein in the infant's diet may be effective with the infant's crying, yet these interventions are perceived only as moderately effective (Drug and Therapeutics Bulletin, 2013). A recent position statement by the Canadian Paediatric Society, Nutrition and Gastroenterology Committee concluded that dietary modifications are beneficial in some cases but not all (Critch, 2011); the use of lactate, probiotics, or prebiotics independently to decrease symptoms of colic had insufficient evidence to support their use. The use of complementary
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medicines for infantile colic, namely fennel extract, herbal tea, and sugar solutions, reportedly lack sufficient evidence to recommend their use (Perry, Hunt, and Ernst, 2011).
Nursing Care Management The initial step in managing colic is to take a thorough, detailed history of the usual daily events. Areas that should be stressed include (1) the infant's diet; (2) the diet of the breastfeeding mother; (3) the time of day when crying occurs; (4) the relationship of crying to feeding time; (5) the presence of specific family members during crying and habits of family members, such as smoking; (6) activity of the mother or usual caregiver before, during, and after crying; (7) characteristics of the cry (duration, intensity); (8) measures used to relieve crying and their effectiveness; and (9) the infant's stooling, voiding, and sleeping patterns. Of special emphasis is a careful assessment of the feeding process via demonstration by the parent.
N u r s i n g A l e r t If cow's milk sensitivity is suspected, breastfeeding mothers should follow a milk-free diet for a minimum of 3 to 5 days in an attempt to reduce the infant's symptoms. Caution mothers that some nondairy creamers may contain calcium caseinate, a cow's milk protein. If a milk-free diet is helpful, lactating mothers may need calcium supplements to meet the body's requirement. Bottle- fed infants may improve with the same dietary modifications as for infants with CMA.
One important nursing intervention (before or after an organic cause has been eliminated) is reassuring both parents that they are not doing anything wrong and that the infant is not experiencing any physical or emotional harm. Parents, especially mothers, become easily frustrated with their infant's crying and perceive this as a sign that something is horribly wrong. Additionally, colicky infants may be at increased risk for being shaken by their caregivers and experiencing traumatic brain injury. A survey of fathers of colicky infants revealed that professional assistance was limited. The fathers described the experience of having a colicky infant as similar to falling into an abyss from which they had to climb with the assistance of family and friends, thus reinforcing the importance of empathetic nurses (Ellett, Appleton, and Sloan, 2009). An empathetic, gentle, and reassuring attitude, in addition to suggestions for treatment, will help allay parents' anxieties, which are usually exacerbated by loss of sleep and preoccupation over the infant's welfare. Colic disappears spontaneously, usually by 3 to 4 months old, although guarantees should never be given, because it may continue for much longer.
Sleep Problems A number of sleep problems occur in small children. The two major categories are the dyssomnias: the child has trouble either falling or staying asleep at night or has difficulty staying awake during the day. The second category, parasomnias, is characterized as confusional arousals, sleepwalking, sleep terrors, nightmares, and rhythmic movement disorders. These typically occur in children 3 to 13 years old and often spontaneously resolve in adolescence (Carter, Hathaway, and Lettieri, 2014). This discussion focuses on minor sleep issues in infants, such as refusal to go to sleep and frequent waking during the night (Table 10-1). Other sleep disturbances, such as obstructive sleep and sleep terrors, are discussed in Chapters 12 and 21.
TABLE 10-1 Selected Sleep Disturbances During Infancy and Early Childhood
Disorder and Description Management Nighttime Feeding Child has a prolonged need for middle-of-night bottle or breastfeeding. Child goes to sleep at breast or with a bottle. Awakenings are frequent (may be hourly). Child returns to sleep after feeding; other comfort measures (e.g., rocking or holding) are usually
ineffective.
Increase daytime feeding intervals to 4 hours or more (may need to be done gradually).
Offer last feeding as late as possible at night; may need to gradually reduce amount of formula or length of breastfeeding.
Offer no bottles in bed. Put to bed awake. When child is crying, check at progressively longer intervals each night; reassure
child but do not hold, rock, take to parent's bed, or give bottle or pacifier. Developmental Nighttime Crying Child 6 to 12 months old with undisturbed nighttime sleep now wakes abruptly; may be accompanied by nightmares.
Reassure parents that this phase is temporary. Enter room immediately to check on child but keep reassurances brief. Avoid feeding, rocking, taking to parent's bed, or any other routine that may
initiate trained nighttime crying. Refusal to Go to Sleep
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Child resists bedtime and comes out of room repeatedly. Nighttime sleep may be continuous, but frequent awakenings and refusal to return to sleep may
occur and become a problem if parent allows child to deviate from usual sleep pattern.
Evaluate if hour of sleep is too early (child may resist sleep if not tired). Assist parents in establishing consistent before-bedtime routine and enforcing
consistent limits regarding child's bedtime behavior. If child persists in leaving bedroom, close door for progressively longer periods. Use reward system with child to provide motivation.
Trained Nighttime Crying (Inappropriate Sleep Associations) Child typically falls asleep in place other than own bed (e.g., rocking chair or parent's bed) and is brought to own bed while asleep; on awakening, cries until usual routine is instituted (e.g., rocking).
Put child in own bed when awake. If possible, arrange sleeping area separate from other family members. When child is crying, check at progressively longer intervals each night; reassure
child but do not resume usual routine. Nighttime Fears Child resists going to bed or wakes during the night because of fears. Child seeks parent's physical presence and falls asleep easily with parent nearby unless fear is
overwhelming.
Evaluate if hour of sleep is too early (child may fantasize when nothing to do but think in dark room).
Calmly reassure the frightened child; keeping a night light on may be helpful. Use reward system with child to provide motivation to deal with fears. Avoid patterns that can lead to additional problems (e.g., sleeping with child or
taking child to parent's room). If child's fear is overwhelming, consider desensitization (e.g., progressively
spending longer periods of time alone; consult professional help for protracted fears).
Distinguish between nightmares and sleep terrors (confused partial arousals).
Modified from Ferber R: Behavioral “insomnia” in the child, Psychiatr Clin North Am 10(4):641-653, 1987.
Concerns regarding sleep are common during infancy. Sometimes these concerns are as basic as parents' questioning whether the infant needs additional sleep. In this case, it is best to investigate the reason for their concern, stressing the individual needs of each child. Infants who are active during wakeful periods and growing normally are sleeping a sufficient amount of time.
Sleep problems in infants have been positively correlated with higher maternal depression scores (Gress-Smith, Luecken, Lemery-Chalfant, et al, 2012; Muscat, Obst, Cockshaw, et al, 2014). Therefore, nurses must discuss infant sleep problems with the mother (and family) in addition to other developmental aspects of newborn care.
When a sleeping problem is presented, a careful assessment is essential. Charting sleep habits both before and after interventions is also an important strategy. Questions regarding the frequency and duration of waking, the usual bedtime routine, the number of nighttime feedings, the perceived problem (e.g., how much disruption the behavior generates), and the attempted interventions are important in planning effective approaches designed for the specific sleep problem. A common suggestion given for any type of sleep problem, “Let the child cry until he or she falls asleep,” is very difficult to implement and is inappropriate for certain conditions. Once the parents relent and console the child, they have only reinforced the crying.
An effective approach to night crying is known as graduated extinction. This involves letting the child cry for progressively longer times between brief parental interventions that consist only of reassurance—not rocking, holding, or using a bottle or pacifier. For example, the parents may check on the child every 5 minutes (of crying) during the first night and progressively extend this interval by 5 minutes on successive nights.
Families that cannot tolerate unexpected crying spells while everyone else is asleep can try the two-step approach. Graduated extinction is used during naps and at bedtime until the parents retire for the night. If the child cries during the night, the parents use comforting measures. However, after the child is partially trained, step 2 is initiated—the use of graduated extinction at all times.
The best way to prevent sleep problems is to encourage parents to establish bedtime rituals that do not foster problematic patterns. Safe sleep recommendations include placing the infant alone in a supine position in their own crib (Hitchcock, 2012). One of the most constructive is placing infants awake in their own crib. When infants are accustomed to falling asleep somewhere else, such as in their parent's arms, and then being transferred to their crib, they awaken in unfamiliar surroundings and are unable to fall asleep until the routine is repeated. Also, the bed should be used for sleeping only, not as a play yard. It is advisable not to hang playthings over or on the bed; in this way, the child associates the bed with sleep, not with activity. Although the interventions described previously and in Table 10-1 are usually successful, it is much easier to prevent the problem with appropriate counseling during the early months of the infant's life.
Sudden Infant Death Syndrome Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year old that remains unexplained after a complete postmortem examination, including an investigation of the death scene and a review of the case history. Since 1994, the incidence of SIDS in the United States has decreased due to the Safe to Sleep campaign (formerly known as the Back to Sleep campaign).* SIDS is the third leading cause of infant deaths (birth to 12 months old) and the leading cause of postneonatal deaths (between 1 and 12 months old). SIDS claimed the lives of 2063 infants in the United States in 2010, a 4% decrease from 2009 (Murphy, Xu, and Kochanek, 2013).
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Despite dramatic decreases in SIDS rates, rates for African-American, American Indian, and Alaskan Native infants remains disproportionately higher than for the rest of the population. In 2007, SIDS rates were 2.4 times higher for American Indian mothers and 1.9 times higher for African-American mothers in comparison to non-Hispanic white mothers (Mathews and MacDorman, 2011). It is also important to note that the percentage of infants born preterm (<37 weeks) was significantly higher (18.5%) in African-American women than in white women (11.7%) (MacDorman and Mathews, 2011). Preterm births rank second as cause of infant death; this trend has been constant since the mid-1990s, when the rates of SIDS deaths significantly decreased in the United States.
The SIDS rate remained fairly static since 2001. This has been attributed to determination of non- SIDS causes of postneonatal mortality, such as suffocation and asphyxia (Moon and Fu, 2012). Table 10-2 summarizes the major epidemiologic characteristics of SIDS.
TABLE 10-2 Epidemiology of Sudden Infant Death Syndrome
Factor Occurrence Incidence 55.4 per 100,000 live births (2008)* Peak age 2 to 3 months old; 90% occur by 6 months old; preterm infants die from sudden infant death syndrome (SIDS) at mean age of 6 weeks later than mean age of death from
SIDS for term infants Gender Higher percentage of boys affected Time of death During sleep Time of year Increased incidence in winter Racial Greater incidence in African Americans and American Indians (see Sudden Infant Death Syndrome in this chapter) Socioeconomic Increased occurrence in lower socioeconomic class Birth Higher incidence in:
• Preterm infants, especially infants of extremely and very low birth weight • Multiple births† • Neonates with low Apgar scores • Infants with central nervous system disturbances and respiratory disorders such as bronchopulmonary dysplasia • Increasing birth order (subsequent siblings as opposed to firstborn child)
Health status Infants with a recent history of illness; lower incidence in immunized infants Sleep habits Highest risk associated with prone position; use of soft bedding; overheating (thermal stress); co-sleeping with adult, especially on sofa or non-infant bed; higher incidence
in co-sleeping with adult smoker Infants co-sleeping with adult at higher risk if younger than 11 weeks old
Feeding habits Lower incidence in breastfed infants Pacifier Lower incidence in infants put to sleep with pacifier Siblings May have greater incidence in siblings of SIDS victims Maternal Young age; cigarette smoking, especially during pregnancy; poor prenatal care; substance abuse (heroin, methadone, cocaine). A few studies have shown an increased risk
in infants exposed to second-hand environmental tobacco smoke.
*Heron M: Deaths: leading causes for 2008, Natl Vital Stat Rep 60(6):1-94, 2012. †Although a rare event, simultaneous death of twins from SIDS can occur. Data from American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome: Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position, Pediatrics 105(3):650- 656, 2000; American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome: SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment, Pediatrics 128(5):1030-1038, 2011.
There has been much debate over the term SIDS, yet the definition noted earlier remains for the time being. Other terms have been developed to explain sudden deaths in infants. Sudden unexpected early neonatal death (SUEND) and sudden unexpected infant death (SUID) share similar features but differ in regards to the timing of death: whereas SUID is considered a death in the postneonatal period, SUEND occurs in the first week of life. The American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome (2011) policy statement considers SIDS to be a component of SUID.
Etiology There are numerous theories regarding the etiology of SIDS; however, the cause remains unknown. One hypothesis is that SIDS is related to a brainstem abnormality in the neurologic regulation of cardiorespiratory control. This maldevelopment affects arousal and physiologic responses to a life- threatening challenge during sleep (Bejjani, Machaalani, and Waters, 2013). Abnormalities include prolonged sleep apnea, increased frequency of brief inspiratory pauses, excessive periodic breathing, and impaired arousal responsiveness to increased carbon dioxide or decreased oxygen. However, sleep apnea is not the cause of SIDS. The vast majority of infants with apnea do not die, and only a minority of SIDS victims have documented apparent life-threatening events (ALTEs) (see Apparent Life-Threatening Event later in this chapter). Numerous studies and meta-analysis indicate that no association exists between SIDS and any childhood vaccine (Moon and Fu, 2012).
A genetic predisposition to SIDS has been postulated as a cause. A deficiency of the complement component C4 is associated with SIDS cases (Opdal and Rognum, 2011). In addition, polymorphisms among interleukin genes, transforming growth factor, tumor necrosis factor, and
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interferon gamma are closely associated with cases of SIDS (Opdal and Rognum, 2011). A number of triple-risk model hypotheses have been proposed to explain the etiology of SIDS.
Some of the proposed factors include an underlying infant vulnerability factor such as a brain abnormality, a critical incident in the fetal developmental period or in early neonatal life, and an environmental stressor such as prone sleep positioning (Matthews and Moore, 2013).
Risk Factors for Sudden Infant Death Syndrome Maternal smoking during pregnancy has emerged in numerous epidemiologic studies as a major factor in SIDS, and tobacco smoke in the infant's environment after birth has also been shown to have a possible relationship to the incidence of SIDS (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). A meta-analysis shows that exposure to tobacco smoke significantly increases an infant's risk for SIDS with an odds ratio of 2.25 for prenatal maternal smoking and 1.97 for postnatal maternal smoking (Zhang and Wang, 2013).
Co-sleeping, or an infant sharing a bed with an adult or older child on a non-infant bed, has been reported to have a positive association with SIDS. Two recent meta-analyses found a significant increase in the risk of SIDS among infants that bed shared compared to infants who slept alone (Das, Sankar, Agarwal, et al, 2014; Carpenter, McGarvey, Mitchell, et al, 2013). A retrospective analysis of infant deaths found a twofold increase of accidental suffocation or strangulation when infants were sleeping on a sofa compared to other locations likely due to the fact that the infant was sharing the area with another person (Rechtman, Colvin, Blair, et al, 2014). Studies correlated higher incidences of SIDS and infant co-sleeping with maternal smoking, co-sleeping with multiple family members, sleeping on a couch, use of a pillow in the infant's bed, soft bedding, and unintentional asphyxiation resulting from adult intoxication (overlaying) (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011; Blair, Sidebotham, Pease, et al, 2014; Li, Zhang, Zielke, et al, 2009).
Prone sleeping may cause oropharyngeal obstruction or affect thermal balance or arousal state. Rebreathing of carbon dioxide by infants in the prone position is also a possible cause of SIDS. Infants sleeping prone and on soft bedding may not be able to move their heads to the side, thus increasing the risk of suffocation and lethal rebreathing. Thus, the side-lying position is no longer recommended for infants sleeping at home, daycare, or hospitals (unless medically indicated). Most preterm infants being discharged from the hospital should be placed in a supine sleeping position unless special factors predispose them to airway obstruction.
One postulated cause of SIDS has been a prolonged Q-T interval or other arrhythmias. Recently cardiac ion channelopathies, which occur as a result of gene mutations and may result in lethal arrhythmias, have been proposed as a possible risk factor for SIDS (Klaver, Versluijs, and Wilders, 2011; Wilders, 2012).
Soft bedding (such as, waterbeds, sheepskins, beanbags, pillows, and quilts) should be avoided for infant sleeping surfaces. Bedding items such as stuffed animals and toys should be removed from the crib while the infant is asleep. Head covering by a blanket has also been found to be a risk factor for SIDS, thus supporting the recommendation to avoid extra bed linens and other items (Mitchell, Thompson, Becroft, et al, 2008). Crib bumper pads have not been shown to reduce infant injury and should therefore be avoided (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011).
In a recent retrospective study of SIDS deaths, Ostfield, Esposito, Perl, et al, (2010) found that at least one modifiable risk factor (such as those previously listed) was present in 96% of the deaths; a total of 78% of the deaths had anywhere from two to seven risk factors.
Protective Factors for Sudden Infant Death Syndrome A meta-analysis indicated that exclusive breastfeeding for any period of time significantly decreased the overall risk of SIDS (Hauck, Thompson, Tanabe, et al, 2011). Some studies have found pacifier use in infants to be a protective factor against the occurrence of SIDS; the data for pacifier use in infants in the first year of life are said to be more compelling than data linking pacifier use to the development of dental complications and the inhibition of breastfeeding (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Therefore, the American Academy of Pediatrics recommends using a pacifier at naptime and bedtime, using a pacifier only if the infant is breastfeeding successfully, not using a sweetened coating on the pacifier, and avoiding forcing the infant to use the pacifier.
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The American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome (2011) recommends that all infants be placed to sleep in the supine (on the back) position and emphasizes that medically stable preterm infants and infants diagnosed with gastroesophageal reflux be placed in a supine sleep position unless there is a specific upper airway disorder wherein the risk of death from the condition is greater than the risk of SIDS. The supine sleep position has not demonstrated an increased risk of choking and aspiration in infants, including those with gastroesophageal reflux (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011).
Since the Back to Sleep campaign in 1994 advocated non-prone sleeping for infants, an increased incidence of positional plagiocephaly has been observed (see later in the chapter). It is recommended that an infant's head position be alternated during sleep time to prevent plagiocephaly. Infants may be placed prone during awake periods to prevent positional plagiocephaly and to encourage development of upper shoulder girdle strength (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Updated childhood immunization status has also been shown to be protective against SIDS.
Although the cause of SIDS is unknown, autopsies reveal consistent pathologic findings (such as, pulmonary edema and intrathoracic hemorrhages) that confirm the diagnosis. Consequently, autopsies should be performed on all infants suspected of dying of SIDS, and findings should be shared with the parents as soon as possible after the death. Postmortem findings in SIDS and accidental suffocation or intentional suffocation, such as in Munchausen syndrome by proxy (see Child Maltreatment, Chapter 13), are practically the same. Individuals with less experience and training in performing autopsies, such as coroners instead of medical examiners, may not correctly identify some deaths as SIDS. Therefore, mortality statistics can vary in different regions.
Infant Risk Factors Certain groups of infants are at increased risk for SIDS: • Low birth weight or preterm birth • Low Apgar scores • Recent viral illness • Siblings of two or more SIDS victims • Male gender • Infants of American Indian or African-American ethnicity
No diagnostic tests exist to predict which infants, including those in the aforementioned groups, will survive, and home monitoring is no guarantee of survival. Whether subsequent siblings of one SIDS infant are at increased risk for SIDS is unclear. Even if the risk is increased, families have a 99% chance that their subsequent child will not die of SIDS. A review of sibling deaths attributed to SIDS in England failed to ascertain a precise risk of recurrence; previous studies suggested a recurrence risk range of 1.7 to 10.1, yet the researchers concluded the studies had too many methodologic flaws to draw any firm conclusions (Bacon, Hall, Stephenson, et al, 2008). Home monitoring is not recommended for this group of children, but it is often used by practitioners and may even be requested by parents (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). There is no evidence that home apnea monitoring prevents SIDS (Strehle, Gray, Gopisetti, et al, 2012). Monitoring is best initiated on an individual basis.
Nursing Care Management Nurses have a vital role in preventing SIDS by educating families about the risk of prone sleeping position in infants from birth to 6 months old, the use of appropriate bedding surfaces, the association with maternal smoking, and the dangers of co-sleeping on non-infant surfaces with adults or other children. Additionally, nurses have an important role in modeling behaviors for parents to foster practices that decrease the risk of SIDS, including placing infants in a supine sleeping position in the hospital. Data indicate that some nurses still place healthy infants in a side- lying position in the hospital due to a belief of safety concerns if the infant is placed supine (Mason, Ahlers-Schmidt, and Schunn, 2013). Many health care workers are concerned that infants placed on the back to sleep will aspirate emesis or mucus, yet studies fail to show an increase in infant deaths, spitting up during sleep, aspiration, asphyxia, or respiratory failure as a result of supine sleep positioning (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011).
Education can change practice. After an educational session and laminated reminder card on safe
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sleep recommendations, neonatal intensive care unit (NICU) nurses had a significant increase in rate of supine positioning (39% before and 83% after), providing a firm sleeping surface (5% before and 96% after), and removal of soft objects in bed (45% before and 75% after) for their NICU patients (Gelfer, Cameron, Masters, et al, 2013). A safe sleeping practice educational session for nurses at a community hospital in the Midwestern area of the United States showed a statistically significant increase in safe sleep practices with their patients (25% compliance pre-intervention and 58% compliance post-intervention) and 95% of parents planned to use the supine sleep position at home (Mason, Ahlers-Schmidt, and Schunn, 2013). Role modeling safe sleep practices and providing education to parents is imperative before hospital discharge because limited opportunities exist for parents to receive information about caring for their infant (Ateah, 2013). Nurses must be proactive in further decreasing the incidence of SIDS; postpartum discharge planning, newborn discharges, follow-up home visits, well-baby clinic visits, and immunization visits provide excellent opportunities to educate parents on these matters.
Research findings have important implications for practices that may reduce the risk of SIDS, such as avoiding smoking during pregnancy and near the infant; using the supine sleeping position; avoiding soft, moldable mattresses, blankets, and pillows; avoiding bed sharing; breastfeeding; and avoiding overheating during sleep. Nurses must continue to take every opportunity to advocate for infants by providing information for parents and caretakers about the modifiable risk factors for SIDS that can be implemented to prevent its occurrence across all sectors of the population.
Care of the Family of a Sudden Infant Death Syndrome Infant Loss of a child from SIDS presents several crises with which the parents must cope. In addition to grief and mourning the death of their child, the parents must face a tragedy that was sudden, unexpected, and unexplained. The psychologic intervention for the family must deal with these additional variables. This discussion focuses primarily on the objectives of care for families experiencing SIDS rather than on the process of grief and mourning, which is explored in Chapter 17.
The first people to arrive at the scene may be the police and emergency medical service personnel. They should handle the situation by asking few questions; giving no indication of wrongdoing, abuse, or neglect; making sensitive judgments concerning any resuscitation efforts for the child; and comforting the family members as much as possible. A compassionate, sensitive approach to the family during the first few minutes can help spare them some of the overwhelming guilt and anguish that commonly follow this type of death.
The medical examiner or coroner may go to the home or place of death and make the death pronouncement; until then, the sleep environment should remain as it was when the infant was initially found. If the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. Usually there is no attempt at resuscitation in the emergency department. While they are in the emergency department, the parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that may suggest responsibility, such as “Why didn't you go in earlier?” “Didn't you hear the infant cry out?” “Was the head buried in a blanket?” or “Were the siblings jealous of this child?” It is the investigators' responsibility to document findings at the scene rather than have parents recount the experience in the emergency department. Parents may also express feelings of guilt about administering cardiopulmonary resuscitation (CPR) correctly or the timing of CPR in relation to finding the infant.
At this time, the physician should initiate the discussion of an autopsy, often with the nurse being present to support the family. The physician or medical examiner, depending on the circumstances, emphasizes that a diagnosis cannot be confirmed until the postmortem examination is completed. Requesting an autopsy may be difficult because of the parents' emotional state; however, an autopsy may clear up possible misconceptions regarding the death. Instructions about the autopsy and funeral arrangements may need to be repeated or put in writing. If the mother was breastfeeding, she needs information about abrupt discontinuation of lactation. The nurse or physician should contact the primary care practitioner for the infant and the mother to avoid any miscommunications or telephone calls at a later date inquiring about the child's health status.
Parents experiencing perinatal death perceive health care workers' responses as having a significant impact on the parents' grieving process. A family-centered approach that involves the
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sociocultural context and unique needs of the family is essential for perinatal bereavement care (Flenady, Boyle, Koopmans, et al, 2014). Health care workers require adequate training and support in order to deliver appropriate care and prevent burnout (Flenady, Boyle, Koopmans, et al, 2014).
An important aspect of compassionate care for these parents is allowing them to say good-bye to their child. These are the parents' last moments with their child, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Encourage parents to hold their infant before leaving the emergency department. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. Comprehensive guidelines have been published for health professionals involved in SIDS investigations to assist the family and at the same time to determine that the infant's death was not the result of other factors, such as child maltreatment (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011).
When the parents return home, a competent, qualified professional should visit them as soon after the death as possible. They should receive printed material that contains excellent information about SIDS (available from the national organizations*).
During the initial visit, help the parents gain an intellectual understanding of the condition. The nursing objectives are to assess what the parents have been told about SIDS; what they think happened; and how they explained this to the other siblings, family members, and friends. One question that the nurse will never be able to answer and therefore should not attempt to is, “Why did this happen to our baby?” or “Who is responsible for this tragedy?” These and other questions may linger in the parents' minds for months or even years.
When the unexpected death of a child occurs, it is common for one parent to blame the other for the child's death. Parents may also experience guilt over the child's death; if they had checked earlier, the child might still be alive. It is important that the nurse assist parents in working through these feelings to prevent marital disruption in addition to the loss of the loved child.
Some parents are able to discuss their feelings openly, and the nurse supports this coping skill. However, others may be reluctant to express their grief, and the nurse can encourage the expression of emotions by asking about crying and feeling sad, angry, or guilty. This is an attempt to provoke a display of emotion, not just an admission of a feeling. During this session, help the parents to explore their usual coping mechanisms and, if these are ineffectual, to investigate new approaches. For example, one parent may refrain from discussing the death for fear of upsetting the other parent, but each may need to hear how the other feels.
Ideally, the number of visits and plans for subsequent intervention need to be flexible. Parents facing the question of having a subsequent child will need support. Both the birth of a subsequent child and the survival of that child, especially past the age of death of the previous child, are important transitional stages for parents.
Positional Plagiocephaly Since the Back to Sleep campaign began in 1994 advocating non-prone sleeping for infants to prevent SIDS, an increase in the incidence of positional plagiocephaly has been observed (Laughlin, Luerssen, Dias, et al, 2011). Approximately 20% of infants have a skull that is most prevalent between 2 and 4 months old (van Wijk, van Vlimmeren, Groothuis-Oudshoorn, et al, 2014). The term plagiocephaly connotes an oblique or asymmetric head; positional plagiocephaly, deformational plagiocephaly, or nonsynostotic plagiocephaly implies an acquired condition that occurs as a result of cranial molding during infancy, usually as a result of lying in the supine position (van Wijk, van Vlimmeren, Groothuis-Oudshoorn, et al, 2014). Because infants' sutures are not closed, the skull is pliable; and when infants are placed on their backs to sleep, the posterior occiput flattens over time (Fig. 10-4, A). A typical bald spot develops, which is usually transient. As a result of prolonged pressure on one side of the skull, that side becomes misshapen; mild facial asymmetry may develop. The sternocleidomastoid muscle may tighten on the preferential side, and torticollis may also develop. Congenital or acquired torticollis may cause plagiocephaly; other causes of deformational plagiocephaly include certain craniofacial syndromes. This discussion centers only on positional plagiocephaly caused by supine sleeping position.
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FIG 10-4 A, Plagiocephaly. B, Helmet used to correct plagiocephaly. (Courtesy of Dr. Gerardo Cabrera-Meza, Department of Neonatology, Baylor College of Medicine, Houston, TX.)
Therapeutic Management Prevention of positional plagiocephaly may begin shortly after birth by placing the infant to sleep supine and alternating the infant's head position nightly, avoiding prolonged placement in car safety seats and swings, and using prone positioning or “tummy time” for approximately 30 to 60 minutes per day when the infant is awake (Laughlin, Luerssen, Dias, et al, 2011).
Treatment of torticollis and plagiocephaly initially involves exercises to loosen the tight muscle and switching head position sides during feeding, carrying, and sleep. If the plagiocephaly is not resolved within 4 to 8 weeks of physical therapy, a customized helmet may be worn to decrease the pressure on the affected side of the skull (see Fig. 10-4, B). If no improvement occurs with physical therapy or a molded helmet over a period of 2 to 3 months, the infant may be referred to a pediatric neurosurgeon or craniofacial surgeon; the referral should optimally occur by 4 to 6 months old (Laughlin, Luerssen, Dias, et al, 2011).
The helmet is worn 23 hours a day for a prescribed period (usually 3 months). Repositioning and physical therapy are said to be more effective when used before the infant can roll over or move his or her head alone (i.e., before approximately 3 to 4 months old) (Robinson and Proctor, 2009).
Nursing Care Management Minor skull flattening is not considered significant, but parents should learn to prevent plagiocephaly by altering the infant's head position during sleep. Infants should be placed prone on a firm surface during awake time (tummy time), which prevents plagiocephaly and facilitates
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development of upper shoulder girdle strength; the latter helps in the progressive development of movements such as rolling over and starting to rise up on all fours, which are precursors to crawling and eventually walking. Thirty to 60 minutes of supervised tummy time per day in infants younger than 6 months old is recommended (Laughlin, Luerssen, Dias, et al, 2011; Robinson and Proctor, 2009).
Despite the perceived increase in the incidence of positional plagiocephaly, the supine sleeping position is still recommended because it has led to a significant decrease in loss of infant lives from SIDS (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Additional measures to prevent positional plagiocephaly include avoiding excessive time spent in car seat restraints, infant seats, and bouncers (Laughlin, Luerssen, Dias, et al, 2011). Alternating the infant's head position for sleep times can also prevent unilateral molding. When a nurse or parent notices plagiocephaly, a consultation with the primary practitioner is recommended to evaluate the head shape and ascertain the need for early intervention.
Nurses are in a unique position in well-child care settings to encourage parents to follow guidelines for preventing plagiocephaly, demonstrate alternating head placement for sleeping, demonstrate sternocleidomastoid muscle exercises (as appropriate to the condition), and encourage tummy time for infants during awake periods. Most important, nurses should continue to encourage parents to place the infant in a supine sleep position despite the development of plagiocephaly. Nurses can also assist parents in the proper use of a skull-molding helmet and reassure them of the high rate of success with the helmet. Allowing parents to verbalize concerns and feelings related to the health status of the child as well as provision of current best practice is an important nursing function. Parents should not become so alarmed by plagiocephaly that they abandon supine sleeping position for the infant but should consult with the practitioner for further advice.
Apparent Life-Threatening Event An apparent life-threatening event (ALTE), formerly referred to as aborted SIDS death or near-miss SIDS, generally refers to an event that is sudden and frightening to the observer in which the infant exhibits a combination of apnea; change in color (pallor, cyanosis, redness); change in muscle tone (usually hypotonia); and choking, gagging, or coughing and that usually involves a significant intervention and even CPR by the caregiver who witnesses the event. The definition of ALTE may include apnea, but ALTE may occur without apnea (Silvestri, 2009). It is erroneous to characterize ALTE as a near-miss SIDS incident (Adams, Good, and Defranco, 2009). Infants with ALTE are at increased risk for SIDS; the risk for SIDS may be three to five times greater in infants who experienced an ALTE (Hunt and Hauck, 2016). One common risk factor for SIDS and ALTE is maternal smoking (Fu and Moon, 2012).
Results from the Collaborative Home Infant Monitoring Evaluation (CHIME) study found that apnea and bradycardia occurred at conventional and extreme alarm thresholds in all groups of infants studied—siblings of SIDS infants, infants with ALTEs, symptomatic (of apnea and bradycardia) and asymptomatic preterm infants weighing less than 1750 g (3.8 pounds) at birth, and healthy term infants. Approximately 30% of infants with ALTE were born at less than 37 weeks' gestation (Hunt and Hauck, 2016). The researchers concluded that many infants experience apnea and bradycardia yet do not die. Furthermore, it was reported that apnea does not appear to be an immediate precursor to SIDS and that cardiorespiratory monitoring is not an effective tool for identifying infants at greater risk for SIDS (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). CHIME data indicate that infants with ALTE did not have some of the typical characteristics associated with SIDS infants; these include fewer infants with low birth weight and who are small for gestational age at birth, fewer teenage pregnancies, and a younger infant age at the time of ALTE. The researchers concluded that despite some similar characteristics between ALTE and SIDS, the differences warrant a separate focus on ALTE events (Esani, Hodgman, Ehsani, et al, 2008).
Diagnostic Evaluation An essential component of the diagnostic process includes a detailed description of the event, including who witnessed the event; where the infant was during the event; and what, if any, activities were involved (e.g., during or after a feeding, riding in a car seat restraint, presence of
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siblings or any minor children, what clothing the infant was wearing). In addition, a prenatal and postnatal history must be obtained. A short period of observation in the emergency department may be appropriate to observe the infant's respiratory pattern and response to feeding. A careful evaluation of late preterm and preterm infants in the car seat restraints currently in use is essential; upper airway occlusion and subsequent apnea and cyanosis may occur if the infant is not positioned properly. Reported diagnoses in infants with ALTE include a neurologic event, such as a seizure (10% to 20% of cases seen); GI problem, including gastroesophageal reflux (48%); respiratory conditions (20% to 30%); cardiac conditions (10% to 20%); and other concerns such as ear, nose, and throat (ENT) abnormalities, ingestions, Munchausen syndrome by proxy, or child abuse (each <5%) (Chu and Hageman, 2013). In some cases, multiple diagnoses may be made.
In the event that an underlying diagnosis (such as, those mentioned previously) is not established, home monitoring may be recommended. The most commonly used monitoring is continuous recording of cardiorespiratory patterns (cardiopneumogram or pneumocardiogram). Four-channel pneumocardiograms (or multichannel pneumogram) monitor heart rate, respirations (chest impedance), nasal airflow, and oxygen saturation. A more sophisticated test, polysomnography (sleep study), also records brain waves, eye and body movements, esophageal manometry, and end-tidal carbon dioxide measurements. However, none of these tests can predict risk. Some children with normal results may still have subsequent apneic episodes.
Therapeutic Management The treatment of an infant with an ALTE depends on the underlying condition (see earlier). Treatment of recurrent apnea (without an underlying organic problem) usually involves continuous home monitoring of cardiorespiratory rhythms and in some cases the use of methylxanthines (respiratory stimulant drugs, such as caffeine). The decision to discontinue the monitoring is based on the infant's clinical condition. A general guideline for discontinuation is when infants with ALTEs have gone 2 or 3 months without significant numbers of episodes requiring intervention.
Newer home apnea monitors allow download of information that assists the practitioner in deciding when to discontinue home monitoring. It is imperative to remember, however, that the home apnea monitor will not predict or prevent SIDS deaths (Strehle, Gray, Gopisetti, et al, 2012). Furthermore, impedance-based monitors detect chest wall movement and will not detect obstructive apnea unless the episode involves significant bradycardia.
Nursing Care Management The diagnosis of an ALTE causes great anxiety and concern in parents, and the institution of home monitoring presents additional physical and emotional burdens. Parents of infants on home apnea monitors report experiencing emotional distress, especially depression and hostility, during the first few weeks after hospital discharge. For parents of a SIDS victim who have a new infant on home apnea monitoring, the anxiety is compounded by the uncertainty of the future of the living child and grief for the lost child. Home apnea monitoring may offer some predictability and control over the current child's survival through the period of uncertainty.
If home monitoring is required, the nurse can be a major source of support to the family in terms of education about the equipment; education regarding observation of the infant's status; and instructions regarding immediate intervention during apneic episodes, including CPR. To help the family cope with the numerous procedures they must learn, adequate preparation before discharge and written instructions are essential. In the first few weeks after discharge, parents may benefit by having a practitioner readily available to answer questions regarding false alarms and for other technical assistance.
Several types of home monitors are available and are set up by either a home monitor equipment company or home health staff. Nurses, especially those involved in the care at home, must become familiar with the equipment, including its advantages and disadvantages. Safety is a major concern because monitors can cause electrical burns and electrocution. The following precautions are recommended: • Remove leads from infant when not attached to the monitor. • Unplug the power cord from the electrical outlet when the cord is not plugged into the monitor. • Use safety covers on electrical outlets to discourage children from inserting objects into sockets.
Siblings should also be supervised when near the infant and taught that the monitor is not a toy.
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Other safety practices include informing local utility and rescue squads of the home monitoring in case of an emergency. Telephone numbers for these services should be posted in the home or set up as speed dial.
N u r s i n g A l e r t If the infant is apneic, gently stimulate the trunk by patting or rubbing it. Call loudly for help even if alone. If the infant is prone, turn to the back and flick the heels of the feet. If there is still no response, immediately begin cardiopulmonary resuscitation (CPR) starting with chest compressions. After approximately 2 minutes of CPR, activate the emergency medical service —“Call 911” and then resume CPR until emergency responders arrive or the infant starts breathing. Never vigorously shake the child. No more than 10 to 15 seconds is spent on stimulation before implementing CPR.
Caregivers need detailed information regarding proper attachment of the electrodes to the infant's chest with impedance monitors that detect chest movement. The electrodes are placed in the midaxillary line at a space one or two fingerbreadths below the nipple. For home use, electrodes attached to a belt that is placed around the child's trunk are preferred (Fig. 10-5). The belt is positioned so that the electrodes contact the skin in the same area. Monitors may have memory chips that allow for event recording, which can be an effective tool in evaluating the use of the monitor, events immediately before and after the ALTE, and reported frequency of alarms.
FIG 10-5 Placement of electrodes or belt for apnea monitoring. In small infants, one fingerbreadth may be used.
Monitors are effective only if they are used. They do not prevent death but alert the caregiver to the ALTE in time to intervene. The need to use the monitor and to respond appropriately to alarms must be stressed. Noncompliance can result in the infant's death.
Many of the stresses observed during the home monitoring period are characteristic of families with chronically ill children. The child with an apnea or cardiorespiratory monitor may have additional health care needs such as a gastrostomy, tracheostomy, and myriad medications or treatments that exacerbate the parents' stress. Parents report increased stress, including concern for the child's survival, fear of incompetence in assuming home responsibility, inadequate respite care, lack of time for other children and spouse, social isolation from friends and extended family, constant work, and fatigue. To deal with these potential effects, nurses need to use the same interventions as those discussed for children with chronic illness and be aware of the need for referral when difficulties are suspected.
To lessen the continuous responsibility of monitoring, other family members, such as grandparents and other immediate family members, should be taught how to manipulate the
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equipment, read and interpret the signals, and administer CPR (if needed). They are encouraged to stay with the infant for regular periods to allow the parents respite. Support groups of other families who have successfully completed monitoring can also be of benefit. Because reliable babysitters are difficult to locate, support group members and nursing students may be potential sources of qualified caregivers.
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NCLEX Review Questions 1. Vitamin A may be administered in significant amounts to children with this childhood
communicable illness to decrease morbidity and mortality: a. Pertussis b. Varicella c. Rubella d. Measles
2. A 10-year-old child with a peanut allergy would be expected to have which of these as an early manifestation of his allergy? Select all that apply. a. Wheezing b. Nausea c. Headache d. Trouble breathing e. Urticaria
3. The recommended treatment for cow's milk protein allergy is the substitution of cow's milk– based formula for: a. Goat's milk b. Soy milk or a hydrolyzed formula c. Whole milk d. Evaporated milk
4. Identify the interventions that can be safely used to manage diaper dermatitis. Select all that apply. a. Blow dry heat on skin with hair dryer. b. Apply a skin barrier paste such as zinc oxide. c. Keep skin surface irritants such as urine and stool off skin. d. Expose skin to air. e. Use only cloth diapers.
5. Which factors are considered protective factors for sudden infant death syndrome (SIDS)? a. Side sleeping position, breastfeeding, updated childhood immunization status b. Supine sleeping position, breastfeeding, soft bedding c. Prone sleeping position, exposure to maternal tobacco use, updated childhood immunization
status d. Supine sleeping position, breastfeeding, updated childhood immunization status
6. A 3-month-old is being seen in the well-child clinic for positional plagiocephaly. The nurse knows that the initial interventions for this condition involve which of the following? Select all that apply. a. Place the infant to sleep in the prone position. b. Place the infant in a prone position when awake (approximately 15 minutes). c. Alternate the infant's head position (side of head) when asleep. d. Have the infant wear a soft helmet for 23 to 24 hours a day. e. Place the infant to sleep in an infant seat twice a day.
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Correct Answers 1. d; 2. a, d, e; 3. b, c; 4. b, c, d; 5. d; 6. b, c
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meta-analysis. Leg Med. 2013;15(3):115–121. *Yogurt does not contain adequate amounts of vitamins A and D yet is an acceptable source of calcium and phosphorus. *Additional information for parents of infants with food allergies is available from the American Academy of Allergy, Asthma and Immunology, 555 E. Wells St., Suite 1100, Milwaukee, WI 53202; 414-272-6071; http://www.aaaai.org. Additional helpful websites for information on food allergy include MedlinePlus (sponsored by US National Library of Medicine and National Institutes of Health), http://www.nlm.nih.gov/medlineplus; Food Allergy and Anaphylaxis Network, 800-929-4040, http://www.foodallergy.org; National Institute of Allergy and Infectious Diseases, http://www.niaid.nih.gov/Pages/default.aspx; and AllergicChild, http://www.allergicchild.com. *Safe to Sleep materials may be ordered by contacting the National Institute of Child Health and Human Development Information Resource Center, Safe to Sleep, PO Box 3006, Rockville, MD 20847; 800-505-CRIB (2742); http://www.nichd.nih.gov/sts/. *American SIDS Institute, 528 Ravens Way, Naples, FL 34110; 239-431-5425; http://www.sids.org; First Candle, 1314 Bedford Ave., Suite 210, Baltimore, MD 21208; 800-221-7437; http://www.sidsalliance.org; The Sudden Unexplained Death in Childhood Foundation, 549 Pomptom Avenue, Suite 197, Cedar Grove, NJ 07009; 800-620-7832; http://www.sudc.org.
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U N I T 5 Family-Centered Care of the Young Child
OUTLINE 11 Health Promotion of the Toddler and Family 12 Health Promotion of the Preschooler and Family 13 Health Problems of Toddlers and Preschoolers
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Health Promotion of the Toddler and Family Cheryl C. Rodgers
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Promoting Optimal Growth and Development The term terrible twos has often been used to describe the toddler years, the period from 12 to 36 months old. It is a time of intense exploration of the environment as children attempt to find out how things work; what the word “no” means; and the power of temper tantrums, negativism, and obstinacy. “Getting into things” is their way of learning about their world, especially relationships. Successful mastery of the tasks of this age requires a strong foundation of trust during infancy and frequently necessitates guidance from others when parents and toddlers face the struggles of toilet training, limit setting, and sibling rivalry. Nurses who understand the dynamics of growth and development of toddlers can help families deal effectively with the tasks of this age.
Biologic Development Proportional Changes Physical growth slows considerably during toddlerhood. The average weight gain is 1.8 to 2.7 kg (4 to 6 pounds) per year. The average weight at 2 years old is 12 kg (26.5 pounds). The birth weight is quadrupled by years old. The rate of increase in height also slows. The usual increment is an addition of 7.5 cm (3 inches) per year and occurs mainly in elongation of the legs rather than the trunk. The average height of a 2-year-old child is 86.6 cm (34 inches). In general, adult height is about twice the 2-year-old child's height. Accurate measurement of height and weight during the toddler years should reveal a steady growth curve that is steplike in nature rather than linear (straight), which is characteristic of the growth spurts during the early childhood years.
The rate of increase in head circumference slows somewhat by the end of infancy, and head circumference is usually equal to chest circumference by 1 to 2 years old. The usual total increase in head circumference during the second year is 2.5 cm (1 inch). Then the rate of increase slows until at age 5 years, the increase is less than 1.25 cm (0.5 inch) per year. The anterior fontanel closes between 12 and 18 months old.
Chest circumference continues to increase in size and exceeds head circumference during the toddler years. The chest's shape also changes as the transverse, or lateral, diameter exceeds the anteroposterior diameter. After the second year, the chest circumference exceeds the abdominal measurement, which, in addition to the growth of the lower extremities, makes the child appear taller and leaner. However, toddlers retain a squat, “pot-bellied” appearance because of their less developed abdominal musculature and short legs. The legs retain a slightly bowed or curved appearance during the second year from the weight of the relatively large trunk.
Sensory Changes Visual acuity of 20/40 is considered acceptable during the toddler years. Full binocular vision is well developed, and any evidence of persistent strabismus requires professional attention as early as possible to prevent amblyopia. Depth perception continues to develop, but because of toddlers' lack of motor coordination, falls from heights continue to be a persistent danger.
The senses of hearing, smell, taste, and touch become increasingly well developed, coordinated with each other, and associated with other experiences. All of the senses are used to explore the environment. Toddlers visually inspect an object by turning it over; they may taste it, smell it, and touch it several times before they are satisfied with their investigation. They shake it to see if it makes noise and vigorously test its durability.
Another example of the integrated function of the senses is toddlers' development of specific taste and texture preferences. Toddlers are much less likely than infants to try new foods because of their appearance, texture, or smell, not just their taste.
Maturation of Systems Most of the physiologic systems are relatively mature by the end of toddlerhood. By the end of the first year, all the brain cells are present but continue to increase in size. Myelination of the spinal cord is almost complete by 2 years old, which parallels the completion of most of the gross motor skills. Brain growth is 75% completed by the end of 2 years.
The volume of the respiratory tract and growth of associated structures continue to increase
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during early childhood, lessening some of the factors that predisposed children to frequent and serious infections during infancy. The internal structures of the ear and throat continue to be short and straight, and the lymphoid tissue of the tonsils and adenoids continues to be large. As a result, otitis media, tonsillitis, and upper respiratory tract infections are common. The respiratory and heart rates slow, and the blood pressure increases. Respirations continue to be abdominal.
The digestive processes are fairly complete by the beginning of toddlerhood. The acidity of the gastric contents continues to increase and has a protective function because it is capable of destroying many types of bacteria. Stomach capacity increases to allow for the usual schedule of three meals a day.
One of the more prominent changes of the gastrointestinal system is the voluntary control of elimination. With complete myelination of the spinal cord, control of the anal and urethral sphincters is gradually achieved. The physiologic ability to control the sphincters probably occurs somewhere between 18 and 24 months old. Bladder capacity also increases considerably. By 14 to 18 months old, children are able to retain urine for up to 2 hours or longer.
Under conditions of moderate variation in temperature, the toddler rarely has the difficulties of young infants in maintaining body temperature. The capillaries are able to conserve core body temperature by constricting in response to cold and dilating in response to heat.
The defense mechanisms of the skin and blood, particularly phagocytosis, are much more efficient in toddlers than in infants. The production of antibodies is well established. However, many young children demonstrate a sudden increase in colds and minor infections when entering day care or preschool because of their exposure to new pathogens.
Rapid growth in neurobehavioral organization contributes to greater regularity of sleep–wake cycles, the diminishing of crying and unexplained fussiness, and the enhanced predictability in mood. Valuable stimulants of early brain development include the various interactions (talking, singing, and playing) between the toddler and caregivers. Adequate nutrition; protection from environmental toxins, such as lead, various drugs, and stress; and promotion of good health care all contribute to healthy brain growth.
Gross and Fine Motor Development The major gross motor skill during the toddler years is the development of locomotion. By 12 to 13 months old, toddlers walk alone using a wide stance for extra balance, and by 18 months old, they try to run but fall easily. At 2 years old, toddlers can walk up and down stairs, and by years old, they can jump using both feet, stand on one foot for a second or two, and manage a few steps on tiptoe. By the end of the second year, they can stand on one foot, walk on tiptoe, and climb stairs with alternate footing.
Fine motor development is demonstrated in increasingly skillful manual dexterity. For example, by 12 months old, toddlers are able to grasp a very small object. At 15 months old, they can drop a raisin into a narrow-necked bottle. Casting or throwing objects and retrieving them become almost obsessive activities at about 15 months old. By 18 months old, toddlers can throw a ball overhand without losing their balance. Mastery of gross and fine motor skills is evident in all phases of toddlers' activity, such as play, dressing, language comprehension, response to discipline, social interaction, and propensity for injuries. Activities occur less in isolation and more in conjunction with other physical and mental abilities to produce a purposeful result. For example, the toddler walks to reach a new location, releases a toy to pick it up or to choose a new one, and scribbles to look at the image produced. The possibilities of the exploration, investigation, and manipulation of the environment—and its hazards—are endless.
Psychosocial Development Toddlers are faced with the mastery of several important tasks. If the need for basic trust has been satisfied, they are ready to give up dependence for control, independence, and autonomy. Some of the specific tasks to be dealt with include: • Differentiation of self from others, particularly the mother • Toleration of separation from parent • Ability to withstand delayed gratification • Control over bodily functions
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• Acquisition of socially acceptable behavior • Verbal means of communication • Ability to interact with others in a less egocentric manner
Mastery of these goals is only begun during late infancy and the toddler years; tasks such as developing interpersonal relationships with others may not be completed until adolescence. However, crucial foundations for successful completion of such developmental tasks are laid during these early formative years.
Developing a Sense of Autonomy (Erikson) According to Erikson (1963), the developmental task of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. As infants gain trust in the predictability and reliability of their parents, environment, and interactions with others, they begin to discover that their behavior is their own and that it has a predictable, reliable effect on others. Although they are aware of their will and control over others, they are confronted with the conflict of exerting autonomy and relinquishing the much-enjoyed dependence on others. Exerting their will has definite negative consequences, whereas retaining dependent, submissive behavior is generally rewarded with affection and approval. On the other hand, continued dependency creates a sense of doubt regarding their potential capacity to control their actions. This doubt is compounded by a sense of shame for feeling this urge to revolt against others' will and a fear that they will exceed their own capacity for manipulating the environment. Skillful monitoring and balance of controls by parents allows a growing rate of realistic successes and the emergence of autonomy.
Just as infants have the social modalities of grasping and biting, toddlers have the newly gained modality of holding on and letting go. Holding on and letting go are evident in how the toddler uses the hands, mouth, eyes, and, eventually, the sphincters, when toilet training is begun. Children constantly express these social modalities in play activities, such as throwing objects; taking objects out of boxes, drawers, or cabinets; holding on tighter when someone says, “No; don't touch;” and refusing to eat certain foods as taste preferences become strong.
Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with negativism, giving a negative response to requests. The words “no” or “me do” can be their sole vocabulary. Emotions become strongly expressed, usually in rapid mood swings. One minute, toddlers can be engrossed in an activity, and the next minute they might be angry because they are unable to manipulate a toy or open a door. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent's legs to be picked up and comforted. Understanding and coping with these swift changes is often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens children in their search for learning acceptable methods of interacting with others (see Temper Tantrums and Negativism later in this chapter).
In contrast to negativism, which frequently disrupts the environment, ritualism, the need to maintain sameness and reliability, provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places, and routines still exist. One can easily understand why any change in the daily routine represents such a threat to these children. Without comfortable rituals, they have little opportunity to exert autonomy. Consequently, dependency and regression occur (see Regression later in this chapter).
Erikson focuses on the development of the ego, which may be thought of as reason or common sense, during this phase of psychosocial development. The child struggles to deal with the impulses of the id, tolerate frustration, and learn socially acceptable ways of interacting with the environment. The ego becomes evident as children are able to tolerate delayed gratification.
Toddlers also have a rudimentary beginning of the superego, or conscience, which is the incorporation of the morals of society and the process of acculturation. With the development of the ego, children further differentiate themselves from others and expand their sense of trust in self. But as they begin to develop awareness of their own will and capacity to achieve, they also become aware of their ability to fail. This ever-present awareness of potential failure creates doubt and shame. Successful mastery of the task of autonomy necessitates opportunities for self-mastery while withstanding the frustration of necessary limit setting and delayed gratification. Opportunities for self-mastery are present in appropriate play activities, toilet training, the crisis of sibling rivalry, and successful interactions with significant others.
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Cognitive Development: Sensorimotor and Preoperational Phase (PIAGET) The period from 12 to 24 months old is a continuation of the final two stages of the sensorimotor phase. During this time, the cognitive processes develop rapidly and at times seem similar to those of mature thinking. However, reasoning skills are still primitive and need to be understood to effectively deal with the typical behaviors of a child of this age.
In the fifth stage of the sensorimotor phase, tertiary circular reactions (13 to 18 months old), the child uses active experimentation to achieve previously unattainable goals. Newly acquired physical skills are increasingly important for the function they serve rather than for the acts themselves. The child incorporates the old learning of secondary circular reactions with new skills and applies the combined knowledge to new situations, with emphasis on the results of the experimentation. In this way, there is the beginning of rational judgment and intellectual reasoning. During this stage, the child further differentiates self from objects. This is evident in child's increasing ability to venture away from their parents and to tolerate longer periods of separation.
Awareness of a causal relationship between two events is apparent. After flipping a light switch, toddlers are aware that a reciprocal response occurs. However, they are not able to transfer that knowledge to new situations. Therefore, every time they see what appears to be a light switch, they must reinvestigate its function. Such behavior demonstrates the beginning of categorizing data into distinct classes and subclasses. Innumerable examples of this type of behavior occur as toddlers continuously explore the same object each time it appears in a new place.
Because classification of objects is still basic, the appearance of an object indicates its function. For example, if the child's toys are stored in a paper bag or large container, the toddler does not perceive a difference between the toy receptacle and the garbage pail or laundry basket. If allowed to turn over the toy receptacle, the child will just as quickly do the same to other similar containers because, in the child's mind, there is no difference. Expecting the child to judge which receptacles are permissible to explore and which are not is inappropriate for this age group. Instead, the forbidden object, such as the garbage pail, should be placed out of reach. This has significant implications for prevention of accidents and accidental ingestion of injurious agents.
The discovery of objects as objects leads to the awareness of their spatial relationships. Children are able to recognize different shapes and their relationships to each other. For example, they can fit slightly smaller boxes into each other (nesting) and can place a round object into a hole even if the board is turned around, upside down, or reversed. Children are also aware of space and the relationship of their bodies to dimensions, such as height. They will stretch, stand on a low stair or stool, and pull a string to reach an object.
Object permanence has also advanced. Although they still cannot find an object that has been invisibly displaced and is no longer visible or moved from under one pillow to another without their seeing the change, toddlers are increasingly aware of the existence of objects behind closed doors, in drawers, and under tables. Parents are usually acutely aware of this developmental achievement and find high places and locked cabinets the only places that are inaccessible to toddlers.
During ages 19 to 24 months, the child is in the final sensorimotor stage, invention of new means through mental combinations. This stage completes the more primitive, autistic thought processes of infancy and prepares the way for more complex mental operations that occur during the phase of preoperational thought. One of the most dramatic achievements of this stage is in the area of object permanence. Toddlers will now actively search for an object in several potential hiding places. In addition, they can infer a cause when only experiencing the effect. They can infer that an object was hidden in any number of places even if they only saw the original hiding place.
Imitation displays deeper meaning and understanding. There is greater symbolization to imitation. Children are acutely aware of others' actions and attempt to copy them in gestures and in words. Domestic mimicry (imitating household activities) and sex-role behavior become increasingly common during this period and during the second year. Identification with the parent of the same gender becomes apparent by the second year and represents the child's intellectual ability to differentiate different models of behavior and to imitate them appropriately (Fig. 11-1).
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FIG 11-1 Domestic mimicry is common during toddlerhood.
The concept of time is still embryonic, but children have some sense of timing in terms of anticipation, memory, and a limited ability to wait. They may listen to the command, “Just a minute,” and behave appropriately. However, their sense of timing is exaggerated—1 minute can seem like an hour. Toddlers' limited attention spans also indicate their sense of immediacy and concern for the present.
Preoperational Phase (Piaget) At approximately 2 years old, children enter the preconceptual phase of cognitive development, which lasts until about 4 years old. The preconceptual phase is a subdivision of the preoperational phase, which spans ages 2 to 7 years. The preconceptual phase is primarily one of transition that bridges the purely self-satisfying behavior of infancy and the rudimentary socialized behavior of latency. 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. Rather, toddlers think primarily on the basis of their perception of an event. Problem solving is based on what they see or hear directly rather than on what they recall about objects and events (Box 11-1).
Box 11-1 C h a r a c t e r i s t i c s o f P r e o p e r a t i o n a l T h o u g h t Egocentrism: Inability to envision situations from perspectives other than one's own
Example: If a person is positioned between the toddler and another child, the toddler (who is facing the person) will explain that both children can see the middle person's face. The young child is unable to realize that the other person views the middle person from a different perspective, the back.
Implication: Avoid moralizing about “why” something is wrong if it requires an understanding of someone else's feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because, to the aggressor, it feels good to hit someone else. Instead, emphasize that hitting is not allowed.
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Transductive reasoning: Reasoning from the particular to the particular
Example: Child refuses to eat a food because something previously eaten did not taste good.
Implication: Accept child's reasoning; offer refused food at different time.
Global organization: Reasoning that changing any one part of the whole changes the entire whole
Example: Child refuses to sleep in his or her room because location of bed has changed.
Implication: Accept child's reasoning; use same bed position or introduce change slowly.
Centration: Focusing on one aspect rather than considering all possible alternatives
Example: Child refuses to eat a food because of its color even though its taste and smell are acceptable.
Implication: Accept child's reasoning.
Animism: Attributing lifelike qualities to inanimate objects
Example: Child scolds stairs for making child fall down.
Implication: Join child in the “scolding.” Keep frightening objects out of view.
Irreversibility: Inability to undo or reverse the actions initiated physically
Example: When told to stop doing something (such as talking), child is unable to think of a positive activity.
Implication: State requests or instructions positively (e.g., “Be quiet.”).
Magical thinking: Believing that thoughts are all-powerful and can cause events
Examples: Child wishes someone died; then if the person dies, child feels at fault because of the “bad” thought that made the death happen. Calling children “bad” because they did something wrong makes them feel as if they are bad.
Implication: Clarify that thoughts do not make things happen and
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that child is not responsible.
• Use “I” messages rather than “you” messages to communicate thoughts, feelings, expectations, or beliefs without imposing blame or criticism. Emphasize that the act, not the child, is bad.
Inability to conserve: Inability to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass (instead, children judge what they see by the immediate perceptual clues given to them)
Example: If two lines of equal length are presented in such a way that one appears longer than the other, child will state that one line is longer even if child measures both lines with a ruler or yardstick and finds that each has the same length.
Implication: Change the most obvious perceptual clue to reorient child's view of what is seen.
• Give medicine in a small medicine cup, rather than a large cup, because the child will imagine that the large vessel contains more liquid. If child refuses the medicine in the small cup, pour it into a large cup because the liquid will appear to be less in a tall, wide container.
• Give a large, flat cookie rather than a thick, small one or do the reverse with meat or cheese; child will usually eat larger size of favorite food and smaller size of less favorite food.
Within the second year, the child increasingly uses language symbolically and is concerned with the “why” and “how” of things. For example, a pencil is “something to write with,” and food is “something to eat.” However, such mental symbolization is closely associated with prelogical reasoning. For instance, a needle is “something that hurts.” Such painful experiences take on new significance because memory is associated with the specific event, and fears are likely to develop, such as resistance to people who wear uniform scrubs or rooms that look like the practitioner's office. Because of the vulnerability of these early years, it is essential to prepare children for any new experience, whether it is a new babysitter or a visit to the dentist.
Spiritual Development Spiritual development in children is often discussed in terms of the child's developmental level because the evolution of spirituality often parallels cognitive development (Mueller, 2010). The child's family and environment strongly influence the child's perception of the world around him or her, and this often includes spirituality. Furthermore, family values, beliefs, customs, and expressions of these influence the child's perception of his or her spiritual self (Mueller, 2010). Neuman (2011) proposes that Fowler's (1981) stages of faith be used to better understand children and spirituality; she provides an excellent overview of the stages of faith in childhood. The relationship between spirituality, illness in childhood, and nursing has been studied in the context of suffering, terminal illness such as cancer, and end-of-life care. In the past decade, there has been an increased interest in and focus on spiritual care in adults and children as further understanding
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of the influence of one's spirituality on health, illness, and well-being has progressed. Toddlers learn about God through the words and the actions of those closest to them. They have
only a vague idea of God and religious teachings because of their immature cognitive processes; however, if God is spoken about with reverence, young children associate God with something special. During this period, the assignment of powerful religious symbols and images is strongly influenced by the manner in which it is presented, usually in the form of rituals, games and songs (Mueller, 2010). Toddlers are said to be in the intuitive-projective phase of Fowler's (1981) faith construct wherein thinking is largely based on fantasy and rather fluid in relation to reality and fantasy. God may be described as being around like air by the toddler because of the fluidity in dividing fantasy and reality (Neuman, 2011).
Toddlers begin to assimilate behaviors associated with the divine (folding hands in prayer). Routines such as saying prayers before meals or at bedtime can be important and comforting. Because toddlers tend to find solace in ritualistic behavior and routines, they incorporate routines associated with religious practices into their behavioral patterns without understanding all of the implications of the rituals until later. Near the end of toddlerhood, when children use preoperational thought, there is some advancement of their understanding of God. Religious teachings, such as reward or fear of punishment (heaven or hell) and moral development (see Chapter 3), may influence their behavior.
Development of Body Image As in infancy, the development of body image closely parallels cognitive development. With increasing motor ability, toddlers recognize the usefulness of body parts and gradually learn their respective names. They also learn that certain parts of the body have various meanings; for example, during toilet training, the genitalia become significant, and cleanliness is emphasized. By 2 years old, toddlers recognize gender differences and refer to themselves by name and then by pronoun. Gender identity is developed by 3 years old. Also by this time, children begin to remember events with reference to their personal significance, forming an autobiographic memory that helps to establish a continuous identity throughout life's events.
Once they begin preoperational thought, toddlers can use symbols to represent objects, but their thinking may lead to inaccuracies. For example, if someone who is pregnant is called “fat,” they will describe all “fat” women as having babies. They begin to recognize words used to describe physical appearance, such as “pretty,” “handsome,” or “big boy.” Such expressions eventually influence how children view their own bodies.
It is evident that body integrity is poorly understood and that intrusive experiences are threatening. For example, toddlers forcefully resist procedures such as examining their ears or mouths and having their axillary temperature taken. The procedure itself (e.g., taking vital signs) does not hurt the child, but it represents an intrusion into the child's personal space, which elicits a strong protest. Toddlers also have unclear body boundaries and may associate nonviable parts, such as feces, with essential body parts. This can be seen in a toddler who is upset by flushing the toilet and watching the stool disappear.
Nurses can assist parents in fostering a positive body image in their child by encouraging them to avoid negative labels, such as “skinny arms” or “chubby legs;” such self-perceptions are internalized and can last a lifetime. Body parts, especially those related to elimination and reproduction, should be called by their correct names. Respect for the body should be practiced.
Development of Gender Identity Just as toddlers explore their environment, they also explore their bodies and find that touching certain body parts is pleasurable. Genital fondling (masturbation) can occur and involves manual stimulation, as well as posturing movements (especially in young girls) such as tightening of the thighs or mechanical pressure applied to the pubic or suprapubic area. Other demonstrations of pleasurable activities include rocking, swinging, and hugging people and toys. Parental reactions to toddlers' behavior influence the children's own attitudes and should be accepting rather than critical. If such acts are performed in public, parents should not condone or bring attention to the behavior but should teach the child that it is more acceptable to perform the behavior in private.
Children in this age group are learning vocabulary associated with anatomy, elimination, and reproduction. Certain associations between words and functions become significant and can
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influence future sexual attitudes. For example, if parents refer to the genitalia as dirty, especially in the context of elimination, this association between “genitalia” and “dirty” may be transferred to sexual functions later in life. Sex-role differences become obvious to children and are evident in much of toddlers' imitative play. Although current research indicates that prenatal exposure to testosterone strongly influences the individual's gender identity, researchers also indicate that there are sensitive periods (e.g., puberty) that may also have an influence on the development of gender identity (Berenbaum and Beltz, 2011; Hines, 2011; Savic, Garcia-Falqueras, and Swaab, 2010). A sense of maleness or femaleness, or gender identity, begins by 24 months old when children are able to label their own and other's gender (Steensma, Kreukels, de Vries, et al, 2013). Early attitudes are formed about affectionate behaviors between adults from observing parental and other adult intimate or sensual activities. (See also Sex Education, Chapters 12 and 14.) The quality of relationships with parents is important to the child's capacity for sexual and emotional relationships later in life.
Social Development A major task of the toddler period is differentiation of the self from significant others, usually the mother. The differentiation process consists of two phases: separation, the children's emergence from a symbiotic fusion with the mother; and individuation, those achievements that mark children's expression of their individual characteristics in the environment. Although the process begins during the latter half of infancy, the major achievements occur during the toddler years.
Toddlers have an increased understanding and awareness of object permanence and some ability to withstand delayed gratification and tolerate moderate frustration. As a result, toddlers react differently to strangers than do infants. The appearance of unfamiliar people does not represent such a significant threat to their attachment to their mothers. They have learned from experience that parents exist when physically absent. Repetition of events such as going to bed without the parents but waking to find them there again reinforces the reliability of such brief separations. Consequently, toddlers are able to venture away from their parents for brief periods because of the security of knowing that the parents will be there when they return. Verbal and visual reassurance from the parents gradually replaces some of the previous need to be physically close for comfort.
The separation-individuation phase of the toddler encompasses the phenomenon of rapprochement; as a toddler separates from the mother and begins to make sense of experiences in the environment, the child is drawn back to the mother for assistance in identifying the meaning of the experiences (Meissner, 2009). Developmentally, the term rapprochement means the child moves away and returns for reassurance. If the mother's response to the toddler is inappropriate, the toddler may experience insecurity and confusion.
Transitional objects, such as a favorite blanket or toy, provide security for children, especially when they are separated from their parents, dealing with a new stress, or just fatigued (Fig. 11-2). Security objects often become so important to toddlers that they refuse to let them be taken away. Such behavior is normal; there is no need to discourage this tendency. During separations, such as daycare, hospitalization, or even staying overnight with a relative, transitional objects should be provided to minimize any fear or loneliness.
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FIG 11-2 Transitional objects, such as a warm and fuzzy stuffed animal, are sources of security to a toddler. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
Learning to tolerate and master brief periods of separation are important developmental tasks for children in this age group. In addition, it is a necessary component of parenting because brief periods of separation allow parents to restore their energy and patience and to minimize directing their irritations and frustrations at the children.
Language Development The most striking characteristic of language development during early childhood is the increasing level of comprehension. Although the number of words acquired—from about 4 at 1 year old to approximately 300 at 2 years old—is notable, the ability to understand speech is much greater than the number of words the child can say. Bilingual children can also achieve their early linguistic milestones in each of the languages at the same time and produce a substantial number of semantically corresponding words in each of their two languages from the very first words or signs.
At 1 year old, children use one-word sentences or holophrases. The word “up” can mean “pick me up” or “look up there.” For children, the one word conveys the meaning of a sentence, but to others, it may mean many things or nothing. At this age, about 25% of the vocalizations are intelligible. By 2 years old, children use multiword sentences by stringing together two or three words, such as the phrases “mama go bye-bye” or “all gone,” and approximately 65% of the speech is understandable. By 3 years old, children put words together into simple sentences, begin to master grammatical rules, know his or her age and gender, and can count three objects correctly (Feigelman, 2016). Reading books together during this period provides an ideal setting for further language development. Researchers have evaluated the impact of television viewing on toddler language development and found that those who started watching television at younger than 12 months old and who watched longer than 2 hours per day had a sixfold increase in the likelihood of language delays (Christakis, 2010). Adult–child conversations with infants and toddlers have been shown to positively affect language development; the researchers recommend reading, storytelling, and interactive adult–child communication (Zimmerman, Gilkerson, Richards, et al, 2009). The American Academy of Pediatrics, Council on Communications and Media (2011) reaffirms that televised or recorded media usage by children younger than 2 years old decreases language skills as well as the time parents interact with the child. Furthermore, educational programs have not been shown to increase cognitive skills in young children.
Gestures precede or accompany each of the language milestones up to 30 months old (putting
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phone to ear, pointing). After sufficient language development, gestures phase out, and the pace of word learning increases.
Personal-Social Behavior One of the most dramatic aspects of development in the toddler is personal-social interaction. Personal-social behaviors are evident in such areas as dressing, feeding, playing, and establishing self-control. Parents frequently wonder why their manageable, docile, lovable infant has turned into a determined, strong-willed, volatile little tyrant. In addition, the tyrant of the terrible twos can swiftly and unpredictably revert back to the adorable infant. All of this is part of growing up as toddlers acquire a more sophisticated awareness that others' feelings and desires can be different from their own. Through interactions with caregivers, children are able to explore these differences and their consequences.
Toddlers are developing skills of independence, which are evident in all areas of behavior. By 15 months old, children feed themselves, drink well from a covered cup, and manage a spoon with considerable spilling. By 2 years old, they use a spoon well; and by 3 years old, they may be using a fork. Between 2 and 3 years old, they eat with the family and like to help with chores such as setting the table or removing dishes from the dishwasher, but they lack table manners and may find it difficult to sit through the family's entire meal.
In dressing, toddlers also demonstrate strides in independence. The 15-month-old child helps by putting their arms or feet out for dressing and pulls off their shoes and socks. The 18-month-old child removes gloves, helps with pullover shirts, and may be able to unzip. By 2 years old, toddlers remove most articles of clothing and put on socks, shoes, and pants without regard for right or left and back or front. Help is still needed to fasten clothes.
Toddlers also begin to develop concern for the feelings of others and develop an understanding of how adult expectations for behavior apply to specific situations (e.g., causing a sibling to cry while playing rough). As their understanding increases, they develop control. Age-appropriate discipline contributes to healthy social and emotional development. Positive reinforcement, redirection, and time-outs are appropriate for most toddlers. Social and emotional problems can develop in the youngest children. Early screening and intervention promote more positive outcomes as young children grow and develop.
Play Play magnifies toddlers' physical and psychosocial development. Interaction with people becomes increasingly important. The solitary play of infancy progresses to parallel play; toddlers play alongside, not with, other children. Although sensorimotor play is still prominent, there is much less emphasis on the exclusive use of one sensory modality. The toddler inspects toys, talks to toys, tests toys' strength and durability, and invents several uses for toys.
Imitation is one of the most distinguishing characteristics of play and enriches children's opportunity to engage in fantasy. With less emphasis on gender-stereotyped toys, play objects such as dolls, carriages, dollhouses, dishes, cooking utensils, child-size furniture, trucks, and dress-up clothes are suitable for both genders (Fig. 11-3); however, boys may be more interested than girls in activities related to trucks, trailers, action figures, and building blocks; girls may prefer doll-related activities.
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FIG 11-3 Young children enjoy dressing up. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
Increased locomotive skills make push–pull toys, straddle trucks or cycles, a small gym and slide, balls of various sizes, and riding toys appropriate for energetic toddlers. Finger paints, thick crayons, chalk, blackboard, paper, and puzzles with large, simple pieces use toddlers' developing fine motor skills. Interlocking blocks in various sizes (but large enough to avoid aspiration) and shapes provide hours of fun and, during later years, are useful objects for creative and imaginative play. The most educational toy is the one that fosters the interaction of an adult with a child in supportive, unconditional play. Parents and other providers are encouraged to allow children to play with a variety of toys that foster creative thinking (such as blocks, dolls, and clay), rather than passive toys that the child observes (battery-operated or mechanical). Active play time should be encouraged over the use of computer or video games. Toys should not be substitutes for the attention of devoted caregivers, but toys can enhance these interactions.
Certain aspects of play are related to emerging linguistic abilities. Talking is a form of play for toddlers, who enjoy musical toys such as “talking” dolls and animals, and toy telephones. Children's television programs are appropriate for some children over 2 years old, who learn to associate words with visual images. However, total media time should be limited to 1 hour or less of quality programming per day. Parents are encouraged to allow the child to engage in unstructured playtime, which is considered much more beneficial than any electronic media exposure (American Academy of Pediatrics, Council on Communications and Media, 2011). Toddlers also enjoy “reading” stories from a picture book and imitating the sounds of animals.
Tactile play is also important for exploring toddlers. Water toys, a sandbox with a pail and shovel, finger paints, soap bubbles, and clay provide excellent opportunities for creative and manipulative recreation. Adults sometimes forget the fascination of feeling textures, such as slippery cream, mud, or pudding; catching air bubbles; squeezing and reshaping clay; or smearing paints. These types of unstructured activities are as important as educational play to allow children the freedom of expression.
Selection of appropriate toys must involve safety factors, especially in relation to size and sturdiness. The oral activity of toddlers puts them at risk for aspirating small objects and ingesting toxic substances. Parents need to be especially vigilant of toys played with in other children's homes and toys of older siblings. Toys are a potential source of serious bodily damage to toddlers, who may have the physical strength to manipulate them but not the knowledge to appreciate their danger. Ride-on toys (i.e., tricycles, wagons, scooters) and early exploratory toys (i.e., blocks, stacking toys, building sets) were the most common type of toy causing injury to children younger than 5 years old (Abraham, Gaw, Chounthirath, et al, 2015). Government agencies do not inspect and police all toys on the market. Therefore, adults who purchase play equipment, supervise purchases, or allow children to use play equipment need to evaluate its safety, including toys that are gifts or those that are purchased by the children themselves. Adults should also be alert to notices of toys determined to be defective and recalled by the manufacturers. Parents and health care workers can obtain information on a variety of recalled products and can report potentially dangerous toys and child products to the US Consumer Product Safety Commission* or, in Canada, the Canadian Toy Testing Council.† Printable tips on toy safety are also available from Safe Kids
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Worldwide (http://www.safekids.org).
Coping with Concerns Related to Normal Growth and Development Table 11-1 summarizes the major features of growth and development for the age groups of 15, 18, 24, and 30 months.
TABLE 11-1 Growth and Development during the Toddler Years
Physical Gross Motor Fine Motor Sensory Language Socialization 15 Months Old Steady growth in height and weight Head circumference, 48 cm (19 inches) Weight, 11 kg (24 pounds) Height, 78.7 cm (31 inches)
Walks without help (usually since 13 months old) Creeps up stairs Kneels without support Cannot walk around corners or stop suddenly without losing balance without support Cannot throw ball without falling
Constantly casting objects to floor Builds tower of two cubes Holds two cubes in one hand Releases a pellet into narrow- necked bottle Scribbles spontaneously Uses cup well but often rotates spoon before it reaches mouth
Able to identify geometric forms; places round object into appropriate hole Binocular vision well developed Displays an intense and prolonged interest in pictures
Uses expressive jargon Says four to six words, including names “Asks” for objects by pointing Understands simple commands May shake head to denote “no” Uses “no” even while agreeing to the request Uses common gestures, such as putting cup to mouth when empty
Tolerates some separation from parent Less likely to fear strangers Beginning to imitate parents, such as cleaning house (sweeping, dusting), folding clothes May discard bottle Kisses and hugs parents; may kiss pictures in a book Expresses emotions; has temper tantrums
18 Months Old Physiologic anorexia from decreased growth needs Anterior fontanel closed Physiologically able to control sphincters
Runs clumsily; falls often Walks up stairs with one hand held Pulls and pushes toys Jumps in place with both feet Seats self on chair Throws ball overhand without falling
Builds tower of three or four cubes Release, prehension, and reach well developed Turns two or three pages in a book at a time In a drawing, makes stroke imitatively Manages spoon without rotation
Says 10 or more words Points to common object, such as a shoe or ball, and to two or three body parts Forms word combinations Forms gesture–word combinations (points while naming) Forms gesture–gesture combinations
Great imitator (domestic mimicry) Takes off gloves, socks, and shoes and unzips zippers Temper tantrums may be more evident Beginning awareness of ownership (“my toy”) May develop dependence on transitional objects, such as security blanket
24 Months Old Head circumference, 49 to 50 cm (19.5 to 20 inches) Chest circumference exceeds head circumference Lateral diameter of chest exceeds anteroposterior diameter Usual weight gain of 1.8 to 2.7 kg (4 to 6 pounds) per year Usual gain in height of 10 to 12.5 cm (4 to 5 inches) per year Adult height approximately double height at 2 years old Primary dentition of 16 teeth May demonstrate readiness for beginning daytime control of bowel and bladder
Goes up and down stairs alone with two feet on each step Runs fairly well, with wide stance Picks up object without falling Kicks ball forward without overbalancing
Builds tower of six or seven cubes Aligns two or more cubes like a train Turns pages of book one at a time In drawing, imitates vertical and circular strokes Turns doorknobs; unscrews lids
Accommodation well developed in geometric discrimination; able to insert square block into oblong space
Has a vocabulary of approximately 300 words Uses two- or three-word phrases Uses pronouns “I,” “me,” “you” Understands directional commands Gives first name; refers to self by name Verbalizes need for toileting, food, or drink Talks incessantly Able to remember and imitate arbitrary sequences of manual actions and gestures
Stage of parallel play Has sustained attention span Temper tantrums decreasing Pulls people to show them something Increased independence from parent Dresses self in simple clothing Develops visual recognition and verbal self-reference (“me big”) Develops awareness that feelings and desires of others may be different and begins to explore implications and consequences
30 Months Old Birth weight quadrupled Primary dentition (20 teeth) completed May have daytime bowel and bladder control
Jumps with both feet Jumps from chair or step Stands on one foot momentarily Takes a few steps on tiptoe
Builds tower of eight cubes Adds chimney to train of cubes Good hand–finger coordination; holds crayon with fingers rather than fist In drawing, imitates vertical and horizontal strokes; makes two or more strokes for cross; draws circles
Gives first and last name Refers to self by appropriate pronoun Uses plurals Names one color
Separates more easily from parent In play, helps put things away; can carry breakable objects; pushes with good steering Begins to notice gender differences; knows own gender May attend to toilet needs without help except for wiping Emotions expand to include pride, shame, guilt, embarrassment
Toilet Training One of the major tasks of toddlerhood is toilet training. Anticipatory guidance and clinical intervention for families surrounding toilet training should begin during routine well-child visits before the child's developmental readiness to toilet train. Preparation and education reveal and allay misconceptions; lead to the development of appropriate expectations; and 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. However, complex psychophysiologic factors are required for readiness. The child must be able to recognize the urge to let go and hold on and be able to communicate this sensation to the parent. In addition, some motivation is probably involved
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in the desire to please the parent by holding on rather than pleasing oneself by letting go. Cultural beliefs may also affect the age at which children demonstrate readiness (Feigelman, 2016).
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 (Rogers, 2013).
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, and (4) being dry for at least 2 hours during the day (Wu, 2010). According to some experts, physiologic and psychological readiness is not complete until 24 to 30 months old (Rogers, 2013); however, parents should begin preparing their children for toilet training earlier than 30 months old. By this time, children have mastered the majority of essential gross motor skills, can communicate intelligibly, are in less conflict with their parents in terms of self-assertion and negativism, and are aware of the ability to control the body and please their parents. There is no universal right age to begin toilet training or an absolute deadline to complete training. An important role for the nurse is to help parents identify the readiness signs in their children (see Nursing Care Guidelines box).* On average, girls are developmentally ready to begin toilet training before boys (Elder, 2016).
N u r s i n g C a r e G u i d e l i n e s Assessing Toilet Training Readiness
Physical Readiness
Voluntary control of anal and urethral sphincters, usually by 24 to 30 months old
Ability to stay dry for 2 hours; decreased number of wet diapers; waking dry from nap
Regular bowel movements
Gross motor skills of sitting, walking, and squatting
Fine motor skills to remove clothing
Mental Readiness
Recognizes urge to defecate or urinate
Verbal or nonverbal communicative skills to indicate when wet or has urge to defecate or urinate
Cognitive skills to imitate appropriate behavior and follow directions
Psychologic Readiness
Expresses willingness to please parent
Able to sit on toilet for 5 to 8 minutes without fussing or getting off
Curiosity about adults' or older sibling's toilet habits
Impatience with soiled or wet diapers; desire to be changed immediately
Parental Readiness
Recognizes child's level of readiness
Willing to invest the time required for toilet training
Absence of family stress or change, such as a divorce, moving, new sibling, or imminent vacation
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Nighttime bladder control normally takes several months to years after daytime training begins. This is because the sleep cycle needs to mature so that the child can awake in time to urinate. Feigelman (2016) indicates that bedwetting is normal in girls up to 4 years old and in boys up to 5 years old. Few children have night wetting episodes after daytime dryness is totally achieved; however, children who do not have nighttime dryness by 6 years old are likely to require intervention.
Bowel training is usually accomplished before bladder training because of its greater regularity and predictability. The sensation for defecation is stronger than that for urination and easier for children to recognize. A well-balanced diet that includes dietary fiber helps keep stool soft and supports the development and maintenance of regular bowel movements.
A number of techniques are helpful when initiating training, and cultural differences should be considered (see Cultural Considerations box). In the United States, some of the options recommended by practitioners include the Brazelton child-oriented approach, the American Academy of Pediatrics guidelines (which are similar to the Brazelton method), Dr. Spock's training method, and the intensive “toilet-training-in-a-day” (operant conditioning) approach by Azrin and Foxx (Wu, 2010). A systematic review by the Agency for Healthcare Research and Quality in 2006 concluded that the child-oriented method and the Azrin and Foxx methods were effective at toilet training healthy children (Kiddoo, 2012). The following discussion of toilet training methods includes suggestions from the child-oriented approach.
C u l t u r a l C o n s i d e r a t i o n s Toilet Training
Cultural practices influence the timing, method, and significance of toilet training. For many families in China, the timing is liberal, the method is distinct, and the significance is low. Children are diapered during infancy. Once they are walking, they wear loose pants with a long slit between the legs, and they eliminate on the ground. This practice may continue until the child is 5 years old. In cold weather, a piece of cloth, like a “curtain,” may be inserted. However, the Chinese have a concept that the buttocks are not susceptible to cold, so this is not a common practice.
Parents should begin the readiness phase of toilet training by teaching the child about how the body functions in relation to voiding and having a stool. Parents can talk about how adults and animals perform such functions on a routine basis. Toilet training should be as easy and simple as possible. Important considerations are the selection of the child's clothing and the potty chair or use of the toilet. A freestanding potty chair allows children a feeling of security (Fig. 11-4, A). Planting the feet firmly on the floor also facilitates defecation. Another option is a portable seat attached to the regular toilet, which may ease the transition from potty chair to regular toilet. Placing a small bench under the feet helps stabilize the child's position. It is probably best to keep the potty in the bathroom and to let the child observe the excreta being flushed down the toilet to associate these activities with usual practices. If a potty chair is not available, having the child sit facing the toilet tank provides added support (see Fig. 11-4, B). Practice sessions should be limited to 5 to 8 minutes, and a parent should stay with the child, practicing sanitary habits after every session. Children should be praised for cooperative behavior and successful evacuation. Dressing children in easily removed clothing; using training pants, “pull-on” diapers, or underwear; and encouraging imitation by watching others are other helpful suggestions.
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FIG 11-4 A, Children may begin toilet training sitting on a small potty chair. B, Sitting in reverse fashion on a regular toilet provides additional security to a young child. (A, ©2011 Photos.com, a division of Getty Images. All
rights reserved.)
When the child begins to experience regular daytime dryness, parents may experiment with underwear during the day. Daytime accidents are common, particularly during periods of intense activity. Young children become so engrossed in play activity that, if they are not reminded, they will wait until it is too late to reach the bathroom. Therefore, frequent reminders and trips to the toilet are necessary. Parents often forget to plan ahead when their toddlers are being toilet trained; before trips outside the house, it is important to remind children to at least try to urinate to decrease the chance of needing to use the toilet while the car is stuck in traffic.
As the child masters each step of toileting (discussion, undressing, going, wiping, dressing, flushing, and hand washing), he or she gains a sense of accomplishment that parents should reinforce. If the parent–child relationship becomes strained, both may need a break to focus on
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enjoyable activities together. Regression may coincide with a stressful family situation or the child being pushed too hard and too fast. Regression is a normal part of toilet training and does not mean failure but should be viewed as a temporary setback to a more comfortable place for the child.
Daycare providers also play a role in the support and education of parents regarding toilet training practices. It is important for parents to inform all caregivers of their individual family values and the child's specific needs when planning for training away from home. Ensuring consistency in care of toddlers and ensuring healthy practices in a sanitary environment allow for safe and effective toilet practices in all settings.
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—all at a time when they thought they were in control of their world. Sibling rivalry tends to be most pronounced in firstborn children, who experience dethronement (loss of sole parental attention). It also seems to be most difficult for young children, particularly in terms of mother– child interaction.
Preparation of children for the birth of a sibling is individual but is dictated to some extent by age. For toddlers, time is a vague concept. A good time to start talking about the baby is when toddlers become aware of the pregnancy and the changes taking place in the home in anticipation of the new member. To avoid additional stresses when the newborn arrives, parents should perform anticipated changes, such as moving the toddler to a different room or bed, well in advance of the birth.
Toddlers need to have a realistic idea of what the newborn will be like. Telling them that a new playmate will come home soon sets up unrealistic expectations. Rather, 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. If toddlers have had no contact with an infant, it is a good idea to introduce them to one, if feasible. 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.
When the new baby arrives, toddlers keenly feel the changed focus of attention. Visitors may initiate problems when they inadvertently shower the infant with attention and presents while neglecting the older child. Parents can minimize this by alerting visitors to the toddler's needs, having small presents on hand for the toddler, and including the child in the visit as much as possible. The toddler can also help with the care of the newborn by getting diapers and doing other small tasks (Fig. 11-5).
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FIG 11-5 To minimize sibling rivalry, parents should include the toddler during caregiving activities.
How children exhibit jealousy is complex. Some will hit the infant, push the child off the mother's lap, or pull the bottle or breast from the infant's mouth. For this reason, infants must be protected by parental supervision of the interaction between the siblings. More often the expressions of hostility and resentment are more subtle and covert. Toddlers may verbally express a wish that the infant “go back inside mommy,” or they will revert to more infantile forms of behavior, such as demanding a bottle, soiling their underpants, clinging for attention, using baby talk, or aggressively acting out toward others. The latter is particularly common in preschoolers, who may seem accepting of the new sibling at home but behave poorly in daycare or preschool. This is a form of displacement that says, “I can't let my parents know how I feel, so I will tell you.” Encouraging parents to explore how their older child is acting with other caregivers is an important aspect of intervention.
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. Although holding one's breath may cause fainting from the lack of oxygen, the accumulation of carbon dioxide will stimulate the respiratory control center, resulting in no physical harm. 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 figures or lack of motor and cognitive skills.
The best approach toward tapering temper tantrums requires consistency and developmentally appropriate expectations and rewards. Ensuring consistency among all caregivers in expectations, prioritizing what rules are important, and developing consequences that are reasonable for the child's level of development help manage the behavior. 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.” Starting at 18 months old, time-outs work well for managing temper tantrums.
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 (Luangrath, 2011): • Offer the child options instead of an “all or none” position.
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• 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 (Daniels, Mandleco, and Luthy, 2012). Nurses should be alert to situations that require further evaluation.
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. When confronted with appropriate choices, such as “You may have a peanut butter and jelly sandwich or chicken noodle soup for lunch,” they are more likely to choose one rather than automatically say no. However, if their response is negative, parents should make the choice for the child.
Nurses working with children and parents can assist parents in understanding this concept by role modeling. For example, when the nurse approaches the toddler for taking vital signs, instead of asking, “Can I listen to your heart?” the nurse can say, “I am going to listen to your heart.” Because of normal developmental behavior, toddlers first resist having their vital signs taken because it is an intrusion on their bodies. Second, toddlers are most likely going to answer “no,” not because they necessarily fear the procedure itself but because of the tendency to answer all questions with a negative response. If the nurse asks the question and the toddler says, “No” but the nurse proceeds anyway, the toddler starts to mistrust the nurse's actions because they contradict his or her words.
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 when one attempts to conserve psychic energy by reverting to patterns of behavior that were successful in earlier stages of development. 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.
At first, such regression appears acceptable and comfortable for children, but the loss of newly acquired achievements is frightening and threatening because children are aware of their helplessness. Parents become concerned about regressive behavior and frequently force the child to cope with an additional source of stress—the pressure to live up to expected standards. Brazelton (1999) suggests that these predictable times of regression, or touchpoints, are an opportunity to prepare parents for the next step in their child's development.
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 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.
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Promoting Optimal Health during Toddlerhood Nutrition During the period from 12 to 18 months old, the growth rate slows, decreasing the child's need for calories, protein, and fluid. However, the protein (13 g/day) and energy requirements are still relatively high to meet the demands for muscle tissue growth and high activity level. The need for minerals (such as iron, calcium, and phosphorus) may be difficult to meet, considering the characteristic food habits of children in this age group. Parents may be tempted to rely on vitamin supplementation, rather than a well-balanced diet, to meet these requirements. Toddlers usually require three meals and two snacks per day; however, the portions consumed are generally smaller compared with those of older children.
The 2008 Feeding Infants and Toddlers Study (FITS) (Butte, Fox, Briefel, et al, 2010) found that, in general, toddlers met or exceeded the requirements for daily energy and protein requirements. However, intake of a variety of foods was seen with advancing age in toddlers as their food preferences changed. FITS recommended that toddlers be fed a more balanced diet of vegetables, fruits, and whole grains.
At approximately 18 months old, most toddlers manifest this decreased nutritional need with a decreased appetite, a phenomenon known as physiologic anorexia. They become picky, fussy eaters with strong taste preferences. They may eat large amounts one day and almost nothing the next. Toddlers are increasingly aware of the nonnutritive function of food (i.e., the pleasure of eating, the social aspect of mealtime, and the control of refusing food). They are influenced by factors other than taste when choosing food. If a family member refuses to eat something, toddlers are likely to imitate that response. If the plate is overfilled, they are likely to push it away, overwhelmed by its size. If food does not appear or smell appetizing, they will probably not agree to try it. In essence, mealtime is more closely associated with psychological components than with nutritional ones. Toddlers like to eat with their fingers and enjoy foods of different colors and shapes.
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. Mixed foods, such as stews or casseroles, are rarely favorites. Because toddlers have unpredictable table manners, it is best to use plastic dishes and cups for both economic and safety reasons. For some children, a regular mealtime schedule also contributes to their desire and need for predictability and ritualism.
Developmentally by 12 months old, most children eat many of the same foods prepared for the rest of the family. Some may have mastered using a cup with occasional spilling, although most cannot use a spoon until 18 months old or later and generally prefer using their fingers.
Nutritional Counseling The emphasis on preventing childhood obesity and subsequent cardiovascular disease in the United States has prompted a number of changes in dietary recommendations for children and adults alike. It is now recognized that lifetime eating habits may be established in early childhood, and health care workers are increasingly emphasizing the role of food selection choices, exercise, stress reduction, and other lifestyle choices (tobacco and alcohol use) on the quality of adult life and survival. Conditions such as obesity and cardiovascular disease can be prevented by encouraging healthy eating habits in toddlers and their families.
If food is used as a reward or sign of approval, a child may overeat for nonnutritive reasons. If food is forced and mealtime is consistently unpleasant, the usual pleasure associated with eating may not develop. Mealtimes should be enjoyable rather than times for discipline or family arguments. The social aspect of mealtime may be distracting for young children; therefore, an earlier feeding hour may be appropriate. Young children are unable to sit through a long meal and become restless and disruptive. This is particularly common when children are brought to the table just after active play. Calling them in from play 15 minutes before mealtime allows them ample opportunity to get ready for eating while settling down their active minds and bodies.
The method of serving food also takes on more importance during this period. Toddlers need to have a sense of control and achievement in their abilities. Giving them large, adult-size portions can
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overwhelm them. In general, what is eaten is much more significant than how much is consumed. Toddlers usually restrict their food preference to four or five main foods and rarely try new foods; in some cases, a toddler may insist on one food such as mashed potatoes for lunch and dinner. Small amounts of meat and vegetables supply greater food value than a large consumption of bread or potato. Serving sizes need to be appropriate for age. Young children tend to like less spicy, bland food, although this is a culturally determined preference. Substitutions can be provided for foods that they do not enjoy, although parents need not cater to all of their desires. Frequent nutritious snacks can replace a meal. Grazing (i.e., nibbling and snacking) is a good way to ensure proper nutrition, provided that appropriate foods are offered.
To determine serving size for young children, use the following guidelines: • A general guide to serving sizes for toddlers is 1 tablespoon of solid food per year of age, or one
fourth to one third of the adult portion size. • Use the tablespoon guide for easily measured foods, such as vegetables or rice. • Use the fraction guide for bread or milk.
Mastication skills continue to mature, putting children at risk for choking; therefore, large round foods (e.g., hot dogs, grapes, peas, carrots, popcorn, and fruit gel snacks) should be avoided until the child is able to chew them effectively. Active play while eating should be discouraged to prevent choking. Appetite and food preferences are sporadic. Often the interest in food parallels a growth spurt; thus periods of good eating are interspersed with phases of poor eating. If exposed to the same food every day, a young toddler does not learn how to manage the complex sensory information needed to eat new, more difficult foods (e.g., vegetables with a different texture vs. pureed, slippery fruits). To help prevent “food jags,” it is recommended that parents present food in various physical forms. The child may need to progress to eating new foods in a stepwise fashion such as visually tolerating the food, interacting with the food, smelling the food, touching the food, tasting the food, and then eating the food.
Many authorities consider this period of picky eating to be a developmental phase and growth charts can be used to demonstrate growth to parents who are often concerned (Parks, Shaikhkhalil, Groleau, et al, 2016). Parents should be encouraged to plan a nutritionally balanced week instead of day because of the way toddlers restrict food intake in their effort to exert control over their environment (Schwartz and Benuck, 2013).
Dietary Guidelines Dietary guidelines are necessary to promote adequate energy and nutrient intake to support physical, emotional, psychological, and cognitive development. A number of new dietary guidelines have been developed to address the issue of childhood obesity, sedentary lifestyles, and increase in cardiovascular disease mortality in the United States.
The Institute of Medicine (2005) has developed guidelines for nutritional intake that encompass the Recommended Dietary Allowances (RDAs) yet extend their scope to include additional parameters related to nutritional intake. The Dietary Reference Intakes (DRIs)* are composed of four categories. These include Estimated Average Requirements (EARs) for age and gender categories, tolerable upper-limit (UL) nutrient intakes that are associated with a low risk of adverse effects, Adequate Intakes (AIs) of nutrients, and new standard RDAs. The guidelines present information about lifestyle factors that may affect nutrient function, such as caffeine intake and exercise, and about how the nutrient may be related to chronic disease. An important factor in the development of the DRIs that affects children, particularly infants from birth to 6 months old, is that the AIs are based on the nutrient intake of full-term, healthy, breastfed infants (by well-nourished mothers), which now represents the gold standard for infant nutrition in this age group. In 2010, new DRIs for vitamin D and calcium were released by the Institute of Medicine.
The 2010 Dietary Guidelines for Americans may also be used to encourage healthy dietary intakes and regular exercise designed to decrease obesity, cardiovascular risk factors, and subsequent cardiovascular disease, which is now known to occur in both young children and adults. The 2010 Dietary Guidelines recommend a caloric intake for a moderately active boy, ages 2 to 3 years, of 1000 to 1400 calories per day. The emphasis in the Dietary Guidelines is in decreasing overall fat and sodium intakes and increasing the amount of daily exercise to reduce the incidence of obesity and cardiovascular disease. The 2010 Dietary Guidelines* are for children ages 2 years and older. They encourage a variety of fruits, vegetables, whole grains, and low-fat dairy and
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nonfat dairy products in addition to fish, beans, and lean meat. Additional resources for dietary counseling include MyPlate†, developed by the US Department
of Agriculture to replace MyPyramid. This colorful plate shows the five main food groups (i.e., fruits, grains, vegetable, protein, and dairy) with the intended purpose to involve children and their families in making appropriate food choices for meals and decrease the incidence of overweight and obesity in the United States. MyPlate provides an online interactive feature that allows the individual to select (click on) an individual food group and see choices for foods in that group. Approximate serving sizes are suggested, and vegetarian substitutions are also provided.
Nutrition during toddlerhood involves a transition as a young toddler is weaned off milk- or formula-based diets. Milk intake, the chief source of calcium and phosphorus, should average two or three servings (24 to 30 oz) a day. Consuming more than a quart of milk daily considerably limits the intake of solid foods, resulting in a deficiency of dietary iron and other nutrients. After 2 years of age, children can be given low-fat milk to reduce daily total fat to less than 30% of calories, saturated fatty acids to less than 10% of calories, and cholesterol to less than 300 mg. Other measures to reduce dietary fat include using lean meats, fat-modified products (e.g., low-fat cheese), and low-fat cooking. Because less fat in children's diets can also mean fewer calories and nutrients, caregivers must know what kinds of food to choose. However, trans fatty acids and saturated fats should be avoided.
Iron-fortified cereals and iron-rich foods are recommended for all children older than 6 months of age. Parents should be encouraged to provide an iron-rich diet that includes heme and nonheme iron sources (red meats, poultry, fish, green leafy vegetables, dried fruit, and beans) and limit whole-milk consumption. Iron supplementation may be necessary in some cases. Calcium and vitamin D are essential for healthy bone development. Adequate intake of calcium for children 1 to 3 years old is 500 mg per day. Whole milk, cheese, yogurt, legumes (beans), and vegetables (broccoli, collard greens, and kale) are good sources for calcium. Popular calcium-fortified foods include waffles, cereals and cereal bars, orange juice, and some white breads. Adequate vitamin D intake is essential to prevent rickets; it is now recommended that children and adolescents have an intake of at least 400 IU of vitamin D daily (Institute of Medicine, 2010). Multivitamin preparations containing 400 IU of vitamin D (by tablet or liquid) are adequate if food intake is poor or exposure to sunlight is minimal; vitamin D–only preparations containing 400 IU are also available commercially. Sources of vitamin D include fish, fish oils, and egg yolks. Fortified cereals, dairy products, and meat are also good sources of zinc and vitamin E.
It is also recommended that toddlers have 1 cup of fruit each day. Vitamin C enhances iron absorption. Toddlers should consume approximately 4 to 6 ounces of juice per day. It tastes good to toddlers and is readily available. A 6-ounce glass of fruit juice equals one fruit serving; however, juices lack the fiber of whole fruit and should not be a substitution for whole fruit. High intake of juice can contribute to diarrhea, overnutrition or undernutrition, and the development of caries; thus, only 4 to 6 ounces of 100% fruit juice per day is recommended for toddlers (American Academy of Pediatrics, Committee on Nutrition, 2014). Fruit-flavored drinks advertised as juices may not actually contain 100% juice and should be avoided.
Vegetarian Diets Vegetarian diets have become increasingly popular in the United States because people are concerned about hypertension; cholesterol; obesity; cardiovascular disease; cancer of the stomach, intestine, and colon; and the influence of the animal rights movement. The American Dietetic Association issued a statement endorsing vegetarian diets for adults and children (Craig, Mangels, and American Dietetic Association, 2009); the statement further notes that well-planned vegetarian diets are adequate for all stages of the life cycle and promote normal growth. Children and adolescents on vegetarian diets have the potential for lifelong healthy diets and have been shown to have lower intakes of cholesterol, saturated fat, and total fat and higher intakes of fruits, fiber, and vegetables than non-vegetarians (Craig, Mangels, and American Dietetic Association, 2009).
The major types of vegetarianism are:
Lacto-ovo vegetarians, who exclude meat from their diet but consume dairy products and rarely fish
Lactovegetarians, who exclude meat and eggs but drink milk
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Pure vegetarians (vegans), who eliminate all foods of animal origin, including milk and eggs
Macrobiotics, who are even more restrictive than pure vegetarians, allowing only a few types of fruits, vegetables, and legumes
Semi-vegetarians, who consume a lacto-ovo vegetarian diet with some fish and poultry: This is an increasingly popular form of vegetarianism and poses little or no nutritional risk to infants unless dietary fat and cholesterol intake is severely restricted.
Many individuals who are concerned about healthy diets subscribe to vegetarian diets that may not be typified by the above categories. Therefore, during nutritional assessment, it is necessary to clearly list exactly what the diet includes and excludes.*
The major deficiencies that may occur in the stricter vegan diets are inadequate protein for growth; inadequate calories for energy and growth; poor digestibility of many of the bulky natural, unprocessed foods, especially for infants; and deficiencies of vitamin B6, niacin, riboflavin, vitamin D, iron, calcium, and zinc. Vitamin D is essential if exposure to sunlight is inadequate (≈5 to 15 min/day on the hands, arms, and face of light-skinned persons; slightly more in darker pigmented individuals) or in persons who are dark skinned or who live in northern latitudes or cloudy or smoky areas. Many of these deficiencies can be avoided in children who are not consuming 100% of the RDA of vitamins and minerals with a multivitamin and mineral supplement.
Evaluate for iron-deficiency anemia and rickets in children on strict vegetarian and macrobiotic diets; this may occur as a result of consuming plant foods such as unrefined cereals, which impair the absorption of iron, calcium, and zinc. The American Academy of Pediatrics, Committee on Nutrition (2014) recommend iron supplementation of 1 mg/kg/day in infants exclusively breastfed after 4 to 6 months old by vegetarian mothers and no dietary fat restrictions in vegetarian children younger than 2 years old. Other factors that affect iron absorption are listed in Box 11-2.
Box 11-2 F a c t o r s t h a t A f f e c t I r o n A b s o r p t i o n Increase
Acidity (low pH): Administer iron between meals (gastric hydrochloric acid).
Ascorbic acid (vitamin C): Administer iron with juice, fruit, or multivitamin preparation.
Vitamin A
Tissue (cellular) need
Meat, fish, poultry
Cooking in cast iron pots
Decrease
Alkalinity (high pH): Avoid any antacid preparation.
Phosphates: Milk is unfavorable vehicle for iron administration.
Phytates—found in cereals
Oxalates—found in many fruits and vegetables (plums, currants, green beans, spinach, sweet potatoes, tomatoes)
Tannins—found in tea, coffee
Tissue (cellular) saturation
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Malabsorptive disorders
Disturbances that cause diarrhea or steatorrhea
Infection
Achieving a nutritionally adequate vegetarian diet is not difficult (except with the strictest diets), but it requires careful planning and knowledge of nutrient sources (American Academy of Pediatrics, Committee on Nutrition, 2014). For children, the lacto-ovo vegetarian diet is nutritionally adequate; however, the vegan diet requires supplementation with vitamins D and B12 for children 2 to 12 years old.
To ensure sufficient protein in the diet, foods with incomplete proteins (those that do not have all the essential amino acids) must be eaten at the same meal with other foods that supply the missing amino acids. The three basic combinations of foods consumed by vegetarians that generally provide the appropriate amounts of essential amino acids are:
1. Grains (cereal, rice, pasta) and legumes (beans, peas, lentils, peanuts)
2. Grains and milk products (milk, cheese, yogurt)
3. Seeds (sesame, sunflower) and legumes
Additional dietary considerations for young children are found in Chapter 12.
Complementary and Alternative Medicine There are four complementary and alternative medicine (CAM) domains according to the National Center for Complementary and Integrative Health; this discussion centers only on one of those— biologically based practices, which include herbs, vitamins, and foods. The National Center for Complementary and Integrative Health (2014) classifies probiotics as a type of natural product and CAM. Many CAM products are sold over the counter as dietary supplements, but the use of some dietary supplements such as calcium for bone health or a multivitamin supplement are not considered to be CAM (National Center for Complementary and Integrative Health, 2014). The National Center for Complementary and Integrative Health (2014) reports that natural products are the most commonly used CAM products in children and most often these products are used for chronic conditions (such as, neck and back pain) and for head and chest colds. Other surveys confirm that CAM is often used for children's chronic remedies for which traditional therapy is not effective (Huillet, Erdie-Lalena, Norvell, et al, 2011).
The misuse of vitamins as a part of CAM has the potential for placing some children at risk for health problems. Zuzak, Zuzak-Siegrist, Rist, et al, (2010) noted that of persons reportedly using CAM, the most common CAM remedies used in children seen in an emergency department were homeopathy (77%), herbs (64%), and traditional Chinese medicine (13%). A survey in a Women, Infants, and Children clinic found that child herbal use was common, especially among Hispanic children attending the clinic. Some herbs used by the children (ma huang, foxglove, anise tea, and mistletoe) have questionable safety (Kemper and Gardiner, 2016). A recent study of CAM use in children on a military base found that 23% of parents reported using CAM in their children, with herbal therapy being the most common type of CAM reported; 50% of the parents who used CAM for their children reported the use of vitamins and minerals in amounts that exceeded the RDA (Huillet, Erdie-Lalena, Norvell, et al, 2011).
There is concern that terms often used to market supplements (such as, megavitamins) may mislead parents regarding the actual benefits (or harm) of such therapies. The intention herein is not to discredit the use of CAM such as vitamin supplements but rather to ensure safety and efficacy in children who may experience inadvertent harm. The use of various herbal therapies, or intake of herbs, is also becoming more popular; many of these have been a part of medicine since early days and are beneficial in some cases. Many mind–body CAM therapies (e.g., guided imagery, distraction) have proved beneficial for children undergoing cancer treatment, but the small sample sizes of the groups being studied may preclude generalization to a larger population group until further studies are undertaken (Landier and Tse, 2010).
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Herbs known to have adverse effects in children include ephedra, comfrey, and pennyroyal; some herbs may not be harmful taken alone but may counteract or potentiate prescription medications when taken together. Parents should be fully informed of the use of herbs to ensure that there is more benefit than potential harm in the ingredients being used. Health care workers also need to be knowledgeable of the benefits or potential harm in herbs to appropriately counsel parents and address their concerns. Little research has been performed in children on many over- the-counter herbal medicines, yet some herbs are known to cause harm in children (Kemper and Gardiner, 2016). Parents should be cautioned not to exceed the upper limits of vitamin intake according to the new DRIs.*
Sleep and Activity Total sleep decreases only slightly during the second year and averages about 11 to 12 hours a day. Most children take one nap a day but may relinquish this habit by the end of the second or third year.
Toddlers are more prone to having bedtime resistance (refusal to go to bed) and frequent night waking. Fears can be provoked by a child's daily stressors, such as pressure to toilet train, moves, sibling birth, experiences of loss, or separation from parents. A recent study found that a consistent nightly bedtime routine is associated with better sleep patterns, such as shorter sleep onset latency, decreased waking, longer total sleep, and decreased daytime behavior problems (Mindell, Li, Sadeh, et al, 2015). In addition, providing transitional objects, such as a favorite stuffed animal or blanket, can ease the child's insecurity at bedtime (see Fig. 11-2). Children may need a light snack before bedtime; a heavy meal immediately before bedtime may interfere with sleep. Other suggestions to help small children sleep better include keeping the television out of the child's room, making the hour before bedtime a quiet time of reading stories, and avoiding stimulating activities, such as computer games and roughhousing (Owens, 2016). Toddlers no longer sleeping in a crib may come out of their rooms after being put to bed. Limit prolonged bedtime rituals by defining a length of time and set of activities (one more story, one more drink). Toddlers who are too immature to respond to the measures identified may need their doorways gated.
A toddler's activity level is high, and there is rarely a problem with too little physical exercise, provided inappropriate restrictions are not instituted. Recently, however, there has been concern that decreased time spent in actual physical play and more time involved with computers and television watching have increased the tendency toward being overweight. This is especially true in large urban centers during the winter months where there may not be adequate “safe” play and physical exercise space. With increasing numbers of young children being cared for outside the home, attention to the kinds of activity provided is important. For example, children with high activity levels may benefit from an environment that encourages vigorous play whether outside or in a large indoor play area.
Dental Health Regular Dental Examinations The American Academy of Pediatric Dentistry (2014a) recommends that every child have an oral health examination by a practitioner by 6 months old; if the child is in a high-risk category for caries, it is recommended that an initial visit to a dentist or pedodontist (pediatric dentist) occur by 6 months old or within 6 months of the eruption of the first tooth. Every child should have an established dental home by 12 months old (American Academy of Pediatric Dentistry, 2014a). Initial visits to the dentist should be nontraumatizing. Because toddlers react negatively to new and potentially frightening experiences, the initial visit can center around meeting the dentist, seeing the equipment, and sitting in the chair. If the child is cooperative, the dentist may just look at the teeth but reserve a more thorough examination for another visit. Modeling, in which the child observes procedures performed on the parent or a cooperative sibling, can also be effective but may not work on all toddlers.
Plaque Removal Oral hygiene measures should be implemented in toddlers to remove plaque, soft bacterial deposits that adhere to the teeth and cause dental caries (decay or cavities) and periodontal (gum) disease.
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Poor oral hygiene and poor dietary habits are associated with the development of caries in children. The most effective methods for plaque removal are brushing and flossing. Several brushing
techniques exist, although there is no universal agreement regarding the best method. One that is suitable for cleaning the primary teeth is the scrub method. The tips of the bristles are placed firmly at a 45-degree angle against the teeth and gums and moved back and forth in a vibratory motion. The ends of the bristles should be wiggling but not moving forcefully back and forth, which can damage the gums and enamel. All the surfaces of the teeth are cleaned in this manner except the lingual (inner) surfaces of the anterior teeth. To clean these surfaces, the toothbrush is placed vertical to the teeth and moved up and down. Only a few teeth are brushed at one time, using six to eight strokes for each section. A systematic approach is used so that all surfaces are thoroughly cleaned (Fig. 11-6).
FIG 11-6 Young children can participate in tooth brushing, but parents need to brush all of the child's teeth thoroughly. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
For young children, the most effective cleaning is done by parents (Fig. 11-7). Several positions can be used that facilitate access to the mouth and help stabilize the head for comfort: • Stand with the child's back toward the adult. (When done in front of a bathroom mirror, both the
child and the adult can see what is being done in the mirror.) • Sit on a couch or bed with the child's head resting in the adult's lap. • Sit on the floor or a stool with the child's head resting between the adult's thighs.
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FIG 11-7 The most effective cleaning of teeth is done by parents.
Use one hand to cup the chin and one to brush the teeth. For easier access to back teeth, hold the mouth partially open. After brushing with a fluoridated paste or gel, avoid rinsing the mouth to maximize the beneficial effects of the fluoride.
N u r s i n g T i p • To encourage children to open their mouths, ask them to “tweet like a bird” or to say “cheese” to
brush the front teeth, and to “roar like a lion” to brush the back teeth.
• Sing, tell stories, or talk to children during teeth cleaning to prevent boredom.
For effective cleaning, a small toothbrush with soft, rounded, multi-tufted nylon bristles that are short and uniform in length is recommended. Nylon bristles dry more rapidly after use and retain their shape better than natural bristles. Toothbrushes are replaced as soon as the bristles are frayed or bent. With young children, brushing may be more easily accomplished using only water because many children dislike the foam from toothpaste, and the foam interferes with visibility. Use a “smear” or “rice-size” amount of toothpaste for children younger than 3 years old (apply across the narrow width of the toothbrush, rather than along its length, to decrease the chance of applying an excessive amount); and a “pea-size” of toothpaste should be used in children 3 to 6 years old (American Academy of Pediatric Dentistry, 2014b).
After the teeth have been cleaned, the teeth are flossed to remove plaque and debris from between the teeth and below the gum margin, where brushing is ineffective. Because young children do not have the dexterity to manipulate dental floss, parents must perform the procedure.
Ideally, the teeth should be cleaned after each meal and especially before bedtime, and the child should be given nothing to eat or drink after the night brushing except water. At times when brushing is impractical, the “swish-and-swallow” method of cleaning the mouth is taught; with a mouthful of water the child rinses the mouth and swallows, repeating the procedure three or four times.*
Fluoride Fluoride supplementation should be considered for any child. Fluoride, a mineral, is found in water, foods, or drinks in which fluoridated water was used as part of the processing system. Because the water fluoridation process and manufacturing of fluoride toothpaste are almost impossible to standardize in the United States, the dosage of fluoride supplements should be determined in consultation with a medical professional (American Academy of Pediatric Dentistry,
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2014b). Increased fluoride ingestion leads to enamel protein retention, hypomineralization of the enamel and dentin, and disturbance of crystal formation. The effects caused by this change range from barely discernible white fiberlike lines or spots to gray-brown stains or pitted areas. Parents should be cautioned against regular use of fluoridated water or beverages such as bottled water containing fluoride if the community water supply already has an adequate amount of fluoride. Topical fluoride treatments (e.g., fluoride varnish) performed in the dental home is also effective in decreasing caries (American Academy of Pediatric Dentistry, 2014c).
Dietary Factors Diet is critical to developing good teeth because the carious process depends primarily on fermentable sugars, especially sucrose, and other carbohydrates. Refined table sugar, honey, molasses, corn syrup, and dried fruits (such as raisins) are highly cariogenic. Complex carbohydrates, such as breads, potatoes, and pasta, also contribute to caries because they lower the plaque pH. Beverages that are commonly consumed by children and adolescents and snacks are also highly cariogenic and may contribute to the incidence of overweight and obesity (American Academy of Pediatric Dentistry, 2014d).
Ideally, highly cariogenic foods, especially those containing complex sugars, should be eliminated. However, because this is impractical, some suggestions can be helpful. First, the frequency with which sugar is consumed is more important than the total amount eaten. Therefore, when sweets are eaten, they are less damaging if consumed immediately after a meal rather than as a snack between meals. When sweets are served as the dessert, the teeth can be cleaned afterward, decreasing the amount of time the sugar is in the mouth.
Second, the form of sugar (sucrose) is important. The more cariogenic foods are those that are sticky or hard because they remain in the mouth longer. Consequently, sucking on lollipops is more cariogenic than eating a chocolate bar. Sometimes the source of the sugar is “hidden,” as in numerous prescription and nonprescription drugs and in many popular cereals, including the “all- natural” variety. Reading food labels is essential in eliminating sources of sucrose.
Some snacks do not contribute to tooth decay. Aged cheeses, such as cheddar, may alter the pH and delay bacterial growth. Sugarless gum chewed after eating may actually protect against cavities by stimulating saliva that neutralizes acid.
A special form of tooth decay in children between 18 months and 3 years old is early childhood caries (ECC) (historically called nursing caries or baby bottle tooth decay) (Fig. 11-8). This often occurs when a child is routinely given a bottle of milk or juice at naptime or bedtime or uses the bottle as a pacifier while awake. Frequent nocturnal breastfeeding for prolonged periods also leads to extensive destruction of the teeth. The practice of coating pacifiers in honey can also contribute to caries and may be a potential source of botulism. As the sweet liquid pools in the mouth, the teeth are bathed for several hours in this cariogenic environment. Prolonged bottle feeding well into toddler years in some cultures may contribute to significant ECC (Brotanek, Schroer, Valentyn, et al, 2009). The maxillary (upper) incisors and molars are affected most because the mandibular (lower) incisors are protected by the lower lip, tongue, and saliva. Severely decayed teeth may require the application of stainless steel bands to preserve the spacing until the permanent teeth erupt.
FIG 11-8 Early childhood caries (ECC). (Courtesy of Bruce Carter, DDS, Texas Children's Hospital, Houston, TX.)
ECC is now considered to be an infectious disease of childhood. There is evidence that
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Streptococcus mutans is a highly cariogenic bacteria (American Academy of Pediatric Dentistry, 2014b). One of the early origins of S. mutans is the mother's saliva; infants of mothers with high counts of the bacteria have a greater incidence of ECC. Therefore, it is important to discuss oral hygiene with pregnant women because of its impact on their children's tooth development.
Prevention involves eliminating the bedtime bottle completely, feeding the last bottle before bedtime, substituting a bottle of water for milk or juice, not using the bottle as a pacifier, and never coating pacifiers in sweet substances. Juice in bottles, especially commercially available ready-to- use bottles, is discouraged; these beverages are especially damaging because the sugar is more readily converted to acid. Juice should always be offered in a cup to avoid prolonging the bottle- feeding habit. Toddlers should be encouraged to drink from a cup at the first birthday and weaned from a bottle by 14 months old. Nurses are in an excellent position to counsel parents regarding the dangers of this habit and other aspects of dental care.*
Safety Promotion and Injury Prevention Unintentional childhood injury was the leading cause of death among children 1 to 19 years old in 2009, accounting for 37% of all deaths in this age-group (Gilchrist, Ballesteros, Parker, 2012). Unintentional death rates among newborns and infants from suffocation nearly doubled from 2000 to 2009. Likewise, unintentional poisoning death rates doubled for adolescents 15 to 19 years old during the same time period (Gilchrist, Ballesteros, Parker, 2012). These deaths and injuries are preventable, and they highlight the need for public health action and education. There is evidence that one-on-one and face-to-face education as well as safety interventions and safety equipment are effective in reducing the number of unintentional childhood injuries that can have catastrophic results (Kendrick, Young, Mason-Jones, et al, 2012). A major factor in the critical increase of injuries during early childhood is the unrestricted freedom achieved through locomotion combined with an unawareness of danger within the environment. Toddlers delight in the repetitive use of gross motor skills, and with increasing age, these skills are refined. This age group is also very curious about how things work and exploration of previously unknown or unseen objects and places is common. Toddlers also have not fully developed or understand the cause-and-effect principles and often are unable to gauge danger; poorly developed depth perception may also contribute to falls and tumbles as does the general bodily structure of toddlers. Specific categories of injuries and appropriate prevention are best understood by associating them with the major growth and developmental achievements of this age (Table 11-2). The discussions of injuries in Chapters 10 and 13 are also relevant to safety concerns at this age.
TABLE 11-2 Injury Prevention during Early Childhood
Developmental Abilities Related to Risk of Injury Injury Prevention Motor Vehicles Walks, runs, and climbs Able to open doors and gates Can ride tricycle Can throw ball and other objects
Use federally approved car restraint per manufacturer's recommendations for weight and height. Supervise child while playing outside. Do not allow child to play on curb or behind a parked car. Do not permit child to play in pile of leaves, snow, or large cardboard container in trafficked area. Supervise tricycle riding; have child wear helmet. Limit playing in driveways with parked cars or provide physical barriers limiting access. Lock fences and doors if not directly supervising children. Teach child to obey pedestrian safety rules: • Obey traffic regulations; cross only at crosswalks and only when traffic signal indicates it is safe. • Stand back a step from the curb until it is time to cross. • Look left, right, and left again, and check for turning cars before crossing street. • Use sidewalks; when there is no sidewalk, walk on the left, facing traffic. • Wear light colors at night and attach fluorescent material to clothing.
Drowning Able to explore if left unsupervised Has great curiosity Helpless in water; unaware of its danger; depth of water has no significance
Supervise closely when near any source of water, including buckets. Never, under any circumstance, leave unsupervised in bathtub. Keep bathroom doors closed and lid down on toilet. Have fence around swimming pool and lock gate.*
Burns Able to reach heights by climbing, stretching, and standing on toes Pulls objects Explores any holes or opening Can open drawers and closets Unaware of potential sources of heat or fire Plays with mechanical objects
Turn pot handles toward back of stove. Place electric appliances, such as coffee maker and popcorn machine, toward back of counter. Place guardrails in front of radiators, fireplaces, and other heating elements. Store matches and cigarette lighters in locked or inaccessible area; discard carefully. Place burning candles, incense, hot foods, and cigarettes out of reach. Do not let tablecloth hang within child's reach. Do not let electric cord from iron or other appliance hang within child's reach. Cover electrical outlets with protective plastic caps. Keep electrical wires hidden or out of reach. Do not allow child to play with electrical appliance, wires, or lighters. Stress danger of open flames; teach what “hot” means. Always check bathwater temperature; adjust water heater temperature to 49° C (120° F) or lower; do not allow children to play with faucets. Apply a sunscreen when child is exposed to sunlight (all year round).
Accidental Poisoning Explores by putting objects in mouth Can open drawers, closets, and most containers
Place all potentially toxic agents, including cosmetics, personal care items, cleaning products, pesticides, and medications, out of reach or in a locked cabinet.
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Climbs Cannot read labels Does not know safe dose or amount
Caution against eating nonedible items, such as plants. Replace medications or poisons immediately in locked cabinet; replace child-guard caps promptly. Administer medications as a drug, not as a candy. Do not store large surplus of toxic agents. Promptly discard empty poison containers; never reuse to store a food item or other poison. Teach child not to play in trash containers. Never remove labels from containers of toxic substances. Know number of nearest poison control center: 800-222-1222.
Falls Able to open doors and some windows Goes up and down stairs Depth perception unrefined
Use window guards; do not rely on screens to stop falls. Place gates at top and bottom of stairs. Keep doors locked or use childproof doorknob covers at entry to stairs, high porch, or other elevated area, including laundry chute. Ensure safe and effective barriers on porches, balconies, decks. Remove unsecured or scatter rugs. Apply nonskid decals in bathtub or shower. Keep crib rails fully raised and mattress at lowest level. Place carpeting under crib and in bathroom. Keep large toys and bumper pads out of crib or play yard (child can use these as “stairs” to climb out) and then move to youth bed
when child is able to climb out of crib. Avoid using mobile walker, especially near stairs. Dress in safe clothing (soles that do not “catch” on floor, tied shoelaces, pant legs that do not touch floor). Keep child restrained in vehicle; never leave unattended in vehicle or shopping cart. Never leave child unattended in high chair. Supervise at playgrounds; select play areas with soft ground cover and safe equipment.
Choking and Suffocation Puts things in mouth May swallow hard or inedible pieces of food
Avoid large, round chunks of meat, such as whole hot dogs (slice lengthwise into short pieces). Avoid fruit with pits, fish with bones, hard candy, chewing gum, nuts, popcorn, grapes, and marshmallows. Choose large, sturdy toys without sharp edges or small removable parts. Discard old refrigerators, ovens, and so on, and remove the door. Install smoke and carbon monoxide alarms; change batteries every 6 months. Develop a fire escape plan for the entire family and have drills. Keep automatic garage door transmitter in an inaccessible place. Select safe toy boxes or chests without heavy, hinged lids. Keep venetian blind cords out of child's reach. Remove drawstrings from clothing; shorten essential drawstrings to 15.24 cm (6 inches) or less. Avoid contact with round, hollow, semirigid plastic items such as half of a plastic ball.
Bodily Injury Still clumsy in many skills Easily distracted from tasks Unaware of potential danger from strangers or other people
Avoid giving sharp or pointed objects (e.g., knives, scissors, or toothpicks) especially when walking or running. Do not allow lollipops or similar objects in mouth when walking or running. Teach safety precautions (e.g., to carry knife or scissors with pointed end away from face). Store all dangerous tools, garden equipment, and firearms in locked cabinet. Be alert to danger of unsupervised animals and household pets. Use safety glass on large glassed areas, such as sliding glass doors. Teach child name, address, and phone number and to ask for help from appropriate people (cashier, security guard, policeman) if
lost; have identification on child (sewn in clothes, inside shoe). Teach stranger safety: • Avoid personalized clothing in public places. • Never go with a stranger. • Tell parents if anyone makes child feel uncomfortable in any way. • Always listen to child's concerns regarding others' behavior. • Teach child to say “no” when confronted with uncomfortable situations.
*Detailed guidelines for swimming pool safety may be found at http://www.poolsafely.gov.
Motor Vehicle Safety Motor vehicle injuries cause more accidental deaths in all pediatric age groups after age 1 year than any other type of injury or disease and are responsible for a significant number of all accidental deaths among children 1 to 4 years old. Many of the deaths are caused by injuries within the car when restraints have not been used or have been used improperly. Unrestrained children riding in the vehicle's front seat are at highest risk for injury. Approved restraints properly installed and applied can reduce the majority of fatalities and injuries (Weaver, Brixey, Williams, et al, 2013).
Car Restraints Nurses are responsible for educating parents regarding the importance of car restraints and their proper use. Five types of restraints are available: (1) infant-only devices, (2) convertible models for both infants and toddlers, (3) booster seats, (4) safety belts, and (5) devices for children with special needs (see Chapter 17). Chapter 9 discusses the infant-type restraints; convertible restraints and boosters are included here. Convertible restraints are suitable for infants and toddlers in the rearward-facing position (Fig. 11-9). The American Academy of Pediatrics (2015) and National Highway Traffic Safety Administration now recommend that children up to 2 years old ride in rear- facing car safety seat until the child has outgrown the manufacturer's weight and height recommendation (Durbin and Committee on Injury, Violence, Poison Prevention, 2011). Many rear- facing car safety seats can accommodate children weighing up to a maximum of 35 pounds (according to the manufacturer's specifications).* Studies indicate that toddlers up to 24 months old are safer riding in convertible seats in the rear-facing position (American Academy of Pediatrics, 2015). Another study indicated that children 0 to 3 years old riding properly restrained in the middle of the backseat had a 43% lower risk of injury than children riding in the outboard (window) seat during a crash (Kallan, Durbin, and Arbogast, 2008).
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FIG 11-9 Rear-facing convertible car seat.
Convertible restraints use different types of harness systems: a five-point harness that consists of a strap over each shoulder, one on each side of the pelvis, and one between the legs (all five come together at a common buckle), as well as a padded overhead shield that uses shoulder straps attached to a shield that is held in place by a crotch strap. With both infant and toddler restraints, it is important not to add extra blankets, head cushions, or padding between the child and the restraint straps that did not come as original equipment because these “add-ons” create spaces of air between the child and the restraint and decrease support for the back, head, and neck. Cars with free-sliding latch plates on the lap or shoulder belt require the use of a metal locking clip to keep the belt in a tight-holding position. The locking clip is threaded onto the belt above the latch plate (Fig. 11-10, A). If parents have newer cars with automatic lap and shoulder belts, they need to have additional lap belts installed to properly secure the restraint.
FIG 11-10 A, Locking clip used with free-sliding lap or shoulder belt to keep the belt in a tight-holding position. B, Automobile booster seat. Note placement of the shoulder strap (away from the neck and
face).
Booster seats are not restraint systems like the convertible devices, because they depend on the vehicle belts to hold the child and booster seat in place. Three booster models have been approved by the National Highway Traffic Safety Administration: the high-back belt-positioning seat (see Fig. 11-10, B), which provides head and neck support for the child riding in a vehicle seat without a head rest; the no-back belt-positioning seat, which should be used only if the vehicle seat has a head rest; and a combination seat, which converts from a forward-facing toddler seat to a booster seat. This last model is equipped with a harness for use by toddlers; the harness may be removed and a shoulder-lap belt used when the child outgrows the harness. The belt-positioning booster seats are used for children who are less than 145 cm (4 feet, 9 inches) tall and who weigh 15.9 kg to 36.3 kg (35 to 80 pounds, depending on the type of booster seat). In general, school-aged children should ride in a belt-positioning booster seat until approximately 7 to 8 years old. Note, however, that because children's sizes vary considerably, manufacturer's recommendations should be followed regarding height and weight limitations. A booster seat should be used until the child is able to sit
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against the back of the seat with feet hanging down and legs bent at the knees. The belt-positioning booster model raises a child higher in the seat, moving the shoulder part of the belt off the neck and the lap portion of the belt off the abdomen onto the pelvis. Children who outgrow the convertible restraint may still be able to ride safely in a booster seat until the midpoint of the head is higher than the vehicle seat back.
Children should use specially designed car restraints until they are 145 cm (4 feet, 9 inches) in height and is between 8 to 12 years old (American Academy of Pediatrics, 2015). Shoulder-lap safety belts should be worn low on the hips, snug, and not on the abdominal area. Children should be taught to sit up straight to allow for proper fit. The shoulder belt is used only if it does not cross the child's neck or face.
Shoulder-only automatic belts are designed to protect adults. Children should use the manual shoulder belts in the rear seat. Air bags do not take the place of child safety seats or seat belts and can be lethal to young children. The safest area of the car for children is the back seat. Children who must ride in the passenger side of the front seat with an air bag should be positioned as far back as possible or have the air bag disabled.
For any restraint to be effective, it must be used consistently and properly. Examples of misuse include misrouting the vehicle seat belt through the restraint; failing to use the vehicle seat belt to secure the restraint; failing to use a tether strap; failing to use the restraint's harness system; and incorrectly positioning the child, especially by facing infants forward instead of rearward. To address these issues, nurses must stress correct use of car restraints and rules that ensure compliance (see Family-Centered Care box). Children riding in car safety seats are generally much better behaved than children left unrestrained, which can be a major benefit to parents and should be emphasized as an additional advantage of restraints.
The LATCH (lower anchors and tethers for children) universal child safety seat system was implemented as a requirement starting in 2002 for all new automobiles and child safety seats. This system provides uniform anchorage consisting of two lower anchorages and one upper anchorage in the rear seat of the vehicle (Fig. 11-11). When used appropriately, the top anchor (tether) strap prevents the child from pitching forward in a crash. If the tether strap is not used, up to 90% of the restraint's protection is lost. Instructions for proper installation of the tether strap and permanent bracket are included with the car restraint. New child safety seats will have a hook, buckle, strap, or other connector that attaches to the anchorage. Seat belts will no longer be used to anchor child safety seats to newer vehicles. After fall 2002, all new cars were required to have the entire LATCH system.
F a m i l y - C e n t e r e d C a r e Using Car Safety Restraints
• Read manufacturer's directions and follow them exactly.
• Provide favorite toy, stuffed animal, or snack for child while in car seat.
• Anchor car safety seat securely to car's anchoring system and apply harness snugly to child.*
• Do not start the car until everyone is properly restrained.
• Always use the restraint even for short trips.
• If child begins to climb out or undo the harness, firmly say, “No.” It may be necessary to stop the car to reinforce the expected behavior. Use rewards, such as stars or stickers, to encourage cooperation.
• Encourage child to help attach buckles, straps, and shields but always double-check fastenings.
• Decrease boredom on long trips. Keep soft toys in the car for quiet play, talk to child, and point out objects and teach child about them. Stop periodically. If child wishes to sleep, make certain he or she stays in the restraint.
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• Insist that others who transport children also follow these safety rules.
*A free car seat restraint inspection may be obtained from a SafeKids inspector. Check for local inspection SafeKids clinics or access website for information: http://www.safekids.org.
FIG 11-11 LATCH (lower anchors and tethers for children) universal child safety seat system. A, Flexible two-point attachment with top tether. B, Rigid two-point attachment with top tether. C, Top tether. (Courtesy
of US Department of Transportation, National Highway Traffic Safety Administration.)
Children with disabilities may require a restraint system that secures them appropriately in the event of a crash. Examples of such devices include car bed restraints for infants who cannot tolerate a semireclining position and specially adapted molded-plastic chairs for children who have spica casts. The E-Z-On vest is a special safety harness for larger children with poor trunk control. A HIPPO (Spica Cast) car seat is available for transporting children with spica casts; these are sold only in the United States. Additional safety restraints and a listing of distributors are available at the SafetyBeltSafe U.S.A. website.* See also Chapter 8 for a discussion of preterm infants being discharged home and car seat evaluation.
Children should not ride in the open back of a truck. The danger of falls can be compounded by another vehicle striking the child or by the truck rolling over. In addition, leaving children unsupervised in a parked vehicle provides an opportunity for a child to release the brake or put the car in gear.
Motor Vehicle–Related Injuries Toddlers are often involved in pedestrian traffic injuries. Because of their gross motor skills of walking, running, and climbing and their fine motor skills of opening doors and fence gates, they are likely to be in hazardous areas when unsupervised. Unaware of danger and unable to approximate the speed of cars, they are hit by moving vehicles. Running after a ball, riding a tricycle, and playing behind a parked car are common activities that may result in a vehicular tragedy.
Toddlers playing in driveways or farmyards are at risk of back-over injury from vehicles in reverse gear. A precaution when children are playing in driveways is attaching a pole to the tricycle with a bright flag that is high enough to be visible through an automobile's back window. Another safeguard is the use of a device that beeps when the vehicle is driven in reverse to alert children to the oncoming car, van, tractor, or truck. Many vehicles now include a rearview motion camera so
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that the driver can see the driveway clearly while backing out. Physical barriers (fences or barricades) limiting children from playing near vehicles help prevent these injuries.
One type of injury that has become more commonplace occurs when children crawl into an open trunk and pull it closed. Asphyxia may occur in such cases; therefore, car trunks should not be left open when children are not being supervised. Some cars are equipped with a safety switch that can be activated from inside the trunk to open a closed trunk door.
Another automobile-related hazard for toddlers is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>27° C [80° F]). Small children dissipate heat poorly, and an increase in body temperature can cause death in a few hours. Since 1998, a total of 661 children died from hyperthermia when left alone in parked cars; in 2014, the total number of child deaths was 41, and it is estimated that an average of 37 children die each year from overheating in cars (Null, 2015). It is estimated that with the ambient temperature at 22° to 35.5° C (72° to 96° F), the vehicle interior temperature rises by 10.5° to 11° C (19° to 20° F) for each 10 minutes even with a window cracked (Duzinski, Barczyk, Wheeler, et al, 2014). Approximately 50% of adults who left a child in a car either forgot or were unaware that the child was still in the car (Duzinski, Barczyk, Wheeler, et al, 2014). Parents are cautioned against leaving infants alone in a vehicle for any reason.
Preventing vehicular injuries involves protecting and educating children about the danger of moving and parked vehicles. Although preschool children are too young to be trusted to always obey, parents should emphasize looking for moving vehicles before crossing the street, recognizing the stop and go colors of traffic lights, and following traffic officers' signals. Physical barriers limiting children from playing near vehicles help prevent these injuries. Most important, what is preached must be practiced. Children learn through imitation, and consistency reinforces learning.
Drowning The highest rate of drowning in the years 2000 to 2006 was in children 0 to 4 years old; children 12 to 36 months old were at highest risk for drowning during the same time period (Weiss and American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, 2010). Drowning deaths in infants occur most commonly in the bathtub and large buckets. With well- developed skills of locomotion, toddlers are able to reach potentially dangerous areas, such as bathtubs, toilets, buckets, swimming pools, hot tubs, and ponds or lakes. Toddlers' intense drive for exploration and investigation combined with an unawareness of the danger of water and their helplessness in water makes drowning always a viable threat. It is also one category of injury that results in death within minutes, diminishing the chance for rescue and survival. Close adult supervision of children when near any source of water is essential; many drownings in this age group occur when a supervising adult becomes distracted. Teaching swimming and water safety can be helpful but cannot be regarded as sufficient protection. Pool fencing, although critical, does not always deter fast-moving children.
Burns Toddlers' ability to climb, stretch, and reach objects above their heads makes any hot surface a potential source of danger. Children pulling pots with hot liquids, especially oil and grease, on top of themselves are a major source of burns. As a precaution, turn pot handles toward the back of the stove, and electric pots including cords should be placed out of reach.
Other sources of heat, such as radiators, fireplaces, accessible furnaces, kerosene heaters, and wood-burning stoves, should have guards placed in front of them. Portable electric heaters must be placed in a high area, well out of reach of climbing young children. Hair curling irons and hot curlers may also be easily reached and can burn the hands of curious toddlers.
Hot objects such as candles, incense, cigarettes, pots of tea or coffee, and irons must be placed away from children. Flame burns represent one of the most fatal types of burns and commonly occur when children play with matches and accidentally set themselves (and the home) on fire. To prevent flame burns, matches and lighters must be stored safely away from children, and parents need to teach children the dangers of playing with such objects. In addition, all homes should have smoke detectors installed to alert the occupants of a fire. A safety plan for immediate escape is also essential.
Electrical burns represent an immediate danger to children. Young toddlers may explore outlets with conductive articles and wires by mouthing them. Because water is an excellent conductor, the chance for a severe circumoral electrical burn is great. Electrical outlets should have protective
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guards plugged into them when not in use (Fig. 11-12) or be made inaccessible by having furniture placed in front of them when feasible. Children should not be allowed to play with electrical cords, appliances, or batteries.
FIG 11-12 Special plastic caps in electrical sockets prevent young fingers from exploring dangerous areas. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
Scald burns are the most common type of thermal injury in children. A scalding burn is often caused by high-temperature tap water, which children come in contact with as a result of turning on the hot-water faucet, falling into a bathtub of hot water, pulling hot pots onto themselves, or suffering deliberate abuse. Limiting household water temperatures to less than 49° C (120° F) is highly recommended. At this temperature, it takes 10 minutes of exposure to the water to cause a full-thickness burn. Conversely, water temperatures of 54° C (130° F), the usual setting of most water heaters, expose household members to the risk of full-thickness burns within 30 seconds. Nurses can help prevent such burns by advising parents of this common household danger and recommending that they readjust their water heaters to a safe temperature (see burns, Chapter 13).
Sunburns are a year-round concern in certain regions. Children spend a large amount of time outdoors, and their increased mobility makes it difficult to prevent sun exposure. Sunburn can be prevented by applying a sunscreen with a sun protection factor (SPF) of 15 or greater, dressing in protective clothing (wide-brimmed hat, protective cotton clothing with a tight weave), and avoiding sun exposure between 10 AM and 2 PM.
Accidental Poisoning Toddlers are at the highest risk for accidental poisoning because of the innate curiosity and ability to open “childproof” containers. Mouthing activity continues to be prevalent after 1 year old, and exploring objects by tasting them is part of children's curious investigation. Toddlers' curiosity and inability to understand logical consequences further place them at risk for ingesting harmful substances. Many household products, medications, and plants can be poisonous if swallowed, if they come in contact with the skin or eyes, or if they are inhaled. Although in many instances poisoning does not result in death, it may cause significant morbidity, such as esophageal stricture from lye ingestion. Toddlers are able to climb most heights, open most drawers or closets, and unscrew most lids. By trial and error, younger children also manage to undo tops of bottles, plastic containers, aerosol cans, and jars, including those with child-resistant lids. Newer forms of drugs, such as transdermal patches and cough-suppressant lozenges, have created additional dangers because they are not packaged with safety caps and the lozenges look like candy.
The major reason for poisoning is improper storage (Fig. 11-13). The guidelines suggested in Chapter 13 apply to children in this age group as well. However, unlike infants, who are confined to certain heights and unable to unlatch child-proof locks, young children manage to find access to many high-level, tight-security places. For this age group, only a locked cabinet is safe.
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FIG 11-13 Children are most likely to ingest substances that are on their level, such as household cleaning agents stored under sinks; rat poison; or plants.
Recent attention has focused on the use of over-the-counter medications used for cough and colds as a common cause of accidental poisonous ingestion in toddlers. Ingestion of acetaminophen is also a common cause of morbidity because it is found in many combination over-the-counter products; caregivers may unknowingly administer a dose of acetaminophen in addition to an over- the-counter drug containing the product without knowing the danger.
Emergency and preventive measures for accidental poisoning are discussed in Chapter 13. Parents should have ready access to the telephone number for the poison control center (National Poison Center, 800-222-1222) and be prepared to act on the advice of the center.
Falls Falls are still a hazard to children in this age group, although by the later part of early childhood, gross and fine motor skills are well developed, decreasing the incidence of falls down stairs and from chairs. However, playground injuries are common. Children need to learn safety at play areas, such as no horseplay on high slides or jungle gyms, sitting on swings, and staying away from moving swings. Passive prevention includes placement of grass, sand, or wood chips under play equipment. Swing seats should be made of plastic, canvas, or rubber and have smooth or rounded edges. Slides should have inclines of no more than 30 degrees, and have evenly spaced rungs for climbing.
The climbing and running of the typical toddler are complicated by the child's total disregard and lack of appreciation for danger, immature coordination, and a high center of gravity. Gates must be placed at both ends of stairs. Accessible windows must have window guards, not screens, to prevent falls to the ground below. Falling from furniture is a major cause of injury, with more children in this age-group sustaining head injuries than older children. Doors leading to stairwells or porches must be locked. A convenient type of lock is a sliding bar or hook that can be attached to the door and frame at a level higher than the child can reach.
Cribs and vehicles are other sources of falls. To avoid injury, crib rails should be fully raised, the mattress should be kept at the lowest position, and toys or bumper pads that may be used as steps to climb out should be removed. Ideally, the floor under the crib should be carpeted or have a throw rug. Crib, bassinets, and play yards were associated with a large number (66% of all fall injuries to children) of accidental falls (Yeh, Rochette, McKenzie, et al, 2011). The manufacture and sale of drop-side cribs has been banned by the Consumer Product Safety Commission (2010). When children reach a height of 89 cm (35 inches), they should sleep in a bed rather than a crib. If a bunk bed is selected, parents should be aware of possible dangers, including falls from the top bed and from the ladder and head entrapment between the mattress and guardrail or between the supporting mattress slats.
Children can fall from high chairs, shopping carts, carriages, car seats, and strollers if not properly restrained or if balance changes by placing heavy objects. Therefore, proper restraint and adequate supervision are essential. Children, especially older infants who are mobile, should not be
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placed in an infant seat on top of a shopping cart because the infant seat may fall off the cart; the safest place for an infant seat is inside the cart's bed.
Aspiration and Suffocation Suffocation death rates among infants younger than 1 year old have dramatically increased in the last decade (Gilchrist, Ballesteros, and Parker, 2012). Suffocation deaths usually occur in this age- group by wedging between a wall and mattress or crib side or collapse of a play yard wall (Theurer and Bhavsar, 2013).
Usually by 1 year old, children chew well, but they may have difficulty with large pieces of food, such as meat and whole hot dogs, and with hard foods, such as nuts. Young children cannot discard pits from fruit or bones from fish. Gel snacks that are sealed in plastic wrappers can be difficult to manage, and the plastic wrapper can be aspirated. Therefore, parents must implement the same precautions as discussed for infants regarding food selection (see Chapter 9).
Play objects for toddlers must still be chosen with an awareness of danger from small parts. Large, sturdy toys without sharp edges or removable parts are safest. Balloons, coins, paper clips, pins, bells, button batteries, pull-tabs on cans, thumbtacks, nails, screws, jewelry (especially pierced earrings), and all types of pins are common household objects that can cause significant harm if swallowed or aspirated. Because of the danger of aspiration, parents should be taught emergency procedures for choking.
Suffocation from causes seen during infancy is less frequent, but old refrigerators, car trunks, ovens, and other large appliances are an ever-present threat. Toddlers can climb inside these appliances and, if they close the door behind them, can be trapped inside. Removing all doors before discarding or storing old appliances prevents such tragic deaths. Toddlers may also suffocate when toy boxes with heavy, hinged lids accidentally close on their heads or necks. Advise parents of this danger and encourage them to buy storage chests with lightweight, removable covers.
Bodily Harm Toddlers are still clumsy in many of their skills and can seriously harm themselves when walking while holding a sharp or pointed object or having food or objects (such as spoons) in their mouths. Preventing such occurrences is the best approach with toddlers. The child should be taught that when walking with a pointed object such as a knife or scissors, the pointed end is held away from the face. Dangerous garden or workshop equipment and all firearms should be stored in locked cabinets. Power lawn mowers and weed eaters are especially dangerous because they can throw rocks and other solid items (projectiles), and young children should not be allowed in an area where such tools are in use; nor should they be taken for a ride on a mower or allowed to operate the device.
Toddlers are often unable to understand that all pets are not as safe as their own; because of the toddlers' height, they are often at the eye level of some dogs and may be bitten on the face. It is imperative to teach pet safety to toddlers and keep animals at a safe distance.
Safety education should include respect for firearms and their appropriate use, including nonpowder guns, such as air guns, rifles (BB and pellet), and paintball guns, which can cause serious penetrating injuries. Firearm safety devices (such as trigger locks, gun safes, and personalized locks) should be used to prevent unintentional firing of guns and subsequent injuries or fatalities.
An additional safeguard for young children is the use of safety glass in doors, windows, and tabletops and the application of decals on glass doors and windows to reduce the likelihood of running through glass. Also, children should not be allowed to run, jump, wrestle, or play ball near glass structures.
Anticipatory Guidance—Care of Families 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. Prevention yields better results than treatment. Anticipatory guidance is paramount if one wishes to prevent future problems (see Family-Centered Care box).
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F a m i l y - C e n t e r e d C a r e Guidance during the Toddler Years
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), and procrastination behaviors that delay hour of sleep.
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.
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!
Point out some of the expected changes of the next year, such as longer attention span, somewhat less negativism, and increased concern for pleasing others.
24 to 36 Months Old
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Discuss importance of imitation and domestic mimicry 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.
Stress that discipline still must be structured and concrete and that relying solely on verbal reasoning and explanation leads to injuries, confusion, and misunderstanding.
Discuss investigation of preschool or daycare center toward completion of second year.
Advice is sometimes not the sole answer. Actual assistance, such as being available for home visiting or telephone consulting, should be part of the nurse's flexible repertoire of interventions. Whether parents are experiencing the dilemmas of rearing a first or a subsequent child, they benefit from sharing their feelings, frustrations, and satisfactions. They need adult companionship, freedom from childrearing responsibilities, and periodic separations from their children. Part of a nurse's responsibility is to provide opportunities for parents to express their feelings and to meet their physical, mental, and spiritual needs.
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NCLEX Review Questions 1. The typical play activity in which toddlers engage is called:
a. Solitary b. Parallel c. Associative d. Cooperative
2. One indication that the toddler is ready to begin toilet training is: a. Child recognizes urge to let go and hold on and is able to communicate this sensation to the
parent b. Child is able to stay dry all night c. Child demonstrates mastery of dressing and undressing self d. Child asks parent to have wet or soiled diaper changed
3. A mother brings her 3-year-old daughter to the well-child clinic and expresses concern that the child's behavior is worrisome and possibly requires therapy or medication at minimum. The mother further explains that the child constantly responds to the mother's simple requests with a “no” answer even though the activity has been a favorite in the recent past. Furthermore, the child has had an increase in the number of temper tantrums at bedtime and refuses to go to bed. The mother is afraid her daughter will hurt herself during a temper tantrum because she holds her breath until the mother picks her up and gives in to her request. The nurse's best response to the mother is that: a. The child probably would benefit from some counseling with a trained therapist. b. The mother and father should evaluate their childrearing practices. c. The child's behavior is normal for a toddler and may represent frustration with control of her
emotions; further exploration of events surrounding temper tantrums and possible interventions should be explored.
d. The child's behavior is typical of toddlers, and the parents should just wait for the child to finish this phase because this will end soon as well.
4. Toddlers are often known to be finicky eaters and may exhibit abnormal eating patterns that may concern parents. Which of the following actions for feeding toddlers should be suggested so that adequate amounts of nutrients for growth and development are consumed? Select all that apply. a. Avoid placing large food portions on the toddler's plate. b. Allow the child to graze on nutritious (not “junk” food) snacks during the day. c. Insist that the child sit at the table until all persons have completed their meals. d. Allow the child to make certain food choices (within reasonable limits)—for example, would
you like a half peanut butter or ham sandwich? e. Provide meals at the same time of day as much as possible so that the toddler has a sense of
consistency. f. Make the child eat all of the food provided, and provide disciplinary actions, such as a “time-
out” if the plate is not cleaned.
5. A common cause of accidental death in children 1 to 19 years old involves motor vehicle crashes. Evidence from test crashes indicates that the safest action to prevent accidental deaths in toddlers includes: a. Placing the child in a rear-facing weight-appropriate car restraint seat until 24 months old b. Allowing the child to ride in the front seat with a lap-shoulder seat restraint to avoid emotional
outbursts c. Allowing the child to ride in a forward-facing booster restraint seat after 12 months old d. Placing the child in the regular seat using the lap-shoulder belt as long as the child weighs at
least 45 pounds
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6. One of the primary reasons for monitoring the toddler's activities and intervening to prevent accidental injury is that: a. Toddlers have oppositional defiant behavior and negativism. b. Toddlers do not understand the concept of “cause and effect,” so explaining that certain actions
will result in serious injury is useless. c. Toddlers will often listen to reasoning about why an activity should be avoided. d. Toddlers enjoy making their parents worry about their safety and like to see the parents'
reactions to the behavior.
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Correct Answers 1. b; 2. a; 3. c; 4. a, b, d, e; 5. a
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*800-638-2772; http://www.cpsc.gov. †613-228-3155; http://www.toy-testing.org. *A helpful book is The American Academy of Pediatrics Guide to Toilet Training, 847-434-4000; http://shop.aap.org. *http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx.
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*http://www.cnpp.usda.gov/DietaryGuidelines.htm. †http://www.cnpp.usda.gov/MyPlate.htm. *Additional information regarding vegetarian diets may be found at the Vegetarian Resource Group; 410-366-8343; http://www.vrg.org. Another helpful resource is the KidsHealth website: http://kidshealth.org. *Helpful websites for health care and consumer information concerning herbs are National Center for Complementary and Integrative Health, https://nccih.nih.gov/; American Botanical Council, http://abc.herbalgram.org; and Herb Research Foundation, http://www.herbs.org. *More detailed information can be obtained from the American Academy of Pediatric Dentistry, http://www.aapd.org. *Sources of information about nursing caries and other aspects of child dental health include the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892-2190; 301-496-4261; http://www.nidcr.nih.gov; American Academy of Pediatric Dentistry, 211 E. Chicago Ave., Suite 1600, Chicago, IL 60611; 312-337-2169; http://www.aapd.org; American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611; 312-440-2500; http://www.ada.org/; and Canadian Dental Association, 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6; 613-523-1770; http://www.cda-adc.ca. *American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007; 800-433-9016; http://www.aap.org; and local division of traffic safety or National Highway Traffic Safety Administration, 1200 New Jersey Ave. SE, West Building, Washington, DC 20590; 888-327-4236; http://www.nhtsa.dot.gov. *http://www.carseat.org.
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Health Promotion of the Preschooler and Family Rebecca A. Monroe
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Promoting Optimal Growth and Development Biologic Development The rate of physical growth slows and stabilizes during the preschool years. The average weight is 14.5 kg (32 pounds) at 3 years old, 16.7 kg (36.8 pounds) at 4 years old, and 18.7 kg (41.5 pounds) at 5 years old. The average weight gain per year remains approximately 2 to 3 kg (4.5 to 6.5 pounds).
Growth in height also remains steady, with a yearly increase of 6.5 to 9 cm (2.5 to 3.5 inches), and generally occurs by elongation of the legs rather than of the trunk. The average height is 95 cm (37.5 inches) at 3 years old, 103 cm (40.5 inches) at 4 years old, and 110 cm (43.5 inches) at 5 years old.
Physical proportions no longer resemble those of the squat, pot-bellied toddler. Preschoolers are slender but sturdy, graceful, agile, and posturally erect. There is little difference in physical characteristics according to gender except as dictated by such factors as dress and hairstyle.
Most organ systems can adjust to moderate stress and change. During this period, most children are toilet trained. For the most part, motor development consists of increases in strength and refinement of previously learned skills, such as walking, running, and jumping. However, muscle development and bone growth are still far from mature. Excessive activity and overexertion can injure delicate tissues. Good posture, appropriate exercise, and adequate nutrition and rest are essential for optimal development of the musculoskeletal system.
Gross and Fine Motor Skills Walking, running, climbing, and jumping are well established by 36 months old. Refinement in eye–hand and muscle coordination is evident in several areas. At 3 years old, preschoolers can ride a tricycle, walk on tiptoe, balance on one foot for a few seconds, and do broad jumps. By 4 years old, children can skip and hop proficiently on one foot (Fig. 12-1) and catch a ball reliably. By 5 years old, children can skip on alternate feet and jump rope and begin to skate and swim.
FIG 12-1 A 4-year-old child has sufficient balance to stand or hop on one foot.
Fine motor development is evident in the child's increasingly skillful manipulation, such as in drawing and dressing. These skills provide readiness for learning and independence for entry into school.
Psychosocial Development Developing a Sense of Initiative (Erikson) After preschoolers have mastered the tasks of the toddler period, they are ready to face the
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developmental endeavors of the preschool period. Erikson maintained that the chief psychosocial task of this period is acquiring a sense of initiative. Children are in a stage of energetic learning. They play, work, and live to the fullest and feel a real sense of accomplishment and satisfaction in their activities. Conflict arises when children overstep the limits of their ability and inquiry and experience a sense of guilt for not having behaved appropriately. Feelings of guilt, anxiety, and fear may also result from thoughts that differ from expected behavior.
A particularly stressful thought is wishing one's parent dead. As a sense of rivalry or competition develops between the child and same-sex parent, the child may think of ways to get rid of the interfering parent. In most situations, this rivalry is resolved when the child strongly identifies with the same-sex parent and peers during the school years. However, if that parent dies before the identification process is completed, the preschooler may be overwhelmed with feelings of guilt for having wished and therefore “caused” the death. Clarifying for children that wishes cannot and do not make events occur is essential in helping them overcome their guilt and anxiety.
Development of the superego, or conscience, begins toward the end of the toddler years and is a major task for preschoolers (see Cultural Considerations box). Learning right from wrong and good from bad is the beginning of morality (see Moral Development).
C u l t u r a l C o n s i d e r a t i o n s Learning Sociocultural Mores
Developing a conscience implies learning the sociocultural mores of the family's heritage. Depending on the type of attitudes conveyed, children will learn not only appropriate behaviors but also tolerant, biased, or prejudicial values concerning their ethnic, religious, and social background and those of other groups. Much of this influence may remain dormant until they associate with children or adults of a different heritage. Then, depending on the particular group, they may be accepted or ostracized for their attitudes.
Cognitive Development One of the tasks related to the preschool period is readiness for school and scholastic learning. Many of the thought processes of this period are crucial for achieving such readiness, and it is intentional that children begin school between 5 and 6 years old rather than at an earlier age.
Preoperational Phase (Piaget) Piaget's cognitive theory does not include a period specifically for children who are 3 to 5 years old. The preoperational phase covers the age span from 2 to 7 years old and is divided into two stages: the preconceptual phase, ages 2 to 4 years, and the phase of intuitive thought, ages 4 to 7 years. One of the main transitions during these two phases is the shift from totally egocentric thought to social awareness and the ability to consider other viewpoints. However, egocentricity is still evident. (For a review of the characteristics of preoperational thought, see Chapter 11.)
Language continues to develop during the preschool period. Speech remains primarily a vehicle of egocentric communication. Preschoolers assume that everyone thinks as they do and that a brief explanation of their thinking makes the entire thought understood by others. Because of this self- referenced, egocentric verbal communication, it is often necessary to explore and understand young children's thinking through other, nonverbal approaches. For children in this age group, the most enlightening and effective method is play, which becomes children's way of understanding, adjusting to, and working out life's experiences.
Preschoolers increasingly use language without comprehending the meaning of words, particularly concepts of left and right, causality, and time. Children may use the concepts correctly but only in the circumstances in which they have learned them. For example, they may know how to put on shoes by remembering that the buckle is always on the outside of the foot. However, if different shoes have no buckles, they cannot reason which shoe fits which foot. In other words, they do not understand the concept of left and right.
Superficially, causality resembles logical thought. Preschoolers explain a concept as they heard it described by others, but their understanding is limited. An example is the concept of time. Because time is still incompletely understood, the child interprets it according to his or her own frame of
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reference, such as “a long time means until Christmas.” Consequently, time is best explained in relationship to an event, such as “Your mother will visit you after you finish your lunch.” Avoiding words such as yesterday, tomorrow, next week, or Tuesday to express when an event is expected to occur and instead associating time with expected daily events help children learn about temporal relationships while increasing their trust in others' predictions.
Preschoolers' thinking is often described as magical thinking. Because of their egocentrism and transductive reasoning, they believe that thoughts are all-powerful. Such thinking places them in the vulnerable position of feeling guilty and responsible for bad thoughts, which may coincide with the occurrence of a wished event. Their inability to logically reason the cause and effect of illness or an injury makes it especially difficult for them to understand such events.
N u r s i n g A l e r t Counseling children whose parents are going through a separation or divorce should involve a discussion with the child about his or her role. Because of magical thinking, the child may believe he or she wished the other parent away. The child should be reassured that this is not the case.
Preschoolers believe in the power of words and accept their meaning literally. An example of this type of thinking is calling children “bad” because they did something wrong. In the preschooler's mind, calling them “bad” means they are a bad person; thus, it is better to say that their actions were bad by saying, for example, “That was a bad thing to do.”
Moral Development Preconventional or Premoral Level (Kohlberg) Young children's development of moral judgment is at the most basic level. They have little, if any, concern about why something is wrong. They behave because of the freedom or restriction that is placed on actions. In the punishment and obedience orientation, children (about 2 to 4 years old) judge whether an action is good or bad depending on whether it results in a reward or a punishment. If children are punished for it, the action is bad. If they are not punished, the action is good regardless of the meaning of the act. For example, if parents allow hitting, the child will perceive that hitting is good because it is not associated with punishment.
From approximately 4 to 7 years old, children are in the stage of naive instrumental orientation in which actions are directed toward satisfying their needs and, less frequently, the needs of others. They have a concrete sense of justice and fairness during this period of development.
Spiritual Development Children generally learn about faith and religion from significant others in their environment, usually from parents and their religious beliefs and practices. However, young children's understanding of spirituality is influenced by their cognitive level. Preschoolers have a concrete concept of a God with physical characteristics, often similar to an imaginary friend. They understand simple Bible stories, memorize short prayers, and imitate the religious practices of their parents without fully understanding the significance of these rituals. Preschoolers benefit from concrete representations of religious practices, such as picture Bible books and small statues, such as those of the Nativity scene.
Development of the conscience is strongly linked to spiritual development. At this age, children are learning right from wrong and behaving correctly to avoid punishment. Wrongdoing provokes feelings of guilt, and preschoolers often misinterpret illness as a punishment for real or imagined transgressions. Observing religious traditions and participating in a religious community can help children and their families cope during stressful periods, such as illness and hospitalization (Purow, Alisanski, Putnam, et al, 2011).
Development of Body Image The preschool years play a significant role in the development of body image. With increasing comprehension of language, preschoolers recognize that individuals have desirable and undesirable
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appearances. They recognize differences in skin color and racial identity and are vulnerable to learning prejudices and biases. They are aware of the meaning of words such as pretty or ugly, and they reflect the opinions of others regarding their own appearance. By 5 years old, children compare their size with that of their peers and can become conscious of being large or short, especially if others refer to them as “so big” or “so little” for their age. Research indicates that girls as young as preschool age already show concern about appearance and weight (Skouteris, McCabe, Swinburn, et al, 2010). Because these are formative years for both boys and girls, parents should make efforts to instill positive principles regarding body image, give their children encouraging feedback regarding their appearance, and emphasize the importance of accepting individuals no matter their differences in appearance.
Despite the advances in body image development, preschoolers have poorly defined body boundaries and little knowledge of their internal anatomy. Intrusive experiences are frightening, especially those that disrupt the integrity of the skin, such as injections and surgery. They fear that if their skin is “broken,” all of their blood and “insides” can leak out. Therefore, bandages are critical to “keep everything from coming out.”
Development of Sexuality Sexual development during these years is an important phase in a person's overall sexual identity and beliefs. Preschoolers are forming strong attachments to the opposite-sex parent while identifying with the same-sex parent. Sex typing, or the process by which an individual develops the behavior, personality, attitudes, and beliefs appropriate for his or her culture and sex, occurs through several mechanisms during this period. Probably the most powerful mechanisms are child- rearing practices and imitations. Gender identification is a result of complex prenatal and postnatal psychological factors, as well as biologic, social, and genetic factors. Most children are aware of their gender and the expected sets of related behaviors by to years of age.
As sexual identity develops beyond gender recognition, modesty may become a concern. Sex-role imitation and dressing up like Mommy or Daddy are important activities. Attitudes and the responses of others to role-playing can condition children to views of themselves and others. For example, comments such as “Boys shouldn't play with dolls” can influence a boy's self-concept of masculinity.
Sexual exploration may be more pronounced now than ever before, particularly in terms of exploring and manipulating the genitalia. Questions about sexual reproduction may come to the forefront in preschoolers' search for understanding (see Sex Education later in this chapter and in Chapter 14).
Social Development During the preschool period, the separation-individuation process is completed. Preschoolers have overcome much of the anxiety associated with strangers and the fear of separation of earlier years. They relate to unfamiliar people easily and tolerate brief separations from their parents with little or no protest. However, they still need parental security, reassurance, guidance, and approval, especially when entering preschool or elementary school. Prolonged separation, such as that imposed by illness and hospitalization, is difficult, but preschoolers respond to anticipatory preparation and concrete explanation. They can cope with changes in daily routine much better than toddlers, although they may develop more imaginary fears. Preschoolers gain security and comfort from familiar objects, such as toys, dolls, or photographs of family members. They are able to work through many of their unresolved fears, fantasies, and anxieties through play, especially if guided with appropriate play objects (e.g., dolls, puppets) that represent family members, health care professionals, and other children.
Language During the preschool years, language becomes more sophisticated and complex and becomes a major mode of communication and social interaction (Fig. 12-2). Through language, preschool children learn to express feelings of frustration or anger without acting them out. Both cognitive ability and environment—particularly, consistent role models—influence vocabulary, speech, and comprehension. Vocabulary increases dramatically, from 300 words at 2 years old to more than
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2100 words at the end of 5 years. Sentence structure, grammatical usage, and intelligibility also advance to a more adult level. Language development during these early years predicts school readiness (Harrison and McLeod, 2010) and sets the stage for later success in school (Reilly, Wake, Ukoumunne, et al, 2010).
FIG 12-2 Preschool children enjoy friends and often use nonverbal messages to communicate.
Children between 3 and 4 years old form sentences of about three or four words and include only the most essential words to convey a meaning. Such speech is often termed telegraphic for its brevity. Three-year-old children ask many questions and use plurals, correct pronouns, and the past tense of verbs. They name familiar objects, such as animals, parts of the body, relatives, and friends. They can give and follow simple commands. They talk incessantly regardless of whether anyone is listening or answering them. They enjoy musical or talking toys or dolls and imitate new words proficiently.
From 4 to 5 years old, preschoolers use longer sentences of four or five words and use more words to convey a message, such as prepositions, adjectives, and a variety of verbs. They follow simple directional commands, such as “Put the ball on the chair,” but can carry out only one request at a time. They answer questions such as “What do you do when you are hungry?” by describing the appropriate action. The pattern of asking questions is at its peak, and children usually repeat a question until they receive an answer.
Personal-Social Behavior The pervasive ritualism and negativism of toddlerhood gradually diminish during the preschool years. Although self-assertion is still a major theme, preschoolers demonstrate their sense of autonomy differently. They are able to verbalize their request for independence and perform independently because of their much-refined physical and cognitive development. By 4 or 5 years old, they need little if any assistance with dressing, eating, or toileting (Fig. 12-3). They can also be trusted to obey warnings of danger; however, 3- or 4-year-old children may exceed their boundaries at times.
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FIG 12-3 Most preschoolers are able to dress themselves but need help with more difficult items of clothing.
Preschoolers are also much more sociable and willing to please. They have internalized many of the standards and values of the family and culture. However, by the end of early childhood, they begin to question parental values and compare them with those of their peer group and other authority figures. As a result, they may be less willing to abide by the family's code of conduct. Preschoolers become increasingly aware of their position and role within the family. Although this is a more secure age for experiencing the addition of another sibling, relinquishing the position of first or youngest is still difficult and requires appropriate preparation (see Sibling Rivalry, Chapter 11).
Play Various types of play are typical of this period, but preschoolers especially enjoy associative play— group play in similar or identical activities but without rigid organization or rules. Play should provide for physical, social, and mental development.
Play activities for physical growth and refinement of motor skills include jumping, running, and climbing. Tricycles, wagons, gym and sports equipment, sandboxes, wading pools, and activities at water parks can help develop muscles and coordination (Fig. 12-4). Activities such as swimming and skating teach safety as well as muscle development and coordination. Children involved in the work of play do not require expensive toys and gadgets to keep them entertained but often enjoy playing with common household items such as a broom handle or even items adults consider junk (boxes, sticks, rocks, and dirt). The imaginative mind of the preschooler enjoys playing for play's sake.
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FIG 12-4 Preschoolers enjoy play activities that promote motor skills, such as jumping and running. Water play is an exciting activity for preschoolers.
Manipulative, constructive, creative, and educational toys provide for quiet activities, fine motor development, and self-expression. Easy construction sets, blocks of various sizes and shapes, a counting frame, alphabet or number flash cards, paints, crayons, simple carpentry tools, musical toys, illustrated books, simple sewing or handicraft sets, large puzzles, and clay are suitable toys. Electronic games and computer programs are especially valuable in helping children learn basic skills, such as letters and simple words.
Probably the most characteristic and pervasive preschool activity is imitative, imaginative, and dramatic play. Dress-up clothes, dolls, housekeeping toys, dollhouses, play store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, and medical kits provide hours of self-expression (Fig. 12-5). Probably at no other time is the reproduction of adult behavior so faithful and absorbing as in 4- and 5-year-old children. Toward the end of the preschool period, children are less satisfied with make-believe or pretend objects and enjoy doing the actual activity, such as cooking and carpentry.
FIG 12-5 Imaginative and imitative play is typical of preschoolers.
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Television and other media also have their place in children's play, although each should be only one part of children's total repertoire of social and recreational activities. Time spent watching television may limit time spent in other meaningful activities, such as reading, physical activity, and socialization (American Academy of Pediatrics, 2013b). Considering the significant increase in media accessibility through various portable electronic devices and smart phones, parents need to be aware of the potential positive and negative effects of media exposure. Parents and other caregivers should supervise the selection of media, watch and discuss programs with their children, schedule limited time for media exposure, and set a good example of media use (Strasburger and American Academy of Pediatrics Council on Communications and Media, 2010). When parents view media with their children and discuss program content, the activity can become interactive and educational.
Play is so much a part of young children's lives that reality and fantasy become blurred. Make- believe is reality during play and only becomes fantasy when the toys are put away or the dress-up clothes are removed. It is no wonder that imaginary playmates are so much a part of this age period. The appearance of imaginary companions usually occurs between and 3 years old, and for the most part, such playmates are relinquished when the child enters school. Differences in birth order and gender have been noted in studies of imaginary companion play. Firstborn children have a higher incidence of imaginary companions, as do young girls; young boys tend to impersonate characters more often (Trionfi and Reese, 2009).
Imaginary companions serve many purposes: They become friends in times of loneliness, they accomplish what the child is still attempting, and they experience what the child wants to forget or remember. It is not unusual for the “friend” to have myriad vices and to be blamed for wrongdoing. Sometimes the child hopes to escape punishment by saying, “My friend George broke the glass.” At other times, the child may fantasize that the companion misbehaved and play the role of the parent. This becomes a way of assuming control and authority in a safe situation.
Parents often worry about the imaginary playmates, not realizing how normal and useful they are. Parents need to be reassured that the child's fantasy is a sign of health that helps differentiate make-believe and reality. Parents can acknowledge the presence of the imaginary companion by calling him or her by name and even agreeing to simple requests such as setting an extra place at the table, but they should not allow the child to use the playmate to avoid punishment or responsibility. For example, if the child blames the companion for messing up a room, parents need to state clearly that the child is the only one they see; therefore, the child is responsible for cleaning up.
Children also benefit from play that occurs between them and a parent. Mutual play fosters development from birth through the school years and provides enriched opportunities for learning. Through mutual play, parents can provide tactile and kinesthetic experiences, maximize verbal and language abilities, and offer praise and encouragement for exploration of the world. In addition, mutual play encourages positive interactions between the parent and child, strengthening their relationship.
Table 12-1 summarizes the major developmental achievements for children 3, 4, and 5 years old.
TABLE 12-1 Growth and Development During the Preschool Years
Physical Gross Motor Fine Motor Language Socialization Cognition Family Relationships 3 Years Old Usual weight
gain of 1.8 to 2.7 kg (4 to 6 lbs.)
Average weight of 14.5 kg (32 lbs.)
Usual gain in height of 7.5 cm (3 inches) per year
Average height of 95 cm (3 feet,
inches) May have
achieved nighttime control of bowel and bladder
Rides tricycle Jumps off
bottom step Stands on one
foot for few seconds
Goes up stairs using alternate feet; may still come down using both feet on step
Broad jumps May try to
dance, but balance may not be adequate
Builds tower of 9 to 10 cubes Builds bridge with three
cubes Adeptly places small pellets
in narrow-necked bottle In drawing, copies circle,
imitates cross, names what has been drawn; cannot draw stick figure but may make circle with facial features
Has vocabulary of about 900 words
Uses primarily “telegraphic” speech
Uses complete sentences of three or four words
Talks incessantly regardless of whether anyone is paying attention
Repeats sentence of six syllables
Asks many questions
Dresses self almost completely if helped with back buttons and told which shoe is right or left
Pulls on shoes Has increased attention
span Feeds self completely Can prepare simple meals,
such as cold cereal and milk
Can help set table; can dry dishes without breaking any
May have fears, especially of dark and going to bed
Knows own gender and gender of others
Play is parallel and associative; begins to learn simple games, but often follows own rules; begins to share
Is in preconceptual phase Is egocentric in thought and
behavior Has beginning understanding of
time; uses many time-oriented expressions, talks about past and future as much as about present, pretends to tell time
Has improved concept of space, as demonstrated by understanding of prepositions and ability to follow directional command
Has beginning ability to view concepts from another perspective
Attempts to please parents and conform to their expectations
Is less jealous of younger sibling; may be opportune time for birth of additional sibling
Is aware of family relationships and sex-role functions
Boys tend to identify more with father or other male figure
Has increased ability to separate easily and comfortably from parents for short periods
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4 Years Old Pulse and
respiration rates decrease slightly
Growth rate is similar to that of previous year
Average weight of 16.5 kg (36.5 pounds)
Average height of 103 cm (3 feet,
inches) Length at
birth is doubled
Maximum potential for development of amblyopia
Skips and hops on one foot
Catches ball reliably
Throws ball overhead
Walks downstairs using alternate footing
Uses scissors successfully to cut out picture following outline
Can lace shoes but may not be able to tie bow
In drawing, copies square, traces cross and diamond, adds three parts to stick figure
Has vocabulary of 1500 words or more
Uses sentences of four or five words
Questioning is at peak
Tells exaggerated stories
Knows simple songs May be mildly
profane if associates with older children
Obeys prepositional phrases, such as “under,” “on top of,” “beside,” “in back of,” or “in front of”
Names one or more colors
Comprehends analogies, such as “If ice is cold, fire is ___”
Very independent Tends to be selfish and
impatient Aggressive physically as
well as verbally Takes pride in
accomplishments Has mood swings Shows off dramatically,
enjoys entertaining others Tells family tales to others
with no restraint Still has many fears Play is associative Imaginary playmates
common Uses dramatic,
imaginative, and imitative devices
Sexual exploration and curiosity demonstrated through play, such as being “doctor” or “nurse”
Is in phase of intuitive thought Causality is still related to
proximity of events Understands time better,
especially in terms of sequence of daily events
Unable to conserve matter Judges everything according to
one dimension, such as height, width, or order
Immediate perceptual clues dominate judgment
Is beginning to develop less egocentrism and more social awareness
May count correctly but has poor mathematic concept of numbers
Obeys because parents have set limits, not because of understanding of right or wrong
Rebels if parents expect too much, such as impeccable table manners
Takes aggression and frustration out on parents or siblings
Do's and don'ts become important
May have rivalry with older or younger siblings; may resent older sibling's privileges and younger sibling's invasion of privacy and possessions
May “run away” from home Identifies strongly with parent
of opposite sex Is able to run simple errands
outside the home
5 Years Old Pulse and
respiration rates decrease slightly
Average weight of 18.5 kg (41 pounds)
Average height of 110 cm (3 feet,
inches) Eruption of
permanent dentition may begin
Handedness is established (about 90% are right- handed)
Skips and hops on alternate feet
Throws and catches ball well
Jumps rope Skates with
good balance Walks
backward with heel to toe
Jumps from height of 12 inches and lands on toes
Balances on alternate feet with eyes closed
Ties shoelaces Uses scissors, simple tools, or
pencil well In drawing, copies diamond
and triangle; adds seven to nine parts to stick figure; prints a few letters, numbers, or words, such as first name
Has vocabulary of about 2100 words
Uses sentences of six to eight words, with all parts of speech
Names coins (e.g., nickel, dime)
Names four or more colors
Describes drawing or pictures with much comment and enumeration
Knows names of days of week, months, and other time-associated words
Knows composition of articles, such as “A shoe is made of ____”
Can follow three commands in succession
Less rebellious and quarrelsome than at 4 years old
More settled and eager to get down to business
Not as open and accessible in thoughts and behavior as in earlier years
Independent but trustworthy, not fool- hardy; more responsible
Has fewer fears; relies on outer authority to control world
Eager to do things right and to please; tries to “live by the rules”
Has better manners Cares for self totally,
occasionally needing supervision in dress or hygiene
Not ready for concentrated close work or small print because of slight farsightedness and still unrefined eye-hand coordination
Play is associative; tries to follow rules but may cheat to avoid losing
Begins to question what parents think by comparing them with age-mates and other adults
May notice prejudice and bias in outside world
Is more able to view other's perspective, but tolerates differences rather than understanding them
May begin to show understanding of conservation of numbers through counting objects regardless of arrangement
Uses time-oriented words with increased understanding
Cautious about factual information regarding world
Gets along well with parents May seek out parent more
often than at 4 years old for reassurance and security, especially when entering school
Begins to question parents' thinking and principles
Strongly identifies with parent of same sex, especially boys with their fathers
Enjoys activities such as sports, cooking, and shopping with parent of same sex
Coping with Concerns Related to Normal Growth and Development Preschool and Kindergarten Experience Some children are home-schooled, but many children attend some type of early childhood program, usually preschool or a daycare center. Group care has become commonplace with the large number of parents currently employed outside the home (see Alternate Child Care Arrangements, Chapter 9). The effects of early education and stimulation on children have increasingly gained recognition. (For a discussion of the effects of daycare on young children, see Working Mothers, Chapter 2). Because social development widens to include age mates and other significant adults, preschool provides an excellent vehicle for expanding children's experiences with others. It is also excellent preparation for entrance into elementary school.
In preschool or daycare centers, children are exposed to opportunities for learning group cooperation; adjusting to sociocultural differences; and coping with frustration, dissatisfaction, and anger. If activities are tailored to provide mastery and achievement, children increasingly have feelings of success, self-confidence, and personal competence. Whether structured learning is imposed is less important than the social climate, type of guidance, and attitude toward the children that is fostered by the teacher or leader. With a teacher who is aware of preschoolers' developmental abilities and needs, children will learn from the activity that is provided. Most programs incorporate a daily schedule of quiet play, active outdoor activity, group activities such as games and projects, creative or free play, and snack and rest periods. Preschool is particularly beneficial for children who lack a peer-group experience, such as only children, and for children from impoverished homes.
One of the issues that parents face is their children's readiness for preschool or kindergarten. There are no absolute indicators for school readiness, but children's social and emotional maturity,
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especially attention span, are as important as their academic readiness. Using a developmental screening tool that addresses cognitive (especially language), social, and physical milestones can identify children who may benefit from diagnostic testing and early intervention programs before starting school. Parents play an integral role in their children's school readiness. They should promote a positive attitude toward learning, participate in their children's learning, read to their children, provide opportunities for social and emotional growth, and choose programs or schools that will partner with the family to foster learning (National Center on Parent, Family, and Community Engagement, 2014).
Nurses and other health care workers can guide parents in selecting enriched social and educational early intervention programs, schools, and child care centers. Careful selection of early childhood education is intrinsic to future learning and development. Licensed and regulated programs are mandated to abide by established standards, which represent minimum requirements and safeguards. Regulation is important to protect children from harm and to promote the conditions essential for a child's healthy development and learning. The National Association for the Education of Young Children serves as the model for optimal care of small children.*
Areas for parents to evaluate include the facility's daily program, teacher qualifications, staff-to- student ratio, discipline policy, environmental safety precautions, provision of meals, sanitary conditions, adequate indoor and outdoor space per child, and fee schedule. References from other parents help in evaluating a facility, but personal observation of the facility is recommended. Encourage parents to meet the director and some of the employees at a few facilities to make an informed choice.
Evaluation of the facility's health practices is extremely important. Preschoolers in child care centers have more illnesses than those not in child care centers, especially gastrointestinal tract and respiratory tract infections (Sacri, De Serres, Quach, et al, 2014). Nurses play an important role in infection control. Not only can they advise parents regarding the evaluation of a facility's sanitary practices, but they can also take an active part in educating staff in measures to minimize transmission of infection (Fig. 12-6).
FIG 12-6 Thorough hand washing is the single most effective method of preventing infection.
Children need preparation for the preschool or kindergarten experience. For young children, it represents a change from their usual home environment and prolonged separation from their parents. Before children begin school, parents should present the idea as exciting and pleasurable. Talking to children about activities (such as painting, building with blocks, or enjoying swings and other outdoor equipment) allows children to fantasize about the forthcoming event in a positive manner. When the first day of school arrives, parents should behave confidently. Such behavior requires parents to have resolved their own feelings regarding the experience.
Parents should introduce their child to the teacher and the facility. In some instances, it is helpful for parents to remain with the child for at least part of the first day until the child is comfortable and at ease. Other specific actions that can help reduce separation anxiety include providing the school
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with detailed information about the child's home environment, such as familiar routines, favorite activities, food preferences, names of siblings or pets, and personal habits. Such information helps the child feel familiar in the strange surroundings. When schools automatically request this information, the parent has a valuable clue to evaluating the quality of the program because the request represents the staff's awareness of each child's needs. Transitional objects, such as a favorite toy, may also help the child bridge the gap from home to school.
Sex Education Preschoolers have assimilated a tremendous amount of information during their short lifetimes. Although their thinking may not be mature, they search constantly for explanations and reasons that are logical and reasonable to them. The word “why” seems to supplant the word “no,” which was common in toddlerhood. It is only natural that as they learn about “me,” they will also want to know “Why me?” and “How me?” Questions such as “Where do babies come from?” are as casual as “What makes it rain?” or “Who is that?” It is the way in which questions about procreation are answered that conditions children, even the youngest, to separate these questions from others about their world.
Two rules govern answering sensitive questions about topics such as sex. The first is to find out what children know and think. After investigating the theories children have produced as a reasonable explanation, parents can give correct information but can also help children understand why their explanation is inaccurate. Another reason for ascertaining what the child thinks before offering any information is that the “unasked for” answer may be given. For example, 4-year-old Emma asked her father, “Where did I come from?” Both parents quickly took this inquiry as a clue for offering sex education. After the explanation, Emma exclaimed, “I don't know about all that! All I know is Katie came from New York, and I want to know where I came from.”
The second rule for giving information is to be honest. It is true that much of the correct information will be forgotten or misunderstood by the preschooler, but the correct information can be restated until the child absorbs and comprehends the facts. Even though the correct anatomical words may be hard to pronounce or even more difficult to remember, they become foundational content for explaining other concepts later on.
Honesty does not imply imparting to children every fact of life or allowing excessive permissiveness in sexual curiosity. When children ask one question, they are looking for one answer. When they are ready, they will ask about the other “unfinished” parts of the story. Sooner or later they will wonder how the “sperm meets the egg” and “how the baby gets out,” but during this period, it is best to wait until they ask.
Regardless of whether children are given sex education, they will engage in games of sexual curiosity and exploration. At about 3 years old, children are aware of the anatomical differences between the sexes and are curious about how the other works. This is not really “sexual” curiosity because many children are still unaware of the reproductive function of the genitalia. Their curiosity is for the eliminative function of the anatomy. Little boys wonder how girls can urinate without a penis, so they watch girls go to the bathroom. Because they cannot see anything but the stream of urine coming out, they want to observe further. “Doctor play” is often a game invented for such investigation. Little girls are no less curious about boys' anatomy. It is intriguing to closely inspect this “thing” that girls do not have.
One question that parents often have is how to handle such sexual curiosity. A positive approach is to neither condone nor condemn the sexual curiosity but to express that if children have questions, they should ask their parents. Then parents can answer their questions and encourage them to engage in some other activity. In this way, children can be helped to understand that there are ways that their sexual curiosity can be satisfied other than through playing investigative games. This in no way condemns the act but stresses alternate methods to seek solutions and answers. Allowing children unrestricted permissiveness only intensifies their anxiety and concern because exploring and searching usually yield little evidence to satisfy their curiosity.
Many excellent books on sex education are available for preschool children at public libraries. The Sexuality Information and Education Council of the United States* and the American Academy of Pediatrics† have bibliographies of suggested reading material. Parents should read the books themselves before giving or reading them to their children.
Another concern for some parents is masturbation, or self-stimulation of the genitalia. This occurs at any age for a variety of reasons and, if not excessive, is normal and healthy. It is most
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common at 4 years old and during adolescence. For preschoolers, it is a part of sexual curiosity and exploration. If parents are concerned about their child masturbating, it is essential for nurses to investigate the circumstances associated with the activity. Masturbation can be an expression of anxiety, boredom, or stress. In the case of excessive masturbation, it may be associated with emotional or behavioral problems and physical or sexual abuse (Strachan and Staples, 2012). Management of normal childhood masturbation includes parent education and reassurance, redirection of the child to other activities, and discussion with the child regarding appropriate boundaries (Strachan and Staples, 2012). In addition, parents should emphasize that masturbation is a private act, thus teaching children socially acceptable behavior.
Fears A great number and variety of real and imagined fears are present during the preschool years, including fear of the dark, being left alone (especially at bedtime), animals (particularly large dogs), ghosts, sexual matters (castration), and objects or persons associated with pain. The exact cause of children's fears is unknown. Parents often become perplexed about handling the fears because no amount of logical persuasion, coercion, or ridicule will send away the ghosts, bogeymen, monsters, and devils. Inappropriate television viewing by preschoolers may increase fears and anxieties because of the inability to separate reality-based experiences from fantasy portrayed on television.
The concept of animism, ascribing lifelike qualities to inanimate objects, helps explain why children fear objects. For example, a child may refuse to use the toilet after watching a television commercial in which the toilet bowl is portrayed as turning into a monster and swallowing a child.
Preschoolers also experience fear of annihilation. Because of poorly defined body boundaries and improved cognitive abilities, young children develop concerns related to loss of body parts. They fear losing body parts with certain medical procedures (such as an intravenous insertion or cast application on a limb) and may see these procedures as real threats to their existence.
The best way to help children overcome their fears is by actively involving them in finding practical methods to deal with the frightening experience. This may be as simple as keeping a night light on in the child's bedroom for assurance that no monsters lurk in the dark. Exposing children to the feared object in a safe situation also provides a type of conditioning, or desensitization. For instance, children who are afraid of dogs should never be forced to approach or touch one, but they may be gradually introduced to the experience by watching other children play with the animal. This type of modeling, with others demonstrating fearlessness, can be effective if the child is allowed to progress at his or her own rate.
Usually by 5 or 6 years old, children relinquish many of their fears. Explaining the developmental sequence of fears and their gradual disappearance may help parents feel more secure in handling preschoolers' fears. Sometimes fears do not subside with simple measures or developmental maturation. When children experience severe fears that disrupt family life, professional help is necessary.
Stress Although for parents the preschool years generally are less troublesome than toddlerhood, this period of life presents children with many unique stresses. Some, such as fears, are innate and stem from preschoolers' unique understanding of the world. Others are imposed, such as beginning school. Although minimal amounts of stress are beneficial during the early years to help children develop effective coping skills, excessive stress is harmful. Young children are especially vulnerable because of their limited capacity to cope. Expression of frustration, fear, or anxiety is hampered by inadequate expressive language.
To help parents deal with stress in their children's lives, they must be aware of signs of stress and be helped to identify the source. Any number of stressors may be present, such as the birth of a sibling, marital discord, separation and divorce, relocation, or illness.
The best approach to dealing with stress is prevention—monitoring the amount of stress in children's lives so that levels do not exceed their coping ability. In many instances, structuring children's schedules to allow rest and preparing them for change, such as entering school, are sufficient measures.
Aggression The term aggression refers to behavior that attempts to hurt a person or destroy property.
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Aggression differs from anger, which is a temporary emotional state, but anger may be expressed through aggression. Hyperaggressive behavior in preschoolers is characterized by unprovoked physical attacks on other children and adults, destruction of others' property, frequent intense temper tantrums, extreme impulsivity, disrespect, and noncompliance. Aggression is influenced by a complex set of biological, sociocultural, and familial variables. Factors that tend to increase aggressive behavior are gender, frustration, modeling, and reinforcement.
Evidence indicates that types of aggression differ between genders. Boys exhibit more physical aggression than girls during preschool years (Lussier, Corrado, and Tzoumakis, 2012). Relational aggression is exhibited at similar rates in boys and girls of this age group; however, differences in the frequency of relational aggression between genders can vary depending upon peer interactions in various situations and settings (McEachern and Snyder, 2012).
Frustration, or the continual thwarting of self-satisfaction by disapproval, humiliation, punishment, or insults, can lead children to act out against others as a means of release. Especially if they fear their parents, these children will displace their anger on others, particularly peers and other authority figures. This type of aggression often applies to children who are well-behaved at home but have a discipline problem at school or are bullies among their playmates.
Modeling, or imitating the behavior of significant others, is a powerful influencing force in preschoolers. Children who see their parents as physically abusive are observing behavior they come to know as acceptable and therefore may exhibit this behavior with others (Knox, 2010). Another aspect of modeling is the “double-standard” for acceptable conduct. For example, in some families, aggression is synonymous with masculinity, and boys are encouraged to defend themselves. Media exposure is also a significant source for modeling at this impressionable age. Numerous studies have found a positive correlation between viewing violent programs and developing aggression; therefore, parents should be encouraged to supervise programming, especially for children with aggressive tendencies (Fitzpatrick, Barnett, Pagani, 2012). The American Academy of Pediatrics (2013a) offers recommendations for healthy television viewing.
Reinforcement can also shape aggressive behavior. Sometimes the reward for aggression is negative (e.g., punishment) yet reinforcing, because it brings attention. For example, children who are ignored by a parent until they hit a sibling or the parent learn that this act garners attention.
When children exhibit extreme behaviors, such as aggression, parents may be concerned about the need for professional help. Generally, the difference between normal and problematic behavior is not the behavior itself but its quantity (number of occurrences), severity (interference with social or cognitive functioning), distribution (different manifestations), onset (when behavior started), and duration (at least 4 weeks).*
Speech Problems The most critical period for speech development occurs between 2 and 4 years old. During this period, children are using their rapidly growing vocabulary faster than they can produce the words. Failure to master sensorimotor integrations results in stuttering or stammering as children try to say the word they are already thinking about. This dysfluency in speech pattern is common during language development in children 2 to 5 years old (Nelson, 2013). Stuttering affects boys more frequently than girls, has been shown to have a genetic link, and usually resolves during childhood (McQuiston and Kloczko, 2011). The National Institute on Deafness and Other Communication Disorders (2010) encourages parents and caregivers of children who stutter to speak slowly and relaxed, refrain from criticizing the child's speech, resist completing the child's sentences, and take time to listen attentively.
The best therapy for speech problems is prevention and early detection. Common causes of speech problems include hearing loss, developmental delay, autism, lack of environmental stimulation, and physical conditions that impede normal speech production (McLaughlin, 2011). Referral for further evaluation and treatment may be necessary to prevent a problem from interfering with learning. Anticipatory preparation of parents for expected developmental norms may allay caregiver concerns.
Children pressured into producing sounds ahead of their developmental level may develop dyslalia (articulation problems) or revert to using infantile speech. Prevention involves educating parents regarding the usual achievement of speech production during childhood. The Denver Articulation Screening Exam is an excellent tool for assessing articulation skills of a child and for explaining to parents the expected progression of sounds.
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Promoting Optimal Health During the Preschool Years* Nutrition Healthy nutrition during childhood should include consuming a variety of nutrient-dense food, ensuring sufficient energy to promote growth and development, and balancing energy intake with energy expenditure to maintain a healthy weight (Kleinman and Greer, 2014). Nutritional needs vary depending upon age, gender, activity level, and state of health. The requirement for calories per unit of body weight continues to decrease slightly to 90 kcal/kg. The estimated daily caloric requirement for preschoolers is 1,000 to 1,800 calories (Kleinman and Greer, 2014). Fluid requirements may also decrease slightly to approximately 100 ml/kg/day, but requirements are affected by climatic conditions. Protein requirements increase during childhood, and the recommended intake for preschoolers is 13 to 19 g/day (0.45 to 0.67 oz/day) (US Department of Agriculture and US Department of Health and Human Services, 2010).
The American Academy of Pediatrics Committee on Nutrition recommends that the total fat intake over several days be 30% of total caloric intake for children 2 years old and older (Kleinman and Greer, 2014). This recommendation is important in the prevention of childhood obesity and the development of other morbidities. Research has shown that the development of obesity, cardiovascular disease, diabetes, and cancer can be influenced by early eating patterns (Macaulay, Donovan, Leask, et al, 2014).
While limiting fat consumption, it is also important to ensure diets contain adequate nutrients. This can be done simultaneously as in the following example regarding calcium. The Recommended Dietary Allowance (RDA) of calcium for children 1 to 3 years old is 700 mg/day, and the recommendation for children 4 to 8 years old is 1,000 mg/day (Institute of Medicine of the National Academies, 2011). Milk and dairy products are excellent sources of calcium. Low-fat and nonfat milk may be substituted for higher fat choices, so the quantity of milk may remain the same while limiting fat intake overall.
Excessive consumption of fruit juices and other sugar-sweetened beverages has been associated with dental caries (Marshall, 2013) and adverse cardiometabolic effects (Kosova, Auinger, Bremer, 2013). The American Academy of Pediatrics recommends limiting the intake of 100% fruit juice to 4 to 6 oz/day for children 1 to 6 years old (Kleinman and Greer, 2014). Parents should be educated regarding non-nutritious fruit drinks, which usually contain less than 10% fruit juice yet are often advertised as healthy and nutritious. While counseling parents regarding moderation in fruit juice consumption, providers should offer suggestions for more appropriate sources of nutrients, such as ascorbic acid, folate, and potassium. In young children, intake of carbonated beverages that are acidic or that contain high amounts of sugar is also known to contribute to dental caries; large amounts of nonnutritive calories in such beverages may also displace or preclude intake of nutrients necessary for growth.
In 2011, the US Department of Agriculture released a new food guide system called MyPlate (US Department of Agriculture, Center for Nutrition Policy and Promotion, 2011). This system is comprehensive and provides information for developing a healthy lifestyle at an early age. Parents can develop customizable food plans created specifically for children 2 to 5 years old and access information on growth during the preschool years, healthy eating habits, physical activity, and food safety at www.ChooseMyPlate.gov/preschoolers.html. Parents can use this information to assist their children in making healthy lifestyle choices and to help prevent adverse health conditions secondary to poor nutrition. The importance of role modeling by parents cannot be overemphasized in regard to food intake and dietary habits; if parents will not eat a particular food or if their dietary habits are poor, children are likely to develop the same habits.
N u r s i n g A l e r t Obesity in young children has increased significantly over the past 3 decades, so efforts to provide a healthy diet and to encourage physical activity should begin early to help children achieve optimum health (Rogers, Hart, Motyka, et al, 2013). The 5-2-1-0 framework provides a foundation for patient education regarding healthy lifestyle choices. This framework refers to five or more servings of fruits and vegetables per day, 2 hours or less of screen time per day, a minimum of 1 hour of physical activity per day, and 0 (or limited) servings of sugar-sweetened beverages (Rogers, Hart, Motyka, et al, 2013).
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Some preschoolers still have food habits that are typical of toddlers, such as food fads and strong taste preferences. When children reach 4 years of age, they seem to enter another period of finicky eating, which is generally characteristic of the more rebellious behavior of children in this age group. As with toddlers, small portions of each item being served should be offered. The practice of having children remain at the table until the plate is clean should be avoided, because this may contribute to overeating and the development of poor eating habits that contribute to poor health later in life. By 5 years old, children are more agreeable to trying new foods, especially if they are encouraged by an adult who allows them to help with food preparation or experiment with a new taste or different dish (Fig. 12-7). Mealtimes can become battlegrounds if parents expect perfect table manners.* Usually 5-year-old children are ready for the social side of eating, but 3- or 4-year- old children still have difficulty sitting quietly through long family meals.
FIG 12-7 Preschool-age children enjoy helping adults and are more likely to try new foods if they can assist in the preparation.
The amount and variety of foods consumed by young children vary greatly from day to day. Consequently, parents sometimes worry about the quantity and quality of food preschoolers consume. In general, the quality is much more important than the quantity, a fact that should be stressed during nutritional counseling.
One way to reduce parental concern is advising parents to keep a weekly record of everything the child eats. In particular, the parents can measure the amount of food, such as setting aside a half cup of vegetables and serving the child from this premeasured amount, to provide a more accurate estimate of food intake at each meal. When parents look at the food record at the end of the week, they are usually amazed by how much the child has consumed. In general, preschoolers consume only slightly more than toddlers, or about half an adult's portion.
Sleep and Activity Sleep patterns vary widely, but the average preschooler sleeps about 12 hours a night and infrequently takes daytime naps. Waking during the night is common throughout early childhood. An appropriate and consistent bedtime, nap schedule (as needed), and bedtime routine can help prevent and treat common sleep problems and night wakings experienced by young children (Honaker and Meltzer, 2014).
Motor activity levels continue to be high and allow preschoolers to explore their environment, begin learning physical games and sports, and interact with others. Sedentary activities, such as television and video or computer games, are increasingly appealing and can become unhealthy substitutes for active play.
Preschoolers' increased gross motor abilities and coordination allow them to engage in many physical activities, if only at a novice level. At this age, children benefit from free play and exposure to a variety of physical activities (Stricker, 2014). Whether young children should begin formalized training in an activity at this early age is controversial. Training programs must consider the child's
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physical and psychological immaturity, and readiness to participate in organized sports should be determined individually. The decision to participate should be based on the child's, not the parent's, motivation and enjoyment. Another key aspect of organized play for preschoolers is that the activity is developmentally appropriate and occurs in a nonthreatening, fun, and safe environment.
Dental Health By the beginning of the preschool period, the eruption of the deciduous (primary) teeth is complete. Dental care is essential to preserve these temporary teeth and to teach good dental habits (see Chapter 11). Although preschoolers' fine motor control is improved, they still require assistance and supervision with brushing, and flossing should be performed by parents. Professional care and prophylaxis, especially fluoride supplements (if needed), should be continued. The frequency of professional dental care should be based on a child's individual risk assessment, including family history, sociodemographic factors, dental development, presence or absence of dental disease, special health care needs, and dietary habits (American Academy of Pediatric Dentistry, Clinical Affairs Committee, 2009). For children cared for away from home, parents should be encouraged to monitor the dental care provided by others, including minimizing cariogenic food and beverages in the diet. Trauma to teeth during this period is common, and prompt evaluation by a dentist is warranted if oral trauma occurs. Preservation of the space previously occupied by an avulsed tooth is necessary for proper eruption of the secondary tooth.
Injury Prevention Because of improved gross and fine motor skills, coordination, and balance, preschoolers are less prone to falls than toddlers. They tend to be less reckless; listen more to parental rules; and are aware of potential dangers, such as hot objects, sharp instruments, and dangerous heights. Putting objects in the mouth as part of exploration has all but ceased, although accidental poisoning is still a danger. Pedestrian motor vehicle injuries increase because of activities such as playing in parking lots, driveways, or streets; riding tricycles, bicycles, and other play vehicles; running after balls; or forgetting safety regulations when crossing streets.
In general, the guidelines suggested for injury prevention in Table 11-3 apply to children in this age group as well. However, emphasis is now on education concerning safety and potential hazards in addition to appropriate protection. This period is an excellent time for enforcing the use of safety items, such as bicycle helmets to prevent head trauma; children are less likely to warm to the idea later in life because of peer pressure. Because preschoolers are great imitators, it is essential that parents set a good example by “practicing what they preach.” Children quickly observe discrepancies in what they are told to do and what they see others do. Establishing good habits at this time, such as wearing protective equipment, can create long-term safety behaviors.
Anticipatory Guidance—Care of Families The preschool years present fewer childrearing difficulties than do the earlier years, and this stage of development is facilitated by appropriate anticipatory guidance in the areas already discussed (see Family-Centered Care box). There is a shift in childrearing practices from protection to education. Whereas injury prevention previously focused on safeguarding the immediate environment with less emphasis on reasoning, now the protective guardrails or electrical outlet caps may be replaced by verbal explanations of why danger exists and how to avoid it.
F a m i l y - C e n t e r e d C a r e Guidance During Preschool Years
3 Years Old
Prepare parents for child's increasing interest in widening relationships.
Encourage enrollment in preschool.
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Emphasize importance of setting limits.
Prepare parents to expect exaggerated tension-reduction behaviors, such as need for a “security blanket.”
Encourage parents to offer child choices.
Prepare parents to expect marked changes at years old when child becomes insecure and exhibits emotional extremes.
Prepare parents for normal dysfluency in speech and advise them to avoid focusing on the pattern.
Prepare parents to expect extra demands on their attention as a reflection of child's emotional insecurity and fear of loss of love.
Warn parents that the equilibrium of a 3-year-old child will change to the aggressive, out-of-bounds behavior of a 4-year-old child.
Inform parents to anticipate a more stable appetite with more food selections.
Stress need for protection and education of child to prevent injury (see Safety Promotion and Injury Prevention, Chapter 11).
4 Years Old
Prepare parents for more aggressive behavior, including motor activity and offensive language.
Prepare parents to expect resistance to parental authority.
Explore parental feelings regarding child's behavior.
Suggest some type of respite for primary caregivers, such as placing child in preschool for part of the day.
Prepare parents for child's increasing sexual curiosity.
Emphasize the importance of realistic limit setting on behavior and appropriate disciplinary techniques.
Prepare parents for the highly imaginative 4-year-old child who indulges in “tall tales” (to be differentiated from lies) and develops imaginary playmates.
Prepare parents to expect nightmares or an increase in them.
Provide reassurance that a period of calmness begins at 5 years of age.
5 Years Old
Inform parents to expect a tranquil period at 5 years of age.
Help parents prepare the child for entrance into school environment.
Make certain that immunizations are up to date before child enters school.
Suggest that unemployed parental caregivers consider own activities when children begin school.
Suggest swimming lessons for the child.
During this period, an emotional transition between parent and child occurs. Although children are still attached to their parents and accept all of their values and beliefs, they are nearing the period of life when they will question previous teachings and prefer the companionship of peers.
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Entry into school marks a separation from home for parents as well as for children. Parents may need help in adjusting to this change, particularly if one parent has focused his or her daily activities primarily on home responsibilities. All family members must adjust to changes, which is part of the process of growth and development.
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NCLEX Review Questions 1. The nurse caring for a preschool child understands which of the following developmental
concepts? Select all that apply. a. Preschoolers have egocentric thought and believe that everyone thinks as they do. b. Play can be therapeutic and enlightening into a child's level of understanding. c. Explanations are helpful when using detail to allay the preschooler's stress. d. Preschoolers understand inferences and can relate to others' feelings with empathy. e. Preschoolers have magical thinking and believe their thoughts have power.
2. When her preschool son is in the hospital, the parent tells the nurse, “I think there is something wrong with him because he is so skinny.” The most appropriate answer by the nurse is: a. Most preschoolers weigh between 10 and 14 kilograms. b. The legs of a preschooler, rather than the trunk, increase in length, which may make him look
slimmer. c. Preschoolers usually keep that pot-bellied appearance until about 4 years old. d. Most preschoolers gain 2 to 3 pounds per year.
3. At the clinic appointment, a 4-year-old's mother wants to discuss several concerns. Which statements require more teaching by the nurse? Select all that apply. a. My husband feels that TV is okay as long as it is educational. b. I think it is okay for my son to play dress-up along with the girls. c. I told my son that his imaginary playmate moved away because it did not seem normal. d. My mother-in-law thinks I should be working around the house all the time, but I believe
playing with my son is very important. e. My neighbor gave me some flash cards with letters and numbers for my son to use, but I said,
“What's the rush? He's only 4.”
4. One of the concerns of the preschool period is adequate nutrition. What can the nurse say to give anticipatory guidance to parents? a. Preschoolers are growing during this period and need to increase their caloric intake to 110
kcal/kg, for an average daily intake of 2200 calories. b. There is some evidence that children self-regulate their caloric intake. If they eat less at one
meal, they compensate at another meal or snack. c. To monitor fat intake, dairy and meat should be limited to twice a day. d. For children who do not like milk, consumption of fruit juices is a healthy alternative.
5. At an appointment at the pediatrician's office, a patient's mother states, “My son gets rough with some of the neighborhood kids. I am worried that he is becoming a bully.” Which statements by the mother need more teaching? Select all that apply. a. When my son becomes aggressive, I feel he needs to be punished. b. I think it is good for him to bond with his dad, so they often watch TV together. c. I am trying to get him to learn to say what he is upset about in words. d. Boys will be boys, so I think this can be considered a normal stage in development. e. I am thinking that a time-out would be a better strategy than spanking when my son shows this
behavior.
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Correct Answers 1. a, b, e; 2. b; 3. a, c, e; 4. b; 5. c, e
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US Department of Agriculture, Center for Nutrition Policy and Promotion. A brief history of USDA food guides. http://www.choosemyplate.gov/sites/default/files/printablematerials/ABriefHistoryOfUSDAFoodGuides.pdf 2011.
US Department of Agriculture, US Department of Health and Human Services. Dietary guidelines for Americans. ed 7. US Government Printing Office: Washington, DC; 2010.
*Information about accreditation criteria and procedures of the National Association for the Education of Young Children Accreditation of Programs for Young Children is available from the National Association for the Education of Young Children, 1313 L St. NW, Suite 500, Washington, DC 20005; 800-424-2460 or 202-232-8777; fax: 202-328-1846; http://www.naeyc.org. These criteria are excellent guidelines for evaluating preschools and daycare centers. *Sexuality Information and Education Council of the United States (SIECUS), 1012 14th St., NW, Suite 1108, Washington, DC 20005; 202-265-2405; http://www.siecus.org. †American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007; 847-434-4000; http://www.aap.org. *Information on child development and behavior can be obtained through the American Academy of Pediatrics, Section on Developmental and Behavioral Pediatrics, http://www2.aap.org/sections/dbpeds. *For a more comprehensive understanding, readers are urged to review Promoting Optimal Health During Toddlerhood, Chapter 11. *Excellent resources for parents related to mealtimes with toddlers and preschoolers include Jana LA, Shu J: Food fights: winning the nutritional challenges of parenthood armed with insight, humor, and a bottle of ketchup, Elk Grove Village, IL, 2008, American Academy of Pediatrics; and Satter E: How to get your kid to eat … but not too much, Boulder, CO, 1987, Bull Publishing Co.
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Health Problems of Toddlers and Preschoolers Cheryl C. Rodgers, Rose U. Baker, Mary A. Mondozzi
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Sleep Problems The preschool years are a prime time for sleep disturbances. Children may have trouble going to sleep, wake during the night, have difficulty resuming sleep after waking during the night, have nightmares or sleep terrors, or prolong the inevitable bedtime through elaborate rituals. Such sleep disturbances are typically related to increasing autonomy, negative sleep associations, nighttime fears, inconsistent bedtime routines, and lack of limit setting (Babcock, 2011).
Media use can also contribute to sleep disturbances. Research has revealed a direct correlation between sleep problems in preschool children and evening media use, as well as daytime exposure to violent media content (Garrison, Liekweg, and Christakis, 2011). Specific sleep problems associated with media use include delayed sleep onset, nightmares, night wakings, daytime tiredness, and difficulty waking in the morning (Garrison, Liekweg, and Christakis, 2011). In addition to limiting the duration of television viewing and other media exposure, parents should ensure that all types of media are age appropriate and are not too frightening or overstimulating.
Consequences of inadequate sleep include daytime tiredness, behavior changes, hyperactivity, difficulty concentrating, impaired learning ability, poor control of emotions and impulses, and strain on family relationships (Bhargava, 2011). Nurses should incorporate assessment of sleep patterns and education about the development of healthy sleep behaviors into every well-child visit. Recommendations for handling a sleep disturbance are offered only after a thorough assessment. Cultural traditions may dictate sleep practices contrary to certain well-accepted professional recommendations. Thus parents may not perceive particular sleep habits as problematic (see Cultural Considerations box).
C u l t u r a l C o n s i d e r a t i o n s Co-Sleeping
Many experts recommend that infants and children be trained to always sleep in their own crib or bed. However, co-sleeping, or the “family bed” (in which parents allow the children to sleep with them), is an accepted cultural practice among many African-American, and Asian families (Ward and Doering, 2014; Mindell, Sadeh, Kohyama, et al, 2010). Others who have adopted co-sleeping include parents who believe that co-sleeping promotes parent-child bonding, parents who think that co-sleeping diminishes their child's nighttime fears or other sleep disturbances, and mothers who are breastfeeding. Co-sleeping may be a practical solution to limited numbers of bedrooms or beds in lower-socioeconomic families. Controversy exists regarding the medical, developmental, and social advantages and disadvantages of co-sleeping. Studies have indicated that co-sleeping is associated with sleep problems, such as frequent night wakings, poor sleep quality, and decreased length of sleep (Mindell, Sadeh, Kohyama, et al, 2010). Parents who are considering co-sleeping should fully investigate the potential risks and benefits. Health care providers should be proactive in discussing sleeping arrangements with families at each visit to ensure children's safety and healthy sleep habits.
Interventions differ greatly; for example, nightmares and sleep terrors require different approaches (Table 13-1). For children who delay going to bed, a recommended approach involves counseling consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Parents should ignore attention-seeking behavior, and the child should not be taken into the parents' bed or allowed to stay up past a reasonable hour. Other measures that may be helpful include keeping a light on in the room, providing transitional objects such as a favorite toy, or leaving a drink of water by the bed.
TABLE 13-1 Comparison of Nightmares to Sleep Terrors
Characteristics Nightmares Sleep Terrors Description A scary dream; takes place during REM sleep
and is followed by full waking A partial arousal from very deep sleep (state IV, non-REM) sleep
Time of distress After dream is over, child wakes and cries or During terror itself, as child screams and thrashes; afterward is calm
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calls; not during nightmare itself Time of occurrence
In second half of night, when dreams are most intense
Usually 1 to 4 hours after falling asleep, when non-REM sleep is deepest
Child's behavior Crying in younger children, fright in all; behaviors persistent even though child is awake
Initially may sit up, thrash, or run in bizarre manner, with eyes bulging, heart racing, and profuse perspiring; may cry, scream, talk, or moan; shows apparent fright, anger, or obvious confusion, which disappears when child is fully awake
Responsiveness to others
Is aware of and reassured by another's presence
Is not very aware of another's presence, is not comforted, and may push person away and scream and thrash more if held or restrained
Return to sleep May be considerably delayed because of persistent fear
Usually rapid; often difficult to keep child awake
Description of dream interventions
Yes (if old enough) Accept dream as real fear Sit with child; offer comfort, assurance, and
sense of protection Avoid forcing child back to his or her own bed Consider professional counseling for recurrent
nightmares unresponsive to above approaches
No memory of dream or of yelling or thrashing Observe child for a few minutes, without interfering, until child becomes calm or wakes fully Intervene only if necessary to protect child from injury Guide child back to bed if needed Stress to parents that sleep terrors are a normal, common phenomenon in preschoolers that requires relatively little
intervention
REM, Rapid eye movement. Modified from Haupt M, Sheldon SH, Loghmanee D: Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder, Pediatric Annals, 42(10), 211-216, 2013.
Helping children slow down before bedtime also reduces resistance to going to bed. One approach is to establish soothing, limited rituals that signal readiness for bed, such as a bath or story. Parents can reinforce the pattern by stating, “After this story, it is bedtime,” and consistently carrying through the routine. If anticipated extra stimulation (e.g., having visitors arrive at the children's bedtime) disrupts this routine, it is advisable to settle children in bed beforehand.
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Skin Disorders Related to Chemical or Physical Contacts Contact Dermatitis Contact dermatitis is an inflammatory reaction of the skin to chemical substances, natural or synthetic, that evoke a hypersensitivity response or direct irritation. The initial reaction occurs in an exposed region, most commonly the face and neck, backs of the hands, forearms, male genitalia, and lower legs. There is a characteristically sharp demarcation between inflamed and normal skin that ranges from a faint, transient erythema to massive bullae on an erythematous swollen base. Itching is a constant symptom.
The cause may be a primary irritant or a sensitizing agent. A primary irritant is one that irritates any skin. A sensitizing agent produces an irritation on those individuals who have encountered the irritant or something chemically related to it, have undergone an immunologic change, and have become sensitized. A sensitizer irritates in relatively low concentrations only persons who are allergic to it.
The major goal in treatment is to prevent further exposure of the skin to the offending substance. Provided there is no further irritation, the skin's normal recuperative powers will produce healing without medical treatment. The most frequent offenders are plant and animal irritants (see discussion later). In infants, the most common contact dermatitis occurs on the convex surfaces of the diaper area. Other agents that produce contact dermatitis include animal irritants (wool, feathers, and furs), metal (nickel found in jewelry and the snaps on sleepers and denim), vegetable irritants (oleoresins, oils, and turpentine), pet dander, dyes, cosmetics, perfumes, and soaps (including bubble baths).
Nursing Care Management Nurses frequently detect evidence of contact dermatitis during routine physical assessments. Skin manifestations in specific areas suggest limited contact, such as around the eyes (mascara), areas of the body covered by clothing but not protected by undergarments (wool), or areas of the body not covered by clothing (ultraviolet [UV] injury). Generalized involvement is more likely to be caused by bubble bath, laundry soap, body soap, or lotion. Often nurses can determine the offending agent and counsel families regarding management. If the lesions persist, are extensive, or show evidence of infection, medical evaluation is indicated.
Poison Ivy, Oak, and Sumac Contact with the dry or succulent portions of any of three poisonous plants (ivy, oak, and sumac) produces localized, streaked or spotty, inflamed, oozing, and painful impetiginous lesions that are often highly urticarial. The offending substance in these plants is an oil and urushiol that is extremely potent. Sensitivity to urushiol is not inborn but is developed after one or two exposures and may change over a lifetime. All parts of the plants contain the oil, including dried leaves and stems (Fig. 13-1, A). Even smoke from burning brush piles can produce a reaction.
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FIG 13-1 A, Development of allergic contact dermatitis. B, Poison ivy lesions; note the “streaked” blisters surrounding one large blister. (A, From Damjanov I, Linder J: Anderson's pathology, ed 10, St Louis, 1996, Mosby/Elsevier. B,
From Habif TP: Clinical dermatology: a color guide to diagnosis and therapy, ed 5, St Louis, 2010, Mosby/Elsevier.)
Animals do not seem to be affected by the oil; however, dogs or other animals that have run or played in the plants may carry the sap on their fur, and animals that eat the plants can transfer the oil in their saliva. Shoes, tools, and toys can transfer the oil. Golf balls that have been in the rough are another source of contact.
Urushiol has an effect as soon as it touches the skin. It penetrates through the epidermis as a mixture of compound molecules called catechols. These catechols bond skin proteins and initiate an immune response. The full-blown reaction is evident after about 2 days, with redness, swelling, and itching at the site of contact. Several days later, streaked or spotty blisters oozing serum from damaged cells produce the characteristic impetiginous lesions (see Fig. 13-1, B). The lesions dry and heal spontaneously, and the itching stops by 10 to 14 days.
Therapeutic Management Treatment of the lesions includes application of calamine lotion, soothing Burow solution compresses, and/or Aveeno baths to relieve discomfort. Topical corticosteroid gel is effective for prevention or relief of inflammation, especially when applied before blisters form. Oral corticosteroids may be needed for severe reactions and those affecting the face, throat, or genital region, and a sedative (such as diphenhydramine) may be ordered.
Nursing Care Management
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The earlier the skin is cleansed, the greater the chance of removing the urushiol before it attaches to the skin. When the child has made contact with the plant, the area is immediately flushed (preferably within 15 minutes) with cold running water to neutralize the urushiol not yet bonded to the skin. Once the oil has been removed from the skin, the allergen has been neutralized. The rash that results from poison ivy cannot be spread to another child; only direct contact with the oil can cause the response. Use of harsh soap and scrubbing the exposed skin is contraindicated because it removes protective skin oils and dilutes the urushiol, allowing it to spread. All clothing that has come in contact with the plant is removed with care and thoroughly laundered in hot water and detergent. Every effort is made to prevent the child from scratching the lesions. Although the lesions do not spread by contact with the blister serum or from scratching, they can become secondarily infected.
Prevention Prevention is best accomplished by avoiding contact and removing the plant from the environment. Teach all children, especially those known to be sensitive, to recognize the plant. Information regarding means for safe removal or destroying poisonous plants can be obtained from the US Department of Agriculture or US Forestry Service. Home garden sprays that kill broad-leaf plants or all vegetation (e.g., Roundup or Spectracide) are ineffective in permanently eliminating poison ivy growth. If poisonous plants are growing in public community area, the local authorities should be contacted to remove the plants.
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Skin Disorders Related to Animal Contacts Arthropod Bites and Stings Arthropods include insects and arachnids, such as mites, ticks, spiders, and scorpions. Most arthropods in the United States, including tarantulas, are relatively harmless. All spiders produce venom that is injected via fangs, some are unable to pierce the skin, and others produce venom that is insufficiently toxic to be harmful. Only scorpions and two spiders—the brown recluse and the black widow—inject venom deadly enough to require immediate attention. Children bitten by these arachnids must receive medical attention as soon as possible. Major offending creatures, their manifestations, and management are outlined in Table 13-2. A brown recluse spider bite is shown in Fig. 13-2.
TABLE 13-2 Skin Lesions Caused by Arthropods
Mechanism and Characteristic Manifestations Management Insect Bites: Flies, Gnats, Mosquitoes, Fleas Mechanism: Foreign protein in insects' saliva
introduced when skin is penetrated for a blood meal
Distribution: Almost everywhere—fleas, mosquitoes, ants Suburbs and rural areas—bees Urban areas—hornets, wasps, yellow jackets
Hypersensitivity reaction Papular urticaria Firm papules; may be capped by vesicles or
excoriated Little or no reaction in non-sensitized person
Treatment: Use antipruritic agents and baths. Administer antihistamines. Prevent secondary infection. Prevention:
Avoid contact. Remove focus, such as treating furniture, mattresses, carpets, and pets, where
insects may live. Apply insect repellent when exposure is anticipated.
Chiggers: Harvest Mites Mechanism: Attach with claws and secrete a
digestive substance that liquefies the host's epidermis
Erythematous papules Intense itching Favor warm areas of body, especially intertriginous
areas and areas covered with clothing
Treatment: May require systemic steroids for extensive bites. Prevention:
Avoid contact, especially in areas of tall grass and underbrush. Apply insect repellant when exposure is anticipated. Spray insecticides such as diazinon in yards.
Hymenopterans: Bees, Wasps, Hornets, Yellow Jackets, Fire Ants Mechanism:
Injection of venom through stinging apparatus Venom contains histamine; allergenic proteins;
and often a spreading factor, hyaluronidase Severe reactions caused by hypersensitivity or
multiple stings
Local reaction: Small red area, wheal, itching, and heat
Systemic reactions: May be mild to severe, including generalized edema, pain, nausea and vomiting, confusion, respiratory impairment, and shock
Treatment: Carefully scrape off stinger or pull out stinger as quickly as possible. Cleanse with soap and water. Apply cool compresses. Apply common household product (e.g., lemon juice, paste made with aspirin or
baking soda). Administer antihistamines. Severe reactions: Administer epinephrine, corticosteroids; treat for shock. Prevention:
Teach child to wear shoes; to avoid wearing bright clothing, flowery prints, shiny jewelry, or perfumed grooming products (cologne, scented hairspray), which might attract the insect; and to avoid places where the insect may be contacted.
Hypersensitive children should wear medical identification to indicate allergy and therapy needed; family should keep emergency medication and be taught its administration.
Black Widow Spider Mechanism: Venom injected through a clawlike
appendage; has neurotoxic action Characteristics:
Shiny black spider, with a body about 1.25 cm (0.5 inch) long and a red or orange hourglass- shaped marking on underside
Avoids light and bites in self-defense
Mild sting at time of bite Area becomes swollen, painful, and erythematous Dizziness, weakness, and abdominal pain Possible delirium, paralysis, seizures, and (if large
amount of venom absorbed) death
Treatment: Cleanse wound with antiseptic. Apply cool compresses. Administer antivenin. Administer muscle relaxant, such as calcium gluconate; analgesics or sedatives;
hydrocortisone or diazepam intravenously. Prevention: Teach children to avoid places that harbor the spider (e.g.,
woodpiles). Brown Recluse Spider Mechanism:
Venom injected via fangs Venom contains powerful necrotoxin Characteristics:
Slender spider, with long legs and body length of 1 to 2 cm (0.4 to 0.8 inch); color is fawn to dark brown; recognized by fiddle-shaped mark on head
Shy; bites only when annoyed or surprised Prefers dark areas where seldom disturbed
Mild sting at time of bite Transient erythema followed by bleb or blister; mild
to severe pain in 2 to 8 hours; purple, star-shaped area in 3 to 4 days; necrotic ulceration in 7 to 14 days
Systemic reactions may include fever, malaise, restlessness, nausea, vomiting, and joint pain
Generalized petechial eruption Wounds heal with scar formation
Treatment: Apply cool compresses locally. Administer antibiotics, corticosteroids. Relieve pain. Wound may require skin graft. Prevention: Teach children to avoid possible nesting sites.
Scorpions Mechanism:
Venom injected via a hooked caudal stinger Venom of more venomous species contains
hemolysins, endotheliolysins, and neurotoxins Characteristics: Usual habitat southwestern United
States
Intense local pain, erythema, numbness, burning, restlessness, vomiting
Ascending motor paralysis with seizures, weakness, rapid pulse, excessive salivation, thirst, dysuria, pulmonary edema, coma, and death
Some species produce only local tissue reaction with swelling at puncture site (distinctive)
Symptoms subside in a few hours Deaths occur among children younger than 4 years
old, usually in first 24 hours
Treatment: Delay absorption of venom by keeping child quiet; place involved area in
dependent position. Administer antivenin. Relieve pain. Admit to pediatric intensive care unit for surveillance. Prevention: Teach children to avoid possible nesting sites.
Ticks Mechanism: In process of sucking blood, head and
mouth parts are buried in skin Characteristics:
Feed on blood of mammals Significant in humans because of pathologic
organism carried May be vectors of various infectious diseases,
such as Rocky Mountain spotted fever, Q fever, tularemia, relapsing fever, Lyme disease, tick paralysis
Must attach and feed for 1 to 2 hours to transmit disease
Usual habitat is wooded area
Tick usually attached to skin, head embedded Firm, discrete, intensely pruritic nodules at site of
attachment May cause urticaria or persistent localized edema
Treatment: Grasp tick with tweezers (forceps) as close as possible to point of attachment. Pull straight up with steady, even pressure; if bare hands, use a tissue to touch
tick during removal; wash hands thoroughly with soap and water. Remove any remaining part (e.g., head) with sterile needle. Cleanse wounds with soap and disinfectant. Prevention:
Teach children to avoid areas where prevalent. Inspect skin (especially scalp) after being in wooded areas.
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FIG 13-2 Brown recluse spider bite. Note the central necrosis surrounded by purplish area and blisters. (From Weston WL, Lane AT: Color textbook of pediatric dermatology, ed 4, St Louis, 2007, Mosby/Elsevier.)
When a hymenopteran (bees in particular) stings, its barbed stinger penetrates the skin. As long as the stinger remains in the skin, the muscles push the stinger deeper, and the venom is pumped into the wound. The best approach is to remove the stinger as quickly as possible; the longer the time interval, the greater the amount of venom. Children who have become sensitized to hymenopteran bites may demonstrate a severe systemic response that can be life threatening. One sting can produce generalized urticaria, respiratory difficulty (from laryngeal edema), hypotension, and death. Intramuscular administration of epinephrine provides immediate relief and must be available for emergency use.
Hypersensitive children should wear a medical identification bracelet. They should also have a kit that contains epinephrine and a hypodermic syringe (i.e., Epi Pen). Families are reminded to check the expiration date on the kit and to replace an outdated one. They should determine whether a nurse is available at the school and find out what the school policy is regarding administration of drugs. If a school nurse is not present, someone at the school should be designated to inject the epinephrine in case of an emergency.
Pet and Wild Animal Bites Animal bites are common in childhood. Wild animal bites are discussed in relation to rabies in Chapter 27. The present discussion is directed primarily toward dog bites, because most animal bites to children are caused by dogs. Cat bites are less frequent, although cat scratches are extremely common (see Cat Scratch Disease, Chapter 6).
Most dog or cat injuries are to the upper extremities. Small children are likely to be bitten or scratched on the head, face, and neck because they tend to put their heads near the animal's head and flail their arms rather than protecting their heads. Most dogs involved are owned by the family of the victim or by a neighbor. Injuries vary in intensity from small puncture wounds to complete evulsion of tissue that is associated with significant crush injury.
Therapeutic Management General wound care consists of rinsing the wound with copious amounts of saline or lactated Ringer solution under pressure via a large syringe and of washing the surrounding skin with mild soap. A clean pressure dressing is applied, and the extremity is elevated if the wound is bleeding. Medical evaluation is advised because of the danger of tetanus and rabies, although dogs in most urban areas must be immunized against rabies. Bites from wild animals, such as bats, raccoons, foxes, and skunks, are potentially dangerous.
Prophylactic antibiotics are indicated for puncture wounds and wounds in areas where infection could result in cosmetic (face) or functional impairment (hand). Extensive lacerations are debrided and may be loosely sutured to allow drainage in the event of infection. Tetanus toxoid is administered according to standard guidelines (see Chapter 6), and rabies protocol is followed in case of a wild animal bite (see Rabies, Chapter 27). Injuries to poorly vascularized areas, such as the hands, are more likely to become infected than those in more vascularized areas, such as the face; puncture wounds are more likely to become infected than lacerations.
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Nursing Care Management The most important aspect related to animal bites is prevention. Children should understand animal behavior and develop respect for animals. Parents should monitor their children's behavior with dogs and instruct them not to tease or surprise dogs, invade their territory, interfere with their feeding or sleeping, take their toys, or interact with sick or injured dogs or dogs with pups. Parents who are considering getting a pet, especially a dog, for themselves or their children should select a dog that has a high level of sociability with, and is unlikely to be a danger to, children.
Human Bites Children often acquire lacerations from the teeth of other humans in rough play, during fights, or as victims of child abuse. Because human dental plaque and gingiva harbor pathogenic organisms, all human bites should receive immediate medical attention. Delayed treatment increases the risk of infection.
The wound is washed vigorously with soap and water, and a pressure dressing is applied to stop bleeding. Ice applications minimize discomfort and swelling. Tetanus toxoid is needed if the child is insufficiently immunized. Wounds larger than 6 mm should receive medical attention.
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Thermal Injury Burns Burn injuries are usually attributed to extreme heat sources but may also result from exposure to cold, chemicals, electricity, or radiation. Most burns are relatively minor and can be treated in an outpatient setting. However, burns involving a large body surface area, critical body parts, or the geriatric or pediatric population often benefit from treatment in specialized burn centers. The American Burn Association has established criteria to guide decisions regarding the severity of injury and the need for transfer for specialized care.*
The extent of tissue destruction is determined by the intensity of the heat source, the duration of contact or exposure, the conductivity of the tissue involved, and the rate at which the heat energy is dissipated by the skin. A brief exposure to high-intensity heat from a flame can produce burn injuries similar to those induced by long exposure to less intense heat in hot water.
When burns are categorized according to the patient's age and type of injury, the following patterns become apparent: (1) hot-water scalds are most frequent in toddlers, (2) flame-related burns are more common in older children, (3) children playing with matches or lighters account for 1 in 10 house fires, and (4) nonaccidental burns indicate maltreatment.
Nonaccidental injury due to maltreatment most commonly occurs in children 3 years old and younger. With nonaccidental injury, scald burns are the most common followed by contact burns. Thirty percent of children suffering recurrent burn injury are eventually fatally injured (Tropez- Arceneaux and Tropez-Sims, 2012). Child abuse should be suspected if the burn distribution on the body is inconsistent with the reported incident or with the child's developmental level, and there was a delay in seeking treatment.
Characteristics of Burn Injury The physiologic responses, treatment modalities, prognosis, and disposition of the injured child are all directly related to the amount of tissue destroyed. Therefore the severity of the burn injury is assessed on the basis of the percentage of total body surface area (TBSA) burned and depth of the burn. Among children in the school-age group or younger age groups, a burn that is 10% TBSA can be life threatening if not treated correctly. Other important factors in determining the seriousness of the injury are the child's age and general health, the causative agent, the location of the wounds, the presence of respiratory involvement, and any associated injury or condition.
Type of Injury The majority of burns result from contact with thermal agents, such as a flame, hot surfaces, or hot liquids. Of those children who die from fire or burns, 44% were ages 4 and under; and of all children deaths due to fire and burns, 87% were involved in a residential home fire (Safe Kids Worldwide, 2015). Electrical injuries caused by household current have the greatest incidence in young children, who insert conductive objects into electrical outlets and bite or suck on connected electrical cords (Pruitt, Wolf, and Mason, 2012). These burns occur most commonly during the spring and summer months and are also associated with risk-taking behaviors in boys. Direct contact with high- or low-voltage current, as well as lightning strikes, is the most frequent mechanism of injury. Trauma results from resistance of the tissue and path of electric current through tissue, muscle compartments, nerves, and vital organs. Criteria for admission, as derived from evidence-based practice for electrical burn injuries, includes a history of loss of consciousness, electrocardiographic (ECG) changes, 10% TBSA affected, or the need for monitoring an affected extremity. Cardiac monitoring is therefore included in standard burn care when ECG changes are identified on admission (Arnoldo, Klein, and Gibran, 2006).
Chemical burns are seen in the pediatric population and can cause extensive injury because noxious agents exist in many cleaning products commonly found in the home. The severity of injury is related to the chemical agent (acid, alkali, or organic compound) and the duration of contact. The mechanism of injury differs from other burns in that there is a chemical disruption and alteration of the physical properties of the exposed body area. In addition to concern for localized damage, the potential for systemic toxicity must be addressed, including exposure of the eyes to chemical agents, the ingestion of caustic substances, and inhalation of toxic gases produced from
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chemicals.
Extent of Injury The extent of a burn is expressed as a percentage of the TBSA. This is most accurately estimated by using specially designed age-related charts (Fig. 13-3). It is more efficient to use a chart designed to assign body proportions to children of different ages.
FIG 13-3 Estimation of distribution of burns in children. A, Children from birth to 5 years old. B, Older children.
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Depth of Injury A burn is a three-dimensional wound that is also assessed in relation to depth of injury. Traditionally, the terms first, second, and third degree have been used to describe the depth of tissue injury. However, with the current emphasis on wound healing, these have been replaced by more descriptive terms based on the extent of destruction to the epithelializing elements of the skin (Fig. 13-4).
FIG 13-4 Classification of burn depth according to depth of injury. (From Black JM: Medical-surgical nursing: clinical management for positive outcomes, ed 8, Philadelphia, 2008, Saunders/Elsevier.)
Superficial (first-degree) burns are usually of minor significance. This type of injury involves the epidermal layer only. There is often a latent period followed by erythema. Tissue damage is minimal, and there is no blistering. The protective functions of the skin (such as bacterial and vapor barrier) remain intact, and systemic effects are rare. Pain is the predominant symptom, and the burn heals in 5 to 10 days without scarring. A mild sunburn is an example of a superficial burn.
Partial-thickness (second-degree) burns involve the epidermis and varying degrees of the dermal layer. These wounds are painful, moist, red, and blistered. With superficial partial-thickness burns, dermal elements are intact, and the wound should heal in approximately 14 to 21 days with variable amounts of scarring (Fig. 13-5). The wound is extremely sensitive to temperature changes, exposure to air, and light touch. Although classified as second-degree or partial-thickness burn, deep dermal burns resemble full-thickness injuries in many respects except that sweat glands and hair follicles remain intact. The burn may appear mottled, with pink, red, or waxy white areas exhibiting blisters and edema formation. Systemic effects are similar to those encountered with full- thickness burns. Although many of these wounds heal spontaneously, healing time may be extended beyond 21 days. These burn wounds often heal with extensive scarring.
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FIG 13-5 Superficial partial-thickness burns on an African-American child. A, Blisters intact. B, Blisters removed. (Courtesy of Hillcrest Medical Center, Tulsa, OK.)
Full-thickness (third-degree) burns are serious injuries that involve the entire epidermis and dermis and extend into subcutaneous tissue (see Fig. 13-4). Nerve endings, sweat glands, and hair follicles are destroyed. The burn varies in color from red to tan, waxy white, brown, or black. It is distinguished by a dry, leathery appearance and texture since the elasticity of the dermis is compromised (Fig. 13-6). Normally, full-thickness burns lack sensation in the area of injury because of the destruction of nerve endings. However, most full-thickness burns have superficial and partial-thickness burned areas at the periphery of the burn, where nerve endings are intact and exposed. As the peripheral fibers regenerate, painful sensations return. Consequently, children often experience severe pain related to the size and depth of the burn. Full-thickness wounds are not capable of re-epithelialization and require surgical excision and grafting to close the wound.
FIG 13-6 Bottom to top: Deep partial-thickness burn (red area), full-thickness burn (white area), and full- thickness burn with eschar (brown area). (Courtesy of Hillcrest Medical Center, Tulsa, OK.)
Fourth-degree burns are full-thickness burns that involve underlying structures, such as muscle,
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fascia, and bone. The wound appears dull and dry, and ligaments, tendons, and bone may be exposed (Fig. 13-7).
FIG 13-7 Full-thickness burn with muscle and fascia involved. (Courtesy of Hillcrest Medical Center, Tulsa, OK.)
Severity of Injury Burns are classified as minor, moderate, or major, which is useful in determining the disposition of the patient for treatment. The extent and depth of the burn (Table 13-3), the causative agent, the body area involved, the patient's age, and concomitant injuries and illnesses determine the severity of the injury.
TABLE 13-3 Severity Grading System Adopted by the American Burn Association
Minor* Moderate Major Partial-thickness burns (% TBSA) <10 10 to 20 >20 Full-thickness burns All Treatment Usually outpatient; may require 1- to 2-day admission Admission to hospital, preferably one with expertise in burn care Admission to a burn center
*Minor burns exclude any burn involving the face, hands, feet, perineum or crossing joints; electrical burns; any injury complicated by the presence of inhalation injury or concomitant trauma; and children with psychosocial factors affecting the injury. TBSA, Total body surface area. From Vaccaro P, Trofino RB: Care of the patient with minor to moderate burns. In Trofino RB, editor: Nursing care of the burn- injured patient, Philadelphia, 1991, FA Davis.
Because the skin of infants is so thin, they are likely to sustain deeper injuries compared with older children. Children younger than 2 years old, especially 6 months old or younger, have a significantly higher mortality rate than older children with burns of similar magnitude. Acute or chronic illnesses or superimposed injuries also complicate burn care and response to treatment.
Inhalation Injury Trauma to the tracheobronchial tree often follows inhalation of heated gases and toxic chemicals produced during combustion. Although direct thermal injury to the upper airway may occur, heat damage below the vocal cords is rare. Inspired heated air is cooled in the upper airway before reaching the trachea. Reflex closure of the cords and laryngospasm also prevent full inhalation. However, evidence of direct thermal injury to the upper airway includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed as long as 24 to 48 hours. Wheezing, increasing secretions, hoarseness, wet rales, and carbonaceous secretions are signs of respiratory tract involvement. Upper airway obstruction is often associated with burn shock and fluid resuscitation. In such situations, endotracheal intubation may also be necessary to preserve a patent airway.
Inhalation of carbon monoxide is suspected when the injury has occurred in an enclosed space. Mucosal erythema and edema followed by sloughing of the mucosa are manifestations of respiratory tract injury. A mucopurulent membrane replaces the mucosal lining and seriously compromises respiration and ventilation. A significant increase in mortality has been observed
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when inhalation injury and pneumonia are both present.
Pathophysiology Burn injuries produce both local and systemic effects that are related to the extent of tissue destruction. In superficial burns, the tissue damage is minimal. In partial-thickness burns, there is considerable edema and more severe capillary damage. With a major burn greater than 30% TBSA, there is a systemic response involving an increase in capillary permeability, allowing plasma proteins, fluids, and electrolytes to be lost. Maximum edema formation in a small burn occurs about 8 to 12 hours after injury. After a larger burn, hypovolemia, associated with this phenomenon, will slow the rate of edema formation, with maximum effect at 18 to 24 hours.
Another systemic response is anemia, caused by direct heat destruction of red blood cells (RBCs), hemolysis of injured RBCs, and trapping of RBCs in the microvascular thrombi of damaged cells. A long-term decrease in the number of RBCs may occur as a result of increased RBC fragility. Initially, there is an increased blood flow to the heart, brain, and kidneys, with decreased blood flow to the gastrointestinal tract. There is an increase in metabolism to maintain body heat, providing for the increased energy needs of the body.
Complications Burn injured children are subject to a number of serious complications resulting both from the burn and systemic alterations. The immediate threat to life is related to airway compromise and profound burn shock. Burn shock is in the immediate post-burn period and is marked by dramatic alterations in circulation. With fluid loss through denuded skin, capillary permeability increases and vessels become dilated. Circulating blood volume decreases rapidly and cardiac output is reduced. During healing, infection—both local and systemic sepsis—is the primary complication. Mortality associated with burns in children increases with the severity of injury and decreases as age advances. In children older than 3 years old, the mortality rate is similar to that of adults. Below this age, the survival rate with burns and their associated complications lessens considerably.
A less apparent respiratory tract injury is inhalation of carbon monoxide. Carbon monoxide has a greater affinity for hemoglobin than does oxygen, thereby depriving peripheral tissues and oxygen- dependent organs (e.g., the heart and brain) of the oxygen needed for survival. Treatment for either of these two problems is 100% oxygen, which reverses the situation rapidly.
Pulmonary problems are a major cause of fatality in children with either direct burns or result in complications in the respiratory tract. Early in the post-burn period, most pulmonary infections result from nosocomial exposure, immobility, and abdominal distention. The hematogenous variety occurs later and is related to the septic burn wound or other foci, such as phlebitis at the site of an invasive intravenous (IV) line. Respiratory problems include inhalation injuries, aspiration in unconscious patients, bacterial pneumonia, pulmonary edema, pulmonary embolus, posttraumatic pulmonary insufficiency, and atelectasis. The most common cause of respiratory failure in the pediatric age group is bacterial pneumonia, which requires prolonged intubation and sometimes a tracheostomy. Tracheostomies increase the incidence of serious complications and are performed only in extreme cases.
A less common complication is pulmonary edema resulting from fluid overload or acute respiratory distress syndrome (ARDS) in association with gram-negative sepsis. ARDS results from pulmonary capillary damage and leakage of fluid into the interstitial spaces of the lung. A loss of compliance and interference with oxygenation are the consequences of pulmonary insufficiency in conjunction with systemic sepsis.
Wound Sepsis Sepsis is a critical problem in the treatment of burns and an ever-present threat after the burn shock phase. Decreased level of consciousness and lethargy are early signs of sepsis. Initially, burn wounds are relatively pathogen free unless they are contaminated with potentially infectious material, such as dirt or polluted water. However, dead tissue and exudate provide a fertile field for bacterial growth. On approximately the third post-burn day, early colonization of the wound surface by a preponderance of gram-positive organisms (primarily staphylococci) changes to predominantly gram-negative opportunistic organisms, particularly Pseudomonas aeruginosa. By the fifth post-burn day, bacterial invasion is well under way beneath the surface of the burn wound. Early surgical excision of eschar together with placement of autograft reduces the incidence of
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sepsis.
Therapeutic Management
Emergency Care The initial management of the burn patient begins at the scene of injury. The first priority is to stop the burning process (see Emergency Treatment box). The child should then be transported immediately to the nearest medical facility for treatment and evaluation. The child and the family are usually extremely frightened and anxious; sensitivity to their emotional state and reassurance should be provided during the transport process.
E m e r g e n c y T r e a t m e n t Burns
Minor Burns
Stop the burning process:
• Remove burned clothing and jewelry.
• Apply cool water to the burn or hold the burned area under cool running water.
• Do not use ice.
Do not disturb any blisters that form unless the injury is from a chemical substance.
Do not apply anything to the burn.
Cover with a clean cloth if risk of damage or contamination.
Major Burns
Stop the burning process:
• Flame burns—smother the fire.
• Place victim in the horizontal position.
• Roll victim in a blanket or similar object; avoid covering the head.
• Remove burned clothing and jewelry.
Assess for an adequate airway and breathing.
If a child is not breathing, begin mouth-to-mouth resuscitation.
Cover burn with a clean cloth.
Keep victim warm.
Begin intravenous (IV) and oxygen therapy as prescribed.
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Transport to medical aid.
Stop the burning process. The chief aim of rescue in flame burns is to smother the fire, not fan it. Children tend to panic and run, which spreads the flames and makes assistance more difficult. The burned child should be placed in a horizontal position and rolled in a blanket, rug, or similar article, with care taken not to cover the head and face because of the danger of inhalation of toxic fumes. If nothing is available, the victim should lie down and roll over slowly to extinguish the flames. Remaining in the vertical position may cause the hair to ignite or the inhalation of flames, heat, or smoke.
Major burns with large amounts of denuded skin should not be cooled. Heat is rapidly lost from burned areas, and additional cooling leads to a drop in core body temperature and potential circulatory collapse. Wet dressings also promote vasoconstriction because of cooling, resulting in impaired circulation to the burned area and increased tissue damage. Chemical burns require continuous flushing with large amounts of water before transport to a medical facility. The use of neutralizing agents on the skin is contraindicated, because a chemical reaction is initiated and further injury may result. If the chemical is in powder form, the addition of water may spread the caustic agent. The powder should be brushed off if possible before flushing the area.
Burned clothing is removed to prevent further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. This also provides access to the burn and prevents painful removal later.
Assess the victim's condition. As soon as the flames are extinguished, the child is assessed. Airway, breathing, and circulation are the primary concerns. Cardiopulmonary complications may result from exposure to electric current, inhalation of toxic fumes and smoke, hypovolemia, and shock. Emergency measures are instituted as appropriate.
Cover the burn. The burn should be covered with a clean dry cloth to prevent contamination, decrease pain by eliminating air contact, and prevent hypothermia. No attempt should be made to treat the burn. Application of topical ointments, oils, or other home remedies is contraindicated.
Transport the child to medical aid. The child with an extensive burn is not given anything by mouth to avoid aspiration in the presence of paralytic ileus and upper airway edema and to prevent water intoxication. The child is transported to the nearest medical facility. If this cannot be accomplished within a relatively short period, IV access should be established, if possible, with a large-bore catheter. Oxygen is administered, if available, at 100%. A report of the initial assessment, associated trauma, and any interventions implemented is given to the medical facility assuming care of the child.
Provide reassurance. Providing reassurance and psychological support to both the family and the child helps immeasurably during the period of post-burn crisis. Reducing anxiety conserves energy the family and child will need to cope with the physiologic and emotional stress of a burn.
Minor Burns Treatment of burns classified as minor can usually be managed adequately on an outpatient basis when it is determined that the parent can be relied on to carry out instructions for care and observation. Patients with less than optimum circumstances may require close follow-up to ensure adherence with treatment.
The burn is cleansed with a mild soap and tepid water. Debridement of the burn includes removal of any embedded debris, chemicals, and devitalized tissue. Removal of intact blisters remains controversial. Some authorities argue that blisters provide a barrier against infection; others maintain that blister fluid is an effective medium for the growth of microorganisms. However, blisters should be broken if the burn is due to a chemical agent to control absorption. Most practitioners favor covering the burn with an antimicrobial ointment to reduce the risk of
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infection and to provide some form of pain relief. The dressing consists of non-adherent fine-mesh gauze placed over the ointment and a light wrap of gauze dressing that avoids interference with movement. This helps keep the burn clean and protect it from trauma. The caregiver is instructed to wash the burn, reapply the dressing, and return the child to the office or clinic as directed for burn wound observation. The frequency of dressing changes may vary from every other day to once a day.
Some practitioners prefer an occlusive dressing, such as a hydrocolloid, which is placed over the burn after cleansing. Hydrogel dressings, which are soothing and non-adherent, may also be used. The dressing is changed when leakage occurs—at regular intervals or at least weekly. This method eliminates the discomfort associated with frequent dressing changes but limits visualization of the burn surface.
If there is a high probability of infection or other complications or if there is doubt about the ability to carry out instructions, the caregiver may be directed to bring the patient in more often for dressing changes and inspection. Another option is to have a nurse make a home visit to inspect the burn and perform the dressing change. Frequent removal of the dressing is an effective mode of debridement. Soaking the dressing in tepid water or normal saline before removal helps loosen the dressing and debris as well as reducing discomfort. Burns of the face are usually treated by an open method. The burn is washed and debrided in the same manner and a thin film of antimicrobial ointment is applied to the skin without a dressing.
A tetanus history is obtained on admission. If there is no history of immunization or if more than 5 years have passed since the last immunization, tetanus prophylaxis is administered. A mild analgesic (such as acetaminophen) is usually sufficient to relieve discomfort; the antipyretic effect of the drug also alleviates the sensation of heat.
Most minor burns heal without difficulty; but if the burn margin becomes erythematous, gross purulence is noted, or the child develops evidence of systemic reaction (such as fever or tachycardia), hospitalization is indicated. The child should also be evaluated for functional impairment, and the caregiver should be instructed in the exercise and ambulation program. After healing, an evaluation of scar maturation and range of motion will indicate any need for further therapy.
Major Burns The first priority is airway maintenance. The inhalation of noxious agents or respiratory burns is suggested when there is a history of injury in an enclosed space; edema of the oral and nasal membranes; burn injury to the face, nares, and upper torso; hyperemia; and blisters or evidence of trauma to the upper respiratory passages. When respiratory involvement is suspected or evident, 100% oxygen is administered and blood gas values, including carbon monoxide levels, are determined.
If the child exhibits changes in sensorium, air hunger, or other signs of respiratory distress, an endotracheal tube is inserted to maintain the airway. When severe edema of the face and neck is anticipated, intubation is performed before swelling makes intubation difficult or impossible. Controlled intubation is preferred to an emergency intubation. Intubation allows for the delivery of humidified oxygen, the removal of secretions from respiratory passages, and the provision of ventilatory support. When full-thickness burns encircle the chest, constricting eschar (dead tissue) may limit chest wall excursion, and ventilation of the child becomes more difficult. Young children are particularly at risk because of the pliability of the skeletal structure. Escharotomy of the chest, where the eschar is incised through to the fatty tissue, relieves this constriction and improves ventilation.
Fluid replacement therapy. The objectives of fluid therapy are to (1) compensate for water and sodium lost to traumatized areas and interstitial spaces, (2) reestablish sodium balance, (3) restore circulating volume, (4) provide adequate perfusion, (5) correct acidosis, and (6) improve renal function.
Fluid replacement is required during the first 24 hours because of fluid shifts that occur after the burn. Various formulas are used to calculate fluid needs, and the one adopted depends on practitioner preference. Crystalloid solutions are used during this initial phase of therapy. Parameters (such as vital signs [especially heart rate], urinary output volume, adequacy of capillary filling, and state of sensorium) determine adequacy of fluid resuscitation.
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After the initial 24-hour period, theoretically there is a capillary seal, and capillary permeability is restored. Colloid solutions (such as albumin, Plasma-Lyte, or fresh-frozen plasma) are useful in maintaining plasma volume. However, children with burns usually require fluids in excess of their calculated maintenance and replacement volume. Reasons for this may include underestimation of burn size (particularly in pediatric patients), pulmonary injury that sequesters resuscitation fluid in the lung, electrical injury with greater tissue destruction than that which is visible, and a delay in the initiation of fluid resuscitation. Irreversible burn shock that persists despite aggressive fluid resuscitation remains a significant cause of death in the immediate post-burn period. Fluid balance may continue to be a problem throughout the course of treatment, especially during periods in which there may be considerable evaporative loss from the burn.
Nutrition. The enhanced metabolic requirements and catabolism in severe burns make nutritional needs of paramount importance and often difficult to satisfy. To avoid protein breakdown, the diet must provide sufficient calories to meet the increased metabolic needs and enough protein. Hypoglycemia can result from the stress of the burn because the liver glycogen stores are rapidly depleted.
A high-protein, high-calorie diet is encouraged. Many children have poor appetites and are unable to meet energy requirements solely by oral feeding. Oral feedings are encouraged unless the child is intubated or paralytic ileus persists. Most children with burns in excess of 25% TBSA require supplementation with tube feeding. Early and continued nutritional support is an important part of therapy for seriously burned patients. Children who require enteral supplementation must be monitored for adequacy of feeds, feeding intolerance and tube malposition. The nurse should also monitor and report any abdominal distention, diarrhea, or electrolyte and metabolic deviations. If nutritional requirements cannot be met entirely by the enteral route, parenteral hyperalimentation is used to supplement intake. However, enteral feeding increases blood flow in the intestinal tract, preserves gastrointestinal function, and minimizes bacterial translocation by decreasing mucosal atrophy of the intestines. These factors make enteral feeding the preferred route of nutritional support (Gauglitz, Finnerty, Herndon, et al, 2012).
To facilitate growth and proliferation of epithelial cells, administration of vitamins A and C is begun early in the post-burn period. Zinc is also supplemented because of its important role in burn healing and epithelialization.
Medication. Antibiotics are usually not administered prophylactically. The administration of systemic antibiotics to control wound colonization is not indicated because decreased circulation to the burned area prevents delivery of the medication to areas of deepest burn injury. Surveillance cultures and monitoring of the clinical course provide the most reliable indicators of developing infection. Appropriate antibiotics are instituted to treat the specific identified organism population (Gallagher, Branski, Williams-Bouyer, et al, 2012). Otitis media should not be overlooked as a source of fever in the pediatric patient.
Some form of sedation and analgesia is required in the care of burned children. Morphine sulfate is the drug of choice for severe burn injuries. Morphine has extensive distribution but is metabolized rapidly; continuous infusion or frequent administration is needed for pain management in burns. Morphine is administered intravenously and titrated to individual needs. The unstable circulatory status and edema formation preclude intramuscular or subcutaneous administration. When combined, midazolam (Versed) and fentanyl (Sublimaze) also provide excellent IV sedation and analgesia to control procedural pain in children with burns (Meyer, Wiechman, Woodson, et al, 2012). The oral form of fentanyl, Oralet, provides effective analgesia in a convenient form that children can suck. Dosage monitoring is important because tolerance to opioids may develop.
The use of short-acting anesthetic agents, such as propofol (Diprivan) and nitrous oxide, has proved beneficial in eliminating procedural pain. Pharyngeal reflexes remain intact, thus ensuring a patent airway. Propofol is an IV sedative hypnotic agent that produces sedation in less than 1 minute and lasts only a few minutes. For any conscious or unconscious sedation, the child must be monitored continuously during the procedure (see Preoperative Care, Chapter 20 and Pain, Chapter 5).
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Management of the burn wound. After the initial period of burn shock and the restoration of fluid balance, the primary concern is the burn itself. The objectives of burn management include prevention of infection, removal of devitalized tissue, and closure of the burn. The application of dressings and topical antimicrobial therapy reduce pain by minimizing the exposure to air.
Primary excision. In children with large, full-thickness burns, excision is performed as soon as the patient is hemodynamically stable after initial resuscitation. Because the burn wound precipitates an exaggerated physiologic response, many complications do not resolve until the eschar is excised and the wound is closed. Early excision of deep partial- and full-thickness burns reduces the incidence of infection and the threat of sepsis.
Debridement. Partial-thickness burns require debridement of devitalized tissue to promote healing. Debridement is painful and requires analgesia and a sedative before the procedure. IV analgesics are most effective when they are administered just before the onset of procedural pain (Meyer, Wiechman, Woodson, et al, 2012). Medications given for pain need to be readily available during this procedure and may need to be titrated up during the procedure.
Hydrotherapy is used to cleanse the burn and involves either showering (spraying off the burn) or immersion (soaking in a tub) at least once a day. Immersion hydrotherapy is becoming less common and is being replaced by shower hydrotherapy. The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Any loose tissue is carefully trimmed away before the burn is redressed. Hydrotherapy helps to cleanse not only the burn, but also the entire body and aids in maintenance of range of motion.
Topical antimicrobial agents. Methods used for managing the burn include: • Exposure: Burns are left open to air; crust forms on partial-thickness burns, and eschar forms on
full-thickness burns. • Open: Topical antimicrobial agent is applied directly to the burn surface and the burn is left
uncovered. • Modified: Antimicrobial agent is applied directly or impregnated into thin gauze and applied to
the burn; gauze or net secures the area. • Occlusive: Antimicrobial agent is impregnated in gauze or applied directly to the burn; multiple
layers of bulky gauze are placed over the primary layer and secured with gauze or net. All of these methods provide burn wound coverage and use some type of topical agent. Topical
agents do not eliminate organisms from the burn but can effectively inhibit bacterial growth. To be effective, a topical application must be nontoxic, capable of diffusing through eschar, harmless to viable tissue, inexpensive, and easy to apply. A topical ointment should not encourage the development of resistant strains of bacteria and should produce minimal electrolyte derangement. A variety of specific agents are available; examples include bacitracin, silver sulfadiazine (Thermazene), collagenase (Santyl), and mafenide acetate (Sulfamylon). Some topical agents are packaged and prepared on fine-meshed gauze that allows ease of application. The gauze provides necessary protection for the burn, maximizes patient comfort, increases rate of healing, decreases the necessity for frequent dressing changes, and is cost effective. Examples include a nanocrystalline film of pure silver (Acticoat), a hydrofiber with ionic silver (Aquacel Ag), a silicone foam dressing with silver (Mepilex Ag), and a wound contact layer with glycosaminoglycan hydrogel (Mepitel).
Biologic skin coverings. Permanent coverage of extensive burns is a prolonged process that requires repeated operative procedures using general anesthesia for atraumatic care in debridement and grafting. Early closure shortens the period of metabolic stress and decreases the likelihood of burn wound sepsis. In the acute phase, biologic dressings cover and protect the burn from contamination, reduce fluid and protein loss, increase the rate of epithelialization, reduce pain, and facilitate movement of joints to
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retain range of motion. Allograft (homograft) skin is obtained from human cadavers that are screened for communicable
diseases. Allograft is particularly useful as a temporary skin covering of surgically excised deep partial- and full-thickness burns and extensive burns when available donor sites are limited. Severe immunosuppression occurs in massively burned children, and the allograft becomes adherent. The allograft can remain in place until suitable donor sites become available. Typically, rejection is seen approximately 14 to 21 days after application (Kagan, Winter, and Robb, 2012). The availability of tissue banks and a supply of suitable donors limit the use of allografts.
Xenograft from a variety of species, most notably pigs, is commercially available. In large burns, the porcine xenograft is commonly applied when extensive early debridement is indicated to cover a partial-thickness burn; this provides a temporary covering for the burn until an available autograft can be applied to the full-thickness areas (Lee, Norbury, and Herndon, 2012). Pigskin dressings are replaced every 1 to 3 days. They are particularly effective in children with partial- thickness scald burns of the hands and face, because they allow relatively pain-free movement, which reduces contracture formation and has the added benefit of improving appetite and morale.
When applied early to superficial partial-thickness burns, biologic dressings stimulate epithelial growth and faster wound healing. However, biologic dressings must be applied to clean burns. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the burn to a full-thickness injury.
Synthetic skin coverings are available for the management of partial-thickness burns and donor sites. Ideally, the dressing should provide the properties of human skin, including adherence, elasticity, durability, and hemostasis. Synthetic skin substitutes are readily available and are composed of a variety of materials that are usually permeable to air, vapor, and fluids.
As with biologic dressings, it is important that the burn be free of debris before the dressing is applied. Body temperature elevation or evidence of purulence, erythema, or cellulitis around the wound edges may indicate that the burn has become infected beneath the dressing. If this occurs, prompt discontinuance of the synthetic dressing is indicated. Biobrane is a flexible silicone–nylon membrane bonded to collagenous peptides of porcine skin. Kaltostat is a calcium sodium alginate treatment for donor sites. All synthetic dressings are reputed to hasten burn wound healing and reduce discomfort.
Permanent skin coverings. Permanent coverage of deep partial- and full-thickness burns is usually accomplished with a split- thickness skin graft. The graft consists of the epidermis and a portion of the dermis removed from the donor site of an intact area of skin by a special instrument called a dermatome (Fig. 13-8). With extensive burns, it is often difficult to find enough viable skin to cover the burns; therefore available donor sites and special techniques are used. Split-thickness skin grafts may be sheet graft or mesh graft.
FIG 13-8 Removal of split-thickness skin graft with a dermatome.
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Sheet graft. A sheet of skin removed from the donor site is placed intact over the recipient site and sutured in place; this is used in areas where cosmetic results are most visible, for example, the face (Fig. 13-9).
FIG 13-9 Sheet graft.
Mesh graft. A sheet of skin is removed from the donor site and passed through a mesher, which produces tiny slits in the skin that allow the skin to cover 1.5 to 9 times the area of the sheet graft; this results in a less desirable cosmetic, but functional outcome (Fig. 13-10).
FIG 13-10 Mesh graft.
The donor site is dressed with synthetic wound coverings or fine-mesh gauze until the dressing separates at 10 to 14 days when the wound is healed. Dressings are not changed on donor sites to avoid damage to newly healed, delicate epithelium. Healed donor sites are available for re- harvesting in patients with extensive burns and limited undamaged skin, but the quality of skin is decreased when multiple grafts are taken.
Dermal replacements. The development of products that replace or allows the dermis to regenerate has produced significant improvement in burn wound healing and decreased scar formation. Integra is a two- layer membrane made of collagen (a fibrous protein from animal tendons and cartilage) and silicone rubber (i.e., Silastic). Applied over the burn following excision, the Silastic layer is later
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peeled off after the dermis is formed. The application of Integra does not replace the grafting procedure, but prepares the burn wound to accept an ultrathin autograft.
AlloDerm is another product that is used similarly to Integra. It is made from natural tissue that is processed to remove cells that can lead to tissue rejection. The resulting acellular tissue contains epithelial elements that provide a foundation for new tissue regeneration. With dermal replacements, advantages include faster healing of the burn wound when integrity of the dermis is restored, faster healing of donor sites with the use of ultrathin grafts, and restoration of sweat glands and hair follicles. A disadvantage is its high cost.
Cultured epithelium. When burns are extensive and donor sites for split-thickness skin grafting are limited, it is possible to culture cells from a full-thickness skin biopsy and produce coherent sheets that can be applied to clean, excised full-thickness burns. Epithelial cell culture grafts offer the possibility of an unlimited source of autografts in patients with extensive burns. Cultured epithelial autografts (CEAs) are effective in early wound closure. The child's own skin is fractionated and cultured in a porcine media to form a thin epithelial layer that is applied to the burn. This technique offers an improved rate of survival in patients with extensive burns and limited donor sites.
Nursing Care Management Because the care of burned children encompasses a broad range of skills, nursing care has been divided into segments that correspond with the major phases of burn treatment. The acute phase, also referred to as the emergent or resuscitative phase, involves the first 24 to 48 hours. The management phase extends from the completion of adequate resuscitation through burn coverage. The rehabilitative phase begins when the majority of the burns have healed and rehabilitation has become the predominant focus of the care plan. This phase continues until all reconstructive procedures and corrective measures are accomplished (often a period of months or years).
Acute Phase The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. IV infusion is begun immediately and is regulated to maintain a urinary output of at least 1 to 2 ml/kg in children weighing less than 30 kg (66 pounds); an output of 30 to 50 ml/hr is expected in children weighing more than 30 kg. Urinary output and specific gravity, vital signs, laboratory data, and objective signs of adequate hydration guide the rate of fluid administration.
Children who are hospitalized with burns require constant observation and assessment for complications. Alterations in electrolyte balance produce clinical symptoms of confusion, weakness, cardiac irregularities, and seizures. Changes in respiratory function and gas exchange are reflected clinically by restlessness, irritability, increased work of breathing, and alterations in blood gas values. The loss of protective function of the skin exposes burned children to increased risk of hypothermia. Edema formation and circulatory impairment result in the loss of sensation and deep, throbbing pain.
N u r s i n g A l e r t Evaluate the burned extremity and check the pulse every hour. If unable to palpate, use a Doppler (an ultrasonic pulse probe that can detect blood flow) to ascertain loss of circulation and pulse. If the pulse is lost, escharotomy may be necessary to relieve the edema causing pressure on blood vessels to restore adequate circulation.
Burn centers maintain a pictorial record of the burns to record progress and for legal purposes (if child abuse is suspected). Burn wounds are treated according to the protocol of the specific burn center. The burn team monitors infection control procedures and ensures that staff and visitors comply with established protocols to prevent cross-contamination in the burn unit.
Throughout the acute phase of care, the psychosocial needs of the children and their families are carefully considered. The child is frightened, uncomfortable, and often confused. Children may be isolated from familiar persons and surroundings; the overwhelming physical needs at this time are
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the primary focus of the staff and parents.
Management and Rehabilitative Phases After the patient's condition is stabilized, the management phase begins. The multidisciplinary team concentrates on preventing burn wound infections, closing the burn as quickly as possible, and managing the numerous complications. Although the rehabilitative phase begins when permanent burn wound closure has been achieved, rehabilitation issues are identified on admission and are included in the care plan throughout the hospital course.
N u r s i n g A l e r t In a pediatric burn patient, a decreased level of consciousness, increased restlessness, and lethargy are some of the first signs of overwhelming sepsis and may indicate inadequate hydration. Assessment of capillary refill and pulses are another important indicator of the adequacy of hydration. With inadequate hydration, a spiking fever and diminished bowel sounds accompanied by paralytic ileus are noted and progressively increase over 48 to 72 hours, after which the temperature falls to subnormal limits. At this time, the wound deteriorates, the white blood cell count is depressed, and septic shock becomes manifest.
Comfort Management The severe pain of the burn and resultant therapies, the anxiety generated by these experiences, sleep deprivation, itching related to burn wound healing, and the conscious and unconscious interpretations of traumatic events contribute to the psychological behaviors commonly observed in children with burns. It is always difficult to deal with a child in pain, and inflicting pain on a helpless child is contrary to the empathic nature of nursing. Interventions to promote comfort may include medications (as previously mentioned), relaxation techniques, distraction therapy, behavioral techniques, operant conditioning (e.g., tokens, star chart), and family participation.
Children need age-appropriate explanations before all procedures. When children appear to accept pain with little or no response, psychological consultation may be needed. Consistency in caregivers is important. If this is not possible, a carefully developed, multidisciplinary care plan is necessary to provide consistency.
Care of the Burn Wound The nurse has a major responsibility for cleansing, debriding, and applying topical medications and dressings to the burn. Pain medication should be administered so that the peak effect of the drug coincides with the procedure. Children who have an understanding of the procedure to be performed and some perceived control demonstrate less maladaptive behavior. Children also respond well to participating in decisions (see Atraumatic Care box).
At r a u m a t i c C a r e Reducing the Stress of Burn Care Procedures
• Have all materials ready before beginning the procedure.
• Administer appropriate analgesics and sedatives.
• Remind the child of the impending procedure to allow sufficient time to prepare.
• Allow the child to test and approve the temperature of the water.
• Allow the child to select the area of the body on which to begin.
• Allow the child to request a short rest period during the procedure.
• Allow the child to remove the dressings if desired.
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• Provide something constructive for the child to do during the procedure (e.g., holding a package of dressings or a roll of gauze).
• Inform the child when the procedure is near completion.
• Praise the child for cooperation.
Outer dressings are removed first. Any dressings that have adhered to the burn can be more easily removed by applying tepid water or normal saline. Loose or easily detached tissue is debrided during the cleansing process. In dressing the burn, it is important that all areas be clean, that medication be amply applied, and that no two burned surfaces touch each other (e.g., fingers or toes; ears touching the side of the head). If they are touching, the burned surfaces will heal together, causing deformity or dysfunction.
Topical medications may be applied directly to the burn with a tongue blade or gloved hand as well as using impregnated fine-mesh gauze. All dressings applied circumferentially should be wrapped in a distal-to-proximal manner. The dressing is applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. An elastic net is then applied to secure the dressing in place. A stable dressing is especially important when the child is ambulatory.
Standard precautions, including the use of protective garb and barrier techniques, should be followed when caring for patients with burns. Frequent hand and forearm washing is the single most important element of the infection control program. Strict policies for cleaning the environment and patient care equipment should be implemented to minimize the risk of cross- contamination. All visitors and members of other departments should be oriented to the infection control policies, including the importance of hand and forearm washing and use of protective garb. Visitors should be screened for infection and contagious diseases before patient contact.
Prevention of Complications
Acute Care The maintenance of body temperature is important to children with burns. Core body temperature is supported when energy is conserved with an environmental temperature of 28° to 33° C (82.4° to 91.4° F). Large areas of the body should not be exposed simultaneously during dressing changes. Warmed solutions, linens, occlusive dressings, heat shields, a radiant warmer, and warming blankets assist in preventing hypothermia.
The chief danger during acute care is infection—wound infection, generalized sepsis, or bacterial pneumonia. Accurate and ongoing assessments of all parameters that provide clues to the early diagnosis and treatment of infection are essential. Symptoms of sepsis include a decreased level of consciousness, a rising or falling white blood cell count, hyperthermia progressing to hypothermia, increasing fluid requirements, hypoactive or absent bowel sounds, a rising or falling blood glucose level, tachycardia, tachypnea, and thrombocytopenia. Infection delays the progress of burn wound healing.
Children are reluctant to move if movement causes pain, and they are likely to assume a position of comfort. Unfortunately, the most comfortable position often encourages the formation of contractures and loss of function. Ongoing efforts to prevent contractures include maintaining proper body alignment, positioning and splinting involved extremities in extension, providing active and passive physical therapy, and encouraging spontaneous movement when feasible. Frequent position changes are important to promote adequate bronchopulmonary hygiene and capillary perfusion to common pressure areas. Low–air loss beds are beneficial for morbidly obese children or children with posterior grafts. Special attention should be given to areas at risk for increased pressure, such as the posterior scalp, heels, sacrum, and areas exposed to mechanical irritation from splints and dressings.
Long-Term Care When the burn heals, the rehabilitative phase of care begins. Scar formation becomes a major problem as the burn heals (Fig. 13-11). Contractile properties of the scar tissue can result in disabling contractures, deformity, and disfigurement.
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FIG 13-11 Extensive scars from a flame burn. (Courtesy of The Paul and Carol David Foundation Burn Institute, Akron, OH.)
Uniform pressure applied to the scar decreases the blood supply. When pressure is removed, blood supply to the scar is immediately increased; therefore periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Continuous pressure to areas of scarring can be achieved by elastic tubular bandages or commercially available pressure garments. Because these custom-made garments are often worn for months, revisions may be required as the child grows. It is much easier to prevent scarring and contracture of the burn than to resolve an existing problem. Splints and appliances may also be needed until wound maturation is achieved (Fig. 13-12).
FIG 13-12 Child in an elasticized (Jobst) garment and “airplane” splints.
Scar tissue has certain significant properties, particularly for growing children. Intense itching may occur in healing burn wounds and scar tissue until the scar is no longer active. Itching is usually treated with a variety of medications; hydroxyzine and diphenhydramine are examples of two such medications, in an attempt to control itching,
Frequent applications of a moisturizer, such as Aveeno Baby, Alpha Keri, Eucerin, or Oil of Olay, or any other brand with the word “ultra-healing” in the title that is free of fragrance and does not contain alcohol can be used. Massage therapy during the application of moisturizers is also beneficial to stretch scar tissue and aid in contracture prevention. Scar tissue has no sweat glands,
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and children with extensive scarring may experience difficulty during hot weather. Caregivers should be alerted to this possibility and be prepared to institute alternate methods of cooling when necessary.
Scar tissue does not grow and expand as does normal tissue, which may create difficulties, especially in functional areas, such as on the hands and over joints. Additional surgery is sometimes required to allow independent functioning in daily activities, to improve cosmetic appearance, or to restore anatomic integrity.
The nursing activities in the rehabilitative phase of treatment focus on the child's and family's adaptation to the burn and their ability to reintegrate into the community. The psychological pain and sequelae of severe burn injury are as intense as the physical trauma. The impact of severe burns taxes the coping mechanisms at all ages. Very young children, who suffer acutely from separation anxiety, and adolescents, who are developing an identity, are probably the most affected psychologically. Toddlers cannot understand why the parents they love and who have protected them can leave them in such a frightening and unfamiliar place. Adolescents, in the process of achieving independence from the family, find themselves in a dependent role with a damaged body. Being different from others at a time when conformity with peers is so important is difficult to accept.
Anticipation of the return to school can be overwhelming and frightening. It is essential that health care professionals recognize the importance of preparing teachers and classmates for the child's return. Teachers need to be provided with information to assist the child and family and to promote the child's optimal adjustment. Hospital-sponsored school reentry programs use a variety of methods to provide education and information about the implications of the injury, the garments and appliances, and the need for support and acceptance. Telephone calls, videotapes, information packets, and visits by members of the health care team offer opportunities to help with reintegration into the school environment—a focal point of the child's life.
Psychosocial Support of the Child Children should begin early to do as much for themselves as possible and to be active participants in their care. Loss of control and perceived helplessness may result in acting-out behaviors. During illness, children can regress to a previous developmental level that allows them to deal with stress. As children begin to participate in their care, they gain confidence and self-esteem. Fears and anxieties diminish with accomplishment and self-confidence. If the child demonstrates non- adherence in the rehabilitative phase, a behavior modification program can be initiated to promote or reward the child's accomplishment in care.
Children need to know that their injury and the treatments are not punishment for real or imagined transgressions and that the nurse understands their fear, anger, and discomfort. They also need human touch. This is often difficult to arrange for the child with massive burns. Stroking areas of unburned skin is comforting. Even older children enjoy sitting on the parent's or caregiver's lap and being cuddled and hugged. This can be a reward or a comfort in times of stress, but most of all it should be kept in mind that it is a natural part of childhood.
Psychosocial Support of the Family Recognizing and respecting each family's strengths, differences, and methods of coping allow the nurse to respond to their unique needs by implementing a family-centered approach to care. In the acute phase, most of the attention is focused on the child, and the parents or caregivers may feel powerless and ineffectual. Parents or caregivers may feel overwhelming guilt, whether or not the guilt is justified. They feel responsible for the injury. These feelings may impede the child's rehabilitation. Parents or caregivers may indulge the child and allow non-adherent behaviors that affect physical and emotional recovery. They need to be informed of the child's progress and helped to cope with their feelings while providing support to their child. The nurse can help them understand that it is not selfish to look after themselves and their own needs to meet their child's needs. It is important to recognize the parents' or caregivers' need to grieve the change in their child's normal appearance as part of the grieving process. Definitive professional help may be needed for those whose response to the injury is severe or whose response to stress is manifested in destructive behavior.
The parents or caregivers are members of the multidisciplinary team and participate in the development of the care plan. It is important to facilitate their input; to consider all aspects of the
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physical, emotional, social, and cultural factors affecting the child and family; and to establish a realistic home therapy program. The family's willingness to assume responsibility for care and their ability to implement the therapeutic regimen are assessed. Home, school, and other environmental factors are explored; financial concerns and available community resources are discussed; and a specific care plan for the child, with an anticipated follow-up program, is developed.
Prevention of Burn Injury The best intervention is to prevent burns from occurring. Hot liquids in the kitchen and bathroom most commonly injure infants and toddlers. Hot liquids should be kept out of reach; tablecloths and dangling appliance cords are often pulled by toddlers, who spill hot grease and liquids on themselves. Electrical cords and outlets represent a potential risk to small children, who may chew on accessible cords and insert objects into outlets.
The Consumer Product Safety Commission recommends a reduction of water heater thermostats to a maximum of 48.9° C (120° F). The “dial-down” recommendation has been suggested by utility companies, burn treatment centers, medical personnel, and others interested in public safety. However, many water heaters continue to remain set at levels well above the safe level. Small children are especially at risk for scald injuries from hot tap water because of their decreased reaction time and agility, their curiosity, and the thermal sensitivity of their skin. Caregivers should never leave a child unattended in a bath and without adult supervision. Water should always be tested before a child is placed in the tub or shower.
The increased use of microwave ovens has resulted in burn injuries from the extremely hot internal temperatures generated in heated items. Baby formula, jelly-filled pastries, noodles, and hot liquids or dishes may result in cutaneous scalds or the ingestion of overheated liquids. Caregivers should use caution when removing items from the microwave oven and should always test the food before giving it to children.
As children mature, risk-taking behaviors increase. Matches and lighters are dangerous in the hands of children. Adults must remember to keep potentially hazardous items out of the reach of children; a lighter, like a match, is a tool for adult use.
Education related to fire safety and survival should begin with very young children. They can practice “stop, drop, and roll” to extinguish a fire. The fire escape route, including a safe meeting place away from the home in case of fire, also should be practiced. Having working smoke alarms greatly reduces the chance of dying in a home fire. Additional information on burn care and prevention can be obtained from the American Burn Association* and the National Safety Council.†
Community activities are also helpful in supporting burn survivors and preventing burns. The Aluminum Cans for Burned Children is an exemplary effort based at the Paul and Carol David Foundation Burn Institute in Akron, Ohio.‡ Activities funded by Aluminum Cans for Burned Children include a Burn Survivors Support Group, Burn Camp, and meetings of Juvenile Firestoppers (for children with fire-setting behavior). Adult weekend retreats and school and family education sessions are a part of this program. The burn center and fire department provide the personnel to present programs.
Sunburn Sunburn is a common skin injury caused by overexposure to UV light waves—either sunlight or artificial light in the UV range. The sun emits a continuous spectrum of visible and nonvisible light rays that range in length from very short to very long. The shorter, higher frequency waves are more damaging than longer wavelengths, but much of the light is filtered out as it travels through the atmosphere. Of the light that does filter through, ultraviolet A (UVA) waves are the longest and cause only minimum burning, but they play a significant role in photosensitive and photoallergic reactions. They are also responsible for premature aging of the skin and potentiate the effects of ultraviolet B (UVB) waves, which are shorter and are responsible for tanning, burning, and most of the harmful effects attributed to sunlight, especially skin cancer.
Numerous factors influence the amount of UVB exposure. In North America, the maximum exposure occurs at midday (10 AM to 3 PM), when the distance from the sun to a given spot on the earth is shortest. Solar intensity varies with seasons, time zones, and altitude. Exposure is greater at higher altitudes and near the equator and less when the sky is hazy (although the effect is easily underestimated). Window glass effectively screens out UVB but not UVA. Fresh snow, water, and
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sand reflect UV rays, especially when the sun is directly overhead. Excessive or long-term exposure to the sun and UV rays permanently damages the skin. Ninety
percent of skin cancers occur in areas of the skin that are exposed to UV rays, and rates of skin cancers are higher in parts of the world where sunlight is more intense.
Nursing Care Management Treatment involves stopping the burning process, decreasing the inflammatory response, and rehydrating the skin. Local application of cool tap water soaks or immersion in a tepid-water bath (temperature slightly below 36.7° C [98° F]) for 20 minutes or until the skin is cool limits tissue destruction and relieves the discomfort. After the cool applications, a bland oil-in-water moisturizing lotion can be applied. Acetaminophen is recommended for relief of discomfort. Partial-thickness burns are treated the same as those from any heat source (see earlier discussion on burns).
Protection from sunburn is the major goal of management, and the harmful effects of the sun on the delicate skin of infants and children are currently receiving increased attention. To protect skin exposed to the sun for extended periods, skin should be covered with clothing, and FDA-approved sun protection agents should be applied. Two types of products are available for sun protection: (1) topical sunscreens, which partially absorb UV light; and (2) sun blockers, which block out UV rays by reflecting sunlight. The most frequently recommended sun blockers are zinc oxide and titanium dioxide ointments.
Sunscreens are products containing a sun protection factor (SPF) based on evaluation of effectiveness against UV rays. Most sunscreens have an SPF ranging from 2 to more than 30; the higher the number, the greater the protection. For example, if individuals normally burn in 10 minutes without a sunscreen, use of a sunscreen with SPF 15 allows them to remain in the sun 15 times 10, or 150 minutes ( hours) before acquiring the same degree of burns. The most effective sunscreens against UVB are p-aminobenzoic acid (PABA) and PABA-esters. However, many individuals are allergic to PABA, and sunscreens without PABA are encouraged to prevent these reactions in children.
Sunscreens are applied evenly to all exposed areas, with special attention to skin folds and areas that might become exposed as clothing shifts. Avoid eye contact. Parents are directed to read labels of sunscreen products carefully for the SPF and follow the manufacturer's directions for application.
N u r s i n g A l e r t Sunscreens are not recommended for infants younger than 6 months old. However, infants younger than 6 months old may have sunscreen applied over small areas of skin (such as the back of hands) that may not be adequately covered by clothing when they are in the sun. Infants should be kept out of the sun or physically shaded from it. Fabric with a tight weave, such as cotton, offers good protection.
Individuals who work in the community, such as teachers, daycare workers, coaches, and youth group leaders, as well as relatives, should all be made aware of sun safety for children. Sunscreens must be applied liberally to exposed skin and reapplied often.
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Ingestion of Injurious Agents Since the passage of the Poison Prevention Packaging Act of 1970, which requires that certain potentially hazardous drugs and household products be sold in child-resistant containers, the incidence of poisonings in children has decreased dramatically. However, despite these advances, poisoning remains a significant health concern, with most cases (49% in 2011) occurring in children younger than 6 years old (Bronstein, Spyker, Cantilena, et al, 2012). Although pharmaceuticals (such as analgesics, cough and cold preparations, topical preparations, antibiotics, vitamins, gastrointestinal preparations, hormones, and antihistamines) are frequently the agents of poisonings, a variety of other substances can also poison children. The most frequently ingested poisons include the following (Bond, Woodward, Ho, 2012; Bronstein, Spyker, Cantilena, et al, 2012):* • Cosmetics and personal care products (deodorants, makeup, perfume, cologne, mouthwash) • Medications (acetaminophen, acetylsalicylic acid, ibuprofen, opioids) • Household cleaning products (bleaches, laundry pods, disinfectants) • Foreign bodies, toys, and miscellaneous substances (desiccants, thermometers, bubble-blowing
solutions) Many poisonings reflect the ready accessibility of the products in the home, which is where more
than 90% of poisonings occur (Bronstein, Spyker, Cantilena, et al, 2012). In a recent review of the American Association of Poison Control Centers, more than 60% of exposures to plants occurred in children 5 years old and younger (Bronstein, Spyker, Cantilena, et al, 2012; Petersen, 2011). Box 13-1 lists common poisonous and nonpoisonous plants.
Box 13-1 P o i s o n o u s a n d N o n p o i s o n o u s Pl a n t s Poisonous Plants (Toxic Parts)
Apple (leaves, seeds)
Apricot (leaves, stem, seed pits)
Azalea (all parts)
Buttercup (all parts)
Castor oil plant (bean or seeds—extremely toxic)
Cherry (wild or cultivated) (twigs, seeds, foliage)
Daffodil (bulbs)
Dumb cane (dieffenbachia) (all parts)
Elephant ear (all parts)
Foxglove (leaves, seeds, flowers)
Holly (berries)
Hyacinth (bulbs)
Ivy (leaves)
Mistletoe* (berries, leaves)
Oak tree (acorn, foliage)
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Philodendron (all parts)
Plum (pit)
Poinsettia† (leaves)
Poison ivy, poison oak (leaves, stems, sap, fruit, smoke from burning plants)
Pokeweed, pokeberry (roots, berries, leaves [when eaten raw])
Pothos (all parts)
Rhubarb (leaves)
Tulip (bulbs)
Wisteria (seeds, pods)
Yew (all parts)
Nonpoisonous Plants
African violet
Aluminum plant
Asparagus fern
Begonia
Boston fern
Christmas cactus
Coleus
Gardenia
Grape ivy
Jade plant
Piggyback plant
Poinsettia†
Prayer plant
Rose
Rubber tree
Snake plant
Spider plant
Swedish ivy
Wax plant
Weeping fig
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Zebra plant
*Eating one or two berries or leaves is probably nontoxic. †Mildly toxic if ingested in massive quantities.
The developmental characteristics of young children predispose them to poisoning by ingestion. Infants and toddlers explore their environment through oral experimentation. Because their sense of taste is not discriminating at this age, they ingest many unpalatable substances. In addition, toddlers and preschoolers are developing autonomy and initiative, which increases their curiosity and noncompliant behavior. Imitation is also a powerful motivator, especially when combined with a lack of awareness of danger.
This section is primarily concerned with the immediate emergency treatment of ingestion of injurious agents. Box 13-2 summarizes specific management of corrosive, hydrocarbon, acetaminophen, salicylate, iron, and plant poisoning. Because of the importance of lead poisoning among young children, ingestion of lead is discussed separately. Appropriate suggestions for poison prevention are discussed later in this chapter.
Box 13-2 S e l e c t e d P o i s o n i n g s i n C h i l d r e n Corrosives (Strong Acids or Alkalis)
Drain, toilet, and oven cleaners
Electric dishwasher detergent (liquid because of higher pH, is more hazardous than granular)
Mildew remover
Batteries
Clinitest tablets
Denture cleaners
Bleach
Clinical Manifestations
Severe burning pain in the mouth, throat, and stomach
White, swollen mucous membranes; edema of the lips, tongue, and pharynx (respiratory obstruction)
Coughing, hemoptysis
Drooling and inability to clear secretions
Signs of shock
Anxiety and agitation
Comments
Household bleach is a frequently ingested corrosive but rarely causes serious damage.
Liquid corrosives are easily ingested and cause more damage than granular/solid preparations. Liquids may also be aspirated, causing upper airway injury.
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Solid products tend to stick to and burn tissues, causing localized damage.
Treatment
Inducing emesis is contraindicated (vomiting re-damages the mucosa).
Contact the PCC immediately. If the PCC or medical advice and treatment not immediately available, it may be appropriate to dilute corrosive with water or milk (usually ≤120 ml [4 oz]).
Do not neutralize. Neutralization can cause an exothermic reaction (which produces heat and causes increased symptoms or produces a thermal burn in addition to a chemical burn).
Maintain patent airway as needed.
Administer analgesics.
Give oral fluids when tolerated.
Esophageal stricture may require repeated dilations or surgery.
Hydrocarbons
Gasoline
Kerosene
Lamp oil
Mineral seal oil (found in furniture polish)
Lighter fluid
Turpentine
Paint thinner and remover (some types)
Clinical Manifestations
Gagging, choking, and coughing
Burning throat and stomach
Nausea
Vomiting
Alterations in sensorium, such as lethargy
Weakness
Respiratory symptoms of pulmonary involvement
• Tachypnea
• Cyanosis
• Retractions
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• Grunting
Comments
Immediate danger is aspiration (even small amounts can cause bronchitis and chemical pneumonia).
Gasoline, kerosene, lighter fluid, mineral seal oil, and turpentine cause severe pneumonia.
Treatment
Inducing emesis is generally contraindicated.
Gastric decontamination and emptying are questionable even when the hydrocarbon contains a heavy metal or pesticide; if gastric lavage must be performed, a cuffed endotracheal tube should be in place before lavage because of a high risk of aspiration.
Symptomatic treatment of chemical pneumonia includes high humidity, oxygen, hydration, and acetaminophen.
Acetaminophen Clinical Manifestations Occurs in four stages post ingestion:
1. 0 to 24 hours
• Nausea
• Vomiting
• Sweating
• Pallor
2. 24 to 72 hours
• Patient improves
• May have right upper quadrant abdominal pain
3. 72 to 96 hours
• Pain in right upper quadrant
• Jaundice
• Vomiting
• Confusion
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• Stupor
• Coagulation abnormalities
• Sometimes renal failure, pancreatitis
4. More than 5 days
• Resolution of hepatoxicity or progress to multiple organ failure
• May be fatal
Comments
This is the most common accidental drug poisoning in children.
Toxicity occurs from acute ingestion. Toxic dose is 150 mg/kg or greater in children.
Treatment
Antidote N-acetylcysteine (Mucomyst) is equally effective given intravenously or orally. When given orally may first be diluted in fruit juice or soda because of the antidote's offensive odor. An antiemetic may be given if vomiting occurs.
Given as 1 loading dose followed by 17 additional doses in different dosages. IV administration is given as a continuous infusion.
Aspirin (Acetylsalicylic Acid) Clinical Manifestations
Acute poisoning (early symptoms):
• Nausea
• Hyperventilation
• Vomiting
• Tinnitus
Acute poisoning (later symptoms):
• Hyperactivity
• Fever
• Confusion
• Seizures
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• Renal failure
• Respiratory failure
Chronic poisoning
• Same as listed above but subtle onset and nonspecific symptoms (often mistaken for viral illness)
• Bleeding tendencies
Comments
May be caused by acute ingestion (severe toxicity occurs with 300 to 500 mg/kg).
May be caused by chronic ingestion (i.e., >100 mg/kg/day for ≥2 days); can be more serious than acute ingestion.
Time to peak serum salicylate level can vary with enteric aspirin or the presence of concretions (bezoars).
Treatment
Hospitalization is necessary for severe toxicity.
Activated charcoal is given as soon as possible (unless contraindicated by altered mental status). If bowel sounds are present, may be repeated every 4 hours until charcoal appears in the stool.
Lavage will not remove concretions of ASA.
Sodium bicarbonate transfusions are used to correct metabolic acidosis, and urinary alkalinization may be effective in enhancing elimination; hypokalemia may interfere with achieving urinary alkalinization.
Be aware of the risk for fluid overload and pulmonary edema.
Use external cooling for hyperpyrexia.
Administer anticonvulsants if seizures present.
Provide oxygen and ventilation for respiratory depression.
Administer vitamin K for bleeding.
In severe cases, hemodialysis (not peritoneal dialysis) is used.
Iron
Mineral supplement or vitamin containing iron
Clinical Manifestations
Occurs in five stages (may have significant variation in symptoms and their progression):
1. Within 6 hours (if child does not develop gastrointestinal symptoms in 6 hours, toxicity is unlikely)
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• Vomiting
• Hematemesis
• Diarrhea
• Hematochezia (bloody stools)
• Abdominal pain
• Severe toxicity may have tachypnea, tachycardia, hypotension, coma
2. Latency period—up to 24 hours of apparent improvement
3. 12 to 24 hours
• Metabolic acidosis
• Fever
• Hyperglycemia
• Bleeding
• Seizures
• Shock
• Death (may occur)
4. 2 to 5 days
• Jaundice
• Liver failure
• Hypoglycemia
• Coma
5. 2 to 5 weeks
• Pyloric stenosis or duodenal obstruction may occur secondary to scarring.
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Comments
Factors related to frequency of iron poisoning include:
• Widespread availability
• Packaging of large quantities in individual containers
• Lack of parental awareness of iron toxicity
• Resemblance of iron tablets to candy (e.g., M&Ms)
Toxic dose is based on the amount of elemental iron ingested. Common preparations include ferrous sulfate (20% elemental iron), ferrous gluconate (12%), and ferrous fumarate (33%). Ingestions of 20 to 60 mg/kg are considered mildly to moderately toxic, and >60 mg/kg is severely toxic and may be fatal.
Treatment
Hospitalization is required when more than mild gastroenteritis is present.
Use whole bowel irrigation if radiopaque tablets are visible on abdominal x-ray; may need to be given via nasogastric tube.
Emesis empties the stomach more effectively than lavage.
Activated charcoal does not absorb iron.
Chelation therapy with deferoxamine should be used in severe intoxication (may turn urine red to orange).
If IV deferoxamine is given too rapidly, hypotension, facial flushing, rash, urticaria, tachycardia, and shock may occur; stop the infusion, maintain the IV line with normal saline, and notify the practitioner immediately.
Plants
Poisonous plants listed in Box 13-1
Clinical Manifestations
Depends on type of plant ingested.
May cause local irritation of oropharynx and entire gastrointestinal tract.
May cause respiratory, renal, and central nervous system symptoms.
Topical contact with plants can cause dermatitis.
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Comments Plants are some of the most frequently ingested substances.
They rarely cause serious problems, although some plant ingestions can be fatal.
Plants can also cause choking and allergic reactions.
Treatment
Wash from skin or eyes.
Provide supportive care as needed.
ASA, Acetylsalicylic acid; IV, intravenous; PCC, poison control center.
Principles of Emergency Treatment A poisoning may or may not require emergency intervention, but in every instance medical evaluation is necessary to initiate appropriate action. Advise parents to call the poison control center (PCC) before initiating any intervention. Parents should post the local PCC telephone number (usually listed in the front of the telephone directory) near each phone in the house* (see Emergency Treatment box).
E m e r g e n c y T r e a t m e n t Poisoning
1. Assess the victim:
• Initiate cardiorespiratory support if needed (circulation, airway, breathing).
• Assess mental status; reevaluate routinely.
• Take vital signs; reevaluate routinely.
• Evaluate for possibility of concomitant trauma or illness; treat prior to initiation of gastric decontamination.
2. Terminate exposure:
• Empty mouth of pills, plant parts, or other material.
• Flush any body surface (including the eyes) exposed to a toxin with large amounts of moderately warm water or saline.
• Remove contaminated clothes, including socks and shoes, and jewelry. Ensure protection of rescuers and health care workers from exposure.
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• Bring victim of an inhalation poisoning into fresh air.
3. Identify the poison:
• Question the victim and witnesses.
• Observe the circumstances surrounding the poisoning (e.g., location, activity before ingestion).
• Look for environmental clues (empty container, nearby spill, odor on breath) and save all evidence of poison (container, vomitus, urine).
• Be alert to signs and symptoms of potential poisoning in the absence of other evidence, including symptoms of ocular or dermal exposure.
• Call the poison control center (PCC) or other competent emergency facility for immediate advice regarding treatment.
4. Prevent poison absorption:
• Place the child in a side-lying, sitting, or kneeling position with the head below the chest to prevent aspiration.
Based on the initial telephone assessment, the PCC counsels the parents to begin treatment at home or to take the child to an emergency facility. When a call is taken, the name and telephone number of the caller are recorded to reestablish contact if the connection is interrupted. Because most poisonings are managed in the home, expert advice is essential in minimizing adverse effects. When the exact quantity or type of ingested toxin is not known, admission to a health care facility with pediatric emergency treatment services for laboratory evaluation and surveillance during the time after ingestion is critical.
Assessment The first and most important principle in dealing with a poisoning is to treat the child first, not the poison. This requires an immediate concern for life support. Vital signs are taken, mental status assessed, and respiratory or circulatory support is instituted as needed. The child's condition is routinely reevaluated. Because shock is a complication of several types of household poisons, particularly corrosives, measures to reduce the effects of shock are important, beginning with the CABs (circulation, airway, and breathing support measures) of resuscitation. Establishing and maintaining vascular access for rapid intravascular volume expansion is vital in the treatment of pediatric shock.
The emergency department nurse's responsibility is to be prepared for immediate intervention with all of the necessary equipment. Because time and speed are critical factors in recovery from serious poisonings, anticipation of potential problems and complications may mean the difference between life and death.
Gastric Decontamination Although pediatric poison ingestions are common, they rarely result in significant morbidity or mortality (Bronstein, Spyker, Cantilena, et al, 2012). Consider using gastrointestinal
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decontamination (GID) only after careful evaluation of the potential toxicity of the poison and the risks versus benefits. GID (such as ipecac, activated charcoal, and gastric lavage) is not routinely recommended for most childhood poisonings. Because of continuing controversy regarding the use of these methods, treat each toxic ingestion individually (Albertson, Owen, Sutter, et al, 2011). Specific antidotes may be administered for certain poisonings.
Syrup of ipecac, an emetic that exerts its action through irritation of the gastric mucosa and by stimulation of the vomiting center, is no longer recommended for routine treatment of poison ingestion (Theurer and Bhavsar, 2013; Albertson, Owen, Sutter, et al, 2011).
N u r s i n g A l e r t Syrup of ipecac is not recommended for routine poison treatment intervention in the home (Theurer and Bhavsar, 2013; Albertson, Owen, Sutter, et al, 2011).
A common method of GID is the use of activated charcoal, an odorless, tasteless, fine black powder that absorbs many compounds, creating a stable complex (Frithsen and Simpson, 2010). The use of activated charcoal has become less common and was used in only 1.2% of pediatric toxic exposures in 2011 (Bronstein, Spyker, Cantilena, et al, 2012). Activated charcoal may be considered in the following situations: • Child may have ingested large amounts of carbamazepine, dapsone, phenobarbital, quinine, or
theophylline. • Time to activated charcoal administration is within 1 hour after the poison ingestion. • Child has an intact or protected airway.
Activated charcoal is mixed with water or a saline cathartic to form a slurry. Slurries are neither gritty nor distasteful but resemble black mud. To increase the child's acceptance of activated charcoal, the nurse should mix it with small amounts of chocolate milk, fruit syrup, or cola drinks and serve it through a straw in an opaque container with a cover (e.g., a disposable coffee cup and lid) or an ordinary cup covered with aluminum foil or placed inside a small paper bag. Super- activated charcoal has three to four times the surface area and can absorb greater quantities of poison (Olson, 2010). For small children, a nasogastric tube may be required to administer activated charcoal. Potential complications from the use of activated charcoal include vomiting and potential aspiration, constipation, and intestinal obstruction (in multiple doses) (Albertson, Owen, Sutter, et al, 2011).
If the child is admitted to an emergency facility, gastric lavage may be performed to empty the stomach of the toxic agent; however, this procedure can be associated with serious complications (gastrointestinal perforation, hypoxia, aspiration). There is no conclusive evidence that gastric lavage decreases morbidity and is no longer recommended to be performed routinely, if at all (Albertson, Owen, Sutter, et al, 2011; Benson, Hoppu, Troutman, et al, 2013). In addition, gastric lavage may be of little benefit if used later than 1 hour after ingestion (Albertson, Owen, Sutter, et al, 2011; McGregor, Parkar, and Rao, 2009). Conditions that may be appropriate for the use of gastric lavage include presentation within 1 hour of ingestion of a toxin, ingestion in patient who has decreased gastrointestinal motility, the ingestion of a toxic amount of sustained-release medication, and a large or life-threatening amount of poison (Albertson, Owen, Sutter, et al, 2011). When gastric lavage is used, the patient requires a protected airway, possible sedation, and the largest diameter tube that can be inserted to facilitate passage of gastric contents. Gastric lavage should only be performed by medical personnel with proper training and expertise (Benson, Hoppu, Troutman, et al, 2013).
In a minority of poisonings, specific antidotes are available to counteract the poison. They are highly effective and should be available in all emergency facilities. The supply of antidotes should be checked routinely and replaced as used or according to expiration dates. Antidotes available to treat toxin ingestion include N-acetylcysteine for acetaminophen poisoning, oxygen for carbon monoxide inhalation, naloxone for opioid overdose, flumazenil (Romazicon) for benzodiazepines (diazepam [Valium], midazolam [Versed]) overdose, digoxin immune fab (Digibind) for digoxin toxicity, amyl nitrate for cyanide, and antivenin for certain poisonous bites.
Prevention of Recurrence
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The ultimate objective is to prevent poisonings from occurring or recurring. Home safety education improves poison prevention practices (Kendrick, Young, Mason-Jones, et al, 2012). Research supports the effectiveness of parent education on preventing unintentional injuries (Kendrick, Mulvaney, Ye, et al, 2013). One effective counseling method is first to discuss the difficulties of constantly watching and safeguarding young children (see Family-Centered Care box). In this way, the challenging task of raising children can lead to a discussion of injury prevention as part of the parental role. This approach also incorporates contributory causes for the incident, such as inadequate support systems; marital discord; discipline techniques (especially use of physical punishment); and any disruption in the family or family activities, such as vacations, moves, visitors, illnesses, or births. A visit to the home, especially after repeat poisonings, is recommended as part of the follow-up care to assess hazards, including family factors, and to evaluate appropriate injury-proofing measures. One method of identifying risk areas is to ask specific questions or to have the parent complete a questionnaire designed to isolate factors that predispose children to poisoning. Another approach is to encourage parents to bend down to the child's eye level and survey the home environment for potential hazards. Have the parents try to open cabinets and reach shelves to access poisons.
F a m i l y - C e n t e r e d C a r e Poisoning
A poisoning is more than a physical emergency for the child; it also usually represents an emotional crisis for the parents, particularly in terms of guilt, self-reproach, and insecurity in the parenting role. The emergency department is no place to admonish the family for negligence, lack of appropriate supervision, or failure to injury proof the home. Rather, it is a time to calm and support the child and parents while unaccusingly exploring the circumstances of the injury. If the nurse prematurely attempts to discuss ways of preventing such an incident from recurring, the parents' anxiety will block out any suggestions or offered guidance. Therefore it is preferable for the nurse to delay the discussion until the child's condition is stabilized or, if the child is discharged immediately after emergency treatment, to make a public health referral or send a packet of information.
Passive measures (those that do not require active participation) have been the most successful in preventing poisoning and include using child-resistant closures and limiting the number of tablets in one container. However, these measures alone are not sufficient to prevent poisoning, because most toxic agents in the home do not have safety closures. Therefore active measures (those that require participation) are essential. The Nursing Care Guidelines box lists the guidelines for preventing the occurrence or recurrence of a poisoning.
N u r s i n g C a r e G u i d e l i n e s Poison Prevention
• Assess possible contributing factors in occurrence of injury, such as discipline, parent–child relationship, developmental ability, environmental factors, and behavior problems.
• Institute anticipatory guidance for possible future injuries based on child's age and developmental level.
• Initiate referral to appropriate agency to evaluate home environment and need for injury-proofing measures.
• Provide assistance with environmental manipulation, such as lead removal, when necessary.
• Educate parents regarding safe storage of toxic substances.
• Advise parents to take drugs out of sight of children.
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• Teach children the hazards of ingesting nonfood items.
• Advise parents against using plants for teas or medicine.
• Discuss problems of discipline and children's noncompliance and offer strategies for effective discipline.
• Instruct parents regarding correct administration of drugs for therapeutic purposes and to discontinue drug if there is evidence of mild toxicity.
• Advise parents to contact the PCC (800-222-1222) or practitioner immediately when a poisoning occurs.
• Tell them to post the number of the regional PCC with an emergency phone list by the telephone.
• Include by the telephone the home address with nearest cross street in case an ambulance is needed. (In an emergency, family members may not remember the house address, and babysitters may not be aware of the information.)
PCC, Poison control center.
Heavy Metal Poisoning Heavy metal poisoning can occur from the ingestion of a variety of substances, the most common being lead. Other sources that are important in terms of children are iron and mercury. Mercury toxicity, a rare form of heavy metal poisoning, has occurred in children from a variety of sources, such as predator fish (king mackerel, shark, swordfish, tilefish), broken thermometers or thermostats, broken fluorescent light bulbs, disk batteries, topical medications, gas regulators, cathartics, and interior latex house paint (Bose-O'Reilly, McCarthy, Steckling, et al, 2010). Elemental mercury (also called metallic mercury or quicksilver) is nontoxic if ingested and if the gastrointestinal tract is healthy (e.g., has no fistulas). However, mercury is volatile at room temperature and enters the bloodstream after it is inhaled. Chronic exposure produces symptoms ranging from nonspecific (e.g., anorexia, weight loss, memory loss, insomnia, gingivitis, diarrhea) to severe (e.g., tremors, extreme behavior changes, delirium). The classic form of mercury poisoning is called acrodynia (or “painful extremities”).
N u r s i n g A l e r t Mercury thermometers are no longer recommended because if they are broken, the inhaled vapors can cause toxicity. To prevent inhalation, clean up spilled mercury quickly, using disposable towels and rubber gloves and washing the hands well afterward.
Heavy metals have an affinity for certain essential tissue chemicals, which must remain free for adequate cell functioning. When metals are bound to these substances, cellular enzyme systems are inactivated. Treatment involves chelation, use of a chemical compound that combines with the metal for rapid and safe excretion.
Lead Poisoning Poisoning from lead has been a problem throughout history and throughout the world. In the United States, the problem became apparent in the early 1900s when white lead was added to paints and when tetraethyl lead was added to gasoline as an antiknock compound. Lead content in paint was decreased in 1950; and in 1978, the use of lead in household paint was banned. The use of lead in paint and leaded gasoline has been banned in the United States. After this change in policy, the average blood lead level (BLL) in the United States for people 1 to 74 years old dropped from 12.8 mcg/dl in 1980 to 1.3 mcg/dl in 2010 (Centers for Disease Control and Prevention, 2013). However, children continue to be exposed to lead; an estimated 0.8% of children in the United States 1 to 5 years old had BLLs of more than 10 mcg/dl in 2010, and more than 5% had BLLs of 5 mcg/dl or higher (Centers for Disease Control and Prevention, 2013).
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Causes of Lead Poisoning Although there are numerous sources of lead (Box 13-3), in most instances of acute childhood lead poisoning, the source is nonintact lead-based paint in an older home or lead-contaminated bare soil in the yard. Microparticles of lead gain entrance into a child's body through ingestion or inhalation and, in the case of an exposed pregnant woman, by placental transfer. When measured, a mother's lead level is nearly the same as that of her unborn child. Although the level of lead may not be harmful to adult women, it can be harmful to the fetuses.
Box 13-3 S o u r c e s o f L e a d* Lead-based paint in deteriorating condition
Lead solder
Lead crystal
Battery casings
Lead fishing sinkers
Lead curtain weights
Lead bullets
Some of these may contain lead:
• Ceramic ware
• Water
• Pottery
• Pewter
• Dyes
• Industrial factories
• Vinyl mini-blinds
• Playground equipment
• Collectible toys
• Some imported toys or children's metal jewelry
• Artists' paints
• Pool cue chalk
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Occupations and hobbies involving lead:
• Battery and aircraft manufacturing
• Lead smelting
• Brass foundry work
• Radiator repair
• Construction work
• Furniture refinishing
• Bridge repair work
• Painting contracting
• Mining
• Ceramics work
• Stained-glass making
• Jewelry making
*The US Consumer Product Safety Commission issues alerts and recalls for products that contain lead and may unexpectedly pose a hazard to young children. Additional information is available from Alliance for Healthy Homes, http://www.cehn.org/alliance_healthy_homes.
Whereas inhalation exposure usually occurs during renovation and remodeling activities in the home, ingestion happens during normal day-to-day play and mouthing activities. Sometimes a child will actually swallow loose chips of lead-based paint because it has a sweet taste. Water and food may also be contaminated with lead. A child does not need to eat loose paint chips to be exposed to the toxin; normal hand-to-mouth behavior, coupled with the presence of lead dust in the environment that has settled over decades, is the usual method of poisoning (Bose-O'Reilly, McCarthy, Steckling, et al, 2010; Campbell, Gracely, Tran, et al, 2012).
Because of family, cultural, or ethnic traditions, a source of lead may be a routine part of life for a child. Nurses must educate themselves about the practices of their patients and identify when such products may be a source of lead. The use of pottery or dishes containing lead may be an issue, as may the use of folk remedies for stomachaches or the use of some cosmetics (see Cultural Considerations box). Children of immigrants and internationally adopted children may have been exposed to sources of lead before arrival in the United States and should also be carefully evaluated for lead exposure (Raymond, Kennedy, and Brown, 2013). Other risk factors for having an elevated BLL include living in poverty, being younger than 6 years old, dwelling in urban areas, and living in older rental homes where lead decontamination may not be a priority. Nurses are often in a position to observe or elicit information about these practices and educate families about their potential harm.
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C u l t u r a l C o n s i d e r a t i o n s Sources of Lead
In some cultures, the use of traditional ethnic remedies that contain lead may increase children's risk of lead poisoning. These remedies include:
Azarcon (Mexico): For digestive problems; a bright orange powder; usual dose is 0.25 to 1 tsp, often mixed with oil, milk, or sugar or sometimes given as a tea; sometimes a pinch is added to a baby bottle or tortilla dough for preventive purposes
Greta (Mexico): A yellow-orange powder used in the same way as azarcon
Paylooah (Southeast Asia): Used for rash or fever; an orange-red powder given as 0.5 tsp straight or in a tea
Surma (India and Pakistan): Black powder used as a cosmetic and as teething powder
Unknown ayurvedic (Tibet): Small, gray-brown balls used to improve slow development; two balls are given orally three times a day
Tamarind jellied, fruit candy (Mexico): Fruit candy packaged in paper wrappers that contain high lead levels
Lozeena (Iraq): A bright orange powder used to color meat and rice
Litargirio (Dominican Republic): Yellow or peach colored powder used as a folk remedy and as an antiperspirant/deodorant
Ba-Baw-San (China): Herbal medicine used to treat colic pain
Modified from Centers for Disease Control and Prevention: Lead poisoning associated with use of traditional ethnic remedies— California, 1991–1992, MMWR Morb Mortal Wkly Rep 42(27):521–524, 1993; Centers for Disease Control and Prevention: Lead poisoning associated with imported candy and powdered food coloring—California and Michigan, MMWR Morb Mortal Wkly Rep 47(48):1041–1043, 1998; Centers for Disease Control and Prevention: Childhood lead poisoning associated with tamarind candy and folk remedies—California, 1992–2000, MMWR Morb Mortal Wkly Rep 51(31):684–686, 2002; Centers for Disease Control and Prevention: Lead poisoning associated with use of litargirio—Rhode Island, MMWR Morb Mortal Wkly Rep 54(09):227–229, 2005.
Pathophysiology and Clinical Manifestation Lead can affect any part of the body, including the renal, hematologic, and neurologic systems (Fig. 13-13). Of most concern for young children is the developing brain and nervous system, which are more vulnerable than those of older children and adults. Lead in the body moves via an equilibration process between the blood, the soft tissues and organs, and the bones and teeth. Lead ultimately settles in the bones and teeth, where it remains inert and in storage. This makes up the largest portion of the body burden, approximately 75% to 90%. At the cellular level, it competes with molecules of calcium, interfering with the regulating action of calcium. In the brain, lead disrupts the biochemical processes and may have a direct effect on the release of neurotransmitters, may cause alterations in the blood-brain barrier, and may interfere with the regulation of synaptic activity (Cunningham, 2012; Jones, 2009).
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FIG 13-13 Main effects of lead on body systems.
There is a relationship between anemia and lead poisoning. Children who are iron deficient absorb lead more readily than those with sufficient iron stores. Lead can interfere with the binding of iron onto the heme molecule. This sometimes creates a picture of anemia even though the child is not iron deficient. Lead toxicity to the erythrocytes leads to the release of the enzyme erythrocyte protoporphyrin (EP). Because EP is not sensitive to BLLs of less than about 16 to 25 mcg/dl, it is no longer used as a screening test. Therefore the BLL test is currently used for screening and diagnosis. However, elevation of the EP level (>35 mcg/dl of whole blood) is a good indicator of toxicity from lead and reflects the length of exposure and body burden of lead in an individual child.
Although adults have been shown to experience adverse renal effects from occupational lead exposure, few studies document renal effects in children except at extremely high lead levels. One can hypothesize that lead can affect the renal integrity of children as well as adults. Therefore the renal system of a child is still considered a potential target for the harmful effects of lead.
The lead levels identified in children have declined since the initiation of screening for children at risk for lead poisoning. With earlier intervention, the most prevalent effects have changed. Since the late 1960s, children have rarely died of lead poisoning, and seizures or cognitive impairment have become less likely. However, even mild and moderate lead poisoning can cause a number of cognitive and behavioral problems in young children, including aggression, hyperactivity, impulsivity, delinquency, disinterest, and withdrawal. Long-term neurocognitive signs of lead poisoning include developmental delays, lowered intelligence quotient (IQ), reading skill deficits, visual-spatial problems, visual-motor problems, learning disabilities, and lower academic success. Chronic lead toxicity may also affect physical growth and reproductive efficiency (Jones, 2009).
Diagnostic Evaluation Children with lead poisoning rarely have symptoms even at levels requiring chelation therapy. A diagnosis of lead poisoning is based only on the lead testing of a venous blood specimen from a venipuncture. The collection process is important. Blood must be collected carefully to avoid contamination by lead on the skin. The acceptable BLL has dropped from 40 mcg/dl in 1970 to 10 mcg/dl today (Chandran and Cataldo, 2010).
Anticipatory Guidance The most effective prevention of lead exposure is ensuring that environmental exposures are
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reduced before children are exposed. The following information should be made available to families beginning during prenatal and postnatal care (Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention, 2012): • Hazards of lead-based paint in older housing • Ways to control lead hazards safely • How to choose safe toys • Hazards accompanying repainting and renovation of homes built before 1978 • Other exposure sources, such as traditional remedies, that might be relevant for a family
There has been recent concern regarding toys and other imported items children play with that were found to contain lead. Parents should carefully evaluate the source of the toy (manufacturer) or item the child may play with and not assume it is safe because it is sold in a United States market. The US Consumer Product Safety Commission (http://www.cpsc.gov) is an excellent resource for parents and caregivers concerned about the safety of a given toy or product that may be harmful.
Screening for Lead Poisoning When primary prevention fails, secondary prevention screening efforts for elevated BLLs can identify children much earlier than in the past. This need is established using BLL surveillance and other risk factor data collected over time to establish the status and risk of children throughout the state. Universal screening should be done at 1 and 2 years old. Any child between 3 and 6 years old who has not been previously screened should also be tested. All children with risk factors should be screened more often.
Targeted screening is acceptable when an area has been determined by existing data to have less risk. Children should be screened when they live in a high-risk geographic area or are members of a group determined to be at risk (e.g., Medicaid recipients) or if their family cannot answer “no” to the following personal risk questions: • Does your child live in or regularly visit a house that was built before 1950? • Does your child live in or regularly visit a house built before 1978 with recent or ongoing
renovations or remodeling within the past 6 months? • Does your child have a sibling or playmate who has or had lead poisoning?
Therapeutic Management The degree of concern, urgency, and need for medical intervention change as the lead level increases. Education is one of the most important elements of the treatment process. Areas that the nurse needs to discuss with the family of every child who has an elevated BLL (≥5 mcg/dl) include the following (Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention, 2012): • The child's BLL and what it means • Potential adverse health effects of an elevated BLL • Sources of lead exposure and suggestions on how to reduce exposure, such as the importance of
wet cleaning to remove lead dust on floors, windowsills, and other surfaces • Importance of good nutrition in reducing the absorption and effects of lead; for persons with poor
nutritional patterns, adequate intake of calcium and iron and importance of regular meals • Need for follow-up testing to monitor the child's BLL • Results of an environmental investigation if applicable • Hazards of improper removal of lead paint (dry sanding, scraping, or open-flame burning)
Treatment actions vary depending on the child's BLL. Based on a diagnosis from a venous BLL test, the Centers for Disease Control and Prevention (2002) recommends the following actions:
Blood Lead Level (mcg/dl) Action <5 Provide family with lead education.
Reassess or rescreen in 1 year. If exposure status changes, do this sooner. 5 to 14 Provide family with lead education, regular developmental/behavioral surveillance, and social service referral if necessary.
Provide follow-up testing within 1 month, and then every 3 to 4 months. 15 to 19 Provide family with lead education, regular developmental/behavioral surveillance, and social service referral if necessary.
Provide follow-up testing within 1 month, and then every 3 to 4 months. Initiate professional environmental cleanup. Follow guidelines for BLL of 20 to 44 mcg/dl if BLL remains 15 mcg/dl or higher on two samples obtained at least 3 months apart.
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20 to 44 Provide family with lead education, regular developmental/behavioral surveillance, and social service referral if necessary. Refer to clinical center specializing in lead poisoning. Provide both clinical and environmental management. Consider treating with appropriate chelation therapy.
45 to 69 Provide lead education. Refer to clinical center specializing in lead poisoning; provide coordination of care. Provide diagnostic testing within 24 to 48 hours. Perform clinical evaluation and management within 48 hours. Provide appropriate chelation therapy. Ensure aggressive environmental intervention. Follow up testing at least once per month.
70 or over Immediately provide diagnostic testing and initiate chelation therapy. Begin other activities (listed above).
Chelation Therapy Chelation is the term used for removing lead from circulating blood and, theoretically, some lead from organs and tissues. It is unclear whether chelation affects lead stores in bones. Although not an antidote in the truest sense, it does serve a similar purpose in that the toxic substance or poison is removed from the body. However, chelation does not counteract any effects of the lead.
Historically, three chelating agents have been used consistently: calcium disodium edetate (CaNa2EDTA, or calcium EDTA), British antilewisite (BAL; dimercaprol, dimercaptopropanol), and Meso-2,3-dimercaptosuccinic acid (DMSA, Chemet, Succimer). BAL (dimercaprol, dimercaptopropanol) is used in conjunction with EDTA with high lead levels or the presence of lead encephalopathy. All of the agents have potential toxic side effects and contraindications. Renal, hepatic, and hematologic parameters should be monitored.
Because of the equilibration process between blood, soft tissues, and other sites in the body, there is often a rebound of the BLL after chelation. After the body burden of lead is reduced enough to stabilize the BLL, rebound will cease. Multiple chelation treatments may be necessary. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys.
Severe lead toxicity (lead level ≥70 mcg/dl) requires immediate inpatient treatment, whether symptoms are present or not. BAL is contraindicated in children with peanut allergies or hepatic insufficiency, nor should it be given in conjunction with iron. Also, use with caution in children with renal impairment or hypertension; monitor for hemolysis with presence of glucose 6- phosphate dehydrogenase deficiency. It must be given only at a deep intramuscular site, in repeated doses over several days. Calcium EDTA should be given intravenously or intramuscularly (in a different site from BAL). The IV route should not be used in children with cerebral edema.
For lead levels of 45 to 69 mcg/dl and an absence of symptoms, DMSA can be used. The capsule is opened and sprinkled on a small amount of food or may be swallowed whole. DMSA can be used in conjunction with iron. Adverse effects include nausea, vomiting, diarrhea, loss of appetite, rash, elevated liver function tests, and neutropenia. Because the chelates are excreted via the kidneys, adequate hydration is essential.
A less used oral chelating agent, d-penicillamine, is sometimes used to treat lead poisoning, but the medication is not approved by the US Food and Drug Administration for use in the United States (Dapul and Laraque, 2014).
Prognosis Although most of the pathophysiologic effects of lead are reversible, the most serious consequences of both high and low lead exposure are the effects on the central nervous system. In children with lead encephalopathy, permanent brain damage can result in cognitive impairment, behavior changes, possible paralysis, and seizures. However, low-dose exposure may also cause permanent neurologic deficits. Increased distractibility, short attention span, impulsivity, reading disabilities, and school failure have been associated with lead exposure (Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention, 2012).
Nursing Care Management The primary nursing goal in lead poisoning is to prevent the child's initial or further exposure to lead. For children with low-level exposure, this requires identifying the sources of lead in the environment. Careful history taking is the most useful and most valuable tool and should concentrate on the personal risk questions. Suggestions for reducing lead in the child's environment are listed in the Community Focus box.
C o m m u n i t y F o c u s
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Reducing Blood Lead Levels
• Make certain children do not have access to peeling paint or chewable surfaces painted with lead- based paint, especially windowsills and wells.
• If a house was built before 1978 and has hard-surface floors, wet mop them at least once per week. Wipe other hard surfaces (e.g., windowsills, baseboards). If there are loose paint chips in an area, such as a window well, use a wet disposable cloth to pick up and discard them. Do not vacuum hard-surfaced floors or windowsills or wells because this spreads dust. Use vacuum cleaners with agitators to remove dust from rugs rather than vacuum cleaners with suction only. If a rug is known to contain lead dust and cannot be washed, it should be discarded.
• Wash and dry children's hands and faces frequently, especially before eating.
• Wash toys and pacifiers frequently.
• Wipe your feet on mats before entering the home, especially if you work in occupations where lead is used. Removing your shoes when you are entering the home is a good practice to control lead.
• If soil around home is or is likely to be contaminated with lead (e.g., if the home was built before 1978 or is near a major highway), plant grass or other ground cover; plant bushes around outside of the house so that children cannot play there.
• During remodeling of older homes, follow correct procedures. Be certain children and pregnant women are not in the home, day or night, until the process is completed. After deleading, thoroughly clean the house using cleaning solution to a damp mop and dust before inhabitants return.
• In areas where lead content of water exceeds the drinking water standard and a particular faucet has not been used for 6 hours or more, “flush” the cold-water pipes by running the water until it becomes as cold as it will get (30 seconds to 2 minutes). The more time water has been sitting in pipes, the more lead it may contain.
• Use only cold water for consumption (drinking, cooking, and especially for reconstituting powder infant formula). Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. It is acceptable to use first-flush water for non-consumption uses (e.g., bathing).
• Have water tested by a competent laboratory. This action is especially important for apartment dwellers; flushing may not be effective in high-rise buildings and in other buildings with lead- soldered central piping.
• Do not store food in open cans, particularly if cans are imported.
• Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service. Do not store drinks or food in lead crystal.
• Avoid folk remedies or cosmetics that contain lead.
• Avoid candy imported from Mexico (e.g., tamarind hard candy).
• Avoid imported toys and toy jewelry that may contain lead.
• Make certain that home exposure is not occurring from parental occupations or hobbies. Household members employed in occupations such as lead smelting should shower and change into clean clothing before leaving work. Construction and lead abatement workers may also bring home lead contaminants.
• Ensure that children eat regular meals because more lead is absorbed on an empty stomach.
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• Ensure that children's diets contain sufficient iron and calcium and not excessive fat.
• Consider iron supplementation if child does not regularly consume foods rich in iron.
Modified from Centers for Disease Control and Prevention: Lead home, 2013, http://www.cdc.gov/nceh/lead/.
For children who undergo chelation therapy, the nurse prepares them for the injections and makes all efforts to reduce injection pain. Chelating agents are administered deeply into a large muscle mass (see Atraumatic Care box). To lessen the pain from calcium EDTA, the local anesthetic procaine is injected with the drug. Rotation of sites is essential to prevent the formation of painful areas of fibrotic tissue. Because calcium EDTA and lead are toxic to the kidneys, keep records of intake and output, and assess the results of urinalysis to monitor renal functioning.
At r a u m a t i c C a r e Lead Chelation Therapy
To lessen the pain from intramuscular injection of calcium disodium edetate (CaNa2EDTA or calcium EDTA), the local anesthetic procaine is injected with the drug. Apply topical anesthetic cream such as eutectic mixture of local anesthetic (e.g., lidocaine-prilocaine [EMLA]) or LMX4 (4% lidocaine) over the puncture site before the injection of EDTA and British antilewisite (BAL) (time per manufacturer's guidelines).
N u r s i n g A l e r t Use extreme caution with chelating agents. Incidences of child death from hypocalcemia have been recorded when Na2EDTA was substituted for CaNa2EDTA and used as a chelating agent (Fountain and Reith, 2014).
N u r s i n g A l e r t Adequate urinary output must be ensured with administration of calcium EDTA. Children receiving the drug intramuscularly must be able to maintain adequate oral intake of fluids.
Discharge planning for children with lead poisoning must include thorough education of families regarding safety from lead hazards, clear instructions regarding medication administration and follow-up, and confirmation that the child will be discharged to a home without lead hazards. Although the nurse must use caution to avoid alarming parents unnecessarily, it is important that they know the risk implications for their child's behavior and cognitive functions. Nurses should observe the development and behavior of children who are hospitalized. Thoroughly evaluate any concerns that are identified. Referral to a child development or speech and language specialist may be necessary.
As in any situational crisis, parents need support and understanding if their child is treated for lead poisoning. Many families at the highest risk for lead poisoning have the fewest resources to comply with measures such as relocation or removal of lead from the environment where the child experiences exposure.
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Child Maltreatment The broad term child maltreatment includes intentional physical abuse or neglect, emotional abuse or neglect, and sexual abuse of children, usually by adults. It is one of the most significant social problems affecting children. In 2011, Child Protective Service agencies in the United States confirmed that an estimated 681,000 children were victims of one or more types of child maltreatment. Of the confirmed cases, about 18% suffered physical abuse, 9% sexual abuse, 79% neglect, and 8% psychological maltreatment or emotional abuse. In 2011, there were an estimated 1570 child fatalities as a result of child abuse and neglect (US Department of Health and Human Services, 2012). Reported statistics only partially represent the actual incidence of child maltreatment because many cases are believed to go unreported.*
Child Neglect Child neglect is the most common form of maltreatment, and 50% of reported neglect cases involve children 5 years old or younger (US Department of Health and Human Services, 2012). Of the children who died, 71% suffered from neglect either exclusively or in combination with another type of maltreatment (US Department of Health and Human Services, 2012). Neglect is generally defined as the failure of a parent or other person legally responsible for the child's welfare to provide for the child's basic needs and an adequate level of care.
Important contributing factors for child neglect are lack of knowledge of child's needs, lack of resources, and caregiver substance abuse. For example, neglectful parents often demonstrate poor parenting skills. They may be unaware that an infant needs to be fed every 3 to 4 hours, may not know what to feed the child, and may have insufficient funds to buy food. The most serious lack of knowledge is failure to recognize emotional nurturing as an essential need of children. (See also Failure to Thrive, Chapter 10.)
Types of Neglect Neglect takes many forms and can be classified broadly as physical or emotional maltreatment. Physical neglect involves the deprivation of necessities, such as food, clothing, shelter, supervision, medical care, and education. Emotional neglect generally refers to failure to meet the child's needs for affection, attention, and emotional nurturance.
Neglect may also include lack of intervention for or fostering of maladaptive behavior, such as delinquency or substance abuse. Emotional abuse or psychological maltreatment, an even more difficult aspect of maltreatment to define, refers to the deliberate attempt to destroy or significantly impair a child's self-esteem or competence. Emotional abuse may take the form of rejecting, isolating, terrorizing, ignoring, corrupting, verbally assaulting, or over pressuring the child (Hibbard, Barlow, MacMillan, et al, 2012).
Physical Abuse The deliberate infliction of physical injury on a child, usually by the child's caregiver, is termed physical abuse. Physical abuse can include anything from bruises and fractures to brain damage. Minor physical injury is responsible for more reported cases of maltreatment than major physical injury, but major physical abuse causes more deaths. In 2011, 48% of fatalities from abuse suffered physical abuse alone or in combination with other types of maltreatment (US Department of Health and Human Services, 2012). Despite the importance of the problem, a universally accepted definition of what constitutes minor and major physical abuse does not exist. Rather, each state in the United States defines abuse according to its individual reporting laws.
Abusive Head Trauma Abusive head trauma (AHT) is a serious form of physical abuse caused by violent shaking of infants and young children. Other commonly used terms including shaken baby syndrome, inflicted head injury, or neuro-inflicted brain injury. This violent shaking would be easily recognized by others as dangerous (American Academy of Pediatrics Committee on Child Abuse and Neglect, 2009; Kemp, 2011) and is most often a result of the caregiver's frustration with crying, maternal stress, or
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depression (Kemp, 2011). Every year in the United States, an estimated 1200 to 1400 children are shaken, and of these victims, 25% to 30% die as a result of their injuries. The rest have lifelong complications (National Center on Shaken Baby Syndrome, n.d.).
It is important to understand what happens in AHT. Infants have a large head-to-body ratio, weak neck muscles, and a large amount of water in the brain. Violent shaking causes the brain to rotate within the skull, resulting in shearing forces that tear blood vessels and neurons. The characteristic injuries that occur are intracranial bleeding (subdural and subarachnoid hematomas) and, in approximately 80% of cases, bilateral retinal hemorrhages, which are classic results of repetitive acceleration–deceleration head trauma (Maguire, Watts, Shaw, et al, 2013). Injuries may also include fractures of the ribs and long bones. Most often, there are no signs of external injury, making diagnosis difficult. Clinicians base an abusive diagnosis on patterns of injuries to the infant but this can be subjective. PredAHT, a prediction tool, assists clinicians with an AHT diagnosis by listing six key clinical features of AHT obtained from high quality publications (Cowley, Morris, Maguire, et al, 2015). The PredAHT has high sensitivity and specificity in estimating the probability of AHT when three or more of the six features are present in the patient (Cowley, Morris, Maguire, et al, 2015).
Traumatic brain injury is often not an isolated event, with a large number of children showing evidence of a previous injury (Kemp, 2011). Victims of AHT can be seen with a variety of symptoms, from generalized flulike symptoms to unresponsiveness with impending death (Altimier, 2008). Many of the presenting symptoms, such as vomiting, irritability, poor feeding, and listlessness, are often mistaken for common infant and childhood ailments. In more severe forms, presenting symptoms may include seizures, posturing, alterations in level of consciousness, apnea, bradycardia, or death. The long-term outcomes of AHT include seizure disorders; visual impairments, including blindness; developmental delays; hearing loss; cerebral palsy; and mild to profound mental, cognitive, or motor impairments (Altimier, 2008). Nurses can take an active role in prevention of AHT by teaching caregivers about care for infants and techniques to cope with inconsolable crying (Barr, 2012).
N u r s i n g A l e r t Stress to parents the danger of shaking infants (shaking can cause AHT). Education must include coping mechanisms on caring for children with inconsolable crying.
Munchausen Syndrome by Proxy Munchausen syndrome by proxy (MSBP), also known as medical child abuse or factitious disorder by proxy, is a rare but serious form of child abuse in which caregivers deliberately exaggerate or fabricate histories and symptoms or induce symptoms. It is a form of child maltreatment that may include physical, emotional, and psychological abuse for the gratification of the caregiver. In most cases, the perpetrator is the biologic mother with some degree of health care knowledge and training. Health care providers can become easily misled and unknowingly enable the perpetrator (Squires and Squires, 2013). Because of the history of symptoms provided by the caregiver, the child endures painful and unnecessary medical testing and procedures. Common symptoms presented are seizures, nausea and vomiting, diarrhea, and altered mental status; they are usually witnessed only by the perpetrator.
Considerations when determining whether a child is a victim of MSBP include: • Is the child's condition consistent with the reported history? • Does diagnostic evidence support the reported history? • Has anyone other than the caregiver witnessed the symptoms? • Is treatment being provided primarily because of the caregiver's demands?
The resolution of symptoms after separation from the perpetrator confirms the diagnosis.
Factors Predisposing to Physical Abuse The causes of child abuse are multifaceted. Child maltreatment occurs across all socioeconomic, religious, cultural, racial, and ethnic groups (US Department of Health and Human Services, 2012). Three risk factors are commonly identified in child abuse: (1) parental characteristics, (2) characteristics of the child, and (3) environmental characteristics. However, no single factor or
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group of factors is predictive of abuse. Rather, the interaction of these factors is thought to increase the risk of abuse occurring in a particular family.
Parental Characteristics Some identified characteristics occur more frequently in parents who abuse their children and are therefore considered risk factors. Younger parents more often are abusers of their children. Single- parent families are at higher risk for abuse; and in single-parent families that include an unrelated partner, the partner is sometimes the abuser, although a biologic parent is most commonly the perpetrator (US Department of Health and Human Services, 2012).
Abusive families are often socially isolated and have few supportive relationships. They often have additional stressors, such as low-income circumstances with little education. Parents with substance abuse problems pose a greater risk for abuse and neglect because of a variety of factors. The additional stressors of substance abuse with the demands of normal care of children create situations in which abuse and neglect can occur, because these parents have impaired judgment and may react with violence while under the influence of drugs or alcohol (Lyden, 2011). With little or no available support system and concurrent stressors imposed by the child or environment, these parents are vulnerable to additional crises of any nature and may strike out at the child as a method of releasing their frustration and anxiety.
Other factors identified in abusive parents include low self-esteem and little knowledge of appropriate parenting skills. Parenting skills are learned behaviors, and parents who grew up with poor parental role models may have difficulty parenting their own children. Often, child abusers were abused or observed some types of abuse in their home (Lyden, 2011).
Characteristics of the Child The onus for child abuse is always on the abuser. However, children who are abused do have some common characteristics. Children from birth to 1 year old are at highest risk for being abused (US Department of Health and Human Services, 2012). Infants and small children require constant attention and must have all their needs met by others. This can result in parental or caregiver fatigue that results in striking out at the child with physical force, shaking the child, or ignoring the child's needs.
The physical and emotional demands placed on the parents or caregiver of an unwanted, brain- damaged, hyperactive, or physically disabled child may overwhelm them, resulting in abuse. Children with disabilities may not understand that abusive behaviors are not appropriate, so they may not tell others or defend themselves. Premature infants may be at risk for maltreatment because of failure of parent–child bonding during early infancy, increased physical needs, or irritability. One child may be singled out in an abusive family. Removing that child from the home often places the other siblings at risk for abuse. Therefore no child is safe if left in the abusive environment unless the parents can be helped to learn new parenting skills, to meet the children's needs, and to release their frustration through alternatives other than attacking their children.
Environmental Characteristics The environment is a significant part of the potentially abusive situation. A typical environment is one of chronic stress, including problems of divorce, poverty, unemployment, poor housing, frequent relocation, alcoholism, and drug addiction. Increased exposure between children and parents, such as that which occurs in crowded living conditions, also increases the likelihood of abuse.
Although most reporting of abuse has been from lower socioeconomic populations, as stated earlier, child abuse is not a problem of any one societal group. Stresses imposed by poverty predispose lower socioeconomic families to abusive situations, and abuse in these groups is more likely to be reported. However, concealed crises may also be present in upper-class families. Families who have substitute caregivers (such as daycare providers and babysitters) may also be at risk for child abuse, especially if the family has not fully evaluated the caregiver. Nurses need to be aware of all these factors to identify the less obvious examples of child abuse and neglect.
Sexual Abuse Sexual abuse is one of the most devastating types of child maltreatment, and estimates indicate that
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it has increased significantly during the past decade (US Department of Health and Human Services, 2012). Some of the apparent increase is due to increased awareness and increased reporting (Evans, 2011).
As with all forms of child maltreatment, no universal definition for sexual abuse exists. The Child Abuse Prevention and Treatment Act (CAPTA), amended by the CAPTA Reauthorization Act of 2010, defines sexual abuse as “the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, sexually explicit conduct or any simulation of such conduct; or the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children” (US Department of Health and Human Services, 2011).
Sexual abuse includes the following types of sexual maltreatment (see also Sexual Assault [Rape], Chapter 16):
Incest: Any physical sexual activity between family members; blood relationship is not required (abusers can include stepparents, unrelated siblings, grandparents, uncles, and aunts); does not include sexual relations between legally sanctioned partners, such as spouses
Molestation: A vague term that includes “indecent liberties,” such as touching, fondling, kissing, single or mutual masturbation, or oral–genital contact
Exhibitionism: Indecent exposure, usually exposure of the genitalia by an adult man to children or women
Child pornography: Arranging and photographing, in any media, sexual acts involving children, alone or with adults or animals, regardless of consent by the child's legal guardian; also may denote distribution of such material in any form with or without profit
Child prostitution: Involving children in sex acts for profit and usually with changing partners
Pedophilia: Literally means “love of child” and does not denote a type of sexual activity but rather the preference of an adult for prepubertal children as the means of achieving sexual excitement
Characteristics of Abusers and Victims Anyone, including siblings and mothers, can be sexual abusers, but a typical abuser is a man whom the victim knows. Offenders come from all levels of society; however, a higher risk of child abuse has been noted among families with incomes below the poverty level (Breyer and MacPhee, 2015). In addition, parents with a high school education are more likely than parents with a college education to be abusers (Breyer and MacPhee, 2015). Many offenders hold full-time jobs, are active in community affairs, and may not have prior criminal records. Offenders often are employed (or volunteers) in positions such as teaching or coaching that bring them into contact with young girls and boys. Offenders may commit many assaults before being caught.
Incestuous relationships between father or stepfather and daughter are generally prolonged, and the victims are usually reluctant to report the situation because of fear of retaliation and fear that they will not be believed. Typically, incestuous relationships begin later than other forms of child abuse. The eldest daughter is usually abused, but in her absence, another sister may be substituted. Sibling incest may also occur. Sexual abuse by relatives with a strong emotional bond with the victim, such as a parent, is often the most devastating to the child.
Boys are also victims of both intrafamilial and extrafamilial abuse. Compared with female victims, male victims are much less likely to report abuse, and they may suffer much greater emotional harm from incestuous relationships. Boys are likely to be subjected to anal penetration and oral–genital contact. They often have subtle physical findings and are abused by a father, stepfather, or mother's boyfriend.
Significant risk factors for child sexual abuse include parental unavailability, lack of emotional closeness and flexibility, social isolation, emotional deprivation, and communication difficulties. Most sexual abuse is committed by men and by persons known to the child, such as family members (Forsdike, Tarzia, Hindmarsh, et al, 2014). Around 20% to 25% of child sexual abuse cases involve penetration or oral–genital contact. In 2011, more than 26% of sexual abuse victims were between 12 and 14 years old, and nearly 22% were between 15 to 17 years old (US Department of
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Health and Human Services, 2012).
Initiation and Perpetuation of Sexual Abuse The cycle of sexual abuse often starts insidiously unless it involves an isolated attack, such as rape. Often offenders spend time with the victims to gain their trust before initiating any sexual contact. Most victims are then pressured into being an accessory to the sexual activity through various means (Box 13-4) and may be unaware that sexual activity is part of the offer. Children may not reveal the truth for fear that their parents would not believe them if they told, especially if the offender is a trusted member of the family. Some fear that they will be blamed for the situation, and many young children with limited vocabulary have difficulty describing the activity when they do have the courage or opportunity to reveal the abuse.
Box 13-4 M e t h o d s U s e d t o P r e s s u r e C h i l d r e n i n t o S e x u a l A c t i v i t y • The child is offered gifts or privileges or has privileges withheld.
• The adult misrepresents moral standards by telling the child that it is “okay to do.”
• Isolated and emotionally and socially impoverished children are enticed by adults who meet their needs for warmth and human contact.
• The successful sex offender pressures the victim into secrecy by describing it as a “secret between us” that other people would take away if they found out.
• The offender plays on the child's fears, including fear of punishment by the offender, fear of repercussions if the child tells, and fear of abandonment or rejection by the family.
Incest most frequently occurs between siblings, but it may also be between fathers or stepfathers and daughters, or grandfather and granddaughter. Sibling incest has been found to have adverse outcomes during childhood that extend into adulthood and are just as damaging as father– daughter abuse (Krienert and Walsh, 2011). Victims may take years to disclose this abuse. However, not all incestuous relationships follow this pattern of silence. Reports of father–daughter incest during child custody conflicts have become more common and have raised serious concerns regarding the possibility of false accusation. Rather than tolerating or denying the child's sexual abuse, the other parent (usually the mother) is typically the chief accuser.
Nursing Care of the Maltreated Child A critical responsibility of health professionals is identifying abusive situations as early as possible. Nurses who increase their knowledge of the different types of abuse and neglect and underlying causes will enhance their ability to identify, intervene, and prevent children from maltreatment and neglect (Lyden, 2011). The characteristics that may predispose members of some families to commit abuse can serve as a framework for assessing vulnerability but are never predictive of actual abuse. A careful, detailed history and interview combined with a thorough physical examination are the diagnostic tools needed to identify abuse. Nurses have a special role because they may be the first person to see the child and parent and are the consistent caregivers if the child is hospitalized (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Talking with Children Who Reveal Abuse
• Provide a private time and place to talk.
• Do not promise not to tell; tell them that you are required by law to report the abuse.
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• Do not express shock or criticize their family.
• Use their vocabulary to discuss body parts.
• Avoid using any leading statements that can distort their report.
• Reassure them that they have done the right thing by telling.
• Tell them that the abuse is not their fault and that they are not bad or to blame.
• Determine their immediate need for safety.
• Let the child know what will happen when you report.
In interviewing the child and family, the nurse must be careful to avoid biasing the child's retelling of the events. Some experts suggest that health professionals limit the interview to the child's physical and mental health concerns and leave topics of the family's social, legal, or other problems to the police or the Child Protective Services (Mollen, Goyal, and Frioux, 2012). If this is not possible, make an effort to coordinate the interview process so that all pertinent health care professionals can be present for the interview.
Recognition of abuse or neglect necessitates a familiarity with both physical and behavioral signs that suggest maltreatment (Box 13-5). No one indicator can be used to diagnose maltreatment. It is a pattern or combination of indicators that should arouse suspicion and lead to further investigation. It is important to note that some situations (such as bleeding disorders, osteogenesis imperfecta, or sudden infant death syndrome) may be misinterpreted as abuse. Also, some cultural practices, such as cupping or coin rubbing (see Health Practices, Chapter 2), may mimic physical abuse. Unintentional injuries, such as burns from metal buckles on car seats, bruising from seat belts, or spiral fractures from a twist and fall injury, may also be wrongly diagnosed as abuse. Normal variants, such as mongolian spots and congenital anomalies of genitalia, can be mistaken for abuse.
Box 13-5 Wa r n i n g S i g n s o f A b u s e • Child has physical evidence of abuse or neglect, including previous injuries.
• History is incompatible with the pattern or degree of injury, such as bilateral skull fractures after being dropped.
• Explanation of how injury occurred is vague or the parent or guardian is reluctant to provide information.
• The patient is brought in with a minor, unrelated complaint, and significant trauma is found.
• Histories are contradictory among caregivers.
• The mechanism of injury provided is not possible given age or developmental level of the patient, such as 6-month-old turning on hot water.
• Bruising or other injury is present in a non-mobile patient.
• The patient's affect is inappropriate in relation to the extent of injury.
• Evidence of abusive or neglectful parent–child interaction is present.
• The parent, guardian, or custodian disappears after bringing in the patient for trauma or a patient with suspicious injury is brought in by an unrelated adult.
• The patient has multiple fractures of differing ages.
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• There was a delay in seeking care.
• The parent or caregiver discloses that abuse has or may have occurred.
• The patient makes an outcry of abuse or neglect.
Caregiver–Child Interaction The nurse can use the initial contact with the family to assess the interaction between the caregiver and the child. Observations of the caregivers should include emotional support for the child, attentiveness to the child's needs, and concern for the child's injury. Although caregivers and children may vary in responses to a stressful event, note an unusual caregiver–child relationship and factor this into the overall evaluation of the child.
Certain behavioral responses of the parents to their child and to the interviewer should alert the nurse to the possibility of maltreatment. Abusive parents may have difficulty showing concern toward their child. They may be unable or unwilling to comfort the child. Abusers may blame the child for the injuries or belittle him or her for being clumsy or stupid. When interacting with health care workers, the parent may become hostile or uncooperative. During the child's hospitalization, they may not participate in the child's care and may show little concern for his or her progress, eventual discharge, or need for follow-up care.
Abused children's responses to their parents or the injury may also support the suspicion of abuse. Although no one pattern is typical, extremes of behavior may be observed. Children may be unresponsive to the parent or excessively clinging and intolerant of separation. They may be overly attached to the abusive parent, possibly in the hope of preventing any upset that may precipitate anger and another attack. During care of the injury, children may be passive and accepting of the discomfort or uncooperative and fearful of any physical contact. They may avoid eye contact. Some children maintain a wary watchfulness of all strangers; some shy away from strangers as if frightened; others are unusually affectionate and outgoing.
History and Interview
Child Physical Abuse It is often difficult to distinguish child maltreatment from accidental injuries. Caregivers whose history of events may be deceptive or incomplete and children who are nonverbal may make the assessment more complex. A purposeful, skilled history and appropriate interview questions help the nurse ensure the right course of action. Knowledge of mechanism of injury and child development is essential. Cases of abuse are often detected when the child or caregiver history of events does not match with physical findings. Children who are verbal can often give a history of the injury. Separating the child from the caregiver may provide a more reliable history. It is important to ask non-leading, open-ended questions. The history should include a narrative of the injury from both caregiver and child (if verbal). Date, time, and location where the injury took place along with who was present at the time of the injury are essential questions. Family history for bleeding and bone disorders is important. Box 13-5 outlines areas of history that are concerning for abuse.
Neglect and Emotional Abuse Each child may manifest different responses to neglect, depending on the situation and developmental age of the child. The goal of the interview is to determine whether the child is in a safe environment and whether the caregiver has the skills and resources to care for the child. It is often difficult to determine whether the circumstances constitute poor parenting skills or true neglect. Box 13-6 lists flags for behaviors to look for in neglected and abused children.
Box 13-6 C l i n i c a l M a n i f e s t a t i o n s o f P o t e n t i a l C h i l d M a l t r e a t m e n t Physical Neglect
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Suggestive Physical Findings
Growth failure
Signs of malnutrition, such as thin extremities, abdominal distention, lack of subcutaneous fat
Poor personal hygiene
Unclean or inappropriate dress
Evidence of poor health care, such as delayed immunization, untreated infections, frequent colds
Frequent injuries from lack of supervision
Suggestive Behaviors
Dull and inactive affect; excessively passive or sleepy
Self-stimulatory behaviors, such as finger sucking or rocking
Begging or stealing food
Absenteeism from school
Substance abuse
Vandalism or shoplifting
Emotional Abuse and Neglect Suggestive Physical Findings
Growth failure (failure to thrive)
Eating or feeding disorder
Enuresis
Sleep disorder
Suggestive Behaviors
Self-stimulatory behaviors, such as biting, rocking, or sucking
During infancy, lack of social smile and stranger anxiety
Withdrawal from environment and people
Unusual fearfulness
Antisocial behavior, such as destructiveness, stealing, cruelty to animals or people
Extremes of behavior, such as over-compliant and passive or aggressive and demanding
Lags in emotional and intellectual development, especially language
Suicide attempts
Physical Abuse Suggestive Physical Findings
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Bruises and welts (may be in various stages of healing)
• On face, lips, mouth, back, buttocks, thighs, or areas of torso
• Regular patterns descriptive of object used, such as belt buckle, hand, wire hanger, chain, wooden spoon, squeeze or pinch marks
• May be present in various stages of healing
Burns
• On soles, palms, back, or buttocks
• Patterns descriptive of object used, such as round cigar or cigarette burns; sharply demarcated areas from immersion in scalding water; rope burns on wrists or ankles from being bound; burns in the shape of an iron, radiator, or electric stove burner
• Absence of “splash” marks and presence of symmetric burns
• Stun gun injury: Lesions circular, fairly uniform (≤0.5 cm), and paired about 5 cm apart
Fractures and dislocations
• Skull, nose, or facial structures
• Injury denoting type of abuse, such as spiral fracture or dislocation from twisting of an extremity or whiplash from shaking the child
• Multiple new or old fractures in various stages of healing
Lacerations and abrasions
• On backs of arms, legs, torso, face, or external genitalia
• Unusual symptoms, such as abdominal swelling, pain, and vomiting from punching
• Descriptive marks, such as from human bites or pulling out of hair
Chemical
• Unexplained repeated poisoning, especially drug overdose
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• Unexplained sudden illness, such as hypoglycemia from insulin administration
Suggestive Behaviors
Wary of physical contact with adults
Apparent fear of parents or going home
Lying very still while surveying environment
Inappropriate reaction to injury, such as failure to cry from pain
Lack of reaction to frightening events
Apprehensive when hearing other children cry
Indiscriminate friendliness and displays of affection
Superficial relationships
Acting-out behavior, such as aggression, to seek attention
Withdrawal behavior
Sexual Abuse Suggestive Physical Findings
Bruises, bleeding, lacerations, or irritation of external genitalia, anus, mouth, or throat
Torn, stained, or bloody underclothing
Pain on urination or pain, swelling, and itching of genital area
Penile discharge
Sexually transmitted disease, nonspecific vaginitis
Difficulty in walking or sitting
Unusual odor in the genital area
Recurrent urinary tract infections
Presence of sperm
Pregnancy in young adolescent
Suggestive Behaviors
Sudden emergence of sexually related problems, including excessive or public masturbation, age- inappropriate sexual play, promiscuity, or overtly seductive behavior
Withdrawn behavior, excessive daydreaming
Preoccupation with fantasies, especially in play
Poor relationships with peers
Sudden changes, such as anxiety, loss or gain of weight, clinging behavior
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In incestuous relationships, excessive anger at mother for not protecting daughter
Regressive behavior, such as bedwetting or thumb sucking
Sudden onset of phobias or fears, particularly fears of the dark, men, strangers, or particular settings or situations (e.g., undue fear of leaving the house or staying at the daycare center or the babysitter's house)
Running away from home
Substance abuse, particularly of alcohol or mood-elevating drugs
Profound and rapid personality changes, especially extreme depression, hostility, and aggression (often accompanied by social withdrawal)
Rapidly declining school performance
Suicidal attempts or ideation
Sexual Abuse An essential component to identifying sexual abuse is the interview. Several dynamics may impede the child's revelation of sexual abuse. Child sexual abuse is often perpetrated by someone known to the child, including family members. In some cases, the child may have been sworn to secrecy. The child may have been told that no one will believe the story or that his or her family would be harmed if he or she told someone about the abuse. Small children may imitate behaviors they have had perpetrated on themselves or have seen others do. The nurse must be able to recognize normal, age-related sexual curiosity and self-stimulating behaviors. Typically, children do not act out specific details of the sexual act or perform intrusive acts on others unless they have sexual knowledge beyond their normal age-related development (Dubowitz and Lane, 2016).
Children's reports of sexual abuse may vary from contradictory stories to unwavering versions of the experience. Stories that sound contradictory may reflect the child's experiences in several instances of abuse. Also, children who repeatedly tell identical facts may have been prompted to do so.
Increasing evidence suggests that the types of interrogation children are exposed to after reports of sexual abuse shape their thinking. To avoid biasing the interaction, nurses must be skillful interviewers when questioning children who may be victims of abuse. Medical records should include verbatim statements made by the child and interviewer that reflect appropriate non-leading questions and statements (Lyden, 2011). The child may not be emotionally ready to discuss the abuse. Establishing rapport with the child is essential to gaining his or her trust. Interviews should not be rushed. Engaging the child in play activities while encouraging conversation may help the child discuss the abuse. It may take several interviews or psychological counseling for the child to be forthcoming about the abuse. Information regarding the last sexual contact is important because it determines the need for a forensic evaluation. Children who have been sexually abused within the past 72 to 96 hours should be considered for forensic testing.
Unfortunately, there is no typical profile of the victim, and the nurse must have a high index of suspicion to identify these children. Physical signs vary and may include any of those listed for sexual abuse. The victim may exhibit various behavioral manifestations, but none of these behaviors is diagnostic. When abused children exhibit these behaviors, the signs may be incorrectly attributed to the normal stresses of childhood, especially in older school-age children or adolescents. Even signs considered most predictive of sexual abuse (such as certain genital findings, sexually inappropriate behavior for age, enactment of adult sexual activity, and intense focus on sexual activity [e.g., masturbation]), do not always indicate that sexual abuse has occurred. Conversely, abused children may not demonstrate more knowledge of sexual activity than non-abused children. However, one difference in the abused children's explanation of sexual activity may be unusual affective responses. For example, abused children have an increased risk for conduct disorders, aggressive behavior, and poor academic performance (Dubowitz and Lane, 2016).
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N u r s i n g A l e r t When children report potentially sexually abusive experiences, take their reports seriously but also cautiously to avoid alarming the child or falsely accusing someone.
Physical Assessment Child Physical Abuse The goal of the physical assessment for child physical abuse is identification of all injuries. A system approach ensures that the whole body is evaluated. In instances of severe abuse and injuries, the assessment should begin with a rapid assessment of airway, breathing, circulation, and neurologic systems. A systematic head-to-toe examination follows. Attention to areas often overlooked, such as the scalp, behind the ears, and the frenulum, is essential. The child's exterior genital area and posterior surface should be completely examined.
Record the location and a detailed description of all injuries. Note the color, size, and location of all bruising. Burn documentation should include the location, pattern, demarcation lines, and presence of eschar or blisters. Diagrams of the injuries using a body diagram form are helpful. If possible, obtain photographs of the injuries using a measurement tool.
Not all forms of physical abuse have obvious signs. Intraabdominal organ injury from blunt trauma to the abdomen can occur without signs of external abdominal bruising. Nurses should consider intraabdominal injury in infants and children who have any other signs of abuse.
N u r s i n g A l e r t Incompatibility between the history and the injury is probably the most important criterion on which to base the decision to report suspected abuse.
All evidence collected must adhere to strict guidelines for legal purposes; the chain of custody must be appropriately maintained with local law enforcement personnel. Documentation on the chain of custody form should include the names of persons collecting and receiving evidence (e.g., photographs and DNA samples), types of evidence collected and received, and date of receipt (Lyden, 2011).
Neglect and Emotional Abuse Neglect from deprivation of necessities is easier to identify than emotional neglect or psychological maltreatment because physical signs are usually evident. Assessment of the child's height, weight, nutritional status, hygiene, and age-appropriate interactions is important for the overall picture of potential neglect. Emotional maltreatment may be readily suspected, but it is difficult to substantiate. Physical signs are often nonspecific, and nurses must rely on behavioral indicators, which range from depression to acting-out behavior, to help identify a possibly abusive situation. Any persistent and unexplained change in the child's behavior is an important clue to possible emotional abuse.
Sexual Abuse Identifying instances of sexual abuse is particularly difficult because, often, few if any obvious physical indications of the activity exist. Physical signs vary and may include any of those listed in Box 13-6 for sexual abuse. The goal of the physical examination is to document genital findings. In most cases, the genital examination findings are normal, which does not mean that sexual abuse did not occur. Fondling or genital-to-genital contact without penetration may leave no physical findings. Forensic evidence obtained directly from a prepubertal victim's body diminishes greatly after 24 hours, with the best chance for evidence collection coming from bed linens or the child's underwear (Girardet, Bolton, Lohoti, et al, 2011). The female genital examination should include a description of the vulva, hymen, and surrounding tissue. Abnormal findings of concern are injuries to the posterior vulva or the lower half of the hymeneal ring or abrasions, bruising, or bleeding of the genital or anal tissue. It is often helpful to use a magnifying instrument (colposcope) to detect subtle injuries. There are many variants of normal findings for female genital anatomy, so it is recommended that the examination be done by a practitioner experienced with these types of cases.
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Contrary to popular myth, the size of the hymeneal opening is not predictive of the likelihood of sexual abuse (Adams, 2011). For male victims, swelling, abrasions, or bruising of the genital tissue raises concerns for abuse. Examine the anal area for symmetry, tone, fissures, or scars. Genital tissue heals very quickly and most often without scars. Therefore unless the child is seen within a few days of injury, the genital tissue may appear normal. In addition, the vaginal and anal mucosa is elastic; therefore penetration without disruption of tissue is possible. This defies another myth that there is always evidence of female virginity. Consider the collection of specimens for determining the presence of sexually transmitted infections, which may have been contracted during the sexual contact.
Nursing Care Management
Protect the Child from Further Abuse Initially, identification of instances of suspected abuse or neglect is essential. The nurse may come in contact with abused children in an emergency department, practitioner's office, home, daycare center, or school.
N u r s i n g A l e r t The priority is to remove the child from the abusive situation to prevent further injury.
All states and provinces in North America have laws for mandatory reporting of child maltreatment. Suspected child abuse is reported to the local authorities.* Referrals usually come to the state child welfare department and are assigned to a caseworker in an agency, such as Child Protective Services. After a referral has been made, a caseworker is assigned to investigate the report. Based on the findings, the child is left in the home or temporarily removed.
A court proceeding may be necessary before the child can be placed outside the home or when parental rights are to be terminated. When the courts are involved, they usually require firsthand testimony by the referring parties. Nurses may be subpoenaed to appear in court, or their notes may be introduced as evidence in court hearings. Accurate and factual documentation is essential. Behaviors are described, not interpreted, and are recorded daily to establish a progress record (see Nursing Care Guidelines box). Conversations among the nurse, child, and parent are recorded verbatim as much as possible.
N u r s i n g C a r e G u i d e l i n e s Recording Assessment Data in Suspected Abuse
History of Injury
Date, time, and place of occurrence
Sequence of events with recorded times
Presence of witnesses, especially person caring for child at time of incident
Time lapse between occurrence of injury and initiation of treatment
Interview with child when appropriate, including verbal quotations and information from drawing or other play activities
Interview with parent, witnesses, and other significant persons, including verbal quotations
Description of parent–child interactions (verbal interactions, eye contact, touching, parental concern)
Name, age, and condition of other children in home (if possible)
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Physical Examination
Location, size, shape, and color of bruises; approximate location, size, and shape on drawing of body outline
Distinguishing characteristics, such as a bruise in the shape of a hand or a round burn (possibly caused by cigarette)
Symmetry or asymmetry of injury; presence of other injuries
Degree of pain; any bone tenderness
Evidence of past injuries; general state of health and hygiene
Developmental level of child; screening test (see Developmental Assessment, Chapter 3)
Support the Child Children suspected of being abused are often hospitalized for medical management of their injuries and to allow further assessment of their safety needs. The needs of these children are the same as those of any hospitalized child. The child should be treated as a child with the usual physical needs, developmental tasks, and play interests—not as a victim of abuse. The goal of the nurse–child relationship is to provide a role model for the parents in helping them to relate positively and constructively to their child and to foster a therapeutic environment for the child in his or her reprieve from the abusing situation.
Support the Family The nurse also encourages the child's relationship with non-offending parents. The nurse does not become a substitute parent but rather acts as a role model for parents in helping them to relate positively and constructively to their child. When parental ignorance of childrearing practices has played a part in the abuse, the nurse can educate the parent regarding children's physical and emotional needs. Because of the parents' own childrearing, they may not be aware of nonviolent methods of discipline, such as time-outs. They may also need help in dealing with their frustration so that they do not vent anger on the child. Because these parents may be sensitive to criticism or resistant to authority figures, teaching is implemented through demonstration and example rather than through lecturing. Praise any competent parenting abilities they demonstrate to promote their sense of parental adequacy.
Advise family members to encourage the child to resume normal activities and observe the child for signs of distress (see Posttraumatic Stress Disorder, Chapter 16). Children express their feelings primarily through behavior. Parents should be alert for changes in behavior that indicate distress resulting from the incident, such as remaining in the house, refusal to go to school, changes in sleeping patterns, and frequency of dreams and nightmares.
Referral to appropriate social service agencies is also essential. Many abusive parents live in poverty, and the daily stresses imposed by their circumstances are overwhelming. Seek resources for financial aid, improved housing, and child care. Self-help groups also provide important services. Groups such as Parents Anonymous* (a group for parents who have abused or fear that they may abuse their child but only in terms of physical abuse, not sexual abuse) are accepting and nonjudgmental.
Plan for Discharge Discharge planning should begin as soon as the legal disposition for placement has been decided, which may be temporary foster home placement, return to the parents, or permanent termination of parental rights. The latter is the most drastic solution, but it is necessary in situations of life- threatening abuse. Whenever children are sent to a foster home or juvenile institution, they must be allowed an opportunity to express their feelings. No matter how severe the abuse, they usually mourn the loss of their parents. They need help to understand why they must not return home and that this new home is in no way a punishment. Whenever possible, foster parents are encouraged to visit in the hospital, and the nurse should take an active role in helping the new parents understand
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the child, as well as the child's health care needs, because studies have shown that the health care needs of children in foster care often go unmet (Schneiderman, Smith, and Palinkas, 2012).
Prevent Abuse Prevention of child maltreatment has been an extremely difficult goal. However, nurses have played an important role in such programs. For example, home visits based on identified risk factors (such as mothers who are teenagers, unmarried, or of low socioeconomic status) were noted to be an effective preventive measure (Selph, Bougatsos, Blazina, et al, 2013). The nurses provided information on normal child growth and development and routine health care needs, served as informal support persons, and referred families to appropriate services when a need for assistance was identified. The Nurse-Family Partnership is one program that has demonstrated evidence- based interventions resulting in the prevention of child maltreatment (Lane, 2014).
Nurses in a variety of settings can implement similar activities. For example, nurses in prenatal clinics can prepare expectant families for adjustment to parenthood. Nursery and postpartum nurses can foster the attachment process by encouraging parents to hold and look at their infant, as well as teach coping mechanisms for prolonged crying. Nurses in neonatal intensive care units can minimize the effects of separation by encouraging parents to visit and can help parents become comfortable caring for their child. Nurses in ambulatory settings can teach parents appropriate methods of bathing, feeding, toileting, disciplining, and preventing injuries while stressing the normal needs and developmental characteristics of children. Nurses must be sensitive to parental needs for attention, reassurance, and reinforcement and should refer parents to community services and self-help groups.
Unlike preventive efforts for neglect and physical abuse, which have been aimed at the potential offender, prevention of child sexual abuse has centered on education of children to protect themselves. Materials are available for parents that describe sexual abuse and its prevention.† Helpful games such as “What if the babysitter wants to wrestle and hug but tells you to keep it a secret?” can be used to explore dangerous situations in advance and help children learn the importance of saying “no.” They need reassurance that no matter what the other person says or does, the parents want to know about it and will not punish them. Even if children participate in the activity before telling their parents, they must be reassured that it was not their fault. It is equally important to teach children safety in terms of potential risk situations. Several suggestions for parents regarding protecting and educating children against possible molestation are presented in the Family-Centered Care box. The nurse is frequently in a position to discuss the topic of abuse with parents and to provide guidelines. In addition, parents need to be made aware that “nice” people, including friends and relatives, can be offenders; parents should carefully observe how others act toward the child. A sudden change in the child's behavior and a response such as “I don't like Uncle Bob anymore” are clues to investigate the relationship. In the event of any doubt, prevent further solitary encounters with this person and the child. It is sometimes to the child's great misfortune that parents do not take certain comments seriously, such as “He hugs me too tight” or “I don't want to go with him.” Casual parental statements such as “He just loves you” or “You do whatever adults tell you to do” can place children in jeopardy. Health professionals must alert parents to such dangers and guide them toward an appreciation of the problem, providing concrete guidelines toward child education and protection.
F a m i l y - C e n t e r e d C a r e Preventing and Dealing with Sexual Abuse of Children
Sexual assault of children is much more common than most people realize. It may be preventable if children have good preparation. To provide protection and preparation:
• Pay careful attention to who is around children. (Unwanted touch may come from someone liked and trusted.)
• Back up a child's right to say no.
• Encourage communication by taking seriously what children say.
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• Take a second look at signals of potential danger.
• Refuse to leave children in the company of those who are not trusted.
• Include information about sexual assault when teaching about safety.
• Provide specific definitions and examples of sexual assault.
• Remind children that even “nice” people sometimes do mean things.
• Urge children to tell about anybody who causes them to be uncomfortable.
• Prepare children to deal with bribes, threats, and possible physical force.
• Virtually eliminate secrets between children and parents.
• Teach children how to say no, ask for help, and control who touches them and how.
• Model self-protective and limit-setting behavior for children.
If it ever becomes necessary to help a child recover from a sexual assault:
• Listen carefully to understand the child.
• Support the child for telling through praise, belief, sympathy, and lack of blame.
• Know local resources and choose help carefully.
• Provide opportunities to talk about the assault.
• Provide opportunities for the entire family to go through a recovery process.
Sexual assault affects everyone. To help deal with this social problem:
• Provide care and support to those who have been victimized.
• Recognize that offenders may not change behavior even with intervention.
• Organize neighborhood programs to support each other's efforts to protect children.
• Encourage schools to provide information about sexual assault as a problem of health and safety.
• Organize community groups to support educational treatment and law enforcement programs.
Modified from Adams C, Fay J: No more secrets: protecting your child from sexual assault, San Luis Obispo, CA, 1981, Impact.
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NCLEX Review Questions 1. The mother of a 4-year-old health clinic patient asks the nurse about night terrors. Which
statement by the mother reveals a need for further teaching? Select all that apply. a. He will grow out of this stage when he is a little older. b. Getting into a specific routine is helpful and can be calming to my son. c. Watching TV with an adult is helpful so that he understands what is real. d. I can help my child with sleep by giving him his favorite stuffed animal or using a night-light. e. Our family often sleeps together, and this seems to help.
2. A child is brought to the emergency department by his parents after noted to be “acting funny” a few hours ago while he was being cared for by his grandmother. When she went to take her evening medication, the grandmother noted that her pill container had been opened and some pills were missing. The parents state that the grandmother has a heart condition. Anticipating the emergency care this child will receive, you know: a. The majority of medications have a specific antidote. b. In this case, gastric lavage may be used. c. Activated charcoal will most likely be used, and it can be mixed with another drink (milk or
juice) to make it more palatable. d. The main concerns are for vital sign assessment, assessment of mental status, and giving
cardiac and respiratory support as needed.
3. You are working with the family of a 4-year-old patient and have concerns about possible exposure to lead poisoning. Which information will determine if follow-up is needed? Select all that apply. a. The child goes daily to the older home of a babysitter. b. One of the child's playmates in the neighborhood has lead poisoning. c. Although living in a newer neighborhood, one of the child's playmates' homes is being
renovated. d. The child is out of the danger age range for screening (1 to 2 years old), so screening is not
needed. e. Past BLL was 12, so no follow-up is needed at this time.
4. When assessing a child's injury in the emergency department, a nurse suspects physical abuse. Based on this suspicion, the nurse's primary legal responsibility is: a. Assist the family in identifying resources for support. b. Report the case in which the abuse is suspected to the local authorities. c. Document the child's physical assessment findings accurately and thoroughly. d. Refer the family to the hospital support group.
5. Nursing care of a child in the hospital with suspected abuse should include: a. Assign a variety of nurses to the child so that he can get to know and trust the whole staff. b. Praise the child's ability to minimize feelings of shame and guilt. c. Treat the child as someone with a specific problem, not as an “abuse” victim, to promote self-
esteem and minimize feelings of guilt. d. Talk with and ask questions as often as possible to show interest and get to know the child
better.
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Correct Answers 1. a, c, e; 2. d; 3. a, b; 4. b; 5. c
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Dapul H, Laraque D. Lead poisoning in children. Adv Pediatr. 2014;61(1):313–333. Dubowitz H, Lane W. Abused and neglected children. Kliegman RM, Stanton BF, St Geme JW,
et al. Nelson textbook of pediatrics. ed 20. Saunders/Elsevier: Philadelphia; 2016. Evans H. Pediatrics tackles child sexual abuse. Arch Pediatr Adolesc Med. 2011;165(9):783–784. Forsdike K, Tarzia L, Hindmarsh E, et al. Family violence across the life cycle. Aust Fam
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ed 4. Saunders/Elsevier: London; 2012. US Department of Health and Human Services. The Child Abuse Prevention and Treatment Act
(CAPTA) 2010. US Government Printing Office: Washington, DC; 2011. US Department of Health and Human Services. Child maltreatment 2011. US Government
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Health Educ Behav. 2014;41(6):577–589. *The American Burn Association offers an Advanced Burn Life Support Program; http://www.ameriburn.org/ablsnow.php. *625 North Michigan Ave., Suite 2550, Chicago, IL 60611; 312-642-9260; email: [email protected]; http://www.ameriburn.org. †1121 Spring Lake Drive, Itasca, IL 60143-3201; 630-285-1121, email: [email protected]; http://www.nsc.org. ‡Akron Children's Hospital, One Perkins Square, Akron, OH 44308-1062; 330-543-1000; http://www.akronchildrens.org. *The most common substances in each category are in parentheses. Substances ingested are not necessarily the most toxic but often are readily available. *Also available by calling 800-222-1222 or online at American Association of Poison Control Centers, http://www.aapcc.org. *Additional information is available from the Children's Bureau, Administration for Children and Families, 370 L'Enfant Promenade SW, Washington, DC 20447; http://www.acf.hhs.gov/programs/cb. *Telephone numbers are usually listed under “Child Abuse” in the business white pages of the local directory or you can call the emergency child abuse hotline: 800-422-4453 (800-4-A-CHILD). *250 West First Street, Suite 250, Claremont, CA 91711; 909-621-6184; http://www.parentsanonymous.org. †Sources of information are: Prevent Child Abuse America, 228 S. Wabash Ave., 10th Floor, Chicago, IL 60604; 312-663-3520 or 800- Children (800-244-5373); http://www.preventchildabuse.org; and American Humane Association, 1400 16th Street NW, Suite 360, Washington DC 20036; 800-227-4645; http://www.americanhumane.org.
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U N I T 6 Family-Centered Care of the School-Age Child and Adolescent
OUTLINE 14 Health Promotion of the School-Age Child and Family 15 Health Promotion of the Adolescent and Family 16 Health Problems of School-Age Children and Adolescents
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Health Promotion of the School-Age Child and Family Cheryl C. Rodgers
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Promoting Optimal Growth and Development The segment of the life span that extends from age 6 to approximately age 12 has a variety of labels, each of which describes an important characteristic of the period. These middle years are most often referred to as school-age or the school years. This period begins with entrance into the school environment, which has a significant impact on development and relationships.
Physiologically the middle years begin with the shedding of the first deciduous tooth and end at puberty with the acquisition of the final permanent teeth (with the exception of the wisdom teeth). Before 5 or 6 years old, children have progressed from helpless infants to sturdy, complicated individuals with an ability to communicate, conceptualize in a limited way, and become involved in complex social and motor behaviors. Physical growth has been equally rapid during the preschool- age years. In contrast, the period of middle childhood, between the rapid growth of early childhood and the prepubescent growth spurt, is a time of gradual growth and development with more even progress in both physical and emotional aspects.
Biologic Development During middle childhood, growth in height and weight assumes a slower but steady pace as compared with the earlier years. Between 6 and 12 years old, children grow an average of 5 cm (2 inches) per year to gain 30 to 60 cm (1 to 2 feet) in height and almost double their weight, increasing 2 to 3 kg (4.4 to 6.6 pounds) per year. The average 6-year-old child is about 116 cm (46 inches) tall and weighs about 21 kg (46 pounds); the average 12-year-old child is about 150 cm (59 inches) tall and weighs approximately 40 kg (88 pounds). During this age, girls and boys differ little in size, although boys tend to be slightly taller and somewhat heavier than girls. Toward the end of the school-age years, both boys and girls begin to increase in size, although most girls begin to surpass boys in both height and weight, to the acute discomfort of both girls and boys.
Physical Changes School-age children are more graceful than they were as preschoolers, and they are steadier on their feet. Their body proportions take on a slimmer look, with longer legs, varying body proportion, and a lower center of gravity. Posture improves over that of the preschool period to facilitate locomotion and efficiency in using the arms and trunk. These proportions make climbing, bicycle riding, and other activities easier. Fat gradually diminishes, and its distribution patterns change, contributing to the thinner appearance of children during the middle years.
Accompanying the skeletal lengthening and fat diminution is an increase in the percentage of body weight represented by muscle tissue. By the end of this age period, both boys and girls double their strength and physical capabilities, and their steady and relatively consistent development of coordination increases their poise and skill. However, this increased strength is often misleading. Although strength increases, muscles are still functionally immature when compared with those of adolescents, and they are more readily damaged by muscular injury caused by overuse.
The most pronounced changes that indicate increasing maturity in children are a decrease in head circumference in relation to standing height, a decrease in waist circumference in relation to height, and an increase in leg length in relation to height. These indicators often provide a clue to a child's degree of physical maturity. There appears to be a correlation between physical indications of maturity and success in school.
Certain physiologic and anatomic characteristics are typical of school-age children. Facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size thereafter. Because all of the primary (deciduous) teeth are lost during this age span, middle childhood is sometimes known as the age of the loose tooth (Fig. 14-1). The early years of middle childhood, when the new secondary (permanent) teeth appear too large for the face, are known as the ugly duckling stage.
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FIG 14-1 Middle childhood is the stage of development when deciduous teeth are shed.
Maturation of Systems Maturity of the gastrointestinal system is reflected in fewer stomach upsets, better maintenance of blood glucose levels, and an increased stomach capacity, which permits retention of food for longer periods. School-age children do not need to be fed as promptly or as frequently as preschool-age children. Caloric needs (kcal/kg) are less than they were in the preschool years and lower than they will be during the coming adolescent growth spurt.
Physical maturation is evident in other body tissues and organs. Bladder capacity, although differing widely among individual children, is generally greater in girls than in boys. The heart grows more slowly during the middle years and is smaller in relation to the rest of the body than at any other period of life. Heart and respiratory rates steadily decrease, and blood pressure increases from 6 to 12 years old (see inside back cover).
The immune system becomes more competent in its ability to localize infections and to produce an antibody–antigen response. However, children have several infections in the first 1 to 2 years of school because of increased exposure to others in school classes.
Bones continue to ossify throughout childhood but yield to pressure and muscle pulls more readily than with mature bones. Children need ample opportunity to move around, but they should observe caution in carrying heavy loads. For example, they should shift books or tote bags from one arm to the other. Backpacks, when worn correctly, distribute weight more evenly.
Wider differences between children are observed at the end of middle childhood than at the beginning. These differences become increasingly apparent and, if they are extreme or unique, may create emotional problems. The associated characteristics of height and weight relationships, rapid or slow growth, and other important features of development should be explained to children and their families. Physical maturity is not necessarily correlated with emotional and social maturity. Seven-year-old children who look like 10-year-old children will think and act like 7-year-olds. To expect behaviors appropriate for an older age is unrealistic and can be detrimental to their development of competence and self-esteem. Conversely, to treat 10-year-old children who look young physically as though they were younger is an equal disservice to them.
Prepubescence Preadolescence is the period that begins toward the end of middle childhood and ends with the 13th birthday. Puberty signals the beginning of the development of secondary sex characteristics, and prepubescence, the 2-year period that precedes puberty, typically occurs during preadolescence.
Toward the end of middle childhood, the discrepancies in growth and maturation between boys and girls become apparent. On the average, there is a difference of approximately 2 years between girls and boys in the age of onset of pubescence. This is a period of rapid growth in height and weight, especially for girls.
There is no universal age at which children assume the characteristics of prepubescence. The first physiologic signs appear at about 9 years old (particularly in girls) and are usually clearly evident in 11- to 12-year-old children. Although preadolescent children do not want to be different,
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variability in physical growth and physiologic changes among children of the same sex and between the two sexes is often striking at this time. This variability, especially in relation to the onset of secondary sex characteristics, is of great concern to preadolescents. Either early or late appearance of these characteristics is a source of embarrassment and uneasiness to both sexes.
Preadolescence is a time when considerable overlapping of developmental characteristics occurs, with elements of both middle childhood and early adolescence apparent. However, several unique characteristics set this period apart from others. In general, puberty begins at 10 years old in girls and 12 years old in boys, but it can be normal for either sex after 8 years old. Boys experience little visible sexual maturation during preadolescence.
Psychosocial Development: Developing a Sense of Industry (Erikson) Freud described middle childhood as the latency period, a time of tranquility between the oedipal phase of early childhood and the eroticism of adolescence. During this time, children experience relationships with same-sex peers following the indifference of earlier years and preceding the heterosexual fascination that occurs for most boys and girls in puberty.
Successful mastery of Erikson's first three stages of psychosocial development is important in terms of development of a healthy personality. Successful completion of these stages requires a loving environment within a stable family unit. These experiences prepare the child to engage in experiences and relationships beyond the intimate family group.
A sense of industry, or a sense of accomplishment, occurs somewhere between 6 years old and adolescence. School-age children are eager to develop skills and participate in meaningful and socially useful work. Interests expand in the middle years, and with a growing sense of independence, children want to engage in tasks that can be carried through to completion (Fig. 14- 2). Failure to develop a sense of accomplishment may result in a sense of inferiority.
FIG 14-2 School-age children are motivated to complete tasks. A, Working alone. B, Working with others.
Many aspects of industry contribute to the child's sense of competence and mastery. Children gain satisfaction from independent behavior in exploring and manipulating their environment and from interaction with peers. Reinforcement in the form of grades, material rewards, additional privileges, and recognition provides encouragement and stimulation.
A sense of accomplishment also involves the ability to cooperate, to compete with others, and to cope effectively with people. Middle childhood is the time when children learn the value of doing things with others and the benefits derived from division of labor in the accomplishment of goals. Peer approval is a strong motivating power.
The danger inherent in this period of development is the occurrence of situations that might result in a sense of inadequacy or inferiority. This may happen if the previous stages have not been successfully mastered or if a child is incapable of or unprepared to assume responsibilities associated with developing sense of accomplishment. Children with physical and mental limitations may be at a disadvantage in the acquisition of certain skills. When the reward structure is based on evidence of mastery, children who are incapable of developing these skills risk feeling
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inadequate and inferior. Even children without chronic disabilities may experience feelings of inadequacy in some areas.
No child is able to do everything well, and children must learn that they will not be able to master every skill that they attempt. All children, even children who usually have positive attitudes toward work and their own abilities, will feel some degree of inferiority when they encounter specific skills that they cannot master.
Children need and want real achievement. Children achieve a sense of industry when they have access to tasks that need to be done and they are able to complete the tasks well despite individual differences in their innate capacities and emotional development.
Cognitive Development (Piaget) When children enter the school years, they begin to acquire the ability to relate a series of events to mental representations that can be expressed both verbally and symbolically. This is the stage Piaget describes as concrete operations, when children are able to use thought processes to experience events and actions. The rigid, egocentric view of the preschool years is replaced by thought processes that allow children to see things from another's point of view. Their steady reduction in egocentricity helps form the basis for logical thought and the development and maturation of morality.
During this stage, children develop an understanding of relationships between things and ideas. They progress from making judgments based on what they see (perceptual thinking) to making judgments based on what they reason (conceptual thinking). They are increasingly able to master symbols and to use their memories of past experiences to evaluate and interpret the present.
One of the major cognitive tasks of school-age children is mastering the concept of conservation (Fig. 14-3). There is a developmental sequence in children's capacity to understand conservation. Children usually grasp the conservation of numbers (ages 5 to 6) before conservation of substance. For example, they first recognize that 7 remains 7 whether it is represented by 3 + 4, 2 + 5, 7 buttons, or 7 stars. Conservation of liquids, mass, and length usually is accomplished at about ages 6 to 7. At this time, they recognize that changing the shape of a substance, such as a lump of clay, does not alter its total mass. They learn conservation of weight sometime later (ages 9 to 10) and conservation of volume or displacement last (ages 9 to 12). For example, they no longer perceive a tall, thin glass of water as containing a greater volume than a short, wide glass; they can distinguish between the weight of items regardless of their size. School-age children also develop classification skills. They can group and sort objects according to the attributes that they share, place things in a sensible and logical order, and hold a concept in mind while making decisions based on that concept. In middle childhood, children derive a great deal of enjoyment from classifying and ordering their environment. They become occupied with collections of objects, such as stickers, shells, dolls, cars, cards, and stuffed animals. They may even begin to order friends and relationships (e.g., best friend, second best friend).
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FIG 14-3 Common examples that demonstrate the child's ability to conserve (ages are only approximate).
They develop the ability to understand relational terms and concepts, such as bigger and smaller, darker and paler, heavier and lighter, to the right of and to the left of, and more than and less than. They view family relationships in terms of reciprocal roles (e.g., to be a brother, one must have a sibling).
School-age children learn the alphabet and the world of symbols called words, which can be arranged in terms of structure and their relationship to the alphabet. They learn to tell time, to see the relationship of events in time (history) and places in space (geography), and to combine time and space relationships (geology and astronomy).
The ability to read is acquired during the school years and becomes the most significant and
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valuable tool for independent inquiry. Children's capacity to explore, imagine, and expand their knowledge is enhanced by reading.
Moral Development (Kohlberg) As children move from egocentrism to more logical patterns of thought, they also move through stages in the development of conscience and moral standards. Young children do not believe that standards of behavior come from within themselves but that rules are established and set down by others. During the preschool years, children perceive rules as definite and require no reason or explanation. They learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Although children 6 or 7 years old know the rules and behaviors expected of them, they do not understand the reasons behind them. Rewards and punishments guide their judgment; a “bad act” is one that breaks a rule or causes harm. Young children believe that what other people tell them to do is right and that what they themselves think is wrong. Consequently, children 6 or 7 years old may interpret accidents or misfortunes as punishment for “bad” acts.
Older school-age children are able to judge an act by the intentions that prompted it rather than just its consequences. Rules and judgments become less absolute and authoritarian and begin to be founded on the needs and desires of others. For older children, a rule violation is likely to be viewed in relation to the total context in which it appears. The situation, as well as the morality of the rule itself, influences reactions. Although younger children judge an act only according to whether it is right or wrong, older children take into account different points of view. They are able to understand and accept the concept of treating others as they would like to be treated.
Spiritual Development Children at this age think in concrete terms but are avid learners and have a great desire to learn about their God or deity. They picture God as human and use adjectives such as “loving” and “helping” to describe their deity. They are fascinated by the concepts of hell and heaven, with a developing conscience and concern about rules, and they may fear going to hell for misbehavior. School-age children want and expect to be punished for misbehavior and, when given the option, tend to choose a punishment that “fits the crime.” Often they view illness or injury as a punishment for a real or imagined misdeed. The beliefs and ideals of family and religious persons are more influential than those of their peers in matters of faith.
School-age children begin to learn the difference between the natural and the supernatural but have difficulty understanding symbols. Consequently, religious concepts must be presented to them in concrete terms. Prayer or other religious rituals comfort them, and if these activities are a part of their daily lives, they can help them cope with threatening situations. Their petitions to their God in prayers tend to be for tangible rewards. Although younger children expect their prayers to be answered, as they get older, they begin to recognize that this does not always occur, and they become less concerned when their prayers are not answered. They are able to discuss their feelings about their faith and how it relates to their lives (see Cultural Considerations box).
C u l t u r a l C o n s i d e r a t i o n s Religious Orientation
Many schools and communities have a Judeo-Christian orientation toward prayer, holidays, and values. This may result in conflict and discomfort for children of other religious or ethnic groups. Sensitivity must be exercised so as not to offend and confuse children from other religious backgrounds, such as the Buddhist, Hindu, and Muslim faiths, and those with no religious backgrounds.
Social Development Peer group identification is an important factor in gaining independence from parents. Peer groups have a culture of their own with secrets, traditions, and codes of ethics that promote feelings of
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solidarity and detachment from adults. Through peer relationships, children learn how to deal with dominance and hostility, how to relate to persons in positions of leadership and authority, and how to explore ideas and the physical environment. The aid and support of the group provide children with enough security to risk the moderate parental rejection brought about by small victories in the development of independence.
A child's concept of the appropriate sex role is acquired through relationships with peers. During the early school years, few gender differences exist in the play experiences of children. Both girls and boys share games and other activities. However, in the later school years, the differences in the play of boys and girls become more marked.
Social Relationships and Cooperation Daily relationships with peers provide important social interactions for school-age children. For the first time, children join group activities with unrestrained enthusiasm and steady participation. Previous interactions were limited to short periods under considerable adult supervision. With increased skills and wider opportunities, children become involved with one or more peer groups in which they can gain status as respected members.
Valuable lessons are learned from daily interaction with age mates. First, children learn to appreciate the numerous and varied points of view that are represented in the peer group. As children interact with peers who see the world in ways that are somewhat different from their own, they become aware of the limits of their own point of view. Because age mates are peers and are not forced to accept each other's ideas as they are expected to accept those of adults, other children have a significant influence on decreasing the egocentric outlook of the child. Consequently, children learn to argue, persuade, bargain, cooperate, and compromise to maintain friendships.
Second, children become increasingly sensitive to the social norms and pressures of the peer group. The peer group establishes standards for acceptance and rejection, and children are often willing to modify their behavior to be accepted by the group. The need for peer approval becomes a powerful influence toward conformity. Children learn to dress, talk, and behave in a manner acceptable to the group. A variety of roles, such as class joker or class hero, may be assumed by individual children to gain approval from the group.
Third, the interaction among peers leads to the formation of intimate friendships between same- sex peers. The school-age period is the time when children have “best friends” with whom they share secrets, private jokes, and adventures; they come to one another's aid in times of trouble. In the course of these friendships, children also fight, threaten each other, break up, and reunite. These dyadic relationships, in which the child experiences love and closeness with a peer, seem to be important as a foundation for relationships in adulthood (Fig. 14-4).
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FIG 14-4 School-age children enjoy engaging in activities with a “best friend.”
Clubs and Peer Groups One of the outstanding characteristics of middle childhood is the formation of formalized groups, or clubs. A prominent feature of these groups is the code of rigid rules imposed on the members. There is exclusiveness in the selection of persons who have the privilege of joining. Acceptance in the group is often determined on a pass–fail basis according to social or behavioral criteria. Conformity is the core of the group structure. There are often secret codes, shared interests, special styles of dress, and special words that signify membership in the group. Each child must abide by a standard of behavior established by the members. Conforming to the rules provides children with feelings of security and relieves them of the responsibility of making decisions. By merging their identities with those of their peers, children are able to move from the family group to an outside group as a step toward seeking further independence. Peer groups and clubs allow children to substitute conformity to a peer group for conformity to a family at a time when children are still too insecure to function independently.
During the early school years, groups are usually small and loosely organized, with changing membership and no formal structure. They do not demonstrate the elements of cooperation and order that are seen in groups of older children. In general, girls' groups are less formalized than boys' are, and although there may be a mixture of both sexes in the early school years, the groups of later school years are composed predominantly of children of the same sex. Common interests are the basis around which the group is structured.
Poor relationships with peers and a lack of group identification can contribute to bullying. Bullying is any recurring activity that intends to cause harm, distress, or control towards another in which there is a perceived imbalance of power between the aggressor(s) and the victim (Hensley, 2013). Although bullying can occur in any setting, it most often occurs in school hallways or on the playground where supervision is minimal but peers are present to witness the attack (Shetgiri, 2013). Cyberbullying involves an electronic medium to harm or bother another individual and can be more harmful than traditional bullying, because the attack can instantly reach a wider audience, while allowing the bully to remain anonymous (Sticca and Perren, 2013). Children who are targeted for bullying often have internalizing characteristics such as withdrawal, anxiety, depression, low self-esteem, and reduced assertiveness that may make them an easy target for bullying (Arseneault, Bowes, and Shakoor, 2010). Bullies are generally defiant toward adults, manipulative, and likely to
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break school rules. They have aggressive attitudes, a positive view of violence, a lack of empathy, and may experience or witness violence or abuse at home (Hensley, 2013). Boys who bully tend to use physical force, referred to as direct bullying, but girls usually use bullying methods, such as exclusion, gossip, or rumors, which are referred to as indirect bullying (Shetgiri, 2013).
The long-term consequences of bullying are significant. Future problems of bullies include a higher risk for conduct problems, hyperactivity, school dropout, unemployment, and participation in criminal behavior (Shetgiri, Lin, and Flores, 2012). Chronic bullies seem to continue their behaviors into adulthood, negatively influencing their ability to develop and maintain relationships. Victims of bullying are at increased risk for low self-esteem, anxiety, depression, feelings of insecurity, loneliness, poor academic performance, and psychosomatic complaints, such as feeling tense, tired, or dizzy (Giesbrecht, Leadbeater, and Macdonald, 2011). School personnel play an important role in implementing anti-bullying interventions in schools; however, research has recognized that involving the whole family in anti-bullying programs greatly increases success (Arseneault, Bowes, and Shakoor, 2010).
There are also dangers in peer group attachments that are too strong. Peer pressures force some children to take risks or engage in behaviors that are against their better judgment. A child's membership in a gang is associated with marked increases in serious delinquent behavior (Bradshaw, Waasdorp, Goldweber, et al, 2013). Peer group activities that result in unlawful or criminal gang violence are increasing in the United States (U.S. Department of Justice, 2011). An integration of family-centered and school-based programs is needed to reduce the influences for children to become affiliated with gangs.
Relationships with Families Although the peer group is influential and necessary for normal child development, parents are the primary influence in shaping their children's personalities, setting standards for behavior, and establishing value systems. Family values usually take precedence over peer value systems. Although children may appear to reject parental values while testing the new values of the peer group, ultimately they retain and incorporate into their own value systems the parental values they have found to be of worth.
In the middle school years, children want to spend more time in the company of peers, and they often prefer peer group activities to family activities. This can be disturbing to parents. Children become intolerant and critical of their parents, especially when their parents' ways deviate from those of the group. They discover that parents can be wrong, and they begin to question the knowledge and authority of their parents, who were previously considered to be all-knowing and all-powerful. Parents can best serve the interests of their children through tolerant understanding and support.
Although increased independence is the goal of middle childhood, children are not prepared to abandon all parental control. They need and want restrictions placed on their behavior, and they are not prepared to cope with all of the problems of their expanding environment. They feel more secure knowing there is an authority figure to implement controls and restrictions. Children may complain loudly about restrictions and try to break down parental barriers, but they are uneasy if they succeed in doing so. They respect adults who prevent them from acting on every urge. Children view this behavior as an expression of love and concern for their welfare.
Children also need their parents to be adults, not “pals.” Sometimes parents, hurt by their children's rejection, attempt to maintain their love and gratitude by assuming the role of pal. Children need the stable, secure strength provided by mature adults to whom they can turn during troubled relationships with peers or stressful changes in their world. With a secure base in a loving family, children are able to develop the self-confidence and maturity needed to break loose from the group and stand independently.
Play Play takes on new dimensions that reflect a new stage of development in the school years. Play involves increased physical skill, intellectual ability, and fantasy. In addition, children develop a sense of belonging to a team or club by forming groups and cliques. Belonging to a group is of vital importance.
Rules and Rituals
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The need for conformity in middle childhood is strongly manifested in the activities and games of school-age children. In the preschool years, children's games were either invented for them or played in the company of a friend or an adult, and rules more or less evolved with the game. Now children begin to see the need for rules, and their games have fixed and unvarying rules that may be bizarre and extraordinarily rigid. Part of the enjoyment of the game is knowing the rules because knowing means belonging. Conformity and ritual permeate their play and are also evident in their behavior and language. Childhood is full of chants and taunts, such as “Eeeny, meeny, miney, mo,” “Last one is a rotten egg,” and “Step on a crack, break your mother's back.” Children derive a sense of pleasure and power from such sayings, which have been handed down with few changes through generations.
Team Play A more complex form of play that evolves from the need for peer interaction is team games and sports. A referee, umpire, or person of authority may be required so that the rules can be followed more accurately. Team play teaches children to modify or exchange personal goals for goals of the group; it also teaches them that division of labor is an effective strategy for attaining a goal.
Team play can also contribute to children's social, intellectual, and skill growth (Eime, Young, Harvey, et al, 2013). Children work hard to develop the skills needed to become team members, to improve their contribution to the group, and to anticipate the consequences of their behavior for the group. Team play helps stimulate cognitive growth because children are called on to learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths and weaknesses of members of their own team and members of the opposing team.
Quiet Games and Activities Although the play of school-age children can be highly active, they also enjoy many quiet and solitary activities. The middle years are the time for collections, and young school-age children's collections are an odd assortment of unrelated objects in messy, disorganized piles. Collections of later school years are more orderly and selective and often are organized in scrapbooks, on shelves, or in boxes.
School-age children become fascinated with complex board, card, or computer games that they can play alone or in groups. As in all games, adherence to the rules is fanatic. Disagreements over rules can cause much discussion and argument but are easily resolved by reading the rules of the game.
The newly acquired skill of reading becomes increasingly satisfying as school-age children expand their knowledge of the world through books (Fig. 14-5). School-age children never tire of stories and, as with preschool children, love to have stories read aloud. They also enjoy sewing, cooking, carpentry, gardening, and creative activities, such as painting. Many creative skills, such as music and art, as well as athletic skills such as swimming, karate, dancing, and skating, are learned during these years and continue to be enjoyed into adolescence and adulthood (Fig. 14-6).
FIG 14-5 Selecting a book with the assistance of an adult.
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FIG 14-6 School-age children take pride in learning new skills.
Ego Mastery Play affords children the means to acquire representational mastery over themselves, their environment, and others. Through play, children can feel as big, as powerful, and as skillful as their imaginations will allow. They can also feel in control and attain vicarious mastery and power over whomever and whatever they choose. School-age children still need the opportunity to use large muscles in exuberant outdoor play and the freedom to exert their newfound autonomy and initiative. They need space in which to exercise large muscles and to deal with tensions, frustrations, and hostility. Physical skills practiced and mastered in play help to develop a feeling of personal competence, which contributes to a sense of accomplishment and provides status in their peer group.
Developing a Self-Concept The term self-concept refers to a conscious awareness of self-perceptions, such as one's physical characteristics, abilities, values, self-ideals and expectancy, and idea of self in relation to others. It also includes one's body image, sexuality, and self-esteem. Although primary caregivers continue to exert influence on children's self-evaluation, the opinions of peers and teachers provide valuable input during middle childhood. With the emphasis on skill building and broadened social relationships, children are continually engaged in the process of self-evaluation.
Body Image Body image is what children think about their bodies and is influenced, but not solely determined, by significant others. The number of significant others that influences children's perception of themselves increases with age. Children are acutely aware of their own bodies, the bodies of their peers, and those of adults. They are also aware of deviations from the norm. Physical impairments, such as hearing or visual defects, ears that “stick out,” or birthmarks, assume great importance. Increasing awareness of these differences, especially when accompanied by unkind comments and taunts from others, may cause a child to feel inferior and less desirable. This is especially true if the defect interferes with the child's ability to participate in games and activities.
Development of Sexuality Many children experience some form of sex play during or before preadolescence as a response to normal curiosity, not as a result of love or sexual urges. Children are experimentalists by nature, and sex play is incidental and transitory. Any adverse emotional consequences or guilt feelings depend on how the behavior is managed by the parents. Many parents discourage sexual exploration, either through subtle cues or expressions of anger or disgust at their child's behavior. These tactics clearly communicate to children that they should not engage in such activities, discourage questions about sex, and limit the sources of information.
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Sex Education An important component of ongoing sex education is effective communication with parents. If parents either repress the child's sexual curiosity or avoid dealing with it, the sexual information that the child receives may be acquired almost entirely from peers. A recent study found the majority of parents of preadolescent and adolescent children believed they were open with sex education discussions; however, only a few parents communicated direct information about safe sex practices (Hyde, Drennan, Butler, et al, 2013). When peers are the primary source of sexual information, it is often transmitted and exchanged in secret conversation and contains misinformation.
Although middle childhood is an ideal time for formal sex education, this subject has created considerable controversy. Many parents and groups are unconditionally opposed to the inclusion of sex education in the schools. When sex education is presented from a life span perspective and treated as a normal part of growth and development, the information is less likely to contain overtones of uncertainty, guilt, or embarrassment that could in turn produce anxiety in children.
Nurse's Role in Sex Education No matter where nurses practice, they can provide information on human sexuality to both parents and children. To discuss the topic adequately, nurses must have an understanding of the physiologic aspects of sexuality, know the common myths and misconceptions associated with sex and the reproductive process, understand cultural and societal values, and be aware of their own attitudes, feelings, and biases about sexuality.
When presenting sexual information to school-age children, nurses should treat sex as a normal part of growth and development. Questions should be answered honestly, in a matter of fact manner, and at the child's level of understanding. There may be times when boys and girls should be taught content separately; however, each group needs information about both sexes.
Children need help to differentiate sex and sexuality. Exercises on clarifying values, identifying role models, engaging in problem-solving skills, and practicing responsibility are important to prepare children for early adolescence and puberty. In addition, children need explanations of sexual information that is provided via the media or jokes. Information about anatomy, pregnancy, contraceptives, and sexually transmitted diseases, including human immunodeficiency virus and human papillomavirus, should be presented in simple, accurate terms. Preadolescents need precise and concrete information that will allow them to answer questions such as, “What if I start my period in the middle of class?” or “How can I keep people from telling I have an erection?” It is important to tell children what they want to know and what they can expect to happen as they become mature sexually.
During encounters with parents, nurses can be open and available for questions and discussion. They can set an example by the language they use in discussing body parts and their function and by the way in which they deal with problems that have emotional overtones, such as exploratory sex play and masturbation. Parents need help to understand normal behaviors and to view sexual curiosity in their children as a part of the developmental process. Assessing the parents' level of knowledge and understanding of sexuality provides cues to their need for supplemental information that will prepare them for the increasingly complex explanations that they will need to provide as their children grow older.
Coping with Concerns Related to Normal Growth and Development Table 14-1 summarizes the major developmental achievements of the school-age years.
TABLE 14-1 Growth and Development During the School-Age Years
Physical and Motor Mental Adaptive Personal-Social Age 6 Years Height and weight gain continues
slowly Weight: 16 to 26.3 kg (35.5 to 58 pounds) Height: 106.7 to 123.5 cm (42 to 49
inches) Central mandibular incisors erupt Loses first tooth
Develops concept of numbers Can count 13 pennies Knows whether it is morning or afternoon Defines common objects (such as fork and chair) in terms
of their use Obeys triple commands in succession Knows right and left hands
At table, uses knife to spread butter or jam on bread At play, cuts, folds, pastes paper; sews crudely if
needle is threaded Takes bath without supervision; performs bedtime
activities alone Reads from memory; enjoys oral spelling game Likes table games, checkers, simple card games
Can share and cooperate better
Has great need for children of own age
Will cheat to win Often engages in rough play Often jealous of younger
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Demonstrates gradual increase in dexterity
Active age; constant activity Often returns to finger feeding More aware of hand as a tool Likes to draw, print, color Vision reaches maturity
Says which is pretty and which is ugly of a series of drawings of faces
Describes the objects in a picture rather than simply enumerating them
Attends first grade
Giggles a lot Sometimes steals money or attractive items Has difficulty owning up to misdeeds Tries out own abilities
brother or sister Does what adults are seen
doing May have occasional temper
tantrums Is a boaster Is more independent, probably
an influence of school Has own way of doing things Increases socialization
Age 7 Years Begins to grow at least 5 cm (2 inches) in
height per year Weight: 17.7 to 30 kg (39 to 66 pounds) Height: 111.8 to 129.5 cm (44 to 51
inches) Maxillary central incisors and lateral
mandibular incisors erupt More cautious in approaches to new
performances Repeats performances to master them Jaw begins to expand to accommodate
permanent teeth
Notices that certain items are missing from pictures Can copy a diamond Repeats three numbers backward Develops concept of time; reads ordinary clock or watch
correctly to nearest quarter hour; uses clock for practical purposes
Attends second grade More mechanical in reading; often does not stop at the
end of a sentence; skips words such as “it,” “the,” and “he”
Uses table knife for cutting meat; may need help with tough or difficult pieces
Brushes and combs hair acceptably without help May steal Likes to help and have a choice Is less resistant and stubborn
Is becoming a real member of the family group
Takes part in group play Boys prefer playing with boys;
girls prefer playing with girls Spends a lot of time alone;
does not require a lot of companionship
Ages 8 to 9 Years Continues to gain 5 cm (2 inches) in
height per year Weight: 19.6 to 39.6 kg (43 to 87 pounds) Height: 116.8 to 141.8 cm (46 to 56
inches) Lateral incisors (maxillary) and
mandibular cuspids erupt Movement fluid; often graceful and
poised Always on the go; jumps, chases, skips Increased smoothness and speed in fine
motor control; uses cursive writing Dresses self completely Likely to overdo; hard to quiet down
after recess More limber; bones grow faster than
ligaments
Gives similarities and differences between two things from memory
Counts backward from 20 to 1; understands concept of reversibility
Repeats days of the week and months in order; knows the date
Describes common objects in detail, not merely their use Makes change out of a quarter Attends third and fourth grades Reads more; may plan to wake up early just to read Reads classic books but also enjoys comics More aware of time; can be relied on to get to school on
time Can grasp concepts of parts and whole (fractions) Understands concepts of space, cause and effect, nesting
(puzzles), conservation (permanence of mass and volume)
Classifies objects by more than one quality; has collections
Produces simple paintings or drawings
Makes use of common tools such as hammer, saw, screwdriver
Uses household and sewing utensils Helps with routine household tasks, such as
dusting, sweeping Assumes responsibility for share of household
chores Looks after all of own needs at table Buys useful articles; exercises some choice in
making purchases Runs useful errands Likes pictorial magazines Likes school; wants to answer all the questions Is afraid of failing a grade; is ashamed of bad
grades Is more critical of self Takes music and sport lessons
Is easy to get along with at home
Likes the reward system Dramatizes Is more sociable Is better behaved Is interested in boy–girl
relationships but will not admit it
Goes about home and community freely, alone or with friends
Likes to compete and play games
Shows preference in friends and groups
Plays mostly with groups of own sex but is beginning to mix
Develops modesty Compares self with others Enjoys organizations, clubs,
and group sports Ages 10 to 12 Years Weight: 24.3 to 58 kg (54 to 128 pounds) Height: 127 to 162.5 cm (50 to 64 inches) Remainder of teeth will erupt and tend
toward full development (except wisdom teeth)
Girls: Pubescent changes may begin to appear; body lines soften and round out
Boys: Slow growth in height and rapid weight gain; may become obese in this period
Writes brief stories Attends fifth to seventh grades Writes occasional short letters to friends or relatives on
own initiative Uses telephone for practical purposes Responds to magazine, radio, or other advertising Reads for practical information or own enjoyment—
stories or library books of adventure or romance, animal stories
Makes useful tools or does easy repair work Cooks or sews in small ways Raises pets Washes and dries own hair; is responsible for a
thorough job of cleaning hair but may need reminding to do so
Is sometimes left alone at home for an hour or so Is successful in looking after own needs or those of
other children left in his or her care
Loves friends; talks about them constantly
Chooses friends more selectively; may have a “best friend”
Enjoys conversation Develops beginning interest in
opposite sex Is more diplomatic Likes family; family really has
meaning Likes mother and wants to
please her in many ways Demonstrates affection Likes father, who is admired
and may be idolized Respects parents
School Experience School serves as the agent for transmitting the values of society to each succeeding generation of children and as a setting for many peer relationships. After the family, schools are the second most important socializing agent in the lives of children.
Entrance into school causes a sharp break in the structure of the child's world. For many children, it is their first experience in conforming to a group pattern imposed by an adult who is not a parent and who has responsibility for too many children to be constantly aware of each child as an individual. Children want to go to school and usually adapt to the new conditions with little difficulty. Successful adjustment is related to the child's physical and emotional maturity and the parent's readiness to accept the separation associated with school entrance. Unfortunately, some parents express their unconscious attempts to delay the child's maturity by clinging behavior, particularly with their youngest child.
By the time they enter school, most children have a fairly realistic concept of what school involves. They receive information regarding the role of a student from parents, siblings, playmates, and the media. In addition, most children have had some experience with daycare, preschool, or kindergarten. Middle-class children have fewer adjustments to make and less to learn about expected behavior because schools tend to reflect dominant middle-class customs and values. If the child has attended a preschool program, the focus of the preschool program also affects the child's adjustment. Some preschool programs provide custodial care only, but others emphasize emotional, social, and intellectual development.
Role of Teachers Teachers, like parents, are concerned about the child's psychological and emotional welfare.
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Although the functions of teachers and parents differ, both place constraints on behavior and both are in a position to enforce standards of conduct. However, the teacher's primary responsibility involves stimulating and guiding children's intellectual development, as opposed to providing for their physical welfare beyond the school setting.
Children respond best to teachers who possess the characteristics of a warm, loving parent. Teachers in the early grades perform many of the activities formerly assumed by the parent, such as recognizing the child's personal needs (e.g., the need to go to the bathroom, need for help with clothing) and helping to develop their social behavior (e.g., manners).
Teachers serve as models with whom children can identify and whom they try to emulate. Children seek their teachers' approval and avoid their disapproval. The teacher is a significant person in the life of the early school-age child, and hero worship of a teacher may extend into late childhood and preadolescence. Teachers who make supportive statements that reassure or commend children, use accepting and clarifying statements that help children refine ideas and feelings, and provide assistance that aids children with their own problem solving contribute to the development of a positive self-concept in the school-age child.
Role of Parents Parents share responsibility for helping children achieve their maximum potential. Parents can supplement the school program in numerous ways (see Family-Centered Care box). Cultivating responsibility is the goal of parental assistance. Being responsible for schoolwork helps children learn to keep promises, meet deadlines, and succeed at their jobs as adults. Responsible children may occasionally ask for help (e.g., with a spelling list), but usually they prefer to think through their work by themselves. Excessive pressure or lack of encouragement from parents may inhibit the development of these desirable traits.
F a m i l y - C e n t e r e d C a r e Helping Children in School
General Guidelines
Be supportive: Provide companionship; share ideas and thoughts.
Be positive: Every child should experience some success each day.
Share an interest in reading: Use the library; discuss books they are reading.
Support and encourage activity rather than passivity.
Encourage originality: Help children make their own projects from discarded articles or other available materials.
Foster the development of hobbies and collections.
Encourage children to wonder and reflect during free time.
Encourage family experiences and trips to places of interest.
Encourage questions: Help children discover sources for information or places to explore and investigate.
Stimulate creative thinking and problem solving: Help children try out new solutions to problems without fear of making mistakes.
Use rewards rather than punishment.
Specific Guidelines
Meet the teacher at the beginning of school and plan to visit the school to see what is taught and
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expected.
Send the child to school every day. Teachers are concerned when parents make other plans for their children; it conveys the impression that school is unimportant.
Demonstrate an interest in what the child is learning.
Demonstrate an interest in content and growth more than in grades.
Make it clear to the child that schoolwork is between the child and the teacher; the teacher and child should set goals for better school performance to allow the child to feel responsible for school successes and failures.
Take advantage of situations that support and reinforce school learning.
Share information with teachers that will help them understand the child better.
Communicate with the teacher if there appears to be a problem; avoid waiting for a scheduled conference.
Provide a quiet, well-lit area for study that is safe from interruption; do not allow television or music.
Avoid dictating a study time but do enforce rules, such as no video games until homework is done; accept the child's word that work is complete.
Help with homework should focus on explaining the question, not giving the answer.
Teach the child to break large tasks (such as a report) into smaller, manageable tasks spread over the allotted time rather than attempting the entire project the night before it is due.
Request special help for children with learning problems.
Support the school staff by showing respect for both the school system and the teacher, at least in the child's presence.
Latchkey Children The term latchkey children is used to describe children in elementary school who are left to care for themselves before or after school without the supervision of an adult. The large numbers of single- parent families and working parents, together with the lack of available child care, have created a stress-provoking situation for many school-age children. Some of these children may have a chronic illness as well.
Inadequate adult supervision after school leaves children at greater risk for injury and delinquent behavior. In some instances, outside activities are curtailed, and relationships with peers may be significantly diminished. Most school-age children feel more lonely, isolated, and fearful when left home alone than children who have someone to care for them (Ruiz-Casares, Rousseau, Currie, et al, 2012). To cope with their fears and anxieties while alone, these children may devise strategies, such as hiding (in a bathroom, closet, or under a bed), playing the television loudly to drown out noises, and using pets for comfort.
Many communities and persons concerned about the welfare of latchkey children are trying to help these children and their parents deal with this potentially serious problem. Some communities and employers have implemented after-school programs. Other types of programs include those designed to teach self-help skills to children, hotlines to provide telephone check-in and reassurance programs for children, and programs that link latchkey children with reassuring older persons in their community. Nurses should be aware of these community services and encourage parents to teach self-help skills to these children.
Discipline Many factors influence the amount and manner of discipline and limit setting imposed on school-
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age children including the parents' psychosocial maturity, their own childrearing experiences during childhood, the children's temperament, the context of the children's misconduct, and the children's response to rewards and punishments. Discipline serves many purposes: (1) to help the child interrupt or inhibit a forbidden action; (2) to point out a more acceptable form of behavior so that the child knows what is right in a future situation; (3) to provide some reason, understandable to the child, that explains why one action is inappropriate and another action is more desirable; and (4) to stimulate the child's ability to empathize with the victim of a misdeed.
To be effective, discipline should take place in a positive, supportive environment with the use of strategies to instruct and guide desired behaviors and eliminate undesired behaviors (Owen, Slep, and Heyman, 2012). Physically aggressive practices, such as spanking, are linked to children with poor internalizing behaviors, including depression, anxiety, hopelessness, and poor external behaviors, such as aggression and violence (Ferguson, 2013). Reasoning, on the other hand, is an effective disciplinary technique for school-age children. With advancing cognitive skills, they are able to benefit from more complex disciplinary strategies. For example, withholding privileges, requiring compensation, imposing penalties, and contracting can be used with great success. Problem solving is the best approach to limit setting, and children themselves can be included in the process of determining appropriate disciplinary measures.
Dishonest Behavior During middle childhood, children may engage in what is considered to be antisocial behavior. Previously well-behaved children may engage in lying, stealing, and cheating. Such behaviors are disturbing and challenging to parents.
Lying can occur for a number of reasons. By the time children enter school, they still “tell stories,” often exaggerating a story or situation as a means of impressing their family or friends but can distinguish between fact and fantasy. If children do not develop this characteristic, parents need to teach them what is real and what is make-believe.
Young children may lie to escape punishment or to get out of some difficulty even when their misbehavior is evident. Older children may lie to meet expectations set by others to which they have been unable to measure up. However, most children know that lying and cheating are wrong, and they are concerned when it is observed in their friends. They are quick to tell on others when they detect cheating.
Parents need to be reassured that all children lie occasionally and that sometimes children may have difficulty separating fantasy from reality. Parents should be helped to understand the importance of their own behavior as role models and of being truthful in their relationships with children.
Cheating is most common in young children 5 to 6 years old. They find it difficult to lose at a game or contest, so they may cheat to win. They have not yet realized that this behavior is wrong, and they do it almost automatically. This behavior usually disappears as they mature. However, when children observe parental behaviors such as boasting about cheating, they assume this to be appropriate behavior. When parents set examples of honesty, children are more likely to conform to these standards.
As with other ethically related behavior, stealing is not unexpected in younger children. Between 5 and 8 years old, children's sense of property rights is limited, and they tend to take things simply because they are attracted to them or to take money for what it will buy. They are equally likely to give away something valuable that belongs to them. When young children are caught and punished, they are penitent—they “didn't mean to” and “promise to never do it again”—but they may repeat the performance the following day. Often they not only steal but also lie about their behavior or attempt to justify it with excuses. It is seldom helpful to trap children into admission by asking directly if they committed the offense. Children do not take responsibility for these behaviors until the end of middle childhood. Stealing can sometimes be an indication that something is seriously wrong or lacking in the child's life. For example, children may steal to make up for love or another satisfaction that they feel is lacking. In most situations, it is wise not to attempt to attach a hidden or deep meaning to the stealing. An admonition, together with an appropriate and reasonable punishment, such as having the older child pay back the money or return the stolen items, will ordinarily take care of most cases. Most children can be taught to respect the property rights of others with little difficulty despite numerous temptations and opportunities. If children's personal rights are respected, they are likely to respect the rights of
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others. Some children simply need more time to learn the rules regarding private property.
Stress and Fear Children today experience significant amounts of stress. Stress in childhood comes from a variety of sources, such as conflict within the family, parental criminality or psychiatric disorder, and low socioeconomic status (Riley, Scaramella, and McGoron, 2014). The school environment and participation in multiple organized activities can be additional sources of stress. The demands from teachers and parents with school work and standardized proficiency testing, in addition to peer pressure, can cause stress on school-age children (White, 2012). In addition, children in the middle school years are often overcommitted with activities such as dance, music, athletics, and other activities until the cumulative effect is overwhelming.
The increasing violence in society has infiltrated into the school setting. In the present information age in which tragedy is broadcast daily in the media, children come to school knowing more about the latest world events than any previous generation of children. Many children know other children who have been killed or children who have brought weapons to school. School-age children can be victims of bullying, verbal insults, unwanted sexual remarks, damaged or stolen property, and physical abuse in the school environment (King, 2014). Furthermore, children are stressed by conflict within the home and the high number of single-parent families result in altered relationships and increasing responsibilities for children.
To help children cope with stress, parents, teachers, and health care providers must recognize signs that indicate a child is undergoing stress, identify the source of the stress promptly, and refer those children who need specialized treatment. They need to frequently reassure children that they are safe, have honest and open communication, and encourage children to express their feelings.
N u r s i n g A l e r t The nurse who observes the following signs of stress in a child should explore the situation further:
• Stomach pains or headache
• Sleep problems
• Bedwetting
• Changes in eating habits
• Aggressive or stubborn behavior
• Withdrawal or reluctance to participate
• Regression to earlier behaviors (e.g., thumb sucking)
• Trouble concentrating or changes in academic performance
Children 7 to 12 years old are capable of identifying their own physiologic responses to stress. Children should be taught to recognize the signs as indicators of stress and to use techniques to manage their stress. Children can learn relaxation techniques such as deep-breathing exercises, progressive relaxation of muscle groups, yoga, and positive imagery to reduce stress (Bothe, Grignon, and Olness, 2014; White, 2012). Encouraging them to “blow off steam” through physical activity reduces tension and anxiety. Children can be encouraged to observe effective coping strategies in others and adopt them for their own use. When an effective strategy has been developed for one situation, parents can show the child how to transfer the coping strategy or technique to other situations.
In addition to stress, school-age children experience a wide variety of fears, including fear of the dark, excessive worry about past behavior, self-consciousness, social withdrawal, and an excessive need for reassurance. These fears are considered normal for children this age. During the middle- school years, children become less fearful of body safety than they were as preschoolers, but they still fear being hurt, being kidnapped, or having to undergo surgery. They also fear death and are
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fascinated by all the aspects of death and dying. The fears of noises, darkness, storms, and dogs lessen, but new fears related predominantly to school and family bother children (e.g., fear of failing, fear of bullies, fear of something bad happening to their parents) during this time.
Promoting Optimal Health during the School Years Nutrition Although caloric needs are diminished in relation to body size during middle childhood, resources are being laid down at this time for the increased growth needs of adolescence. Parents and children need to be aware of the value of a balanced diet to promote growth. The quality of the child's diet depends on the family's pattern of eating.
Likes and dislikes established at an early age continue in middle childhood, although preferences for single foods subside, and children develop a taste for a variety of foods. However, the easy availability of fast-food restaurants, the influence of the mass media, and the temptation of “junk food” make it easy for children to fill up on empty calories. Foods that do not promote growth, such as sugars, starches, and excess fats, are common in school-age children's diets. The easy availability of high-calorie foods, combined with the tendency toward more sedentary activities, has also contributed to an epidemic of childhood obesity. This problem is discussed further in Chapter 16.
Parents are unable to monitor what their children eat when they are away from home. A parent may pack a lunch for school but is unaware of how much is eaten, traded, sold, or thrown away. Nutrition education can and should be integrated in the curriculum throughout the school years. Important aspects of nutrition education include the US Food and Drug Administration's MyPlate, elements of a wholesome diet, and how food products are grown, processed, and prepared. School cafeterias may not always provide healthy, nutritious meals; however, parents should advocate for the availability of nutritious food options and the elimination of unhealthy foods at schools.
Sleep and Rest The amount of sleep and rest required during middle childhood is highly individualized. The amount of sleep depends on the child's age, activity level, and other factors, such as health status. The growth rate slows in the school-age years, and less energy is expended in growth than during preceding years.
School-age children usually do not require naps, but they do need to sleep approximately 11.5 hours at 5 years old and 9 hours at 11 years old each night (Galland, Taylor, Elder, et al, 2012). Although fewer bedtime problems occur during these years, occasional difficulties are still associated with the bedtime ritual. Usually children 6 or 7 years old exhibit few bedtime problems, and encouraging quiet activity before bedtime (such as coloring or reading) facilitates the task of going to bed. However, most children in middle childhood must be reminded frequently to go to bed; 8- to 9-year-old children and 11-year-old children are particularly resistant (Bhargava, 2011). Often these children are unaware that they are tired; if they are allowed to remain up later than usual, they are fatigued the following day. Sometimes bedtime resistance can be resolved by allowing a later bedtime as the child gets older. Twelve-year-old children usually offer no resistance at bedtime; some even retire early to read or listen to music.
Exercise and Activity The improved capabilities and adaptability of school-age children permit greater speed and effort in motor activities. Larger, stronger muscles permit longer and increasingly strenuous play without exhaustion. School-age children acquire the coordination, timing, and concentration that are required to participate in adult-type activities, but they may lack the strength, stamina, and control of adolescents and adults. They can engage in a greater amount of physical activity during the school years. However, parents, teachers, and coaches must remember that although children this age are large and appear strong, they may not be ready for strenuous competitive athletics.
All growing children need regular exercise and opportunities for satisfying experiences consistent with individual likes and dislikes. Appropriate activities during the school-age years include running, jumping rope, swimming, roller skating, ice skating, dancing, and bicycle riding. Positive reinforcement achieved by experiencing increasingly smooth, rhythmic, and efficient use of the body conditions the child toward regular physical activity. Exercise is essential for muscle
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development and tone, refinement of balance and coordination, increased strength and endurance, and stimulation of body functions and metabolic processes. Children need ample space to run, jump, skip, and climb in addition to safe indoor and outdoor facilities and equipment. Most children have abundant energy and need little encouragement to engage in physical activity. Children with disabling conditions or those who hesitate to become involved in active play (e.g., obese children) require special assessment and help so that activities appeal to them and are compatible with their limitations while also meeting their developmental needs.
Sports Considerable controversy surrounds the trend toward early participation in competitive athletics and the amount and type of competitive sports that are appropriate for children in the elementary grades. The current view is that virtually every child is suited for some sport, and authorities do not discourage participation if children are matched to the type of sport appropriate to their abilities and to their physical and emotional constitution. School-age children enjoy competition (Fig. 14-7). However, teachers and coaches must understand the physical limitations of children this age and teach them the proper techniques and safety measures needed to avoid injuries. A safe and appropriate sport can be identified for even the most unskilled and uncompetitive child, including children with chronic illnesses and mental retardation. Common sporting activities for school-age children include baseball, soccer, gymnastics, and swimming. Equipment must be maintained in safe condition, and protective apparatus should be worn to prevent serious injury (see Traumatic Injury, Chapter 29).
FIG 14-7 The activities engaged in by school-age children vary according to interest and opportunity. A, Little League competitors. B, Playing tug-of-war.
During the school-age years, girls have the same basic body structure as boys and have a similar response to systematic exercise training. However, at puberty, boys become larger and have more muscle mass, and at this stage, it is usually recommended that girls compete only against other girls. Before puberty, there is no essential difference in strength and size between girls and boys, making these precautions unnecessary.
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Preadolescence is a time to teach fundamental motor skills; develop fitness in a practical, safe, and gradual manner; and promote healthy attitudes and values. Activities should include both practice sessions and unstructured play; the actual game or event should be managed in a manner that stresses mastery of the sport and enhancement of self-image rather than winning or pleasing others. All children should have an opportunity to participate, and special ceremonies should recognize all participants, not just individuals who excel in sports or athletics.
Acquisition of Skills School-age children demonstrate increasing fine motor abilities and complex artistic skills. Handedness is well established by the beginning of the school years, and children make great strides in writing and drawing during this period. It is a time of energetic and vibrant creative productivity. With the tools of language and reading, children create poems, stories, and plays. With more advanced fine motor skills, they are able to master an unlimited variety of handicrafts, such as ceramics, needlework, woodworking, and beadwork. They avidly pursue these skills in solitude, with a friend, or through organized groups such as boys' or girls' clubs or special interest groups that use crafts or other activities as a means to occupy, entertain, and educate children.
School-age children are capable of assuming responsibility for their own needs, although their distaste for soap and water and “dress” clothes is legendary. School-age children can and want to assume their share of household tasks, which usually are related to the male and female roles that have been defined by their culture. Many children also assume responsibility for tasks outside the home, such as babysitting, yard work, or paper routes.
Television, Video Games, and the Internet Children spend a significant amount of time each day involved in media-related activities, including the use of tablets, video games, and cell phones. Children 8 to 10 years old spend at least 8 hours every day with various forms of media, and teenagers spend more than 11 hours per day (American Academy of Pediatrics, Council on Communications and Media, 2013). Because of the long periods of exposure, media has more time to develop children's attitudes than do parents and teachers.
There is no doubt that children learn from various forms of media, but the values and attitudes depicted on these forums are not always realistic and may conflict with previously taught values. Violence is common in various forms of media, and significant exposure to media violence increases aggressive behavior in some children (American Academy of Pediatrics, Council on Communications and Media, 2013). In addition, repeated exposure to violence can desensitize children to violence, convey a message that violence is acceptable, and teach children that initiating violent behavior is an appropriate form of protection (Brown and Tierney, 2011). Parents should make the ultimate decision about which programs their child will watch, which video games they are allowed to play, and what Internet sites they can access. These forms of media have valuable educational opportunities, but there are also risks that parents must acknowledge.
Dental Health The first permanent (secondary) teeth erupt at about 6 years old, beginning with the 6-year molar, which erupts posterior to the deciduous molars. Other permanent teeth appear in approximately the same order as eruption of the primary teeth and follow shedding of the deciduous teeth (Fig. 14- 8). With the appearance of the second permanent (12-year) molar, most permanent teeth are present. Permanent dentition is more advanced in girls than in boys.
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FIG 14-8 Sequence of eruption of the secondary teeth. (Data from Dean JA: McDonald and Avery's dentistry for the child and adolescent, ed 10, St Louis, 2016, Mosby/Elsevier.)
Because the permanent teeth erupt during the school-age years, dental hygiene and regular attention to dental caries are important parts of health supervision during this period. Correct brushing techniques should be taught or reinforced, and the role that fermentable carbohydrates play in production of dental caries should be emphasized. It is important to be alert to possible malocclusion problems that may result from irregular eruption of permanent teeth and that may impair function. Regular dental supervision and continued fluoride supplementation are integral parts of the health maintenance program.
The most effective means of preventing dental caries is proper oral hygiene. Children should be taught to perform their own dental care with the supervision and guidance of the parents. Parents should learn the correct brushing technique with their children, and they should monitor their child's efforts until the child can assume full responsibility.
Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life. For school-age children with mixed and permanent dentition, the best toothbrush is one with soft nylon bristles and an overall length of about 21 cm (8 inches). Several methods of brushing have been described and recommended for children, but there is no conclusive evidence that one method is superior to another. Thorough cleaning is more important than the specific technique used. The dentist should assess factors, such as the manipulative skills and special needs of the child, and suggest the most appropriate brushing technique and regimen. Flossing follows brushing. Parents should perform the flossing until children acquire the manual dexterity required (usually at about 8 or 9 years old).
Dental Problems Limited or inadequate dental care results in the most common dental problems: dental caries, malocclusion, and periodontal disease. Trauma, especially tooth avulsion, is another important dental problem. All of these conditions benefit from early intervention to prevent tooth loss.
Dental caries (cavities) is the principal oral problem in children and adolescents. Reducing the incidence and consequences of dental caries is extremely important in childhood. If untreated, dental caries can result in total destruction of the involved teeth. The prevalence rate of caries increases steadily across the life span; whereas 25% of children younger than 5 years old have caries, 68% of children have caries by 19 years old (Mahat, Lyons, and Bowen, 2014).
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Dental caries is a multifactorial disease involving susceptible teeth, cariogenic microflora, and an appropriate oral environment. The incidence of lesions and the likelihood of progressive invasion vary considerably and depend on a number of factors being present in the right combination. Because many children are exposed to health care but not dental care, oral inspection is an integral part of the physical assessment of every child. If there is any evidence of dental caries or other unhealthy dental state, the child should be referred for dental services. An alarming number of children do not receive regular dental supervision, and a significant number reach adulthood without dental examinations or treatment by a dentist.
Periodontal disease, an inflammatory and degenerative condition involving the gums and tissues supporting the teeth, often begins in childhood and accounts for a significant amount of tooth loss in adulthood. The more common periodontal problems are gingivitis (simple inflammation of the gums) and periodontitis (inflammation of the gums and loss of connective tissue and bone in the supporting structures of the teeth). Gingivitis, the most prevalent periodontal disease, is a reversible inflammatory disease that can begin in early childhood and is most often associated with the buildup of plaque on the teeth. Management is directed toward prevention by conscientious brushing and flossing, including the use of fluoride. Children should see a dentist at any signs of inflammation or irritation.
Malocclusion occurs when teeth of the upper and lower dental arches do not approximate in the proper relationships. As a result, the physiologic function of chewing is less effective, and the cosmetic effect is displeasing. Teeth that are uneven, crowded, or overlapping are unable to meet their counterparts in the opposite jaw in the appropriate relationships and may be predisposed to disease in later years.
Orthodontic treatment is most successful when it is started in the late school-age or early teenage years after the last primary teeth have been shed and before growth ceases. However, referral should be made as soon as malocclusion is evident because some deformities can be corrected at an earlier age.
Dental injury may occur in childhood and includes fractures of varying degrees of severity, chipping, dislocation, or avulsion. All tooth injuries require prompt treatment by a competent dentist to prevent permanent displacement or loss. Delayed examination and diagnosis of tooth damage can result in infection or pulp involvement. Because it can affect the remaining teeth, replacement of the lost tooth is needed to maintain normal alignment and position of the other teeth.
A tooth that is avulsed (exarticulated, or “knocked out”) should be replanted by the child, parent, or nurse and stabilized as soon as possible so that the blood supply to the tooth can be reestablished and the tooth kept alive (see Emergency Treatment box). A tooth that is replanted promptly has a good survival rate. Avulsed primary teeth are usually not reimplanted.
E m e r g e n c y T r e a t m e n t Avulsed Permanent Tooth
Recover tooth.
Hold tooth by crown; avoid touching root area.
If tooth is dirty, rinse it gently under running water or saline; be certain to insert stopper in sink or basin (to avoid tooth loss).
To Reimplant the Tooth
Insert tooth into socket; be certain that the lip side (or convex surface) is facing front.
Have child maintain tooth in place by slowly biting down on a piece of gauze.
Transport child to dentist immediately.
Avoid sudden stops or sharp turns to prevent dislodging tooth.
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If Reluctant to Reimplant the Tooth
Place avulsed tooth in suitable medium for transport:
• Cold milk
• Saliva—under child's or parent's tongue
If child is holding tooth in the mouth, avoid sudden stops to prevent swallowing tooth.
Do not forget to take the tooth.
As with all injuries to the mouth, an avulsed tooth causes a large amount of bleeding, which is frightening to children and their families; therefore, the nurse or anyone faced with dental trauma should be prepared to provide support and reassurance during the dental trauma.
School Health Child health maintenance is ultimately the responsibility of the parents; however, the public schools and health departments in the United States have contributed to the improvement of child health by providing a healthful school environment, health services, and health education that emphasize sound health practices. Most of these functions constitute major components of community health services and involve large amounts of public funds and large numbers of health professionals, including nurses.
A school health program is involved in ongoing health maintenance through assessment, screening, and referral activities. Routine health services provided by most schools include health appraisal, emergency care, safety education, communicable disease control, counseling, and follow- up care. Health education of school-age children is directed toward providing knowledge of health and influencing habits, attitudes, and conduct in relation to health and injury prevention.
Traditionally, school nurses were viewed from a limited perspective as the individuals who detected diseases in the school, applied bandages, and cared for students who were ill or injured. Although these are important functions, this traditional role has acquired much broader dimensions. School nurses develop, implement, and evaluate health care plans and programs. In some settings, school health services have enlarged into family health centers that meet the needs of not only school-age children but also their families and the community. In these settings, school nurse practitioners provide health care that includes assessment of physical, psychomedical, psychoeducational, behavioral, and learning problems, as well as comprehensive well-child care.
The passage of the Public Laws 94-142 and 99-457 require the integration of children with chronic illnesses and disabilities into the least restrictive environments, including regular classrooms whenever possible. School nurses are responsible for the medical and nursing needs of these children while they are in the school setting. School nurses develop, implement, and evaluate individualized health care plans for these children. Not all schools have a school nurse, and unlicensed assistive personnel (UAP) are used in some cases. After appropriate training and certification, UAP can provide standardized routine health care to students but must be overseen by a school nurse (Resha, 2010). Delegation and supervision of UAP requires skillful nursing assessment, effective communication, and professional judgment.
Injury Prevention Because school-age children have developed more refined muscular coordination and control and can apply their cognitive capacities to their behavior, the number of injuries in middle childhood is diminished compared with the number in early childhood. The most common cause of severe injury and death in children older than 4 years old is motor vehicle crashes—either as a pedestrian or passenger (National Highway Traffic Safety Administration, 2013). It is important that nurses continue to emphasize three automobile safety measures that have been found to reduce the severity of injuries: effective car restraint systems, door-lock mechanisms, and appropriate
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passenger seating locations in the motor vehicle. The rear vehicle seat is the safest place for children younger than 13 years old and booster seats should be used until the child is 57 inches tall (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2015).
School-age children's desire for riding bicycles increases the risk of injury on streets. Other serious injuries include accidents on skateboards, roller skates, in-line skates, scooters, and other sports equipment. All-terrain vehicles (ATVs) are responsible for a large number of childhood injuries, because they are unstable, not easily seen by others, and able to obtain substantial speed. Several national organizations have developed policy and position statements to discourage the use of ATVs in any child younger than 16 years old (Campbell, Kelliher, Borrup, et al, 2010).
Most injuries occur in or near the home or school. The most effective means of prevention is education of the child and family regarding the hazards of risk taking and the improper use of equipment. Safety helmets, protective eye and mouth shields, and protective padding are strongly recommended for children engaging in active sports, even though they may not be required equipment. Falls from bicycles are the cause of a significant number of head injuries in school-age children, and the most important aspect of bicycle safety is to encourage children to wear protective helmets (Fig. 14-9) (Meehan, Lee, Fischer, et al, 2013).
FIG 14-9 The right size bike is important. The child should be able to sit on the bike and place the balls of both feet on the ground. The foot should comfortably reach and manipulate the pedal in the down
position. Wearing a protective helmet is mandatory. The helmet should be positioned so it sits low on the forehead and parallel to the ground when the head is held upright. It should not rock back and forth or shift
from side to side. The strap should fasten securely under the chin.
Physically active school-age children are also highly susceptible to cuts and abrasions, and the incidence of childhood fractures, strains, and sprains is high. Trampoline injuries are highest in children 5 through 14 years old and account for numerous fractures, sprains, and head injuries. Trampolines in the home environment, routine physical education classes, or outdoor playgrounds are not recommended for children younger than 6 years old (American Academy of Pediatrics, Council on Sports Medicine and Fitness, 2012). Serious injuries are discussed elsewhere in the book: burns (Chapter 13), eye trauma (Chapter 18), submersive injury (Chapter 27), and head injuries (Chapter 27). The prevalence of injuries depends on the dangers present in the environment, the protection offered by adults, and children's behavior patterns. Table 14-2 lists characteristics of school-age children that make them prone to injury and suggestions for injury prevention. Family- Centered Care boxes provide safety guidelines for bicycle, and skateboard, in-line skate, and scooter guidance during the school years.
F a m i l y - C e n t e r e d C a r e Bicycle Safety
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• Always wear a properly fitted bicycle helmet that is approved by the US Consumer Product Safety Commission; replace a damaged or outgrown helmet.
• Ride bicycles with traffic and away from parked cars.
• Ride single file.
• Walk bicycles through busy intersections only at crosswalks.
• Give hand signals well in advance of turning or stopping.
• Keep as close to the curb as practical.
• Watch for drain grates, potholes, soft shoulders, loose dirt, and gravel.
• Keep both hands on handlebars except with signaling.
• Never ride double on a bicycle.
• Do not carry packages that interfere with vision or control; do not drag objects behind a bike.
• Watch for and yield to pedestrians.
• Watch for cars backing up or pulling out of driveways; be especially careful at intersections.
• Look left, right, and then left before turning into traffic or roadway.
• Never hitch a ride on a truck or other vehicle.
• Learn rules of the road and respect for traffic officers.
• Obey all local ordinances.
• Wear shoes that fit securely while riding.
• Wear light colors at night and attach fluorescent material to clothing and bicycle.
• Equip the bicycle with proper lights and reflectors.
• Be certain the bicycle is the correct size for rider (see Fig. 14-9).
• Equip the bicycle with proper lights and reflectors.
• Children riding as passengers must wear appropriate-size helmets and sit in specially designed protective seats.
Modified from American Academy of Pediatrics, Committee on Injury and Poison Prevention: Bicycle helmets, Pediatrics 122(2):450, 2008.
F a m i l y - C e n t e r e d C a r e Skateboard, In-Line Skate, and Scooter Safety
• Children younger than 5 years old should not use skateboards or in-line skates because they are not developmentally prepared to protect themselves from injury. Children ages 6 to 10 years old should use these only with close adult supervision.
• The age when children are ready to use in-line skates safely is not known because of differences in the ability to acquire the skills needed to participate in the sport. Novice skaters should learn indoors on a flat, smooth surface. Children who ride skateboards, in-line skates, or scooters should wear helmets and other protective equipment, especially on their knees, wrists, and
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elbows, to prevent injury.
• Skateboards, in-line skates, and scooters should never be used near traffic or in streets. Their use should be prohibited on streets and highways. Activities that bring skateboards together (e.g., “catching a ride”) are especially dangerous.
• Some types of use, such as riding homemade ramps on hard surfaces, may be particularly hazardous.
Data from Brudvik C: Injuries caused by small wheel devices, Prev Sci 7:313-320, 2006; and American Academy of Pediatrics, Committee on Injury and Poison Prevention: In-line skating injuries in children and adolescents, Pediatrics 123:1421-2422, 2009.
F a m i l y - C e n t e r e d C a r e Guidance During School Years
Age 6 Years
Prepare parents to expect strong food preferences and frequent refusal of specific food items.
Prepare parents to expect an increasingly ravenous appetite.
Prepare parents for emotional reactions as child experiences erratic mood changes.
Help parents anticipate continued susceptibility to illness.
Teach injury prevention and safety, especially bicycle safety.
Encourage parents to respect child's need for privacy and to provide a separate bedroom for child, if possible.
Prepare parents for child's increasing interests outside the home.
Help parents understand the need to encourage child's interactions with peers.
Ages 7 to 10 Years
Prepare parents to expect improvement in health with fewer illnesses but warn them that allergies may increase or become apparent.
Prepare parents to expect an increase in minor injuries.
Emphasize caution in selecting and maintaining sports equipment and reemphasize safety.
Prepare parents to expect increased involvement with peers and interest in activities outside the home.
Emphasize the need to encourage independence while maintaining limit setting and discipline.
Prepare mothers to expect more demands at 8 years old.
Prepare fathers to expect increasing admiration at 10 years old; encourage father–child activities.
Prepare parents for prepubescent changes in girls.
Ages 11 to 12 Years
Help parents prepare child for body changes of pubescence.
Prepare parents to expect a growth spurt in girls.
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Make certain child's sex education is adequate with accurate information.
Prepare parents to expect energetic but stormy behavior at 11 years old, and child becoming more even-tempered at 12 years old.
Encourage parents to support child's desire to “grow up” but to allow regressive behavior when needed.
Prepare parents to expect an increase in child's masturbation.
Instruct parents that the child may need more rest.
Help parents educate child regarding experimentation with potentially harmful activities.
Health Guidance
Help parents understand the importance of regular health and dental care for the child.
Encourage parents to teach and model sound health practices, including diet, rest, activity, and exercise.
Stress the need to encourage children to engage in appropriate physical activities.
Emphasize providing a safe physical and emotional environment.
Encourage parents to teach and model safety practices.
TABLE 14-2 Injury Prevention During the School-Age Years
Developmental Abilities Related to Risk of Injury Injury Prevention
Motor Vehicle Accidents Is increasingly involved in activities away
from home Is excited by speed and motion Is easily distracted by environment Can be reasoned with
Educate child regarding proper use of seat belts while a passenger in a vehicle. Maintain discipline while the child is a passenger in a vehicle (e.g., ensure that children keep arms inside, do not lean against doors, and do
not interfere with driver). Remind parents and children that no one should ride in the bed of a pickup truck. Emphasize safe pedestrian behavior. Insist on child wearing safety apparel (e.g., helmet) when applicable, such as riding bicycle, motorcycle, moped, or ATV (see Family-Centered
Care boxes). Drowning Is apt to overdo May work hard to perfect a skill Has cautious, but not fearful, gross motor
actions Likes swimming
Teach child to swim. Teach basic rules of water safety. Select safe and supervised places to swim. Check sufficient water depth for diving. Caution child to swim with a companion. Ensure that child uses an approved flotation device in water or boat. Advocate for legislation requiring fencing around pools. Learn cardiopulmonary resuscitation.
Burns Has increasing independence Is adventurous Enjoys trying new things
Make certain home has smoke detectors. Set water heaters to 48.9° C (120° F) to avoid scald burns. Instruct child regarding behavior in areas involving contact with potential burn hazards (e.g., gasoline, matches, bonfires or barbecues, lighter
fluid, firecrackers, cigarette lighters, cooking utensils, chemistry sets). Instruct child to avoid climbing or flying kite around high-tension wires. Instruct child in proper behavior in the event of fire (e.g., fire drills at home and school). Teach child safe cooking (use low heat; avoid any frying; be careful of steam burns, scalds, or exploding foods, especially from microwaving).
Poisoning Adheres to group rules May be easily influenced by peers Has strong allegiance to friends
Educate child regarding hazards of taking nonprescription drugs and chemicals, including aspirin and alcohol. Teach child to say “no” if offered illegal or dangerous drugs or alcohol. Keep potentially dangerous products in properly labeled receptacles, preferably out of reach.
Bodily Damage Has increased physical skills Needs strenuous physical activity Is interested in acquiring new skills and
perfecting attained skills Is daring and adventurous, especially
with peers Frequently plays in hazardous places Confidence often exceeds physical
capacity Desires group loyalty and has strong
need for friends' approval Delights in physical activity Attempts hazardous feats Accompanies friends to potentially
hazardous facilities Is likely to overdo Growth in height exceeds muscular
growth and coordination
Help provide facilities for supervised activities. Encourage playing in safe places. Keep firearms safely locked up except under adult supervision. Teach proper care of, use of, and respect for potentially dangerous devices (e.g., power tools, firecrackers). Teach children not to tease or surprise dogs, invade their territory, take dogs' toys, or interfere with dogs' feeding. Stress use of eye, ear, or mouth protection when using potentially hazardous objects or devices or when engaging in potentially hazardous
sports. Do not permit use of trampolines except as part of supervised training. Teach safety regarding use of corrective devices (glasses); if child wears contact lenses, monitor duration of wear to prevent corneal damage. Stress careful selection, use, and maintenance of sports and recreation equipment, such as skateboards and in-line skates (see Family-Centered
Care boxes). Emphasize proper conditioning, safe practices, and use of safety equipment for sports or recreational activities. Caution against engaging in hazardous sports, such as those involving trampolines. Use safety glass and decals on large glassed areas, such as sliding glass doors. Use window guards to prevent falls. Teach name, address, and phone number and emphasize that child should ask for help from appropriate people (e.g., cashier, security guard,
police) if lost; have identification on child (e.g., sewn in clothes, inside shoe). Teach safety and stranger safety:
Avoid personalized clothing in public places. Never go with a stranger. Have child tell parents if anyone makes child feel uncomfortable in any way. Teach child to say “no” when confronted by uncomfortable situations. Always listen to child's concerns regarding others' behavior.
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ATV, All-terrain vehicle.
Anticipatory Guidance—Care of Families Parents of the school-age child must share their child's time with the increasingly important peer group. Experiences with the peer group prepare school-age children for the broader world of relationships and increased independence from their parents. Parents must learn to provide support as unobtrusively as possible without feeling rejected, hurt, or angry. The nurse can help parents of the school-age child by providing anticipatory guidance and reassurance throughout this period (see Family-Centered Care box).
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NCLEX Review Questions 1. A hallmark of cognitive development in the school-age child is in what Piaget describes as
concrete operations. In this stage the child: a. Uses thought processes to experience events and actions b. Is unable to see things from another's point of view c. Has a limited perspective of how others' interpretations of a given event differ d. Makes judgments based on what he or she sees
2. In terms of social development, the school-age child does which of the following? Select all that apply. a. Begins to explore the environment beyond the family b. Has an increased interest in persons of the opposite sex (gender) c. May actively participate in same-sex groups or clubs d. Strives to be different from those in the peer group e. Begins to form strong relationships with persons of the same sex (gender)
3. Characteristics of bullying include: a. Unintentional harm inflicted upon another person that is part of the socialization process in
childhood b. The infliction of repetitive physical, verbal, or emotional abuse upon another person with intent
to harm c. An attempt to gain acceptance and be liked by same-sex peers d. An early sign of a severely disturbed personality disorder that escalates in adulthood
4. A school nurse in middle school (grades 6, 7, and 8) is preparing an outline for a sex education class. Which of these statements represent important concepts to be covered in discussing this topic with this age group? Select all that apply. a. Consider separating the boys and girls into same-sex groups with a leader of the same sex. b. Answer questions in a matter-of-fact manner and honestly and appropriate to the children's
level of understanding. c. Use vernacular or slang terms to describe human physiologic functions. d. Avoid discussing sexually transmitted diseases in this age group. e. Discuss common myths and misconceptions associated with sex and the reproductive process. f. Avoid controversial topics such as birth control.
5. School-age children are prone to accidental injury primarily because of: a. Peer pressure and risk-taking behaviors b. Physical awkwardness and clumsiness c. Parents' lack of supervision d. Attempts to impress members of the opposite sex
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Correct Answers 1. a; 2. a, c, e; 3. b; 4. a, b, e; 5. a
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References American Academy of Pediatrics, Council on Communications and Media. Media education.
Pediatrics. 2013;132(5):958–961. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Trampoline safety
in childhood and adolescence. Pediatrics. 2012;130(6):1102–1109. Arseneault L, Bowes L, Shakoor S. Bullying victimization in youths and mental health
problems: ‘much ado about nothing?’. Psychol Med. 2010;40:717–729. Bhargava S. Diagnosis and management of common sleep problems in children. Pediatr Rev.
2011;32(3):91–98. Bothe DA, Grignon JB, Olness KN. The effects of a stress management intervention in
elementary school children. J Dev Behav Pediatr. 2014;35(1):62–67. Bradshaw CP, Waasdorp TE, Goldweber A, et al. Bullies, gangs, drugs, and school:
understanding the overlap and the role of ethnicity and urbanicity. J Youth Adolesc. 2013;42(2):220–234.
Brown P, Tierney C. Media role in violence and the dynamics of bullying. Pediatr Rev. 2011;32(10):453–454.
Campbell BT, Kelliher KM, Borrup K, et al. All-terrain vehicle riding among youth: how do they fair? J Pediatr Surg. 2010;45(5):925–959.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Child passenger safety. http://www.cdc.gov/MotorVehicleSafety/Child_Passenger_Safety/CPS-Factsheet.html; 2015.
Eime RM, Young JA, Harvey JT, et al. A systematic review of the psychological and social benefits of participation in sport for children and adolescents: informing development of a conceptual model of health through sport. Int J Behav Nutr Phys Act. 2013;10:98.
Ferguson CJ. Spanking, corporal punishment and negative long-term outcomes: a meta- analytic review of longitudinal studies. Clin Psychol Rev. 2013;33(1):196–208.
Galland BC, Taylor BJ, Elder DE, et al. Normal sleep patterns in infants and children: a systemic review of observational studies. Sleep Med Rev. 2012;16(3):213–222.
Giesbrecht GF, Leadbeater BJ, Macdonald SW. Child and context characteristics in trajectories of physical and relational victimization among early elementary school children. Dev Psychopathol. 2011;23(1):239–252.
Hensley V. Childhood bullying: a review and implications for health care professionals. Nurs Clin North Am. 2013;48(2):203–213.
Hyde A, Drennan J, Butler M, et al. Parents' constructions of communication with their children about safer sex. J Clin Nurs. 2013;22(23–24):3438–3446.
King KK. Violence in the school setting: a school nurse perspective. The Online Journal of Issues in Nursing. 2014 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol- 19-2014/No1-Jan-2014/Violence-in-School.html.
Mahat G, Lyons R, Bowen F. Early childhood caries and the role of the pediatric nurse practitioner. J Nurse Pract. 2014;10(3):189–193.
Meehan WP 3rd, Lee LK, Fischer CM, et al. Bicycle helmet laws are associated with a lower fatality rate from bicycle-motor vehicle collisions. J Pediatr. 2013;163(3):726–729.
National Highway Traffic Safety Administration. Traffic safety facts 2011 data: children. http://www-nrd.nhtsa.dot.gov/pubs/811767.pdf; 2013.
Owen DJ, Slep AM, Heyman RE. The effect of praise, positive nonverbal response, reprimand, and negative nonverbal response on child compliance: a systematic review. Clin Child Fam Psychol Rev. 2012;15(4):364–385.
Resha C. Delegation in the school setting: is it a safe practice?. The Online Journal of Issues in Nursing. 2010 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation- in-the-School-Setting.html.
Riley MR, Scaramella LV, McGoron L. Disentangling the associations between contextual stress, sensitive parenting, and children's social development. Fam Relat. 2014;63:287–299.
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Ruiz-Casares M, Rousseau C, Currie JL, et al. ‘I hold on to my teddy bear really tight’: children's experiences when they are home alone. Am J Orthopsychiatry. 2012;82(1):97–103.
Shetgiri R. Bullying and victimization among children. Adv Pediatr. 2013;60(1):33–51. Shetgiri R, Lin H, Flores G. Identifying children at risk for being bullies in the United States.
Acad Pediatr. 2012;12(6):509–522. Sticca F, Perren S. Is cyberbullying worse than traditional bullying? Examining the differential
roles of medium, publicity, and anonymity for the perceived severity of bullying. J Youth Adolesc. 2013;42(5):739–750.
U.S. Department of Justice. Highlights of the 2009 national youth gang survey. https://www.ncjrs.gov/pdffiles1/ojjdp/233581.pdf; 2011.
White LS. Reducing stress in school-age girls through mindful yoga. J Pediatr Health Care. 2012;26(1):45–56.
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Health Promotion of the Adolescent and Family Cheryl C. Rodgers
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Promoting Optimal Growth and Development Adolescence is a period of transition between childhood and adulthood—a time of rapid physical, cognitive, social, and emotional maturation.
Several terms are used to refer to this stage of growth and development. Puberty refers to the maturational, hormonal, and growth process that occurs when the reproductive organs begin to function and the secondary sex characteristics develop. This process is sometimes divided into three stages: prepubescence, the period of about 2 years immediately before puberty when the child is developing preliminary physical changes that herald sexual maturity; puberty, the point at which sexual maturity is achieved, marked by the first menstrual flow in girls but by less obvious indications in boys; and postpubescence, a 1- to 2-year period after puberty during which skeletal growth is completed and reproductive functions become fairly well established. Adolescence, which literally means “to grow into maturity,” is generally regarded as the psychological, social, and maturational process initiated by the pubertal changes. It involves three distinct subphases: early adolescence (ages 11 to 14), middle adolescence (ages 15 to 17), and late adolescence (ages 18 to 20). The term teenage years is used synonymously with adolescence to describe ages 13 through 19 years old. The changes that occur during the early, middle, and late phases of adolescence are summarized in Table 15-1.
TABLE 15-1 Growth and Development During Adolescence
Early Adolescence (11 to 14 Years Old) Middle Adolescence (15 to 17 Years Old) Late Adolescence (18 to 20 Years Old) Growth Rapidly accelerating growth Reaches peak velocity Secondary sex characteristics appear
Growth decelerating in girls Stature reaches 95% of adult height Secondary sex characteristics well advanced
Physically mature Structure and reproductive growth almost
complete Cognition Explores newfound ability for limited abstract thought Clumsy groping for new values and energies Comparison of “normality” with peers of same sex
Developing capacity for abstract thinking Enjoys intellectual powers, often in idealistic terms Concern with philosophic, political, and social problems
Established abstract thought Can perceive and act on long-range options Able to view problems comprehensively Intellectual and functional identity established
Identity Preoccupied with rapid body changes Trying out various roles Measurement of attractiveness by acceptance or rejection of peers Conformity to group norms Decline in self-esteem
Modifies body image Self-centered; increased narcissism Tendency toward inner experience and self-discovery Has a rich fantasy life Idealistic Able to perceive future implications of current behavior and
decisions; variable application
Body image and gender role definition nearly secured
Mature sexual identity Phase of consolidation of identity Increase in self-esteem Comfortable with physical growth Social roles defined and articulated
Relationships with Parents Defining independence–dependence boundaries Strong desire to remain dependent on parents while trying to detach No major conflicts over parental control
Major conflicts over independence and control Low point in parent–child relationship Greatest push for emancipation; disengagement Final and irreversible emotional detachment from parents;
mourning
Emotional and physical separation from parents completed
Independence from family with less conflict Emancipation nearly secured
Relationships with Peers Seeks peer affiliations to counter instability generated by rapid
change Upsurge of close, idealized friendships with members of the same
sex Struggle for mastery within peer group
Strong need for identity to affirm self-image Behavioral standards set by peer group Acceptance by peers extremely important—fear of rejection Exploration of ability to attract opposite sex
Peer group recedes in importance in favor of individual friendship
Testing of romantic relationships against possibility of permanent alliance
Relationships characterized by giving and sharing Sexuality Self-exploration and evaluation Limited dating, usually group Limited intimacy
Multiple plural relationships Internal identification of heterosexual, homosexual, or bisexual
attractions Exploration of “self appeal” Feeling of “being in love” Tentative establishment of relationships
Forms stable relationships and attachment to another
Growing capacity for mutuality and reciprocity Dating as a romantic pair May publicly identify as gay, lesbian, or bisexual Intimacy involves commitment rather than
exploration and romanticism Psychological Health Wide mood swings Intense daydreaming Anger outwardly expressed with moodiness, temper outbursts, and
verbal insults and name calling
Tendency toward inner experiences; more introspective Tendency to withdraw when upset or feelings are hurt Vacillation of emotions in time and range Feelings of inadequacy common; difficulty in asking for help
More constancy of emotion Anger more likely to be concealed
Biologic Development The physical changes of puberty are primarily the result of hormonal activity and are controlled by the anterior pituitary gland in response to a stimulus from the hypothalamus. The obvious physical changes are noted in increased physical growth and in the appearance and development of secondary sex characteristics; less obvious are physiologic alterations and neurogonadal maturity, accompanied by the ability to procreate. Physical distinction between the sexes is made on the basis of distinguishing characteristics. Primary sex characteristics are the external and internal organs that carry out the reproductive functions (e.g., ovaries, uterus, breasts, penis). Secondary sex characteristics are the changes that occur throughout the body as a result of hormonal changes (e.g.,
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voice alterations, development of facial and pubertal hair, fat deposits) but that play no direct part in reproduction.
Neuroendocrine Events of Puberty The events of puberty are caused by a cluster of events that trigger the production of gonadotropin- releasing hormone (GnRH) by the hypothalamus. GnRH travels to the anterior pituitary gland, where it stimulates the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Increasing levels of FSH and LH stimulate a gonadal response, which for females consists of growth of ovarian follicles, production of estrogen, and initiation of ovulation; for males, it consists of maturation of the testicles and testosterone and stimulation of sperm production.
The ovaries, testes, and adrenals secrete sex hormones. These hormones are produced in varying amounts by both sexes throughout the life span. The adrenal cortex is responsible for the small amounts secreted before the pubescent years, but the sex hormone production that accompanies maturation of the gonads is responsible for the biologic changes observed during puberty.
Estrogen, the feminizing hormone, is found in low quantities during childhood. Beginning in early puberty, FSH stimulates estrogen production by the ovaries; however, estrogen levels are not high enough to cause ovulation until mid-puberty. The increasing quantity of estrogen in early puberty causes a building of the endometrial lining of the uterus and first menstruation, or menarche. As puberty progresses, one ovarian follicle becomes dominant during each menstrual cycle and produces increasing amounts of estrogen that releases an ovum, a process called ovulation. After ovulation, the follicle involutes and estrogen production decreases. The pituitary gland responds to the decreased estrogen production by increasing production of FSH which initiates a new menstrual cycle. Androgens, the masculinizing hormones, are also secreted in small and gradually increasing amounts up to about 7 or 9 years old, at which time there is a more rapid increase in both sexes, especially boys, until about 15 years old. These hormones have tremendous growth-promoting properties that result in rapid increases of muscle mass, skeletal growth, and bone density. Androgens are responsible for the development of pubic, axillary, facial, and body hair, acne, body odor, and an increase in height.
Boys do not experience a discrete event analogous to menstruation or ovulation in girls; however, FSH and LH act on testicular cells to stimulate production of testosterone and sperm. The production of viable sperm tends to follow boys' first ejaculation. The capacity to ejaculate occurs approximately 1 year after initial testicular enlargement and pubic hair appearance.
Sexual Maturation The visible evidence of sexual maturation is achieved in an orderly sequence, and the state of maturity can be estimated on the basis of the appearance of these external manifestations. The age at which these changes are observed and the time required to progress from one stage to another may vary among children. The time from the appearance of breast buds to full maturity may be to 6 years for adolescent girls. It may take 2 to 5 years for male genitalia to reach adult size. The stages of development of secondary sex characteristics and genital development have been defined as a guide for estimating sexual maturity and are referred to as the Tanner stages (Box 15-1). The usual sequence of appearance of maturational changes is presented in Box 15-2.
Box 15-1 Ta n n e r S t a g e s The Tanner stages were developed by Dr. J.M. Tanner and colleagues. Tanner stages describe the stages of pubertal growth and are numbered from stage 1 (immature) to stage 5 (mature) for both males and females. In girls and young women, the Tanner stages describe pubertal development based on breast size and the shape and distribution of pubic hair. In boys and young men, the Tanner stages describe pubertal development based on the size and shape of the penis and scrotum and the shape and distribution of pubic hair.
Data from Tanner JM: Growth of adolescents, Oxford, 1962, Blackwell Scientific Publications.
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Box 15-2 U s u a l S e q u e n c e o f M a t u r a t i o n a l C h a n g e s Girls
Breast changes
Rapid increase in height and weight
Growth of pubic hair
Appearance of axillary hair
Menstruation (usually begins 2 years after first signs)
Abrupt deceleration of linear growth
Boys
Enlargement of testicles
Growth of pubic hair, axillary hair, hair on upper lip, hair on face and elsewhere on body (facial hair usually appears about 2 years after appearance of pubic hair)
Rapid increase in height
Changes in the larynx and consequently the voice (usually take place along with growth of penis)
Nocturnal emissions
Abrupt deceleration of linear growth
Sexual Maturation in Girls In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche, which occurs between 8 and 13 years old (Fig. 15-1). This is followed in approximately 2 to 6 months by growth of pubic hair on the mons pubis, known as adrenarche (Fig. 15-2). In a minority of normally developing girls, however, pubic hair may precede breast development. The average age of thelarche for white girls is 9.7 years old, Hispanic girls is 9.3 years old, and African- American girls is 8.8 years old (Herman-Giddens, 2013).
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FIG 15-1 Development of breasts in girls. Stage 1 (prepubertal—elevation of papilla only) is not shown. (Modified from Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls, Arch Dis Child 44[235]:291-303,
1969; and Daniel WA, Paulshock BZ: A physician's guide to sexual maturity, Patient Care 13:122-124, 1979.)
FIG 15-2 Growth of pubic hair in girls. (Modified from Marshall WA, Tanner JM: Variations in pattern of pubertal changes in girls, Arch Dis Child 44[235]:291-303, 1969; and Daniel WA, Paulshock BZ: A physician's guide to sexual maturity, Patient Care 13:122-
124, 1979.)
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The initial appearance of menstruation, or menarche, occurs about 2 years after the appearance of the first pubescent changes, approximately 9 months after attainment of peak height velocity, and 3 months after attainment of peak weight velocity. There is evidence that girls are developing secondary sex characteristics at a younger age among various ethnicities. The explanation for this is not yet clear but appears to be influenced by being overweight as well as environmental influences (Currie, Ahluwalia, Godeau, et al, 2012). The normal age of menarche ranges from to 15 years, with the average age being 12 years, 8 months for Caucasian girls, and 12 years 2 months for African-American girls (Cabrera, Bright, Frane, et al, 2014). Ovulation and regular menstrual periods usually occur 6 to 14 months after menarche. Girls may be considered to have pubertal delay if breast development has not occurred by 13 years old (Villanueva and Argente, 2014).
Sexual Maturation in Boys The first pubescent changes in boys are testicular enlargement accompanied by thinning, reddening, and increased looseness of the scrotum (Fig. 15-3). These events usually occur between
and 14 years old. Early puberty is also characterized by the initial appearance of pubic hair. Penile enlargement begins, and testicular enlargement and pubic hair growth continue throughout mid-puberty. During this period, there is also increasing muscularity, early voice changes, and development of early facial hair. Temporary breast enlargement and tenderness, gynecomastia, are common during early to mid-puberty, occurring in up to 70% of boys (Ali and Donohoue, 2016). The spurts in height and weight occur concurrently toward the end of mid-puberty. For most boys, breast enlargement disappears within 2 years; however, gynecomastia may persist in obese individuals. By late puberty, there is a definite increase in the length and width of the penis, testicular enlargement continues, and first ejaculation occurs. Axillary hair develops, and facial hair extends to cover the anterior neck. Final voice changes occur secondary to the growth of the larynx. Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes by 14 years old (Villanueva and Argente, 2014).
FIG 15-3 Developmental stages of secondary sex characteristics and genital development in boys. (Modified from Marshall WA, Tanner JM: Variations in pattern of pubertal changes in boys, Arch Dis Child 45[239]:13-23, 1970;
and Daniel WA, Paulshock BZ: A physician's guide to sexual maturity, Patient Care 13:122-124, 1979.)
Physical Growth During Puberty Along with increases in reproductive hormones and sexual maturation, a dramatic increase in growth occurs. The final 20% to 25% of linear growth is achieved during puberty, and up to 50% of ideal adult body weight is gained during this time as well. Most of this growth of skeletal muscles and internal organs occurs during a 24- to 36-month period—the adolescent growth spurt. This
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accelerated growth occurs in all children but, as in other areas of development, is highly variable in age of onset, duration, and extent. The growth spurt begins earlier in girls, usually between and
years old; on average it begins between and 16 years old in boys. During this period, the average boy gains 10 to 30 cm (4 to 12 inches) in height and 7 to 30 kg (15.5 to 66 pounds) in weight. The average girl, in whom the growth spurt is slower and less extensive, gains 5 to 20 cm (2 to 8 inches) in height and 7 to 25 kg (15.5 to 55 pounds) in weight. Growth in height typically ceases 2 to
years after menarche in girls and at 18 to 20 years old in boys. This increase in size is acquired in a characteristic sequence. Growth in length of the extremities
and neck precedes growth in other areas, and because these parts are the first to reach adult length, the hands and feet appear larger than normal during adolescence. Increases in hip and chest breadth take place in a few months followed several months later by an increase in shoulder width. These changes are followed by increases in length of the trunk and depth of the chest. This sequence of changes is responsible for the characteristic long-legged, gawky appearance of early adolescent children.
Sex Differences in General Growth Patterns Sex differences in general growth and distribution patterns are apparent in skeletal growth, muscle mass, adipose tissue, and skin. Skeletal growth differences between boys and girls are apparently a function of hormonal effects at puberty. The earlier cessation of growth in girls is caused by epiphyseal unity under the potent effect of estrogen secretion, and the hormonal effect on female bone growth is much stronger than the similar effect of testosterone in boys. In boys, the prolonged growth period before puberty and the less rapid epiphyseal closure are reflected in their greater overall height and longer arms and legs. Other skeletal differences are increased shoulder width in boys and broader hip development in girls.
Hypertrophy of the laryngeal mucosa and enlargement of the larynx and vocal cords occur in both boys and girls to produce voice changes. Girls' voices become slightly deeper and considerably fuller, but the effect in boys is striking. The change in the voice of adolescent boys occurs between Tanner stages 3 and 4, with the voice often shifting uncontrollably from deep to high tones in the middle of a sentence. The average lengthening of the vocal cords is 10.9 mm (0.4 inch) for boys and 4.2 mm (0.17 inch) for girls.
Growth of lean body mass, principally muscle, which tends to occur after the bone growth spurt, takes place steadily during adolescence. Lean body mass is both quantitatively and qualitatively greater in boys than in girls at comparable stages of pubertal development. Nonlean body mass, primarily fat, is also increased but follows a less orderly pattern. There may be a transient increase in subcutaneous fat just before the skeletal growth spurt, especially in boys. This is followed 1 to 2 years later by a modest to marked decrease, which is again more marked in boys. Later, variable amounts of fat are deposited to fill out and contour the mature physique in patterns characteristic of the adolescent's sex, particularly in the regions over the thighs, hips, and buttocks and around the breast tissue. It should be noted, however, that pediatric obesity is steadily on the increase in the United States, and obesity can change the timing and sequence of puberty. This may have long-term effects for increased risk of adult adiposity and obesity (Bralic, Tahirovic, Matanic, et al, 2012). A review of recent evidence indicates an association between obesity and onset of early puberty in girls rather than a causal relationship, and other factors such as hormones and insulin resistance may account for early onset puberty as well. No correlations between body fat and earlier puberty in boys have been reported (Biro, Greenspan, and Galvez, 2012).
Other Physiologic Changes A number of physiologic functions are altered in response to some of the pubertal changes. The size and strength of the heart, blood volume, and systolic blood pressure increase, whereas the heart rate decreases (see inside back cover). Blood volume, which has increased steadily during childhood, reaches a higher value in boys than in girls, a fact that may be related to the increased muscle mass in pubertal boys. Adult values are reached for all formed elements of the blood. The lungs increase in both diameter and length during puberty. Respiratory rate decreases steadily throughout childhood and reaches the adult rate in adolescence. Respiratory volume and vital capacity are increased and to a far greater extent in males than in females. The rate of steady decline in basal metabolic rate from birth to adulthood slows during puberty. During this period,
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physiologic responses to exercise change drastically: performance improves, especially in boys, and the body is able to make the physiologic adjustments needed for normal functioning after exercise is completed. These capabilities are a result of the increased size and strength of muscles and the increased level of cardiac, respiratory, and metabolic functioning.
Cognitive Development Emergence of Formal Operational Thought (Piaget) Cognitive thinking culminates with the capacity for abstract thinking. This stage, the period of formal operations, is Piaget's fourth and last stage. Adolescents are no longer restricted to the real and actual, which was typical of the period of concrete thought; now they are also concerned with the possible. They think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of future events that might occur, including college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions, such as dropping out of school. At this time, their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. They become increasingly capable of scientific reasoning and formal logic.
Adolescents are capable of mentally manipulating more than two categories of variables at the same time. For example, they can consider the relationship between speed, distance, and time in planning a trip. They can detect logical consistency or inconsistency in a set of statements and evaluate a system or set of values in a more analytic manner. For instance, they question the parent who insists on honesty in the youngster but at the same time cheats on an income tax report or expense account.
In adolescence, young people begin to consider both their own thinking and the thinking of others. They wonder what opinion others have of them, and they are able to imagine the thoughts of others. With this capacity comes the ability to differentiate between others' thoughts and their own and to interpret the thoughts of others more accurately. They are able to understand that few concepts are absolute or independent of other influencing factors. As they become aware that other cultures and communities have different norms and standards from their own, it becomes easier for them to accept members of these other cultures, and the decision to behave in their own culture in an accepted manner becomes a more conscious commitment.
Moral Development (Kohlberg) Although younger children merely accept the decisions or point of view of adults, adolescents question absolutes and rules, and they view moral standards as subjective and based on points of view that are subject to disagreement. There are occasions when social conventions are questioned and principles of justice, caring, and quality of life take precedence over established social norms. Aspects of conventional and principled moral reasoning are present in adolescence and used at different times in different situations.
Late adolescence is characterized by serious questioning of existing moral values and their relevance to society and the individual. Adolescents can easily take the role of another. They understand duty and obligation based on reciprocal rights of others and the concept of justice that is founded on making amends for misdeeds and repairing or replacing what has been spoiled by wrongdoing. However, they seriously question established moral codes, often as a result of observing that adults verbally ascribe to a code but do not adhere to it.
Spiritual Development Religious beliefs also become more abstract and principled during the adolescent years. Specifically, adolescents' beliefs become more oriented toward spiritual and ideological matters and less oriented toward rituals, practice, and the strict observance of religious customs. Compared to children, adolescents place more emphasis on the internal aspects of religion and less on external manifestations.
Generally, the stated importance of participation in organized religion declines somewhat during the adolescent years. More high school students than postsecondary school young people attend religious services regularly, and, not surprisingly, the younger the adolescents, the more likely they
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are to view religion as being important to them. Among older adolescents, the importance of organized religion declines more among college students than among those not in college. Late adolescence appears to be a time when individuals reexamine and reevaluate many of the beliefs and values of their childhood. Consistent with developmental changes in value autonomy, the religious beliefs of young people are likely to become more personalized and less bound to the traditional religious practices they may have been exposed to when they were younger. As adolescents mature and form an identity, they may either reject their family's traditional beliefs or they may decide to conform to those beliefs (Neuman, 2011).
Greater levels of religiosity and spirituality are associated with fewer high-risk behaviors and more health-promoting behaviors (Michaelson, Pickett, Robinson, et al, 2014). Nurses play an important role for teens by providing an opportunity to discuss issues regarding spirituality.
Psychosocial Development Identity Development (Erikson) The task of identity formation is to develop a stable, coherent picture of oneself that includes integrating one's past and present experiences with a sense of where one is headed in the future. Throughout childhood, individuals have been going through the process of identification as they concentrate on various parts of the body at specific times. During infancy, children identify themselves as being separate from the mother; during early childhood, they establish gender role identification with the appropriate-sex parent; and in later childhood, they establish who they are in relation to others. In adolescence, they come to see themselves as distinct individuals, somehow unique and separate from every other individual.
Adolescence begins with the onset of puberty and extends to relative physical and emotional stability at or near graduation from high school. During this time, adolescents are faced with the crisis of group identity versus alienation. In the period that follows, individuals strive to attain autonomy from the family and develop a sense of personal identity as opposed to role diffusion. A sense of group identity appears to be essential to the development of a personal identity. Young adolescents must resolve questions concerning relationships with a peer group before they are able to resolve questions about who they are in relation to family and society.
Group Identity During the early stage of adolescence, pressure to belong to a group is intensified. Teenagers find it essential to belong to a group from which they can derive status. Belonging to a crowd helps adolescents establish the differences between themselves and their parents. They dress as the group dresses and wear makeup and hairstyles according to group criteria, all of which are different from those of the parental generation. Language, music, and dancing reflect a culture that is exclusive to adolescents. If adults begin to emulate these fashions and interests, the style changes immediately. The evidence of adolescent conformity to the peer group and nonconformity to the adult group provides teenagers with a frame of reference for self-assertion and rejection of the identity of their parents' generation. To be different is to be unaccepted and alienated from the group.
Individual Identity The quest for personal identity is part of the ongoing identification process. As adolescents establish identity within a group, they also attempt to incorporate multiple body changes into a concept of the self. Body awareness is part of self-awareness. In their search for identity, adolescents consider the relationships that have developed between themselves and others in the past, as well as the directions they hope to take in the future.
Significant others hold expectations for the behavior of adolescents. Often these expectations or demands are persistent enough that individuals make certain decisions that they would not make if they were solely responsible for identity formation. Adolescents may find it too easy to slip into the roles expected by others without incorporating their own personal goals or questioning decisions. Thus, individuals may become what parents or others wish them to be based on these premature decisions. Young persons might form a negative identity when society or their culture provides them with a self-image that is contrary to the values of the community. Labels such as “juvenile delinquent,” “hoodlum,” or “failure” are applied to certain adolescents, who then accept and live up to these labels with behaviors that validate and strengthen them.
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The process of evolving a personal identity is time consuming and fraught with periods of confusion, depression, and discouragement. Experts emphasize that adolescents still need monitoring and input from parents during their search for identify; total abandonment during this phase is undesirable and may leave the adolescent feeling fragmented, alone, and adrift, resulting in the development of psychopathology (Stortelder and Ploegmakers-Burg, 2010). Determining an identity and a place in the world is a critical and perilous feature of adolescence (see Critical Thinking Case Study box). However, as the pieces gradually shift and settle into place, a positive identity emerges. Role diffusion results when the individual is unable to formulate a satisfactory identity from the multiplicity of aspirations, roles, and identifications.
C r i t i c a l T h i n k i n g C a s e S t u d y Discussing the Future
Jeremy, 17 years old, will be graduating from high school in the spring. His mother, a single parent, tells you that she is concerned because graduation is quickly approaching and Jeremy has made no plans for what he will do with his life after graduation. Whenever Jeremy mentions the topic, his mother tells him, “This is what you must do” and begins to outline the steps he must take. Jeremy just walks away. She asks, “What should I do?” What advice should you give Jeremy's mother?
Questions
1. Evidence: Is there sufficient evidence to draw any conclusions about what advice to give Jeremy's mother?
2. Assumptions: Describe an underlying assumption about each of the following issues:
a. Adolescents and the search for personal identity
b. The influence of others on the adolescent's search for personal identity
c. Ways to communicate with adolescents
3. What implications and priorities for nursing care can be drawn at this time?
4. Does the evidence objectively support your argument (conclusion)?
Sex-Role Identity Adolescence represents a critical time in the development of sexuality and a sex-role identity. Hormonal, physical, cognitive, and social changes that occur during adolescence all have an impact on sexual development. Of all the developmental changes that affect adolescent sexuality, none is more obvious than the impact of puberty. Adolescents must come to terms with hormonal influences, physiologic manifestations such as menstruation and ejaculation, and physical changes such as breast and genital development. All of these changes have a profound impact on the way teenagers perceive their bodies (i.e., body image). In addition to transitions in body image, increasing levels of pubertal hormones contribute to increased levels of sexual motivation among both boys and girls. The emergence of formal operational thinking also increases adolescents' decision-making capabilities concerning sexual issues. As they mature, teenagers become better able to think through potential risks and benefits of sexual behaviors before they engage in any behavior. Older adolescents may also be able to conceptualize more long-term consequences of present behaviors. One of the important tasks of adolescence is to incorporate sexuality successfully into close, intimate relationships. This task is made possible by the advanced cognitive abilities that emerge over the course of adolescence.
Part of adolescent identity formation involves the development of sexual identity. As they begin
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to integrate changes involved with puberty, young adolescents also develop emotional and social identities separate from their families'. For young adolescents, the process of sexual identity development usually involves forming close friendships with same-sex peers. Many teenagers begin to make a shift from relationships with same-sex peers to intimate relationships with members of the opposite sex during middle adolescence (Fig. 15-4). Opposite-sex relationships typically begin with peer activities involving both boys and girls. Pairing off as couples becomes more common as middle adolescence progresses. The type and degree of seriousness of partner relationships vary. Initial relationships are usually noncommittal, extremely mobile, and seldom characterized by any deep romantic attachments. Sexual activity becomes more common during middle adolescence. The relationship between love and sexual expression is brought into focus during middle adolescence. Most young people oppose exploitation, pressure, or force in sex, as well as sex solely for the sake of physical enjoyment without a personal relationship. Adolescents find it hard to believe that sex can exist without love; therefore they view each relationship as real love.
FIG 15-4 Romantic relationships are important for most adolescents. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
An integrated sexual identity often emerges during late adolescence as individuals incorporate sexual experiences, feelings, and knowledge. For most, this identity is consistent with their own physical and mental capacities and with societal limits and expectations. Most adolescents identify themselves as being predominantly heterosexual; however, about 1% of high school students identify themselves as bisexual or homosexual and 10% are unsure (Steever, Francis, Gordon, et al, 2014). Whatever their sexual orientation, most teenagers possess the capacity to have intimate relationships that satisfy the emotional and sexual needs of both partners.
Sexual orientation is an important aspect of sexual identity. Sexual orientation is defined as a pattern of sexual arousal or romantic attraction toward persons of the opposite gender (heterosexual), of the same gender (homosexual), or of both genders (bisexual). Sexual orientation encompasses several dimensions, including attraction, fantasy, actual sexual behavior, and self- labeling or group affiliation. In individuals, the direction and intensity of each dimension are not necessarily consistent with any of the others. For example, individuals may be attracted most strongly to their same gender, fantasize about both genders, have sexual activity only with the
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opposite gender, and identify as gay or lesbian. Other individuals may engage in same-gender sexual behavior and fantasize about both genders but identify as heterosexual. As with all aspects of sexual identity, the dimensions of sexual orientation are influenced by cultural meaning and expectation, by gender, by peer groups, and by other environmental contexts.
Adolescence is the period during which individuals commonly begin to identify their sexual orientation as part of their developing sexual identity. However, this identification process can be profoundly influenced by cultural beliefs and values, by societal and family pressures, or by a lack of similar peers. The majority of adolescents eventually report an orientation toward exclusively heterosexual relationships. For adolescents whose orientation encompasses any same-gender dimensions, the identity process during adolescence can be complicated, especially when community norms disapprove of orientations other than heterosexual. Adolescents who have witnessed harassment or violence directed at gay, lesbian, and bisexual people, for example, may be reluctant to self-identify even when their attractions and behaviors are exclusively same-gender or bisexual.
The development of sexual orientation as part of sexual identity includes several developmental milestones during late childhood and throughout adolescence. These milestones do not necessarily occur in the same order for everyone, nor are they completed in the same amount of time. They include (1) the realization of romantic or erotic attraction to people of one (or both) genders; (2) erotic daydreaming about one or both genders; (3) romantic partners or dates without sexual activity; (4) sexual activity with people of the preferred gender or genders (also, for some teens, sexual activity with a non-preferred gender, out of curiosity or through social pressure); (5) self- identification of the orientation that best fits one's current circumstances and understanding; (6) publicly self-identifying that orientation, usually to intimate friends and family first and then the wider social group; and (7) an intimate, committed sexual relationship with a person of the gender appropriate to one's orientation.
There is no evidence that homosexual or bisexual adults are more or less likely to create long- term, stable relationships than are heterosexual couples. It should be noted that bisexual adolescents and adults do not generally engage in sexual relationships with both genders concurrently; self-identification as bisexual usually refers to the ability to be attracted to either gender but does not imply that such a person requires partners of both genders or that one must be equally attracted to and have sexual experience with both genders in order to be bisexual.
Although the order of these milestones varies greatly among adolescents, adolescents who identify as gay, lesbian, or bisexual tend to publicly self-identify later than heterosexual peers. Without positive gay, lesbian, or bisexual role models or a supportive peer group, sexual-minority teens can feel isolated, and they may not share their orientation with anyone for fear of rejection or violence (see Critical Thinking Case Study box).
C r i t i c a l T h i n k i n g C a s e S t u d y Discussing Sexual Orientation with Adolescents
John, a 17-year-old adolescent, comes into the school-based clinic and tells the nurse practitioner that he thinks he is gay. Based on this information, answer the following questions:
Questions
1. Evidence: Is there sufficient evidence to draw any conclusions about John's statement regarding his sexual orientation at this time?
2. Assumptions: Describe an underlying assumption about each of the following issues:
a. Development of sexual orientation in adolescents
b. Society's reaction to homosexuality
c. Health care professionals and adolescent sexuality
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3. What is the most appropriate response by the nurse practitioner to John's statement?
4. Does the published evidence support your argument (conclusion)?
Social Environments The biologic, cognitive, and social changes of adolescence are shaped by the social environment in which the changes take place. The social environment provides opportunities, barriers, role models, and support for individuals' development and health. Systems within the social environment, including family, peers, schools, community (including the Internet-based community), and the larger society, all contribute uniquely to an adolescent's development and health.
Families During adolescence, the parent–child relationship changes from one of protection/dependency to one of mutual affection and equality. The process of achieving independence often involves turmoil and ambiguity as both parent and adolescent learn to play new roles and work toward establishing the ultimate relationship. As teenagers assert their rights for grown-up privileges, they frequently create tensions within the home. They resist parental control, and conflicts can arise from almost any situation or any subject. Favorite topics of dispute include Internet use, the need for a personal cell phone, manners, dress, chores and duties, homework, disrespectful behavior, friendships, dating and relationships, money, automobiles, alcohol and other substance abuse, and time schedules.
Teenagers' earliest attempts to achieve emancipation from parental controls are manifested in a period of rejection of the parents. They absent themselves from home and family activities and spend an increasing amount of time with the peer group. They confide less in their parents, but parents continue to play an important role in the personal and health-related decision making of adolescents. With advancing adolescence, teenagers become more competent, and with this competence comes a need for more autonomy. Although they may be psychologically prepared for independence, they are often thwarted in their efforts by lack of money or other parental barriers. Conflict arises in relation to the teenagers' outside activities and the elements of privacy and trust. Parental monitoring remains important throughout adolescence and may have a direct influence on adolescent sexual and substance use behavior. Parents should be guided toward authoritative parenting in which authority is used to guide the adolescent while allowing developmentally appropriate levels of freedom and providing clear, consistent messages regarding expectations. However, to gain the trust of adolescents, parents must respect their adolescent's privacy and show an honest and sincere interest in what the adolescent believes and feels (see Family-Centered Care box).
F a m i l y - C e n t e r e d C a r e Communication with Adolescents: The Art of Listening
Conflicts between parents and their adolescents are often a result of a natural characteristic of parenthood: the desire to protect one's offspring from harm or from simply doing something “stupid,” something embarrassing, or something they may later regret. Teens sometimes bounce their thoughts and ideas off adults. At times, they really want some feedback, but sometimes they simply want to elicit a reaction.
I found it easy to listen openly, thoughtfully, and without interrupting when my teenagers' friends discussed troublesome topics. However, one day, when one of my own teenagers had a similar conversation with me, the parent part kicked in. I felt responsible and spoke my piece on the spot. This brought communication to a halt and resulted in defensiveness. It was a long time before my child tried to talk to me about anything controversial again.
The next time one of my teenagers started a similar conversation, I decided to try to trick myself. Throughout the entire conversation, I told myself over and over again to act as if this were not my teenager but rather someone else's child. I found this actually worked quite well, and I was able to listen without interrupting. I continue to use the system, sometimes with more success than at other times.
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—Mother of four
Over the past several decades, changes have taken place within the family microsystem that have important implications for adolescent health. Higher rates of divorce and remarriage, increasing numbers of single-parent or blended families, and greater percentages of working mothers have become characteristic of contemporary United States society. Changes in family structure and parent employment have resulted in adolescents having more time unsupervised by adults and increased time alone or with peers. Decreased adult supervision may result in more risk-taking behaviors, such as substance use and sexual intercourse, and decreased opportunities to develop a supportive relationship with parents. Adolescents who feel close to their parents show more positive psychosocial development and behavioral competence, less susceptibility to negative peer pressure, and lower tendencies to be involved in risk-taking behaviors (Smith, Stewart, Peled, et al, 2009).
Peer Groups For the majority of teenagers, peers assume a more significant role in adolescence than they did during childhood. The peer group serves as a strong support to adolescents, individually and collectively, providing them with a sense of belonging and a feeling of strength and power. The peer group forms the transitional world between dependence and autonomy.
The peer group has an intense influence on adolescents' self-evaluation and behavior. Peers serve as credible sources of information, role models of new social behaviors, sources of social reinforcement, and bridges to alternative lifestyles. To gain acceptance by a group, younger adolescents tend to conform completely in such things as mode of dress, hairstyle, taste in music, and vocabulary. Peers can also be a positive force in health promotion by encouraging healthy behaviors, serving as role models, and promoting positive health norms.
Schools In contemporary society, schools play an increasingly important role in preparing young people for adulthood. Schooling is essential for a successful future. Failure to complete high school reduces employment opportunities and the probability of earning an adequate income. The dropout rate among minority students is higher than nonminority students; however, 95% of Caucasian adults and 89% of African-American adults 25 to 29 years old graduated from high school in 2012 (Child Trends Data Bank, 2014).
The school is psychologically important to adolescents as a focus of social life. Teenagers usually distribute themselves into a relatively predictable social hierarchy. They know to which groups they and others belong. A sense of school connectedness and optimal social connectedness is associated with positive outcomes for school completion, positive mood, and decreased high-risk behavior in adolescents (Chapman, Buckley, Reveruzzi, et al, 2014). School connectedness is correlated with caring teachers and the absence of prejudice or discrimination from peers.
Within the larger groups are smaller, distinct, and exclusive crowds or cliques of selected close friends who are emotionally attached to one another. The selection is based on common tastes, interests, and background. Although cliques may become formalized, most remain informal and small. However, each has an identifying feature that proclaims its difference from others and its solidarity within itself in much the same manner as the adolescent generation as a whole sets itself apart from the adult generation. Cliques are usually made up of one sex, and girls tend to be more cliquish than boys and to have a greater need for close friendships (Fig. 15-5). Within the intimacy of the group, adolescents gain support in learning about themselves, consideration for the feelings of others, and increased ego development and self-reliance. To belong is of utmost importance; thus, adolescents behave in a way that will ensure their establishment in a group. Adolescents are highly susceptible to social approval, acceptance, and demands. To be ignored or criticized by peers creates feelings of inferiority, inadequacy, and incompetence.
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FIG 15-5 Teenagers like to gather in small groups. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
Work For the majority of young people in the United States, the workplace becomes a fourth microsystem. Most adolescents are employed in an array of jobs as restaurant workers, cashiers, sales clerks, clerical assistants, and unskilled laborers. The jobs tend to require little initiative or decision making and rarely use skills learned in school. Adolescent work may negatively affect development as it fails to link adolescents to vocational mentors, is not intellectually stimulating, may take time away from other activities that could contribute to identity development, can lead to fatigue, decreased interest in school, and poorer grades. These detrimental effects are likely to affect adolescents who work more than 20 hours a week.
Interests and Activities Adolescents spend a large amount of time engaged in leisure-time activities. These leisure-time activities move from being family centered to being peer centered. In addition to providing teenagers with fun and enjoyment, leisure-time activities assist in the development of social, physical, and cognitive skills. Leisure-time activities also allow teenagers the opportunity to learn to set priorities and structure their time.
The role of social media and advanced technology are nowhere more prominent than in the lives of today's adolescents. The widespread availability of the Internet and access to social networking websites such as Facebook, Snap-chat, Instagram, email, blogs, and Twitter have created “virtual” communities and ways for young people to interact with others; web cameras even allow those interactions to include real-time video communication. Cellular telephones offer more mobile opportunities to talk on the phone, send text messages or instant messaging, send photos, or use video phone capabilities (Fig. 15-6).
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FIG 15-6 Cell phones allow adolescents to talk for hours with their peers. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
Social networking websites have created a more public arena for trying out identities and developing interpersonal skills with a wider network of people, occasionally with anonymity. This can create opportunities for young people who have a limited access to friends (because of rural location, shyness, or rare chronic conditions) to interact with people like themselves. However, most adolescents appear to be using the online social environment to interact with the same peers that they spend their day with at school.
Text messaging has become a common activity and can sometimes be disruptive. In addition, both the online and the text environment can create opportunities for cyberbullying, where teens engage in insults, harassment, and publicly humiliating statements online or on cell phones. There is increased danger of adolescents coming in contact and sharing personal information with sexual predators who pose as adolescents in an attempt to make personal contact with underage victims or engage them in sexting (sending sexually explicit or suggestive pictures or messages online) (Dowdell, Burgess, and Flores, 2011). Adolescent sexting, rather than being an innocent anonymous activity, has been linked to risky sexual behaviors in a few studies (Rice, Rhoades, Winetrobe, et al, 2012; Temple, Paul, van den Berg, et al, 2012).
Studies have noted that adolescents are not only enthusiastic technology users, but they frequently use multiple types of media at the same time. They may be listening to music on their digital music player while the television is on, and they are surfing the Internet and texting friends on their cell phone. It is unclear how this multitasking and multiple media exposure will affect development of the brain and attention, but frequent media use has been associated with late nights and sleep deprivation (Owens, Adolescent Sleep Working Group, and Committee on Adolescence, 2014). There is increased concern focusing on adolescent vehicle driving and distractions, such as texting or cell phone usage. In 2011, 32.8% of adolescents reported having texted or emailed someone while driving on at least 1 day in the 30 days prior to the survey (Eaton, Kann, Kinchen, et al, 2012). Many states have outlawed the use of handheld mobile devices while actively operating a vehicle (Chase, 2014).
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Promoting Optimal Health during Adolescence For adolescents, health promotion involves helping youth acquire the power (including knowledge, attitudes, and skills), authority (permission to use their power), and opportunities to make choices that increase the likelihood of positive expressions of health for themselves. A comprehensive approach to health promotion combines activities aimed at individuals with interventions focused on changing norms, attitudes, and behaviors of peer groups, families, communities, and society at large.
The rationale for focusing on health issues becomes obvious when one examines the major sources of mortality and morbidity during adolescence. The leading causes of mortality during adolescence in the United States are motor vehicle crashes, other accidental injuries, homicide, and suicide, which together are responsible for approximately 75% of all adolescent deaths (Blum and Qureshi, 2011; Eaton, Kann, Kinchen, et al, 2012). The sources of morbidity in adolescence include injury (primarily motor vehicle related), depression, eating disorders, substance use, sexually transmitted infections (STIs), and pregnancy; obesity may begin in childhood or adolescence, with secondary health consequences becoming evident in adolescence. Health promotion for this age group consists mainly of teaching and guidance to avoid risk-taking activities and health-damaging behaviors. Adolescence provides an opportunity for teenagers to incorporate healthy lifestyle behaviors that will benefit them not only during the teenage years but also throughout the life span.
Effective health promotion for adolescents should incorporate a developmentally appropriate, multifaceted approach and incorporate adolescents' perspectives on what health means. One strategy for health promotion used by nurses and other professionals in health care settings is the one-on-one health screening (see Nursing Care Guidelines box). Through a health screening interview, the health professional can identify both assets and threats to an adolescent's health and well-being, and provides an opportunity to build a trusting relationship with the adolescent. In addition, the health screening interview provides an opportunity for teaching adolescents self- advocacy skills.
N u r s i n g C a r e G u i d e l i n e s Interviewing Adolescents
• Ensure confidentiality and privacy; interview adolescent without parents.
• Explain the limits of confidentiality (e.g., legal duty to report physical or sexual abuse or to get others involved if patient is suicidal).
• Show concern for adolescent's perspective, saying: “First, I'd like to talk about your main concerns” and “I'd like to know what you think is happening.”
• Offer a nonthreatening explanation for the questions you ask, such as: “I'm going to ask a number of questions to help me better understand your health.”
• Maintain objectivity; avoid assumptions, judgments, and lectures.
• Ask open-ended questions when possible; move to more directive questions if necessary.
• Begin with less sensitive issues and proceed to more sensitive ones.
• Use language that both the adolescent and you understand.
• Restate: Reflect back to adolescents what he or she has said, along with feelings that may be associated with their descriptions.
Adolescents' Perspectives on Health To be most effective, adolescent health promotion efforts must incorporate adolescents' perspectives
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on what health means. Such efforts also must focus on adolescents' concerns and priorities related to health and health care services. From a positive perspective, adolescents' developmentally based sense of curiosity and movement toward autonomy provide opportunities for health promotion.
Adolescents' health-related interests and concerns include stress and anxiety, relationships with adults and peers, weight, acne, and feelings of sadness or depression. Health concerns are often consistent with the immediate developmental task that teenagers face. For example, younger adolescents have a particular interest in issues related to growth and development, whereas middle adolescents have questions and concerns related to peer-group acceptance, relationships with friends, and physical appearance. Older adolescents focus increasingly on school performance, future career and employment plans, and emotional health issues.
Among the behaviors that adolescents view as risky are substance use, sexual activity, and the use of recreational and motor vehicles. Adolescents identify health threats that primarily involve psychological issues, such as clinical depression and eating or weight problems. The availability of confidential services is particularly important to adolescents, especially when they have concerns related to sensitive issues. Adolescents are more likely to participate in health care services when services are delivered by caring, respectful providers.
Health Concerns of Adolescence As adolescents develop, they are able to assume additional responsibility for their own health, including maintaining health practices, taking prescribed medications, keeping appointments, and performing procedures when necessary. Health professionals who work with adolescents should consider their increasing independence and responsibility while maintaining privacy and ensuring confidentiality (see Nursing Care Guidelines box). Parents should also respect their teenager's independence and move toward the role of consultant about health issues while maintaining some level of involvement throughout adolescence.
Several professional organizations have published guidelines aimed at improving and maintaining health care for adolescents and young adults. The American Academy of Pediatrics, American Academy of Family Physicians, American Medical Association, and U.S. Preventive Services Task Force have similar guidelines for health supervision of adolescents. These guidelines emphasize the need to provide health services to adolescents that meet their physical and emotional needs. They place great importance on the provision of health care by health care providers who are trained in meeting the adolescents' needs. Bright Futures (American Academy of Pediatrics, 2015) emphasizes that the following issues should be addressed with adolescents over the course of multiple visits: • Emotional well-being (coping, mood regulation, mental health, sexuality) • Physical growth and development (physical and dental health, body image, healthy nutrition,
physical activity) • Social and academic competence (relationships with peers and family, school performance,
interpersonal relationships) • Risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs) • Violence and injury prevention (safety belt and helmet use, substance abuse and riding in a
vehicle, interpersonal violence, bullying) The following sections focus on some of the Bright Futures topics; other adolescent health issues
are discussed later in this chapter.
Emotional Well-Being Adolescents vacillate in their emotional states between considerable maturity and childlike behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed and withdrawn. Unpredictable but essentially normal, mood swings are common during this time. As the tension is relieved, emotion is brought under control, and individuals retreat to review what has happened, to attempt to master their anger, and to grow in their ability to control their emotions and gain from the new experience. Because of these mood swings, adolescents are frequently labeled as unstable, inconsistent, and unpredictable. Little things can cause an emotional upheaval and, depending on the teenager's interpretation, can mean a great deal.
Teenagers are better able to control their emotions in later adolescence as they can approach
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problems more calmly and rationally. Although they are still subject to periods of sadness, their feelings are less vulnerable, and they begin to demonstrate the more mature emotions of later adolescence. Whereas early adolescents react immediately and emotionally, older adolescents can control their emotions until socially acceptable times and places for expression present themselves. They are still subject to heightened emotion, and when it is expressed, their behavior reflects feelings of insecurity, tension, and indecision.
As sources of credible information, support, and encouragement, nurses can help adolescents cope with the changes and challenges they face. To promote both emotional health and psychosocial adjustment, nurses and other health care professionals can encourage adolescents to develop (1) skills to cope with stress and change and (2) skills to become involved in personally meaningful activities.
Intentional and Unintentional Injury Injuries kill more adolescents in the United States than any other single cause, with unintentional injury accounting for 48% of deaths among teens 12 to 19 years old between 1996 and 2005 (Blum and Qureshi, 2011). Motor vehicle crashes are the single greatest source of unintentional injury and death in young people. Many factors contribute to the higher rate of crashes among teen drivers, including the lack of driving experience and maturity, driving too fast, using alcohol, and using cell phones to talk or text. Homicide, a form of intentional injury, is the second leading cause of death among all adolescents in the United States (Centers for Disease Control and Prevention, 2012). Homicides among adolescents mostly involve firearms; many adolescents report easy access to a gun.
Injuries also account for substantial morbidity among adolescents. During adolescence, peak physical, sensory, and psychomotor function gives teenagers a feeling of strength and confidence that they have never experienced before. Their propensity for risk-taking behavior plus feelings of indestructibility makes adolescents especially prone to injuries. The leading causes of injury-related morbidity among adolescents include vehicular crashes, firearms, drowning, poisoning, burns, and falls. Some of the developmental characteristics of teenagers and injury prevention suggestions are outlined in Box 15-3.
Box 15-3 I n j u r y P r e ve n t i o n D u r i n g A d o l e s c e n c e Developmental Abilities Related to Risk of Injury
Need for independence and freedom
Testing independence
Age permitted to drive a motor vehicle (varies from state to state)
Inclination for risk taking
Feeling of indestructibility
Need for discharging energy, often at expense of logical thinking and other control mechanisms
Strong need for peer approval
Attempting hazardous maneuvers
Peak incidence for practice and participation in sports
Access to more complex tools, objects, and locations
Can assume responsibility for own actions
Injury Prevention
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Motor or Nonmotor Vehicles Pedestrian
Emphasize and encourage safe pedestrian behavior.
• Use cross-walks.
• At night, walk with a friend.
• If someone is following you, go to nearest public place with people.
• Do not walk in secluded areas; take well-traveled walkways.
Passenger
Promote appropriate behavior while riding in a motor vehicle. Refuse to ride with an impaired person or one who is driving recklessly.
Driver
Provide competent driver education; encourage judicious use of vehicle; discourage drag racing or playing chicken; maintain vehicle in proper condition (e.g., brakes, tires).
Teach and promote safety and maintenance of two- and three-wheeled vehicles.
Promote and encourage wearing of safety apparel, such as a helmet and long trousers.
Reinforce the dangers of drugs, including alcohol, when operating a motor vehicle.
Discourage distractions while driving—cell phone talking or texting, eating, smoking, or reading.
Drowning
Teach non-swimmers to swim.
Teach basic rules of water safety.
• Judicious selection of places to swim
• Sufficient water depth for diving
• Swimming with a companion
• No alcohol with water sports
Burns
Reinforce proper behavior in areas with burn hazards (gasoline, electric wires, and fires).
Advise against excessive exposure to natural or artificial sunlight (ultraviolet burn).
Discourage smoking.
Encourage use of sunscreen.
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Poisoning
Educate in hazards of drug use, including alcohol.
Falls
Teach and encourage general safety measures in all activities.
Bodily Damage
Promote acquisition of proper instruction in sports and use of sports equipment.
Instruct in safe use of and respect for firearms and other devices with potential danger (e.g., power tools, firecrackers).
Provide and encourage use of protective equipment when using potentially hazardous devices.
Promote access to or provision of safe sports and recreational facilities.
Be alert for signs of depression (potential suicide).
Instruct regarding proper use of corrective devices (e.g., glasses, contact lenses, hearing aids).
Encourage and foster judicious application of safety principles and prevention.
Dietary Habits, Eating Disorders, and Obesity Puberty marks the beginning of accelerated physical growth, which can double some adolescents' nutritional requirements. At the same time, growing independence, the need for peer acceptance, concern with physical appearance, and an active lifestyle may affect eating habits, food choices, nutrient intake, and nutritional status.
Pressure for time and commitments to activities adversely affect teenagers' eating habits. Omitting breakfast or eating a breakfast that is nutritionally poor in quality is frequently a problem. Snacks, usually selected on the basis of accessibility rather than nutritional merit, become increasingly a part of the habitual eating pattern during adolescence (Fig. 15-7). Excess intake of calories, sugar, fat, cholesterol, and sodium is common among adolescents and is found in all income and racial or ethnic groups and both genders. Inadequate intake of certain vitamins (folic acid, vitamin B6, vitamin A) and minerals (iron, calcium, zinc) is also evident, particularly among girls and teenagers of low socioeconomic status. In combination with other factors, these dietary patterns could result in increased risk for obesity and chronic diseases, such as heart disease, osteoporosis, and some types of cancer later in life. Maximum bone mass is also acquired during adolescence; therefore the calcium deposited during these years determines the risk of osteoporosis. Milk is usually passed over in favor of soft drinks.
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FIG 15-7 Snacking on empty calories is common among adolescents, especially during inactivity. (©2015 iStock.com.)
Overeating or undereating during adolescence presents special problems. When they experience the normal increase in weight and fat deposition of the growth spurt, teenage girls often resort to dieting. The desire for a slim figure and a fear of becoming “fat” prompt teenage girls to embark on nutritionally inadequate reducing regimens that drain their energy and deprive their growing bodies of essential nutrients. Although most teens try to lose weight through exercise and diet, approximately 4.3% of adolescents engage in risky weight loss practices such as vomiting after meals or taking laxatives (Eaton, Kann, Kinchen, et al, 2012). Boys are less inclined to undereat or adopt risky weight loss practices. They are more concerned about gaining size and strength. However, they tend to eat foods high in calories but low in other essential nutrients.
Obesity is increasing among both children and adolescents in the United States. Poor dietary habits and increasingly sedentary lifestyles have caused this obesity epidemic. Currently 21% of children 12 to 19 years old are obese (Centers for Disease Control and Prevention, 2015). The vast majority (90%) of obese adolescents remain obese into their 30s: 94% of women overall and 88% of men (Gordon-Larsen, The, and Adair, 2010).
Health problems traditionally thought of as adult comorbidities of obesity, including type 2 diabetes mellitus, obstructive sleep apnea, and nonalcoholic steatohepatitis, are occurring in adolescents. Routine nutrition screening for all adolescents should include questions about meal patterns, dieting behaviors, consumption of high-fat and high-salt foods, and recent changes in weight. Discuss healthy dietary habits with all adolescents, including the benefits of a healthy diet; ways to consume foods rich in calcium, iron, and other vitamins and minerals; and safe weight management. Lifestyle changes necessary for adolescents to lose weight require the involvement of family members who provide support and encourage active participation.
Physical Fitness Although today's youth are less fit than children 20 years ago, adolescents probably spend more time and energy practicing and participating in sports activities than members of any other age group. In 2011, nearly one half (49.5%) of all high school students reported that they participated in activities that made them “sweat and breathe hard for at least 20 minutes” three or more times in the past week (Eaton, Kann, Kinchen, et al, 2012). Many adolescents participate in sports within school settings (Fig. 15-8). School-based, health-oriented physical education may provide both immediate effects of the activity and sustained effects through encouragement of lifelong activity patterns. Participation in school physical education classes declines with age, because schools often do not have mandatory requirements past grade 9 or 10. To improve health outcomes, the U.S. Department of Health and Human Services recommended school-age children and adolescents should engage in a minimum of 60 minutes of moderate to vigorous physical activity daily and muscle-strengthening activity at least 3 days per week (Song, Carroll, and Fulton, 2013).
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FIG 15-8 Adolescents should be encouraged to participate in activities that contribute to lifelong physical fitness. (©2011 Photos.com, a division of Getty Images. All rights reserved.)
The practice of sports, games, and even dancing contributes significantly to growth and development, the education process, and better health. These activities provide exercise for growing muscles, interactions with peers, and a socially acceptable means of enjoying stimulation and conflict. In addition, competitive activities help teenagers in the process of self-appraisal and the development of self-respect and concern for others. Because physical fitness appears to be a major influence on one's lifelong health status, children should be encouraged to participate in activities that contribute to lifelong physical fitness. Nurses can encourage participation as a way to promote health and build self-esteem. However, adolescents should not be encouraged to engage in physical activities that are beyond their physical or emotional capacity (see Sports Participation and Injury, Chapter 29).
Sexual Behavior, Sexually Transmitted Infections, and Unintended Pregnancy In the United States, sexual activity significantly decreased among youth in the 1990s through 2009. As a result, unintended pregnancy and birth among teens in 2009 was 39.1 births per 1000 females, which represents a 37% decrease from 61.8 births per 1000 females in 1991 (Centers for Disease Control and Prevention, 2011a). This is the lowest teen birth rate ever in the United States, yet other developed countries have much lower teen birth rates. Rates of STIs and human immunodeficiency virus (HIV) infection among teens have increased, although this may be due to increased testing and better sensitivity of STI testing. However, many sexually active young people engage in behaviors that put them at risk for STIs or pregnancy, such as having sex with multiple partners and having sex without using contraception.
Obtaining a sexual history can be an important step in promoting sexual health and preventing STIs and unintended pregnancies among young people. Questions about sexuality should be prefaced by an explanation of the purpose and limits of confidentiality. Initially questions can cover less sensitive topics, such as pubertal development, and then address dating behaviors, gender attractions, and sexual activity. Screening questions regarding sexual attractions and experiences should be phrased in ways that allow adolescents to discuss same- and opposite-gender attractions, such as the term partner instead of boyfriend or girlfriend. Sexually active youth should be asked about their consistency and motivation to use condoms or other barrier methods for preventing STIs; use of birth control pills or other forms of hormonal contraception; the number of sexual partners over the past 6 months; and the use of alcohol or other substances in connection with
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sexual activity. Sexually active adolescents should be screened for STIs with laboratory tests for gonorrhea,
chlamydia, and if applicable, syphilis. For females, a Papanicolaou (Pap) test to detect human papillomavirus (HPV) infection or other cervical dysplasia. Both males and females should be evaluated for HPV by visual inspection and should also be asked about whether they have received the HPV vaccine series. Adolescents at risk for HIV infection should be offered confidential HIV screening tests. The frequency of laboratory screening for STIs and HIV depends on sexual practices and STI history of individual adolescents.
All adolescents should receive medically accurate health guidance regarding responsible sexual behaviors, including abstinence. Counsel sexually active adolescents about ways to reduce their risk of STIs and unwanted pregnancy and provide positive reinforcement for responsible sexual behaviors. Gay, lesbian, and bisexual adolescents need the same sexuality education and information as heterosexual adolescents. All adolescents should be counseled on ways to reduce their risk of sexual exploitation.
Gay, Lesbian, and Bisexual Adolescents The population of gay, lesbian, and bisexual adolescents has unique developmental issues and health challenges. Although adolescents may participate in same-gender sexual activity or have same-gender attractions, they do not necessarily become gay, lesbian, or bisexual adults. Assigning sexual orientation labels to adolescents is complex and should be approached cautiously.
Most of the health challenges of sexual minority teens are responses to negative societal attitudes and messages about homosexual or bisexual orientation. They may use alcohol and other substances to escape their anxieties, and they are at much greater risk for suicidal behaviors than their heterosexual peers. Although nurses should screen all youth about suicidal thoughts and history of suicide attempts, it is especially critical for an adolescent who identifies as gay, lesbian, or bisexual or one who is questioning his or her orientation.
Publicly disclosing a gay, lesbian, or bisexual orientation during adolescence (“coming out”) brings additional challenges. Many adolescents disclose their orientation to a close peer, then a sibling, and finally a parent (Steever, Francis, Gordon, et al, 2014). Adolescents face hostility, violence, and even rejection from their families. Nurses should not encourage teens to disclose their sexual orientation to their families without first forming a safety plan in case the reaction is not supportive. For the majority of young people, referral to an agency providing support services or social opportunities for gay, lesbian, and bisexual adolescents is appropriate. Parents who seek assistance in adjusting to their son's or daughter's disclosure can be referred to a local chapter of Parents, Families and Friends of Lesbians, Gays, Bisexuals (www.pflag.org). Adolescents who acknowledge same-gender attractions or relationships are also at risk for violence and harassment from schoolmates, neighbors, and even strangers. Sexual minority adolescents may fear similar uncaring attitudes among health care providers and might avoid disclosing their orientation during health assessments. To provide sensitive, professional care for gay, lesbian, and bisexual adolescents, nurses should be sensitive in their choice of language and be nonjudgmental and caring in their communication.
Use of Tobacco, Alcohol, and Other Substances Experimentation with substances is common among adolescents in the United States. Among 12th graders, 70% used alcohol, 40% smoked cigarettes, and 46% used cannabis in the past month (Goncy and Mrug, 2013). Many adolescents use these substances because they provide an opportunity to challenge authority, demonstrate autonomy, gain entry into a peer group, or simply to relieve stress. There are many documented consequences of early experimentation with alcohol, tobacco, and other drugs, such as becoming heavier smokers, lower academic achievement, dropping out of school, and early sexual behavior.
Depression and Suicide A national survey of 9th- through 12th-grade students found that 34% of boys and 22% of girls reported feeling sad or hopeless (Eaton, Kann, Kinchen, et al, 2012) due to real or perceived stress (Fig. 15-9 and Box 15-4). Nearly 16% of high school students reported seriously considering suicide during the past year, with female students being more likely than male students to consider a suicide attempt (Eaton, Kann, Kinchen, et al, 2012).
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FIG 15-9 Adolescents use being alone as a method of coping with stress. Health care professionals need to assess whether this indicates clinical depression. (©2011 Photos.com, a division of Getty Images. All rights
reserved.)
Box 15-4 A r e a s o f S t r e s s i n A d o l e s c e n c e • Body image
• Sexuality conflicts
• Academic pressures
• Competitive pressures
• Relationships with parents
• Relationships with siblings
• Relationships with peers
• Finances
• Decisions about present and future roles
• Career planning
• Ideologic conflicts
A brief psychological screening is necessary during a routine health visit. Screening for depression or suicidal risk should be done with adolescents who note declining school grades, chronic melancholy, family dysfunction, alcohol or other drug use, gay, lesbian, or bisexual orientation, a history of abuse, or previous suicide attempts. Immediate referral for an acute intervention with a psychiatrist or other mental health professional is indicated for any suicidal patient.
School and Learning Problems In 2011, 7% of American youth between the ages of 16 and 24 years old dropped out before completing high school (Davis and Bauman, 2013). Among in-school adolescents, a low grade point average has been associated with higher levels of emotional distress; cigarette, alcohol, and marijuana use; and earlier onset of sexual activity. School problems and dropping out of school can be markers for difficulties, such as learning disabilities, language barriers, family problems, lack of supportive relationships at school, and employment needs. In contemporary American society,
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education is critical to economic self-sufficiency. Adolescents who drop out of high school can expect to earn approximately $400,000 less over a lifetime than those who graduate (Center for Labor Market Studies, 2011).
Questions about recent grades, school absences, suspensions, and any history of repeating a grade in school can be used to screen for school-related problems. Specific management plans for youth who note school problems should be coordinated with school personnel and with the adolescent's parents or caregivers if possible.
Hypertension As adolescents experience sexual maturation, along with increases in height and weight, blood pressure increases from the onset of adolescence and continues to rise until the end of pubertal growth. This trend is especially apparent among males. Approximately 1% of adolescents have sustained hypertension, which is defined as a blood pressure greater than the 95th percentile of standards. The detection of hypertension during adolescence is important because hypertension is one of the major preventable risk factors for adult cardiovascular disease. With increasing levels of obesity, there have been reports of increasing incidence of hypertension among adolescents (LaRosa and Meyers, 2010). Screening for hypertension and associated risk factors should take place annually beginning at 3 years old. Specific guidelines for monitoring and treatment of hypertension in adolescents are found in the 2011 National Heart Lung Blood Institute Summary Report (see also Chapter 23).
Hyperlipidemia Along with hypertension, smoking, and obesity, elevated serum cholesterol and triglyceride levels are major risk factors for the development of adult cardiovascular disease. The National Heart Lung Blood Institute (2011) recently issued a recommendation for universal lipid (nonfasting or fasting) screening of all children and adolescents between 9 and 11 years old and again between 17 and 21 years old. Low-density lipoprotein (LDL) cholesterol–lowering drug therapy is recommended for children and adolescents 10 years old and older whose LDL remains elevated after 6 months to 1 year on a restricted fat diet, lifestyle modification (exercise), and weight management (National Heart Lung Blood Institute, 2011). Additional information and practice guidelines for monitoring cholesterol levels and initiation of LDL cholesterol–lowering medication, as well as specific dietary modifications, are found in the 2011 National Heart Lung Blood Institute Summary Report at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric- guidelines/summary.
Immunizations An immunization update is an important part of adolescent preventive care. Obtaining a record of the teenager's prior immunizations is important. The Tdap (tetanus, diphtheria, acellular pertussis) vaccine is recommended for adolescents 11 to 18 years old who have not received a tetanus booster (Td) or Tdap dose and have completed the childhood DTaP/DTP series. When the Tdap is used as a booster dose, it may be administered at any time earlier than the previous 5-year interval to provide adequate pertussis immunity (regardless of interval from the last Td dose) (Centers for Disease Control and Prevention, 2011b). Meningococcal vaccine (Menactra or Menveo) should be given to adolescents 11 to 12 years old with a booster dose at 16 years old. If not previously vaccinated, they should receive 1 dose at 13 through 18 years old (Centers for Disease Control and Prevention, 2013a) (see also Immunizations, Chapter 6).
The quadrivalent HPV vaccine or the bivalent HPV vaccine is recommended for the prevention of cervical precancers and cancers for girls beginning at a minimum age of 9 years old. The quadrivalent HPV vaccine is recommended for males 9 through 18 years old to reduce their likelihood of genital warts (Centers for Disease Control and Prevention, 2013b). Each one of the HPV vaccines is administered in a three-dose series; it is important to follow the recommended dose intervals for optimal effectiveness.
All adolescents who have not previously received three doses of hepatitis B vaccine should be vaccinated against hepatitis B virus. The hepatitis A vaccine should be given to adolescents who live in areas where vaccination programs target older children or who are at increased risk for infection or for whom immunity against hepatitis A is desired (Centers for Disease Control and Prevention, 2013b). Annual influenza vaccination with either the live attenuated influenza vaccine
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or the trivalent influenza vaccine is recommended for all children and adolescents (see Chapter 6). All adolescents should also be assessed for previous history of varicella infection or vaccination. Vaccination with the varicella vaccine is recommended for those with no previous history; for those with no previous infection or history, the varicella vaccine may be given in two doses 4 or more weeks apart to adolescents 13 years old or older (Centers for Disease Control and Prevention, 2013b). Adolescents should receive a tuberculin skin test if they have been exposed to active tuberculosis (TB), have lived in a homeless shelter, have been incarcerated, have lived in or come from an area with a high prevalence of TB, or currently work in a health care setting.
Body Art Body art (piercing and tattooing) is an aspect of adolescent identity formation. The skin has become the latest source of parent–adolescent conflict. Adolescents often seek body art as an expression of their personal identity and style. Tattoos may mark significant life events, such as new relationships, births, and deaths. Piercing the ear, nose, nipple, eyebrow, navel, penis, or tongue may sometimes create a health problem. It is a nurse's responsibility to caution girls and boys against having piercing performed by friends, parents, or themselves. Although in most cases piercings have few (if any) serious side effects, there is always a risk of complications such as infection, cyst or keloid formation, bleeding, dermatitis, or metal allergy. Using the same unsterilized needle to pierce body parts of multiple teenagers presents the same risk of HIV, hepatitis C, and hepatitis B virus transmission as occurs with other needle-sharing activities.
A qualified operator using proper sterile technique should perform the procedure. This is especially important if an adolescent has a history of diabetes, allergies, or skin disorders. Adolescents should be informed about the approximate time for healing after body piercing and the care of the pierced area during and after healing. Some body sites need extra precautions. For example, cartilage (ear, nose) has a poor blood supply and heals slowly and scars easily; nipple piercing puts adolescents at risk for breast abscesses. Finally, migration of the piercing is common with naval and other flat skin surface piercing. Piercing guns should not be used for piercing anything other than the earlobe, because guns place the piercing too deeply.
The presence of body art in the form of tattoos and branding is common among adolescents and young adults. Professionals, as well as amateur artists, administer tattoos. The risk to adolescents receiving tattoos is low. The greatest risk is for the tattoo artist, who comes in contact with the client's blood. Adolescents who are amateur tattoo artists benefit from discussions about standard precautions and the hepatitis B vaccination. Many states either have no regulations or do not enforce existing regulations of piercing and tattooing facilities. The local health department is a source of information about local regulatory requirements. The Centers for Disease Control and Prevention has an excellent website that outlines safety concerns for persons performing and receiving body art (http://www.cdc.gov/niosh/topics/body_art/).
Sleep Deprivation and Insomnia The changing social environment of adolescents can often change their sleep patterns at a time when their growth and development require additional sleep for health. Although adolescents should generally get around 9 hours of sleep each night, early morning school scheduling, extracurricular activities, homework, employment, and desired social time with peers or on the Internet can make it difficult for them to get sufficient sleep. Sleep deprivation can affect physical and mental health and has been associated with higher rates of overweight and obesity, depression, somatic complaints (such as headaches and stomachaches), fatigue, and difficulties with concentration. These physical and psychological effects of inadequate sleep can also affect school performance and thus contribute to school problems. Health teaching and health promotion should include information to promote sufficient sleep.
Tanning The quest for an attractive appearance leads many teenagers to excessive sunbathing and artificial means for tanning. However, this practice has serious long-term risks, and adolescents should be educated regarding the detrimental effects of sunlight on the skin (see Sunburn, Chapter 13). Long- term effects include premature aging of the skin; increased risk of skin cancer; and, in susceptible individuals, phototoxic reactions.
The increasing popularity of artificial tanning has prompted concern from health professionals
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regarding the use of sunlamps and tanning machines. The long-term effects of tanning machines are similar to those of the sun; dermatologists do not recommend tanning by this means. Those who insist on using tanning equipment should be warned that goggles must be worn in tanning booths to prevent serious corneal burning. Education on the use of sunscreens, including hypoallergenic products, with a sun protective factor (SPF) of at least 15 and a non-alcohol base without lanolin, parabens, or fragrance, is important. Broad-spectrum sunscreens that protect against both ultraviolet A and B (UVA and UVB) are the most effective. Self-tanning creams safely stimulate the appearance of a tan; however, teens using these products should be cautioned that with sun exposure, protection is still required. Targeting health education messages to adolescents and incorporating educational components relating to sun protection behaviors in school health curricula and in health care visits will increase adolescents' knowledge and awareness.
Nursing Care Management With continued increases in the numbers of adolescents in the United States and rising rates of health-related problems of youth, there is an unprecedented need for adolescent health promotion. Nursing professionals can make significant contributions to health promotion among adolescents and their families. Because nurses understand the biologic, cognitive, psychosocial, and social transitions of adolescence and their impact of health behavior, they can address adolescents' developmental and health needs. Working with colleagues from other disciplines, community members, parents, and adolescents themselves, nurses must become part of a comprehensive approach that delivers consistent messages across clinical, school, and community-based settings. Nurses should be at the forefront of developing and disseminating culturally appropriate health promotion interventions.
Both adolescents and their parents are often confused and perplexed about the changes and behavior of this stage of development. Parents need support and guidance to help them through this trying time. They need to understand the changes taking place and to accept the expected behaviors that accompany the process of detachment. Parents may need help to “let go” and to promote the changed relationship from one of dependence to one of mutuality. Suggestions for anticipatory guidance of parents of adolescents are listed in the Family-Centered Care box.
F a m i l y - C e n t e r e d C a r e Guidance During Adolescence
Encourage parents to:
• Accept adolescent as a unique individual.
• Respect adolescent's ideas, likes and dislikes, and wishes.
• Be involved with school functions and attend adolescent's performances, whether it is a sporting event or school play.
• Listen and try to be open to teenager's views even when they disagree with parental views.
• Avoid criticism about no-win topics.
• Provide opportunity for choosing options and accept natural consequences of these choices.
• Allow young persons to learn by doing, even when choices and methods differ from those of adults.
• Provide adolescent with clear, reasonable limits.
• Clarify house rules and consequences for breaking them. Let society's rules and consequences teach responsibility outside the home.
• Allow increasing independence within limitations of safety and well-being.
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• Respect adolescent's privacy.
• Try to share adolescent's feelings of joy or sorrow.
• Respond to feelings as well as words.
• Be available to answer questions, give information, and provide companionship.
• Try to make communication clear.
• Avoid comparisons with siblings.
• Assist adolescent in selecting appropriate career goals and preparing for adult roles.
• Welcome adolescent's friends into the home and treat them with respect.
• Provide unconditional love and acceptance.
• Be willing to apologize when mistaken.
Be aware that adolescents:
• Are subject to turbulent, unpredictable behavior.
• Are struggling for independence.
• Are extremely sensitive to feelings and behavior that affect them.
• May receive a different message from what was sent.
• Consider friends extremely important.
• Have a strong need to belong.
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NCLEX Review Questions 1. According to Jean Piaget, adolescent cognitive development is represented by the stage of formal
operational thought that includes which of the following? Select all that apply. a. Believing that thoughts are all-powerful b. Thinking in abstract terms c. Thinking about hypotheses d. Using a future time perspective e. Thinking in the here and now
2. What is the most common source of unintentional injury and death in young people? a. Motor vehicle crashes b. Drowning c. Poisoning d. Chronic illnesses
3. What factors should the nurse consider when interviewing an adolescent patient? a. Begin with sensitive issues then proceed with less sensitive topics b. Assume you understand the adolescent by including your own experiences c. Interview the adolescent with the parents to ensure accuracy d. Ask open-ended questions
4. Which of the following immunization booster vaccines should be considered for a 12-year-old adolescent who has completed all recommended routine childhood vaccinations? Select all that apply. a. DTaP vaccine b. Tdap vaccine c. Meningococcal vaccine d. Pneumococcal vaccine e. Hepatitis B vaccine
5. As a nurse caring for children, an understanding of childhood depression is essential. Some important information about depression includes which of the following statements? Select all that apply. a. Authorities agree that childhood depression exists, and the manifestations are often similar to
adult depression. b. Identification of the depressed child requires a careful history taking (e.g., health, growth and
development, social and family health); interviews with the child; and observations by the nurse, parents, and teachers.
c. If antidepressants are prescribed, the child and family need to know that antidepressants must be at a therapeutic level for 4 to 6 weeks to achieve a beneficial effect.
d. Depressed children often exhibit a distinctive style of thinking characterized by low self- esteem, hopelessness, poor social engagement with peers, and a tendency to explain negative events in terms of personal shortcomings.
e. Nurses should be aware that depression is a problem that can be easily overlooked in the school-age child and one that can interrupt normal growth and development.
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Correct Answers 1. b, c, d; 2. a; 3. d; 4. b, c; 5. b, d, e
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Health Problems of School-Age Children and Adolescents Cheryl C. Rodgers, Meg Bruening
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Health Problems of School-Age Children Problems Related to Elimination Enuresis Enuresis (bedwetting), or nocturnal enuresis, is a common and troublesome disorder that is defined as intentional or involuntary passage of urine in children who are beyond the age when voluntary bladder control should normally have been acquired. Medical evaluation is recommended when inappropriate voiding of urine occurs at least once a month for a minimum of 3 consecutive months, and the chronologic or developmental age of the child is at least 5 years old (Caldwell, Deshpande, and Von Gontard, 2013). In addition, the urinary incontinence must not be related to the direct physiologic effects of a medication (e.g., diuretics) or a general medical condition (e.g., diabetes mellitus or diabetes insipidus, spina bifida, or seizure disorder).
Enuresis is more common in boys (Caldwell, Deshpande, and Von Gontard, 2013); nocturnal bedwetting usually ceases between 6 and 8 years old. Enuresis can also be defined as primary (bedwetting in children who have never been dry for extended periods) or secondary (the onset of wetting after a period of established urinary continence). The passage of urine may occur only during nighttime sleep, with the child remaining dry during the day (monosymptomatic), or it may be polysymptomatic, where the child has daytime urinary urgency and an occasional daytime accident in conjunction with other conditions, such as sleep disorders, urinary tract infection, neurologic impairment, constipation, or emotional stressors (Elder, 2016).
During the initial phases of evaluation, a routine physical examination is performed to rule out physical causes related to enuresis. These include structural disorders of the urinary tract; urinary tract infection; neurologic deficits; disorders that increase the normal output of urine, such as diabetes; and disorders that impair the concentrating ability of the kidneys, such as chronic renal failure. In other cases, enuresis is influenced by psychological factors. If psychological difficulties are evident, a routine psychiatric evaluation is warranted.
A detailed history of voiding and bowel habits is obtained, including information about the toilet training process. An important feature of assessment is a baseline count of enuretic incidents and the time of day when each occurs. Despite parental reports that these children sleep more soundly than other children, the depth of sleep has not been identified as the cause of nocturnal enuresis, although defective sleep arousal may contribute to the problem (Elder, 2016). Nocturnal enuresis has a strong familial tendency.
The physical examination may be followed by diagnostic evaluation of function bladder capacity. Normal bladder capacity (in ounces) is the child's age plus 2 (up to 14 years old); therefore normal bladder capacity for a 6-year-old is 8 ounces (237 ml). A bladder volume of 10 to 12 ounces (300 to 350 ml) is sufficient to hold a night's urine.
Enuresis has been treated in several ways. No single method has achieved universal endorsement, and more than one technique is often employed by families coping with enuresis. Therapeutic techniques used to manage nocturnal enuresis include medications, complementary and alternative medicine techniques, such as hypnotherapy, restriction or elimination of fluids after the evening meal, avoidance of caffeinated and sugar-containing beverages after 4 PM, purposeful interruption of sleep to void, and motivational therapy. Devices designed to establish a conditioned reflex response to waken the child at the initiation of voiding, such as bedwetting alarms, are the first-line treatment for children with nocturnal enuresis (Deshpande and Caldwell, 2012).
Drug therapy can be prescribed to treat enuresis. The selection depends on the interpretation of the cause. Desmopressin acetate (DDAVP), an analog of vasopressin, is commonly used for the treatment of nocturnal enuresis. DDAVP works by increasing water reabsorption thus reducing urine production to a volume less than functional bladder capacity. The medication is available as a nasal spray or oral preparation and is generally well tolerated but may cause nasal irritation, hyponatremia, or, rarely, headache or nausea. The drug imipramine (Tofranil) exerts an anticholinergic action in the bladder to inhibit urination. A systematic review of 58 trials showed that imipramine cured bedwetting in 20% of children; however, almost all children relapse when the medication is stopped (Caldwell, Deshpande, and Von Gontard, 2013). Because side effects of this drug, including cardiac arrhythmias, hypotension, and hepatotoxicity, are especially dangerous, this medication is used with resistant cases only (Caldwell, Deshpande, and Von
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Gontard, 2013). Anticholinergic drugs, such as oxybutynin, reduce uninhibited bladder contractions and increase the bladder's storage capacity. These medications are commonly used in patients with small bladder capacity. Usually ineffective as monotherapy, anticholinergic drugs can improve the treatment when used in combination with other treatments, such as desmopressin, imipramine, or enuresis alarms (Caldwell, Deshpande, and Von Gontard, 2013). Drugs are considered second-line management for enuresis, and parents should be cautioned not to think that these agents will cure the condition; parents are also advised of the drug's side effects (Elder, 2016).
Nursing Care Management No matter what techniques are used, the nurse can support both children and parents who are coping with the problem of enuresis, the treatment plan, and the difficulties they may encounter in the process. Essential to the success of any method is the supportive management of parents and their children. Both need encouragement and patience. The problem is discussed with both the parent and the child because all treatments involve and require the child's active participation. In some treatment interventions, the child is in charge of the intervention; therefore parents must learn to support the child rather than intervene themselves. Parents should also be taught to observe for side effects of any medications used. Parents should encourage the child to maintain a regular bowel evacuation regimen; constipation can contribute to nocturnal enuresis (Elder, 2016). A calendar with wet and dry nights may be helpful to motivate the child to stay dry and maintain a positive perspective on the problem.
Many parents believe that enuresis is caused by an emotional disturbance and fear that they have somehow produced the situation by improper childrearing practices. They need reassurance that bedwetting does not represent willful misbehavior. Parents need to understand that punishment such as scolding, shaming, and threatening is contraindicated because of its negative emotional impact and limited success in reducing the behavior. Children need to believe that they are helping themselves, and they need to sustain feelings of confidence and hope. Encourage parents to be patient, to be understanding, and to communicate love and support to the child.
Communication with children is directed toward eliminating the emotional impact of the problem, relieving feelings of shame and guilt and the burden of parental disapproval, building self-confidence, and motivating children toward independent control. More important, the nurse can provide consistent support and encouragement to help children through the inconsistent and unpredictable treatment process. Children need to believe that they are helping themselves and to maintain feelings of confidence and hope.
Encopresis Encopresis is the repeated involuntary passage of feces of normal or near-normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. The event must occur at least once per month for at least 3 months, and the child's chronologic or developmental age must be at least 4 years old (Coehlo, 2011). The fecal incontinence must not be caused by any physiologic effect, such as a laxative, or a general medical condition. The consistency of the stool may vary from normal to liquid, with a more liquid stool seen in individuals who have overflow incontinence secondary to fecal retention.
Primary encopresis is identified by 4 years old when a child has not achieved fecal continence. Secondary encopresis is fecal incontinence occurring in a child older than 4 years of age after a period of established fecal continence. The disorder is more common in males than in females (Coehlo, 2011).
One of the most common causes of encopresis is constipation, which may be precipitated by environmental change, such as having a new sibling, moving to a new house, changing schools, or even having to use new or unfamiliar toilet facilities. Chronic, severe constipation has a tendency to impair the usual movement and contractions of the colon, which can lead to fecal obstruction. Abnormalities in the digestive tract (e.g., Hirschsprung disease, anorectal lesions, malformations, rectal prolapse) and medical conditions (such as hypothyroidism, hypokalemia, hypercalcemia, lead intoxication, myelomeningocele, cerebral palsy, muscular dystrophy, and irritable bowel syndrome [IBS]) are also associated with constipation, which can lead to encopresis. Voluntary retention of stool may also follow an incident of painful defecation (e.g., in a child with anal fissures). Involuntary retention may be produced by emotional problems caused by the encopresis, which sets up a fear–pain cycle and results in learned abnormal defecation patterns. Psychogenic
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encopresis, in which the soiling is caused by emotional problems, is often related to a disturbed mother–child relationship.
Normally, children and adolescents have one or two soft-formed stools per day. Children with soiling problems tend to form large-bore stools, which are painful to excrete. Therefore they tend to avoid defecation and withhold stooling. Stool held in the rectum and sigmoid colon loses water and progressively hardens, which causes successively more painful bowel movements and a stretched rectal vault. Over time, the child will lose the urge to defecate on his or her own (Mosca and Schatz, 2013). A pain–retention–pain cycle is established. Many children have diarrhea or loose leakage in their clothing and pass small amounts of hard stool, which suggests leakage around an impaction.
Children may experience exacerbations with transitions in the school setting. Some reasons for developing retentive tendencies at this time are fear of using school bathrooms, a busy schedule, and the interruption of an established time schedule for bowel evacuation. Children may also react to stress with bowel dysfunction.
Therapeutic management consists of determining the cause of the soiling and using appropriate interventions to correct the problem. To determine the cause, a detailed history including risk factors (negative toilet training, child abuse or neglect, fear of bathrooms), comorbid conditions (such as attention deficit disorder, cognitive delays, oppositional disorders), and associated symptoms of bowel movements (retention, overflow soiling, incontinence) are obtained (Mosca and Schatz, 2013). Next, a thorough physical examination including a rectal examination is completed. Abdominal radiography may be done to determine the severity of impaction.
Many children require an extensive and invasive bowel cleansing to remove the bowel impaction before starting treatment (Mosca and Schatz, 2013). Fecal impaction is relieved by lubricants (such as mineral oil), osmotic laxatives (such as lactulose, sorbitol, or polyethylene glycol [PEG or MiraLax]), and magnesium hydroxide. Customary dosages are usually insufficient to produce a therapeutic response. Mineral oil should be avoided in children who have dysphagia or vomiting to prevent aspiration.
Children without bowel impaction can start treatment immediately. Dietary modifications, lubricants, and behavior therapy that encourage the child to establish normal defecation are used. Dietary changes including consumption of increased amounts of high-fiber foods such as fruits, vegetables, cereals, and increased hydration with water are encouraged. Stool softeners and laxatives are used until stools become soft. Behavior therapy, such as maintaining regular bathroom routines, increasing exercise, and having the child take on more responsibility for their bowel program, is a vital part of the treatment plan (Coehlo, 2011). Psychotherapeutic intervention with the child and the family may become necessary.
Nursing Care Management A thorough history of the soiling is essential, including when soiling began, how often it occurs and under what circumstances, and whether the child uses the toilet successfully at all. Because the parents and child are reluctant to volunteer information, direct questioning about the soiling is more successful.
Education regarding the physiology of normal defecation, toilet training as a developmental process, and the treatment outlined for the particular family is a prerequisite to a successful outcome. Bowel retraining with mineral oil, a high-fiber diet, and a regular toileting routine is essential in treating encopresis or chronic constipation. The toilet routine should consist of the child sitting on the toilet 10 to 15 minutes after meals for intervals of 10 minutes, and placing a footstool below the feet may relax the abdomen and make the child more comfortable. Positive reinforcement such as giving stickers, praising the child, and awarding special activities may encourage the child to participate in the bowel regimen.
Family counseling is directed toward reassurance that most problems resolve successfully, although the child may have relapses during periods of stress, such as vacations or illness. If encopresis persists beyond occasional relapses, the condition needs to be reevaluated. Behavior modification techniques are explained, and the family is assisted with a plan suited to the particular situation.
School-Age Disorders with Behavioral Components Attention-Deficit/Hyperactivity Disorder and Learning Disability
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Attention-deficit/hyperactivity disorder (ADHD) refers to developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity (American Psychiatric Association, 2013). Early identification of affected children is important because the characteristics of ADHD significantly interfere with the normal course of emotional and psychological development. Their behavior evokes negative responses from others, and repeated exposure to negative feedback adversely affects their self-concept. Children with ADHD are at greater risk for conduct disorders, oppositional defiant disorders, depression, anxiety disorders, and developmental disorders (such as speech and language delays and learning disabilities) than are children without ADHD (American Academy of Pediatrics, 2011a).
Clinical Manifestations The behaviors exhibited by the child with ADHD are not unusual aspects of child behavior. The difference lies in the quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity that the child displays. The manifestations may be numerous or few, mild or severe, and vary with the child's developmental level (Minzenberg, 2012). Mild manifestations of the symptoms are apparent in at least two settings, usually educational and family environments. Every child with ADHD is different from all other children with ADHD (American Psychiatric Association, 2013).
Most behavioral manifestations are apparent at an early age, but the learning disabilities may not become evident until the child enters school. A major clinical manifestation is distractibility. The stimuli may come from external sources or internal sources. Children frequently demonstrate immaturity relative to chronologic age. Selective attention is often seen in which the child has difficulty attending to “non-preferred” tasks, such as completing chores or finishing homework. The child may not consider the consequences of behavior, may take excessive physical risks (often beginning early in life), and may demonstrate inappropriate social skills.
Children with ADHD demonstrate one of three subtypes (American Psychiatric Association, 2013):
1. Combined type: Six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months. Most children and adolescents with the disorder have the combined type.
2. Predominantly inattentive type: Six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least 6 months.
3. Predominantly hyperactive-impulsive type: Six (or more) symptoms of hyperactivity- impulsivity (but fewer than six symptoms of inattention) have persisted for at least 6 months. Inattention may often still be a significant clinical feature in such cases.
Diagnostic Evaluation It is important to emphasize the need for a complete and thorough multidisciplinary evaluation of the child, incorporating the efforts of the primary pediatric health care provider and the family as well as possible support from a psychologist, developmental pediatrician, neurologist, pediatric nurses, classroom teachers, and administrators. The clinicians and professionals must first determine whether the child's behavior is age appropriate or truly problematic.
Prior to diagnosis a complete medical and developmental history is obtained. A description of the child's behavior in the home, school, and social situations are obtained from as many observers of the child as possible, especially the parents and teachers involved in the child's care. A physical examination, including vision and hearing screening and a detailed neurologic evaluation is completed. Psychological testing, especially projective tests, is used to identify visual-perceptual difficulties, problems with spatial organization, and other phenomena that suggest cortical or diencephalic involvement, and it helps to identify the child's intelligence and achievement levels.
Behavioral checklists and adaptive scales should be completed by the child's caregivers and educators and scored by the primary care provider. These assessment tools are helpful in measuring social adaptive functioning in children with ADHD as well as providing benchmarks for evaluation of improved or worsening behavioral changes once therapy has begun. Psychiatric disorders, medical problems, and traumatic experiences are ruled out, including lead poisoning,
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seizures, partial hearing loss, psychosis, and witnessing of sexual activity or violence.
Therapeutic Management Treatment of ADHD depends on the child's age and severity of symptoms. Evidence supports behavioral therapy as the first-line treatment, but other approaches include family education and counseling, medication, proper classroom placement, environmental manipulation, and psychotherapy for the child.
Behavioral Therapy Behavioral therapy focuses on the prevention of undesired behavior. Families are helped to identify new appropriate contingencies and reward systems to meet the child's developing needs. They may also receive instruction in effective parenting skills, such as delivering positive reinforcement, rewarding small increments of desired behaviors, and providing age-appropriate consequences (e.g., time-out, response cost). Through collaborative teamwork parents learn techniques to help the child become more successful at home and in school.
Pharmacologic Therapy The most effective and frequently used medications are stimulants: methylphenidate hydrochloride and dextroamphetamine (Minzenberg, 2012). Non-stimulant medications, including norepinephrine reuptake inhibitors and adrenergic agonists, have also shown to be effective with fewer side effects in school-age and adolescent children (American Academy of Pediatrics, 2011a). Children are given a small dosage initially, and the dosage is gradually increased until the desired response is achieved. Children who receive stimulants should be monitored carefully for side effects of the medication: appetite loss, abdominal pain, headaches, sleep disturbances, and growth velocity. Stimulants should be avoided in children who have a history of tic-like behaviors, a family history of Tourette syndrome (TS), or ADHD combined with TS, because these medications may exaggerate tics.
Other medications, including tricyclic antidepressants and extended-release clonidine, may be used as adjunct therapy for ADHD, primarily for children with coexisting conditions, such as sleep disturbances (American Academy of Pediatrics, 2011a).
It is important to remember that these medications are not prescribed based on the child's weight (except atomoxetine), but on resolution of the symptoms; therefore it is important to follow the child closely and evaluate for therapeutic effects as well as potential side effects. Regularly scheduled reevaluation of the child is essential with all of these medications to determine medication effectiveness, detect and evaluate any side effects, monitor development and health status (especially growth and blood pressure), and assess family interaction (see Critical Thinking Case Study box).
C r i t i c a l T h i n k i n g C a s e S t u d y Attention-Deficit/Hyperactivity Disorder
Johnnie, an 8-year-old third grader, was recently diagnosed with ADHD. He has been taking the drug methylphenidate (Ritalin) for about 1 month. In the short time that Johnnie has been taking this medication, his math teacher has noticed an improvement in his performance in math class. He is receiving a grade of B instead of his previous grades of D on most math quizzes. The math teacher has also noted that Johnnie is socializing more with his classmates and that he now has a “best friend” in math class. Johnnie usually receives his methylphenidate from the school nurse before lunch. Yesterday Johnnie's mother told the school nurse that he has not eaten his lunch for the past week and that he is not hungry.
What important issues regarding Johnnie's medication should the nurse consider in her discussions with Johnnie's mother?
Questions
1. Evidence: Is there sufficient evidence to draw conclusions about Johnnie's medication from his behavior?
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2. Assumptions: Describe some underlying assumptions about the following:
a. Pharmacologic action of methylphenidate in ADHD
b. Side effects of methylphenidate
c. Management of side effects
3. What implications for nursing care can be drawn at this time?
4. Does the evidence objectively support your conclusion?
ADHD, Attention-deficit/hyperactivity disorder.
Multimodal treatment. The results of several studies suggest that multimodal treatment involving the use of pharmacotherapy and behavioral intervention as well as close follow-up and feedback from school personnel is more effective than intensive behavioral treatment alone (Selekman, 2010).
Environmental manipulation. Encourage families to learn how to modify the environment to allow the child to be more successful. Consistency is especially important for children with ADHD. Consistency between families and teachers in terms of reinforcing the same goals is essential. Fostering improved organizational skills requires a more highly structured environment than most children need. The child should be encouraged to make more appropriate choices and to take responsibility for their actions.
Other helpful interventions include teaching parents how to make organizational charts (e.g., listing all activities that must be performed before leaving for school) and decrease distractions in the environment while the child is completing homework (e.g., turning off the television, having a consistent study area equipped with needed supplies) and helping parents to understand ways to model positive behaviors and problem solving. The focus is on strategies to help the child succeed and cope with deficits while emphasizing strengths.
Appropriate classroom placement. Children with ADHD need an orderly, predictable, and consistent classroom environment with clear and consistent rules. Homework and classroom assignments may need to be reduced, and more time may need to be allotted for tests to allow the child to complete the task. Verbal instructions should be accompanied by visual references, such as written instructions on the blackboard. Schedules may need to be arranged so that academic subjects are taught in the morning when the child is experiencing the effects of the morning dose of medication. Low-interest and high-interest classroom activities should be intermingled to maintain the child's attention and interest. Regular and frequent breaks in activity are helpful because sitting in one place for an extended time may be difficult. Computers are helpful for children who have difficulty with written assignments and fine motor skills.
If learning disabilities exist, special training activities may be accomplished. These include self- contained classes limited to six to eight children, special resource rooms with equipment and teaching teams, mobile consultants who move from room to room to provide assistance to teachers and children, and special first-grade programs in which high-risk children receive special attention to prevent or reduce the need for services as they progress. The purpose of programs for children with learning disabilities is to assist them toward more successful achievement, personal adjustment, and retention in the regular classroom.
Prognosis. With appropriate intervention, ADHD is relatively stable through early adolescence for most children. Some children experience decreased symptoms during late adolescence and adulthood,
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but a significant number of these children carry their symptoms into adulthood. The goal for children with ADHD is to help them identify their areas of weakness and learn to compensate for them.
Nursing Care Management Nurses, especially school nurses, are active participants in all aspects of management of children with ADHD. Nurses in the community work with families and school personnel on a long-term basis to help plan and implement therapeutic regimens and to evaluate the effectiveness of therapy. They coordinate services and serve as a liaison between health and education professionals directly involved in the child's therapy program. School nurses understand the child's special needs and work with teachers (see Family-Centered Care box). Nurses in any setting (community, school, hospital, practitioner's office) provide support and guidance to children and families during the difficult period of the child's growing up with a disabling condition.
F a m i l y - C e n t e r e d C a r e A Child's Perception of Taking Ritalin at School
I feel embarrassed by having to leave class early to go take my medication. The other kids always ask where I'm going and why. It would be better if we could leave class at the same time as everyone else, go take the medication, and then just be a little late to the next class. Students don't ask why people are late for class, only why they leave early. It also bothers me when kids tell other kids, “Go take a pill” and other mean things just because someone is acting up.
What could nurses and teachers do to help? Most kids do not understand why other kids have to take medication. I think it would help if a nurse or teacher talked with the other kids and explained why some children take the medication and how ADHD affects people. That way there would be more understanding among all the kids.
—Marissa White, age 16 years
Management begins with an explanation to the parents and the child about the diagnosis, including the nature of the problem and the practitioner's concept of the underlying CNS basis for the disorder. Parents need to be informed of the possible side effects of medications. If decreased appetite is a concern, giving the psychostimulants with or after meals rather than before, encouraging consumption of nutritious snacks in the evening when the effects of the medication are decreasing, and serving frequent small meals with healthy “on the go” snacks are helpful interventions. Sleeplessness is reduced by administering medication early in the day.
Children taking tricyclic antidepressants display a dramatic increase in the incidence of dental caries. The marked anticholinergic action of the drugs increases saliva viscosity and produces a dry mouth. Emphasis on rigorous dental hygiene, conscientious home fluoride treatments, regular visits to the dentist, limited intake of refined carbohydrates, and use of artificial saliva is an important nursing function. The child should drink plenty of fluids and be well hydrated.
Parents often express concern that their children will become addicted to the psychostimulants or the antidepressant drugs. Both types of drugs have the potential for abuse, and all children taking these drugs should be monitored closely for psychological dependence, tolerance, depression, and other adverse behavior changes or idiosyncratic effects. Most children with ADHD are not interested in abusing their drugs because the effect of the drugs in these children is opposite that produced in normal individuals. However, caution parents to keep these drugs safely stored away from young children who may inadvertently ingest them and adolescents who may abuse these drugs.
Parents need information about the prognosis and an understanding of the treatment plan. The greater their understanding of the disorder and its effects, the more likely they will be to carry out the recommended program of therapy. It is important that they understand that the therapy is not necessarily a panacea and that it will extend over a long period. This has particular significance for changes they need to make in environmental management. Reading material to help the child and family can be obtained from a variety of sources.
Posttraumatic Stress Disorder
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Posttraumatic stress disorder (PTSD) refers to the development of characteristic symptoms after exposure to an extremely traumatic experience or catastrophic event. The traumatic experience is typically life threatening to self or a significant other and may involve witnessing mutilation or death, experiencing or witnessing a serious injury, or physical coercion. An accident, assault, or victimization; a natural disaster (e.g., earthquake, flood); sexual abuse; or witnessing a suicide, homicide, beating, or shooting can lead to PTSD. It is important to note that PTSD is not limited to children who have lived in “war-torn” countries. Events such as automobile, school, or recreational accidents and bullying have also been identified as causes of PTSD.
The characteristic symptoms are persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal. The response to the event takes place in three stages. The initial response involves intense arousal, which usually lasts for a few minutes to 1 or 2 hours. The stress hormones are at the maximum as the individual prepares for “fight or flight.” A prolonged arousal phase may indicate psychosis.
The second phase, which lasts approximately 2 weeks, is one in which defense mechanisms are mobilized. It is a period of calm in which the event appears to have produced no impression. The victim feels numb, and stress hormone secretion is absent. Defense mechanisms are less adaptive to specific situations and may not be what the situation demands. Denial that anything is wrong is a frequently observed defense mechanism. Without professional support the victim may develop severe depression, aggression, or psychosis (Gerson and Rappaport, 2013).
The third phase is one of coping and consciously directed inquiry, which normally extends over 2 to 3 months. The victims want to know what happened and appear to be getting worse when actually he or she is getting better. Numerous psychological symptoms, such as depression, repetitive phenomena, phobic symptoms, anxiety, and conversion reactions, may be apparent. Children frequently display repetitive actions. They play out the situation over and over again in an attempt to come to terms with their fear. Flashbacks are common. This phase can be self- perpetuating, and a prolonged reaction can develop into an obsession with the traumatic event. Some traumatic effects remain indefinitely.
Nursing Care Management Children need to deal with any traumatic event; much hinges on the intensity of the event and their reactions to it. Children's reactions depend heavily on their social environment and the way in which their caretaking adults react to the event. In the second phase of PTSD, the appropriateness of the defense mechanism must be assessed, and children must be assisted in coping with their emotions.
Coping is a learned response, and children in the third phase can be helped to use their coping strategies to deal with their fears. Children usually are willing to accept reasoning. Those who are assisted in their catharsis and allowed expression will survive without serious lasting effects. Encourage them to play out the stress and discuss their feelings about the event.
Children need professional help if any of the phases of PTSD are prolonged. Boys tend to have a prolonged defense phase more often than girls. Occasionally, the precipitating event will go unrecognized (bullying and psychological abuse are most common in school-age children), and the affected child will engage in what is considered to be unusual behavior. Children exhibiting any sudden change in behavior need to be assessed for exposure to a traumatic event. When the change in behavior is traced to a traumatic event, treatment should be implemented immediately to prevent or reduce the long-term emotional and psychological effects of PTSD (Gerson and Rapport, 2013).
School Phobia Children, other than beginning students, who resist going to school or who demonstrate extreme reluctance to attend school for a sustained period as a result of severe anxiety or fear of school- related experiences are said to have school phobia. The terms school refusal and school avoidance are also used to describe this behavior. School phobia occurs in children of all ages, but it is more common in children 10 years old and older. School avoidance behaviors occur in both boys and girls and in children from all socioeconomic levels.
Anxiety that verges on panic is a constant manifestation, and children can develop symptoms as a protective mechanism to keep them from facing the situation that distresses them. Physical symptoms are prominent and may affect any part of the body; anorexia, nausea, vomiting, diarrhea,
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dizziness, headache, leg pains, or abdominal pains are most common. Children may even develop a low-grade fever. A striking feature of school phobia is the prompt subsiding of symptoms when it is evident that the child can remain at home. Another significant observation is absence of symptoms on weekends and holidays unless they are related to other places, such as Sunday school or parties. Occasional mild reluctance to attend school is common among schoolchildren, but if the fear continues for longer than a few days, it must be considered a serious problem.
The onset is usually sudden and precipitated by a school-related incident. By taking a careful history, nurses find out whether a poor attendance record is caused by trivial reasons.
Nursing Care Management Treatment for school phobia depends on the cause. The primary goal is school attendance. The longer a child is permitted to stay out of school, the more difficult it is for the child to reenter. Parents must be convinced gently but firmly that immediate return is essential and that it is their responsibility to insist on school attendance.
A school reentry protocol may be necessary for the child with severe symptoms. In reentry programs, the child role-plays routines involved in getting ready for school and that occur at school. Relaxation techniques are also used. The child usually goes to school initially for a half day and then progresses to a full day. Often the school nurse can provide support to the parents and the teacher during the reentry process. If the problem persists, professional help is recommended.
Conversion Reaction Conversion reaction, also known as hysteria, hysterical conversion reaction, and childhood hysteria, is a psychophysiological disorder with a sudden onset that can usually be traced to a precipitating environmental event. The disorder is observed with equal frequency in both sexes in childhood, but affected girls outnumber affected boys during adolescence. The manifestations involve primarily the voluntary musculature and special senses and include abdominal pain, fainting, pseudoseizures, paralysis, headaches, and visual field restriction. Once considered rare in childhood, the disorder occurs more frequently than has generally been acknowledged. The most commonly observed symptom is seizure activity, which can be differentiated from symptoms of neurogenic origin by formal tests, the most useful of which is the finding of a normal electroencephalogram.
Many children with conversion reaction have experienced a major family crisis before the onset of symptoms, such as loss of a parent or other significant person through death, divorce, or moving. The families of children with conversion reaction characteristically display problems in communication and depression or hypochondriasis in a parent.
Educating the child and family regarding the cause of emotional stresses or feelings and alternative approaches to coping with stress may alleviate the child's symptoms. If deep personality problems are evident, psychiatric consultation is indicated. Nursing care is similar to that for the child with recurrent abdominal pain (see also Chapter 22).
Childhood Depression Depression in childhood is often difficult to detect because children may be unable to express their feelings and tend to act out their problems and concerns rather than identify them verbally. Adult caregivers, health care professionals, and educators may not recognize early warning signs of depression in children or may delay referral and treatment, believing symptoms of depression are “just a stage of development” and will resolve with maturation. Authorities agree that childhood depression exists, but the manifestations often differ from those in depressed adults. Depressed children often exhibit a distinctive style of thinking characterized by low self-esteem, hopelessness, poor social engagement with peers, and a tendency to explain negative events in terms of personal shortcomings (Box 16-1).
Box 16-1 C h a r a c t e r i s t i c s o f C h i l d r e n w i t h D e p r e s s i o n Behavior
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Predominantly sad facial expression with absence or diminished range of affective response
Solitary play or work; tendency to be alone; disinterest in play
Withdrawal from previously enjoyed activities and relationships
Lowered grades in school; lack of interest in doing homework or achieving in school
Diminished motor activity; tiredness
Tearfulness or crying
Dependent and clinging or aggressive and disruptive behavior
Internal States
Utterance of statements reflecting lowered self-esteem, sense of hopelessness, or guilt
Suicidal ideations
Physiological Manifestations
Constipation
Nonspecific complaints of not feeling well
Change in appetite resulting in weight loss or gain
Alterations in sleeping pattern, sleeplessness, or hypersomnia
Some states of depression are temporary, such as acute depression precipitated by a traumatic event. The causative event might include a period of hospitalization; loss of a parent through death or divorce; or loss of a significant relationship with something (a pet), someone (a friend or family member), or a place (move from a familiar home, neighborhood, or city). The easily identified manifestations include a sad face; tearfulness; irritability; and withdrawal from previously enjoyed activities and relationships. The child tends to spend more time in solitary activities and schoolwork is impaired. Sleeplessness or hypersomnia, changes in appetite or weight (either increased or decreased), constipation, tiredness, and nonspecific complaints of not feeling well are common reactions.
More serious and less common are depressive responses to more chronic stress and loss. These are frequently observed in children with chronic illness or disability. The manifestations are similar to those seen in acute reactions. Major depressive disorders in childhood have a number of similarities with several other psychological disorders.
Therapeutic Management Depressed children are managed by a health team that is specially trained in the care of children with mental disorders. Treatment is highly individualized and undertaken in the least restrictive environment. Suicidal children are admitted to the hospital for protection if the family is unable to provide constant monitoring. Hospitalization may also be advised for children with associated disruptive behavior, such as fighting with peers or family. Most therapeutic regimens focus on various combinations of counseling, psychotherapy, family therapy, cognitive therapy, education (teaching social and life skills that facilitate coping), environmental improvement, and pharmacotherapy.
Pharmacotherapy may involve tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), paroxetine (Paxil), bupropion (Wellbutrin), or venlafaxine (Effexor). There have been reports that antidepressant medications may cause increased suicidal thinking and behaviors in pediatric patients. This prompted the US Food and Drug Administration to require black box drug labeling detailing potential suicide-related risks for pediatric patients.
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Nursing Care Management Nurses should be aware that depression is a problem that can be easily overlooked in children and one that can interrupt normal growth and development. Recognizing depression and making appropriate referrals are important nursing functions. Identification of a depressed child requires a careful history (health, growth and development, social and family health); interviews with the child; and observations by the nurse, parents, and teachers. If antidepressants are prescribed, the child and family need to know that antidepressants must be at a therapeutic level for 2 to 4 weeks to achieve a beneficial effect. The child and family also need to monitor the child for side effects of the specific drug prescribed and any interactions with other drugs.
Childhood Schizophrenia Childhood schizophrenia refers to severe deviations in ego functioning and is generally reserved for psychotic disorders that appear in children younger than 15 years old. Childhood schizophrenia is a very rare illness among children in the general population; only about 2 in every 1000 with mental illness have childhood schizophrenia.
Childhood schizophrenia is characterized by symptoms that last at least 6 months and that seriously interfere with the child's functioning in school, at home, or in other social situations. The basic core disturbance is a lack of contact with reality and the subsequent development by the child of a world of his or her own. The most common manifestations are language disturbances, impaired interpersonal relationships, and inappropriate affect (outward expression of emotion). Treatment involves management of symptoms, prevention of relapse, and social and occupational rehabilitation of the young person. Antipsychotic drugs that may be used include haloperidol, clozapine, chlorpromazine, and risperidone. Family interventions and family therapy often result in improvements in psychotic symptoms, thought disorders, and social functioning among children with schizophrenia.
Nursing Care Management Nursing of psychotic children is a highly specialized area. However, nurses should be alert to the possibility that schizophrenia can occur in children and refer children who consistently demonstrate abnormal behavior for evaluation. In addition, nurses need to teach family members of children taking antipsychotic drugs to observe for possible side effects. Common side effects of these drugs include dizziness; drowsiness; tachycardia; hypotension; and extrapyramidal effects, such as abnormal movements and seizures.
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Health Problems of Adolescents Acne Acne vulgaris is the most common skin problem treated by physicians during adolescence. Acne stimulates the sebaceous glands of the skin to enlarge, or produce oil, and plug the pores. Comedogenesis (formation of comedones) results in a noninflammatory lesion that may be either an open comedone (“blackhead”) or a closed comedone (“whitehead”).
More than half of the adolescent population will experience acne by the end of the teenage years. Although the disorder can appear before 10 years old, the peak incidence occurs in middle to late adolescence (16 to 17 years old in girls and 17 to 18 years old in boys). It is more common in boys than in girls. After this age period, the disease usually decreases in severity, but it may persist into adulthood. Although the disease is self-limiting and is not life threatening, it has great significance to affected adolescents. Health professionals should not underestimate the impact that acne has on teens.
Numerous factors affect the development and course of acne. Its distribution in families and a high degree of concordance in identical twins suggest hereditary factors. Premenstrual flare-ups of acne occur in nearly 70% of adolescent girls, suggesting a hormonal cause. Studies do not indicate a clear association between stress and acne, but adolescents commonly cite stress as a cause for acne outbreaks. Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butyl stearate, and oleic acid can increase comedone production. Exposure to oils in cooking grease can be a precursor in adolescents working in fast-food restaurants. The link between dietary intake and the development or worsening of acne lesions has been a topic of much discussion. There is evidence that there may be an association with the intake of dairy products and high glycemic index foods that may potentiate hormonal and inflammatory factors that contribute to acne severity (Burris, Rietkerk, and Woolf, 2013; Mahmood and Bowe, 2014).
Pathophysiology Four pathophysiologic factors have the greatest influence on acne development: excessive sebum production, alterations in follicular growth and differentiation with colonization of Propionibacterium acnes, and an accompanying immune response and inflammation (Eichenfield, Krakowski, Piggott, et al, 2013). Acne severity is proportional to the sebum secretion rate, which is genetically determined and increases at the time of adrenocortical maturation. Inflammation occurs with the proliferation of Propionibacterium acnes, which draws in neutrophils, causing inflammatory papules, pustules, nodules, and cysts (Fig. 16-1). Acne can be categorized as comedonal, inflammatory, or both and can be classified as mild, moderate, or severe based on the number and type of comedones and the extent of affected skin (Eichenfield, Krakowski, Piggott, et al, 2013).
FIG 16-1 Acne vulgaris. A, Acne vulgaris. B, Comedones with a few inflammatory pustules. (From Zitelli BJ, McIntire SC, Nowalk AJ: Zitelli and Davis' atlas of pediatric physical diagnosis, ed 6, St Louis, 2012, Saunders/Elsevier.)
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Therapeutic Management Successful management of acne depends on a cooperative effort between the care provider, adolescent, and parents. Unlike many dermatologic conditions, acne lesions resolve slowly, and improvement may not be apparent for at least 6 weeks. Individual comedones can take several weeks to months to resolve, and papules and pustules usually resolve in about 1 week. The multifactorial causes of acne require a combined approach for successful treatment. Treatment consists of general measures of care and specific treatments determined by the type of lesions involved.
General measures. The practitioner provides the adolescent with an overall explanation of the disease process, emphasizing the patient's involvement. Improvement of the adolescent's overall health status is part of the general management. Adequate rest, moderate exercise, a well-balanced diet, reduction of emotional stress, and elimination of any foci of infection are all part of general health promotion.
Cleansing. Acne is not caused by dirt or oil on the surface of the skin. Gentle cleansing with a mild cleanser once or twice daily is usually sufficient. Antibacterial soaps are ineffective and may be drying when used in combination with topical acne medications. For some adolescents, hygiene of the hair and scalp appears to be related to the clinical activity of acne. Acne on the forehead may improve with brushing the hair away from the forehead and more frequent shampooing.
Medications. Treatment success depends on commitment from the adolescent. Before prescribing treatment, the practitioner should determine the adolescent's level of comfort and readiness to begin treatment. The adolescent should be reminded that clinical improvement may take weeks to months. Early intervention, most often with topical medications, may prevent the development of more severe acne.
Tretinoin (Retin-A) is the only drug that effectively interrupts the abnormal follicular keratinization that produces microcomedones, the invisible precursors of the visible comedones. Tretinoin alone is usually sufficient for management of comedonal acne (Kim and Armstrong, 2011). Tretinoin is available as a cream, gel, or liquid. This drug can be extremely irritating to the skin and requires careful patient education for optimal usage. The patient should be instructed to begin with a pea-sized dot of medication, which is divided into the three main areas of the face and then gently rubbed into each area. The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The avoidance of the sun and the daily use of sunscreen must be emphasized because sun exposure can result in severe sunburn. Adolescents should be advised to apply the medication at night and to use a sunscreen with a sun protection factor (SPF) of at least 15 in the daytime.
Topical benzoyl peroxide is an antibacterial agent that inhibits the growth of P. acnes. Benzoyl peroxide is effective against both inflammatory and noninflammatory acne and is an effective first- line agent. This medication is available as a cream, lotion, gel, or wash. Benzoyl peroxide and salicylic acid are the most effective acne treatment kits available over the counter. The patient should be informed that the medication may have a bleaching effect on sheets, bedclothes, and towels. The adolescent can be reassured that skin bleaching will not occur. Accommodation to the medication can be gained with a gradual increase in the strength and frequency of application.
When inflammatory lesions accompany the comedones, a topical antibacterial agent may be prescribed. These agents are used to prevent new lesions and to treat preexisting acne. Clindamycin, erythromycin-metronidazole, and azelaic acid are currently available topical antibacterial therapy. Side effects of these medications include erythema, dryness, and burning; using the medications every other day will decrease the adverse effects. Topical antimicrobials combined with benzoyl peroxide are more effective than either product alone. Retinoids in combination with antimicrobials also improve the penetration of these topical agents and are the only means to address three of the pathogenic causes of acne: keratinization, P. acnes, and inflammation. Systemic antibiotic therapy is initiated when moderate to severe acne does not respond to topical treatments. The foundation for using systemic antibiotics in acne treatment has been the elimination of the inflammatory effects of P. acnes by suppressing the bacteria.
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Tetracycline, erythromycin, minocycline, and doxycycline are systematic antibiotics used to treat acne (Eichenfield, Krakowski, Piggott, et al, 2013). They are relatively free of side effects, with the exception of occasional gastrointestinal upset, photosensitivity, or vaginal candidiasis.
Adolescent girls with mild to moderate acne may respond to topical treatment and the addition of an oral contraceptive pill (OCP). OCPs reduce the endogenous androgen production and decrease the bioavailability of the woman's circulating androgens. Combination OCPs containing levonorgestrel, norethindrone, norgestimate, drospirenone, or dienogest decrease acne in women (Arowojolu, Gallo, Lopez, et al, 2012).
Isotretinoin, 13-cis-retinoic acid (Accutane), is a potent and effective oral agent that is reserved for severe cystic acne that has not responded to other treatments. Isotretinoin is the only agent available that affects factors involved in the development of acne. However, treatment with isotretinoin should be managed only by a dermatologist. Adolescents with multiple, active, deep dermal or subcutaneous cystic and nodular acne lesions are treated for 20 weeks. Multiple side effects can occur, including dry skin and mucous membranes, nasal irritation, dry eyes, decreased night vision, photosensitivity, arthralgia, headaches, mood changes, aggressive or violent behaviors, depression, and suicidal ideation. Adolescents taking this drug should be monitored for depression and suicidal ideation (Misery, 2011). The drug should be given only at the recommended doses for no longer than the recommended duration. The most significant side effects of this drug are the teratogenic effects. Isotretinoin is absolutely contraindicated in pregnant women. Sexually active young women must use an effective contraceptive method during treatment and for 1 month after treatment. Patients receiving isotretinoin should also be monitored for elevated cholesterol and triglyceride levels. Significant elevation may require discontinuation of the medication.
A 5% dapsone gel has recently been approved for the treatment of inflammatory acne lesions and is reported to be effective when used in combination with a topical retinoid, such as adapalene or tazarotene (Eichenfield, Krakowski, Piggott, et al, 2013).
Nursing Care Management Because acne is so common and its appearance may seem so mild, the health care provider may underestimate the relative importance of the disease to the adolescent. The nurse should assess the individual adolescent's level of distress, current management, and perceived success of any regimen before initiating a referral. If adolescents do not perceive the acne to be a problem, they may lack motivation to follow the treatment plan.
The nurse can provide ongoing support for the adolescent when a treatment plan is initiated. The family is also encouraged to support the adolescent in his or her efforts. Discuss the use of medications and basic skin care information in detail with the adolescent. Written instructions to accompany the verbal discussion are helpful. Information to dispel myths regarding the use of abrasive cleansing products can prevent unnecessary costs and trauma to the skin. Adolescents also need education about the factors that aggravate acne and damage the skin, such as too vigorous scrubbing. Picking, squeezing, and manual expression with fingernails break down the ductal walls of lesions and cause the acne to worsen. Mechanical irritation, such as vinyl helmet straps that rub areas predisposed to acne, can also cause the development of lesions.
Health Conditions of the Male Reproductive System Many obvious anomalies, such as hypospadias, hydrocele, and cryptorchidism, are identified with corrective measures instituted during infancy or early childhood. Uncircumcised males may encounter problems related to a tight foreskin that cannot be retracted (phimosis) and are at a higher risk for infections, such as balanitis and prostatitis.
Adolescent boys are also self-conscious about their changing bodies and need preparation for a genital examination. The most successful approach is to assume a matter-of-fact attitude toward the examination, explain precisely what will take place, and maintain a continuous commentary about what is being done and the findings at each phase of the examination.
Varicocele A varicocele is characterized by elongation, dilation, and tortuosity of the veins of the spermatic cord superior to the testicle. The finding is rare in prepubertal children, but the incidence increases
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dramatically at the onset of puberty. A varicocele can be palpated as a wormlike mass situated above the testicle that decreases in size when the male is recumbent and becomes distended and tense when he is upright. Idiopathic varicocele is the most common treatable cause of male-related impaired infertility, especially if caught and treated early (Nork, Berger, Crain, et al, 2014). Varicocelectomy is indicated in adolescents when there is growth arrest of the affected testicle or when there is pain associated with the varicocele.
Epididymitis Epididymitis is an inflammatory reaction of the epididymis of the testicle primarily as a result of infection (such as Chlamydia trachomatis) but can also occur from a chemical irritant or a nonspecific cause, such as local trauma. Clinical presentation is slow and insidious with unilateral scrotal pain, redness, and swelling. Associated symptoms include urethral discharge, dysuria, fever, and pyuria. Treatment consists of analgesics, scrotal support, bed rest, and appropriate antibiotic therapy.
Testicular Torsion Torsion of the testicle is a condition in which the tunica vaginalis, which normally encases the testicle, fails to do so and the testis hangs free from its vascular structures. This condition can result in partial or complete venous occlusion with rotation around the vascular axis. In severe torsion, the organ can become swollen and painful; the scrotum becomes red, warm, and edematous and appears to be immobile or fixed as a result of spasm of the cremasteric fibers.
Testicular torsion occurs annually in 1 in every 4000 males younger than 25 years old, with a peak onset of 13 years old (Wampler and Llanes, 2010). Rapid growth and increasing vascularity of the testicles are thought to be precursors to torsion, accounting for the occurrence at puberty. Typically, the adolescent complains of pain that is severe and acute; nausea and vomiting may accompany the pain. Absence of the cremasteric reflex is a confirmation of testicular torsion (Gunther and Rubben, 2012). Emergency surgery is often necessary to preserve the testicle.
Gynecomastia Some degree of bilateral or unilateral breast enlargement occurs frequently in boys during puberty. Approximately half of adolescent boys have transient gynecomastia, usually lasting less than 1 year, which subsides spontaneously with achievement of male development. A careful assessment of the pubertal stage at the onset of gynecomastia; medication history, including anabolic steroids; and the exclusion of renal, liver, thyroid, and endocrine disorders or dysfunction allow the examiner to reassure the adolescent that the changes are pubertal gynecomastia and that no further assessment is indicated. Gynecomastia may also be drug induced; calcium channel blockers, cancer chemotherapeutic agents, histamine2-receptor antagonist, and oral ketoconazole medications have all been shown to cause the condition.
If gynecomastia persists or is extensive enough to cause embarrassment, plastic surgery is indicated for cosmetic and psychological considerations. Administration of testosterone has no effect on breast development or regression and may aggravate the condition.
Nursing Care Management Management usually consists of assurance to the adolescent and his parents that the situation is benign and temporary. However, all adolescents with gynecomastia should receive a careful medical evaluation to rule out pathologic causes. The adolescent may benefit from the knowledge that this condition occurs in more than 50% of all adolescent boys.
Health Conditions of the Female Reproductive System Amenorrhea Menarche, or the first menstrual period, occurs relatively late in female pubertal development. Although girls vary in the onset and rate of progression of pubertal development, the sequence and tempo should be the same. When an adolescent is seen with a complaint of absence of menses, a careful history of the timing of her pubertal development will help to determine if there is a need for further evaluation or if reassurance is all that is necessary.
Primary amenorrhea is an absence of secondary sex characteristics and no uterine bleeding by 13
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years old or absence of uterine bleeding with secondary sex characteristics by 16.5 years old (Lobo, 2012). Primary amenorrhea is also characterized when menarche has not occurred 5 years after thelarche (Klein and Poth, 2013). The cause of primary amenorrhea may be anatomic, hormonal, genetic, or idiopathic. A thorough patient and family history and physical examination provide clues to the etiology.
Secondary amenorrhea is defined as the absence of menses after menstruation was previously established for at least 6 months in a woman with regular menstrual cycles or at least 12 months in a woman with irregular menstrual cycles (Roberts-Wilson, Spencer, and Fantz, 2013). Irregular menstrual cycles are common within the first year after menarche, because these early cycles may be anovulatory, resulting in regular, irregular, or absent bleeding. Girls with a later onset of menarche take longer to establish regular ovulatory cycles.
Pregnancy is the most common cause of secondary amenorrhea and should be ruled out in both types of amenorrhea even if the adolescent denies sexual activity. Other factors that disturb the hypothalamic–pituitary–gonadal axis and cause amenorrhea include physical or emotional stress; hyperthyroidism or hypothyroidism; polycystic ovary syndrome; sudden and severe weight loss; strenuous exercise; eating disorders; and use of extrinsic pharmacologic agents, especially phenothiazines, contraceptive steroids, and heroin.
Nursing Care Management When amenorrhea is caused by hypothalamic disturbances, the nurse is an ideal health professional to assist the adolescent because many causes are potentially reversible (e.g., stress, weight loss for nonorganic reasons). Counseling and education are primary interventions and appropriate nursing roles.
Dysmenorrhea Dysmenorrhea, pain during or shortly before menstruation, is one of the most common gynecologic problems in women of all ages. Approximately 75% of women report some level of discomfort associated with menses, and approximately 15% report severe dysmenorrhea that interferes with work or school (Lentz, 2012). Dysmenorrhea is associated with menarche prior to 12 years old, nulliparity, heavy menses, pelvic inflammatory disease (PID), body mass index (BMI) greater than 20, smoking, and depression (Roberts, Hodgkiss, DiBenedetto, et al, 2012). Symptoms usually begin with menstruation, although some women may have discomfort several hours before onset of flow. The range and severity of symptoms are different from woman to woman and from cycle to cycle in the same woman. Symptoms of dysmenorrhea may last several hours to several days. Pain is usually located in the suprapubic area or lower abdomen. Women describe the pain as sharp, cramping, or a steady, dull ache.
Dysmenorrhea is differentiated as primary or secondary. Primary dysmenorrhea is a condition associated with ovulatory cycles. Primary dysmenorrhea has a biochemical basis and arises from the release of prostaglandins with menses. The pain begins with the onset of menstruation and lasts 8 to 48 hours (Lentz, 2012). Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established.
Secondary dysmenorrhea is defined as painful menses associated with a pathologic condition, such as adenomyosis, endometriosis, PID, endometrial polyps, or fibroids. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrhea is often characterized by dull, lower abdominal aching that radiates to the back or thighs, and is often associated with feelings of bloating or pelvic fullness. In addition to a history and physical examination, diagnosis may be assisted by ultrasound examination, dilation and curettage (D&C), endometrial biopsy, or laparoscopy.
Therapeutic Management Management of dysmenorrhea depends on the severity of the problem and the individual woman's response to various treatments. Heat and exercise minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia. Massaging the lower back can reduce pain by relaxing paravertebral muscles and increasing the pelvic blood supply. Soft, rhythmic rubbing of the abdomen (effleurage) is useful because it provides a distraction and alternative focal point. Biofeedback, transcutaneous electrical nerve stimulation (TENS), progressive relaxation, Hatha yoga, acupuncture, and meditation are also used to decrease menstrual discomfort although
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evidence is insufficient to determine their effectiveness (Lentz, 2012). First-line medication treatment for adolescents with dysmenorrhea is the administration of
nonsteroidal antiinflammatory drugs (NSAIDs), which block the formation of prostaglandins. Girls should be instructed to begin the medication either at the first sign of symptoms or bleeding or 1 to 2 days before the onset of their menses, and then take on a regular schedule for 2 to 3 days (Roberts, Hodgkiss, DiBenedetto, et al, 2012). The medications should be taken with food. If an NSAID such as ibuprofen is not effective, another NSAID should be tried because some women receive relief from different NSAIDs.
OCPs are also effective and a reasonable choice for women who want to use a contraceptive agent. OCPs are effective in relieving symptoms of primary dysmenorrhea for approximately 90% of women, but no single OCP has been shown to be superior to another (Lentz, 2012). However, OCPs may be contraindicated for some women.
Nursing Care Management All adolescent girls need reassurance that menstruation is a normal function. When nurses are asked for advice regarding menstrual problems, they have a valuable opportunity to engage in health teaching concerning menstrual physiology; hygiene; and the importance of a well-balanced diet, exercise, and general health maintenance. Health teaching can dispel myths about menstruation and femininity.
A careful history indicates a potential problem and the need for evaluation, referral to an appropriate practitioner, health service, or clinic. The history should include the onset of symptoms; the duration, type of pain, and relationship to menstrual flow; the age at menarche; family history of dysmenorrhea; and sexual history. The nurse should also ask about previous treatments, including dosages of medications. Depending on the results of the history, the physical examination may include a gynecologic examination.
If a gynecologic examination is necessary, the nurse can play a supportive role for the adolescent girl. Whether it is her first experience or not, she is often filled with apprehension. Almost all adolescents are extremely self-conscious about their bodies and the changes taking place. They need continuing support in the form of anticipatory guidance regarding what to expect and suggestions of what to do to relax during the procedure. Most girls favor a semi-sitting position, which has the additional advantage of allowing eye contact during the procedure. Sometimes a pillow helps the patient feel more comfortable and less vulnerable. The provision of a mirror for the girl to see what is taking place if she so desires helps the examiner explain various aspects of anatomy. When possible, it is important to respect the adolescent's request for a female provider and to have her mother or other supportive person present if she desires.
Premenstrual Syndrome Approximately 30% to 80% of women experience mood and/or somatic symptoms that occur with their menstrual cycles (Lentz, 2012). Premenstrual syndrome (PMS) is a poorly understood condition that includes one or more of a large number of physical and psychological symptoms beginning in the luteal phase of the menstrual cycle that occurs to such a degree that lifestyle or work is affected. Symptoms include fluid retention, behavioral or emotional changes, premenstrual cravings, headache, fatigue, and backache. All age groups are affected.
Premenstrual dysphoric disorder (PMDD) is a more severe variant of PMS. Approximately 3% to 8% of women are affected and experience marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed (Lentz, 2012).
Therapeutic Management There is little agreement on management. A careful, detailed history and daily log of symptoms and mood fluctuations spanning several cycles may give direction to a plan of management. Education is an important component of the management. Nurses advise women that self-help modalities often result in significant symptom improvement. Diet changes can provide symptom relief for some women. Nurses can suggest that women limit their consumption of refined sugar, salt, alcohol, and caffeinated beverages. Three small to moderate-size meals and three small snacks a day that are rich in complex carbohydrates and fiber have been reported to relieve symptoms (American College of Obstetricians and Gynecologists, 2011). Exercise may also provide symptom relief. Aerobic exercise increases beta-endorphin levels to offset symptoms of depression and
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elevate mood. Stress reduction techniques may also help with symptom management (Lentz, 2012). If these strategies do not provide significant symptom relief in 1 to 2 months, medication is often
added. Medications used in the treatment of PMS include diuretics, prostaglandin inhibitors (NSAIDs), progesterone, and OCPs; however, no single medication alleviates all PMS symptoms.
Vaginal Infections Vaginal discharge and itching of the vulva and vagina are among the most common reasons a woman seeks help from a health care provider. Women complain of vaginal discharge more than any other gynecologic symptoms; however, vaginal discharge resulting from an infection must be distinguished from normal secretions. Physiologic leukorrhea is a normal vaginal secretion occurring at ovulation and just before menses. It is clear to cloudy in appearance, nonirritating, and has a mild inoffensive odor. On the other hand, inflammatory leukorrhea is caused by physical (e.g., forgotten tampon), chemical (e.g., bubble baths, douching), or infectious (e.g., Candida fungi, Trichomonas protozoa parasites, bacteria) agents. It is a glutinous, gray-white discharge with an offensive odor. Diagnosis is confirmed with microscopic evaluation of vaginal secretions, vaginal culture, or rapid testing methods.
Treatment varies depending on the cause. Health teaching is important in the management of vaginal discharge. Adolescent girls need reassurance that increased vaginal mucus can occur at the time of ovulation, before menstruation, or with sexual excitement. Many teenage girls mistake these variations as signs of infection. Girls should be taught to wipe from front to back after toileting and to realize that vaginitis can result from irritation, foreign objects, and sexual activity. Nurses should stress the importance of an evaluation to determine the exact cause.
Health Conditions Related to Reproduction The prevalence of high school students in the United States ever having sexual intercourse has been decreasing, from 54.1% in 1991 to 46.8% in 2013 (Kann, Kinchen, Shanklin, et al, 2014). The same trend was noted among students having had sexual intercourse before 13 years old (10.2% in 1991 to 5.6% in 2013) and students having had sexual intercourse with four or more people (18.7% in 1991 to 15.0% in 2013) (Kann, Kinchen, Shanklin, et al, 2014). Many serious health consequences are associated with adolescent sexual activity, including unplanned pregnancy and sexually transmitted infections (STIs); additional health problems may arise from an increased number of sexual partners over time and incomplete education regarding sexual practices in adolescents. Health professionals must understand the issues related to adolescent sexual activity and the psychosocial dynamics that influence them.
Adolescent Pregnancy Over the last several decades, the teenage pregnancy rate in the United States has shown a continual downward trend; however, adolescent pregnancy rates in the United States continue to rank higher than other developed nations. The 2013 teen birth rate was 26.5 per 1000 females 15 to 19 years old (Martin, Hamilton, Osterman, et al, 2015). The decline is attributed to increased condom and contraception use, as well as a delay in the initiation of sexual activity for adolescents. However, the less familiar an adolescent is with his or her partner, the less likely it is that they will use contraception during intercourse. Discontinuation of contraception is common; 30% of women age 15 to 19 years old and 47% of women age 20 to 24 years old have discontinued at least one method because of dissatisfaction (Pazol, Whiteman, Folger, et al, 2015). Teens who postpone the initiation of sexual intercourse decrease their risk for STIs, including human immunodeficiency virus (HIV).
In most cases, with early prenatal care, teenage pregnancy is no longer considered to be biologically disadvantageous to the child. However, teenage parenting is still regarded as socially, educationally, psychologically, and economically disadvantageous to both mother and child. Predictors of maternal success include participation in a program for pregnant teens, a social support system, and a sense of control over one's life. With better facilities available for care, the mortality associated with teenage pregnancies is decreasing, but morbidity remains high. Teenage girls and their unborn infants are at greater risk for complications of both pregnancy and delivery. Medical concerns of the adolescent include poor maternal weight gain, anemia, and pregnancy- induced hypertension (Pinzon, Jones, Committee on Adolescence, et al, 2012). Labor is often
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prolonged in younger teenagers, particularly those 12 to 16 years old, because of a fetopelvic incompatibility and the teenager's smaller stature and incomplete growth process. Delivery concerns include premature labor, and low-birth-weight infants. Information should be provided regarding the pregnant adolescent's nutritional status and health care needs related to the unborn fetus' condition. Because adolescent nutrition habits may vary, it is important to stress that the mother's overall health status will ultimately influence that of her newborn. Myths such as “you can now eat for two” must be addressed. The diet must provide sufficient nutrients to meet growth needs of both the prospective mother and the unborn child without the threat of excessive weight gain or fetal malnutrition.
Nursing Care Management A pregnant teenager needs careful assessment by the nurse to determine the level of social support available to her and her partner. The adolescent needs to make many important decisions and may not have the life experience to know how to cope with this stress. Whenever possible, guidance from the adults in her life will be invaluable. Information about options to continue the pregnancy and parent the child, continue the pregnancy with adoption, or terminate the pregnancy with abortion should be given in a nonjudgmental manner. If the adolescent chooses to continue the pregnancy, prenatal care should be initiated as soon as possible.
Basic to the implementation of any care program is communication and the establishment of a trusting relationship. Initially the adolescent may appear apathetic and display little interest in discussing her pregnancy. The nurse must make every effort to put the adolescent at ease and avoid undue pressure. Conveying a nonjudgmental and genuine caring acceptance of the adolescent and her goals will assist the nurse in gaining the adolescent's confidence and trust.
Communication takes time and patience. Asking open-ended questions and listening for cues will help identify physical, emotional, social, and cultural influences that might affect the adolescent's progress through the maternity cycle.
The adolescent needs to know what is happening to her, what is expected of her, and how she can help in developing a care plan. Adolescents have their own ideas about the type of help and support they need. Nurses should consult with them and provide them an opportunity to share their ideas.
N u r s i n g A l e r t All pregnant women should take a vitamin and mineral supplement to ensure the recommended dietary allowance for folic acid (0.4 mg [400 mcg] daily) to help prevent neural tube defects (see Meningomyelocele Prevention, Chapter 30). Initiation before pregnancy has been shown to have the most benefit. Consider a multivitamin for all sexually active women.
Contraception Family planning services have developed and expanded during recent years, but the need for contraceptive services as part of the health care of adolescents remains great. The birth control pill and condom remain the most popular methods for adolescents; 3-month injectable contraception is more popular among lower-income adolescents. Adolescents commonly delay seeking contraceptive information. The typical interval from onset of sexual intercourse until the first visit for contraception is 1 year. A pregnancy scare is usually the precipitating event for the contraception appointment. Counseling about contraceptive options should be conducted in a manner that is consistent with the cognitive level of the adolescent. The adolescent should be given accurate information about the risks and benefits of each method before making a choice.
Many teenagers feel ambivalent regarding their sexual activity and avoid many contraceptives because their use seems too premeditated and implies that sex is planned rather than a spontaneous activity. Most of these girls believe that sex is all right if it is not planned. This may often play a role in adolescents delaying contraception, waiting for a relationship that is “close enough.” A close relationship would allow adolescents to accept and acknowledge their sexual activity.
The choice of a safe and effective contraceptive method must be suited to the individual (Table 16-1). The choice is based on preference after the adolescent is informed of the benefits and disadvantages. Motivation is necessary for most methods. For example, the pill is effective if used correctly, but the adolescent must remember to take the pill at approximately the same time every
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day. For many young women, a medroxyprogesterone injection (Depo-Provera) is an ideal choice because it is extremely effective and is administered every 12 weeks, but side effects such as weight gain and decreased bone mineralization may make it undesirable. Sexually active adolescents need to know that contraceptive devices other than condoms do not prevent STIs. Condom use is still important and must be discussed with all sexually and non–sexually active adolescents.
TABLE 16-1 Advantages and Disadvantages of Contraceptive Methods in Adolescents
Method Advantages Disadvantages Behavioral Methods Abstinence 100% effective in preventing STIs and
pregnancy Peer pressure to conform Relatively high failure rate from noncompliance
Withdrawal (coitus interruptus) Withdrawal of penis before ejaculation
No medical visit necessary High failure rate Some seminal fluid often released before ejaculation Ejaculate at vaginal orifice may enter vagina No STI protection
Calendar method Refrain from intercourse during fertile period (time of ovulation)
Teaches adolescent girls about their menstrual cycle
Encourages couple participation
High failure rate Requires a regular, predictable menstrual cycle (irregular menses are
common for first 2 years after menarche) No STI protection
Barrier Methods Condom Minimal side effects
Easy to use Available without prescription Portable Provides protection against STIs
Requires consistent use Requires premeditated intent for sexual union May decrease sensation Misuse results in failure Decreased spontaneity
Male: Penile covering to trap sperm Spermicidal condoms increase effectiveness for pregnancy and STI prevention
Inexpensive compared with female condom
Latex sensitivity or allergies in a small percentage of people Improper use may lead to pregnancy or development of STI
Female: Inserted into vagina with base covering part of perineum; may be inserted 8 hours before intercourse
Female participation Made of polyurethane; no latex
sensitivities and can be used with oil-based lubricants
Provides protection from STIs
May be difficult to insert Noisy
Diaphragm Cervical covering to prevent sperm from reaching egg Must be used in conjunction with spermicidal jelly May be inserted 4 to 6 hours before intercourse If inserted early, should be checked for placement before coitus
Can be fitted in virgins Low failure rate when used correctly Few contraindications May be reused
High failure rate in adolescents because of inconvenience of use Requires consistent use Requires fitting and instruction by medical personnel Requires premeditated intent for sexual union Requires body awareness and comfort with touching oneself for
insertion Minimal STI protection May increase incidence of urinary tract infection
Lea's shield Reusable vaginal contraceptive made of silicone; elliptical bowl placed in
vagina up to 48 hours before sexual intercourse; removed 8 hours after intercourse
Non latex (silicone) Reusable Very effective in nulliparous women Simple fitting
Less effective in women who have delivered a baby Requires prescription No STI protection More effective if spermicidal cream is used May increase incidence of urinary tract infection
Cervical cap Soft rubber dome with a firm but pliable rim; fits over base of the cervix
close to the junction of the cervix and vaginal fornices
May be inserted hours before intercourse
Insertion and removal similar to diaphragm
Available in only four sizes Must remain in place at least 6 hours after intercourse but no longer
than 48 hours Not recommended for women with abnormal Papanicolaou test
result, history of toxic shock syndrome, or difficulty with proper fitting
No STI protection Chemicals Spermicidal foam, jelly, cream, and suppositories Substance inserted into vagina to kill sperm
Available without prescription Inexpensive Easy to use No major health concerns
High failure rate unless combined with condom Possible for sperm to be ejaculated directly into uterine os, bypassing
spermicide in vagina Must be used shortly before coitus; therefore requires interruption of
sexual experience Repeated sexual union requires repeated application Requires premeditated intent for sexual union Messy Nonoxynol-9 associated with increased transmission of HIV to
women; should not be used with anal sex in male partner sex for same reason
No STI protection Hormonal Methods Oral contraceptives Estrogen and progesterone-like compounds Inhibit ovulation by blocking release of gonadotropins from anterior
pituitary gland
99% effective if used correctly Safe for adolescents Method of choice for most
adolescents Administered by mouth Becomes a ritual not associated with
sexual activity Regulates menses, decreases
dysmenorrhea and acne, decreases menstrual flow
Prevents ovarian and endometrial cancers
Prevents functional ovarian cysts
Higher failure rate in adolescents than in older women Need to follow precise instructions; requires continued motivation,
consistent use Requires prescription Price substantial for teenager No STI protection Possible side effects include headaches, missed or scanty periods,
breakthrough bleeding, blood clot Increased rates of chlamydia
Medroxyprogesterone acetate (Depo-Provera) Progestin that suppresses hormonal cycle and prevents ovulation Injection given every 3 months
No interruption of intercourse Invisible method
No STI protection Possible side effects include significant weight gain, decreased bone
density, decreased HDLs, irregular menses or amenorrhea, decreased libido, depression
Fertility perhaps delayed after discontinuation Must return to care provider every 3 months for injection US Food and Drug Administration recommends discontinuation after
2 years because of decreased bone density Ortho Evra transdermal system 4.5-cm square patch with norelgestromin and ethinyl estradiol Hormonal patch applied to skin weekly for 3 weeks per month Suppresses ovulation, thickens cervical mucus, and thins endometrium
88.2% effective in perfect users Simple to use Regular menstrual cycles Not associated with sexual activity Avoids first-pass metabolism,
resulting in more constant levels
Not recommended for women >90 kg (198 pounds) Possible side effects include skin reaction at site, nausea, headache,
dysmenorrhea, and breast tenderness Slight increase in risk of blood clot formation over combination OCP Patch may be visible No STI protection
NuvaRing Etonogestrel plus ethinyl estradiol Soft flexible transparent ring placed in vagina for 3 weeks Suppresses ovulation
99.3% effective Immediate return to ovulation at
discontinuation May leave in place during sexual
intercourse Avoids first-pass metabolism,
Device may be felt by female or partner during sexual intercourse Device may fall out Possible side effects include headache, vaginitis, leukorrhea, nausea,
and breakthrough bleeding May have late withdrawal bleeding requiring placement of ring
during menses
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resulting in more constant levels No spermicide needed No vaginal erosion No weight gain
No STI protection
Levonorgestrel intrauterine system (Mirena) T-shape intrauterine device that releases 20 mcg/d of levonorgestrel Inserted within 7 days of menses and remains in place for 5 years Thickens cervical mucus and inhibits sperm mobility and function
>99% effective Effectively prevents fertilization,
resulting in low rates of ectopic pregnancy
Reduced length and quantity of menstrual bleeding
Reduced dysmenorrhea No weight gain
Risk of perforation at time of insertion 2% to 12% expulsion rate Not recommended in nulliparous women or women not in
monogamous relationships Possible side effects include abdominal pain, headache, vaginal
discharge, and breast pain No STI protection
Etonogestrel implant (Implanon) 40 × 2 mm implanted rod Progestin-only method Suppresses ovulation
>99% effective Efficacy not user dependent Provides 3 years of protection Single rod insertion and removal Palpable but not visible after
insertion
Irregular menstrual bleeding Other less common side effects include headache, vaginitis, weight
gain (average 1.7 kg [3.7 pounds] at 2 years) No STI protection
Emergency or Postcoital Contraception Emergency contraception works in one of three ways: by suppressing or
delaying ovulation, by preventing the meeting of sperm and egg, or by preventing implantation
Progestin-only pill given within 72 hours of intercourse or Insertion of a copper-releasing intrauterine device up to 7 days after
unprotected intercourse
Useful in unplanned sexual intercourse or contraceptive failure
May be given in advance for emergency use
Available without prescription for adults
No STI protection May cause nausea if combination method used May change timing of next menstrual cycle
HDL, High-density lipoprotein; HIV, human immunodeficiency virus; OCP, oral contraceptive pill; STI, sexually transmitted infection.
Confidentiality is a critical issue when discussing contraception with adolescents. Privacy is important to adolescents as they struggle to forge a personal identity and establish social relationships. Adolescents are particularly concerned about the judgments of others. The predominant belief among many health professionals is that parental notification is important but that the “parents' rights” view is not necessarily sensitive to the health needs and basic rights of youth. No evidence substantiates the belief that providing contraceptive guidance contributes to sexual irresponsibility and promiscuity.
Nursing Care Management Nurses are often involved in providing education about contraception. Such education is ideally combined with ongoing sex education. Although sexual abstinence is a highly desirable form of contraception for teenagers, nurses working with adolescents must recognize that teens feel multiple pressures to engage in sexual intercourse. Postponing sexual involvement requires effective communication and decision-making skills. Adolescents benefit from role-playing refusal skills and opportunities to practice making decisions in a safe environment. Information about safe sex must be provided, and role-playing how to discuss condom use with a partner is helpful to teenagers.
Education concerning contraception should be provided in both oral and written form. All available methods, including their benefits, disadvantages, and side effects, should be discussed. Concrete, concise language must be used, demonstrations of how to use the contraceptive should be provided, and adolescents should repeat all instructions in their own words. If teenagers are using OCPs, they should be encouraged to use a daily activity as a reminder or cue to take the pill. A knowledgeable phone triage person should be available for questions and concerns. Parents or other important adults may be included in all discussions, with the adolescent's permission. An organization that provides education and services for adolescents, including both individual and group counseling, is the Planned Parenthood Federation of America. It has branches in most cities in the United States.
Sexually Transmitted Infections STIs are infections or infectious disease syndromes transmitted primarily by sexual contact. The term sexually transmitted infection includes more than 25 infectious organisms that are transmitted through sexual activity. STIs are among the most common health problem in the United States today with an estimated 19 million people in the United States being infection with STIs every year (Mark, Jordan, Cruz, et al, 2012). Lack of awareness regarding one's susceptibility to STIs when engaged in unprotected sexual activity, be it oral, anal, or vaginal intercourse, is perhaps one of the greatest dangers adolescents face.
Preventing infection (primary prevention) is the most effective way of reducing the adverse consequences of STIs for adolescents. Prompt diagnosis and treatment of current infections (secondary prevention) can prevent personal complications and transmission to others. A critical step in preventing the spread of STIs is including questions about an adolescent's sexual history, sexual risk behaviors, and drug-related risky behaviors as part of every assessment. When the nurse
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identifies risk factors, there is an opportunity to provide prevention counseling. Prevention messages should include descriptions of specific actions to prevent contracting or transmitting STIs and should be individualized for each adolescent. To be motivated to take preventive actions, the adolescent must believe that acquiring a disease will be serious and that he or she is at risk for infection.
Sexually Transmitted Bacterial Infections C. trachomatis is the most frequently reported infectious disease in the United States, yet most cases are still undiagnosed (Torrone, Papp, Weinstock, et al, 2014). In women, chlamydial infections are difficult to diagnose; the symptoms are nonspecific and the organism is expensive to culture. These infections are highly destructive, causing PID, increased risk of ectopic pregnancy, and tubal factor infertility. Manifestations, treatment, and nursing considerations of C. trachomatis are listed in Table 16-2.
TABLE 16-2 Selected Sexually Transmitted Infections*
Manifestations Therapy Nursing Care Management Gonorrhea (Neisseria gonorrhoeae) Male: Urethritis (dysuria with profuse yellow discharge, frequency, urgency, nocturia) or
pharyngitis Female: Cervicitis (postpubertal); may be associated with discharge, dysuria, dyspareunia,
vulvovaginitis (prepubertal), or pharyngitis
For uncomplicated urogenital and anorectal gonorrhea:
Single intramuscular dose of ceftriaxone plus Single oral dose of azithromycin
Instruct patient to abstain from sexual intercourse for 7 days after single-dose treatment.
Test and treat for other STIs. Find and treat sexual contacts. Educate young people regarding facts of the
disease and its spread. Encourage use of condoms in sexually active
young people. Chlamydia (Chlamydia trachomatis) Male: Meatal erythema, tenderness, itching, dysuria, urethral discharge; or no symptoms Female: Mucopurulent cervical exudate with erythema, edema, congestion; or no symptoms
Single oral dose of azithromycin or 7 days of oral doxycycline administered
twice daily If pregnant—azithromycin
Same as above. Rescreen pregnant women 3 weeks after
treatment. Repeat infection elevates risk for PID.
Syphilis (Treponema pallidum) Primary stage: Chancre, a hard, painless, red, sharply defined lesion with indurated base,
raised border, eroded surface, and scanty yellow discharge; usually located on the penis, vulva, or cervix
Secondary stage: Systemic influenza-like symptoms; lymphadenopathy; rash; usually appears few weeks to months after healing of chancre
Single intramuscular dose of benzathine penicillin G
Instruct patients to use condoms to avoid spread or infection with other organisms.
Identify sexual contacts of infected person(s). Test women in pregnancy and prior to delivery
(VDRL and RPR). Evaluate newborn for presence of disease if
mother is untreated. Herpes Progenitalis (Genital Herpes Simplex Virus) Small (usually painful) vesicles on genital area, buttocks, and thighs; itching is usually the initial symptom; when vesicles break, shallow, circular, extremely painful lesions remain
No known cure Uncomplicated cases: Acyclovir,
famciclovir, or valacyclovir by mouth for 10 days
Complicated cases: Acyclovir intravenously
May need chronic suppressive therapy for recurrences
Instruct patients to use condoms to avoid spread or infection with other organisms.
Infection can be transmitted to infant during birth.
Evaluate maternal history and observe infant for signs or symptoms.
Cultures may be obtained in newborn.
Trichomoniasis (Trichomonas vaginalis) Pruritus and edema of external genitalia; foul-smelling, greenish vaginal discharge;
sometimes postcoital bleeding May be asymptomatic, especially in men
Single oral dose of metronidazole or tinidazole
Patient should not consume alcohol while taking medication and for at least 48 hours after the last dose.
Sexual partners should be treated. Human Papillomavirus Warts found on any part of male or female genitalia Patient applied:
Podofilox solution or gel (0.5%) or imiquimod (5%) cream or sinecatechins ointment (15%)
Provider applied: Podophyllin resin 10% to 25% in
compound tincture of benzoin Freezing with liquid nitrogen
(cryotherapy) Trichloroacetic acid or bichloracetic acid
80% to 90% Laser therapy or injectable interferon or
surgical removal
An acceptable alternative is to forgo treatment and await spontaneous resolution.
Treatments are usually painful; analgesics may be needed, and steroid cream may provide relief.
Vaccine available for prevention (see Chapter 6).
*Updated information on specific treatment of STIs may be accessed at http://www.cdc.gov/std/treatment. PID, Pelvic inflammatory disease; RPR, rapid plasma reagin; STI, sexually transmitted infection; VDRL, Venereal Disease Research Laboratory.
Gonorrhea is the oldest communicable disease in the United States with an estimated 300,000 American men and women contracting gonorrhea each year (Centers for Disease Control and Prevention, 2014b). Women are often asymptomatic, therefore the Centers for Disease Control and Prevention recommends screening all women at risk for gonorrhea including women with previous gonorrhea infection, other STIs, multiple sex partners with inconsistent condom use, and those engaged in commercial sex work and drug use (Centers for Disease Control and Prevention, 2014b). Manifestations, treatment, and nursing considerations of gonorrhea are listed in Table 16-2.
Syphilis is caused by Treponema pallidum, a motile spirochete. Transmission occurs by entry through microscopic abrasions in the subcutaneous tissue, kissing, biting, or oral-genital sex.
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Syphilis is a complex disease that can lead to serious systematic disease and even death when untreated. Manifestations, treatment, and nursing considerations of syphilis are listed in Table 16-2.
Sexually Transmitted Protozoa Infections Trichomonas vaginalis is a common cause of vaginal infections and is almost always transmitted as an STI. Trichomoniasis is caused by T. vaginalis, an anaerobic, one-celled protozoan with characteristic flagella. Manifestations, treatment, and nursing considerations of trichomoniasis are listed in Table 16-2.
Sexually Transmitted Viral Infections Human papillomavirus (HPV) infection is the most common viral STI seen in ambulatory health care settings. An estimated 20 million Americans are infected with HPV, and about 6.2 million new infections occur every year (Eaton, Kann, Kinchen, et al, 2012). HPV, a double-strand DNA virus, has more than 100 strains with 40 strains found in the genital area that can be sexually transmitted (Bellia-Weiss, Parsons, Sebach, et al, 2013). HPV can be classified as low or high risk with low risk types (HPV 6 and HPV 11) not linked to cancer and high risk types (HPV 16 and HPV 18) linked to 80% of anal squamous cell cancers, 70% of cervical cancers, and 50% of all penile cancers (Bellia- Weiss, Parsons, Sebach, et al, 2013).
Herpes simplex virus (HSV) is caused by two different antigen subtypes: HSV type 1 (HSV-1) and HSV type 2 (HSV-2). HSV-1 is commonly associated with gingivostomatitis and oral labial lesions (fever blisters), whereas HSV-2 is transmitted sexually and characterized with genital lesions. It is estimated that about 50 million people in the United States are infected with HSV-2 (Workowski, Berman, and Centers for Disease Control and Prevention, 2010). Adolescents and women between the ages of 15 and 34 years old are most likely to become infected, especially if they have multiple partners. Many people are unaware that they are infected and transmit the disease unknowingly.
Five different viruses (hepatitis viruses A, B, C, D, and E) account for almost all cases of viral hepatitis in humans. These are discussed in Chapter 22.
HIV is a bloodborne pathogen and transmission of the virus can occurs through the perinatal period, sexual intercourse with an infected person, or sharing needles with an infected person. HIV is discussed in Chapter 24.
Nursing Care Management Nursing responsibilities encompass all aspects of STI education, confidentiality, prevention, and treatment. Part of the sex education of young people should include providing information about STIs, including their symptoms and treatment, and dispelling the myths associated with their mode of transmission. Many vulnerable adolescents are uninformed or misinformed about STIs.
Primary prevention efforts for STIs include encouraging abstinence and postponing sexual involvement, encouraging condom use, and ensuring vaccination for hepatitis A and B and HPV. Nurses play a role in secondary prevention by helping to identify early cases and referring adolescents for treatment. Nurses can also be involved in tertiary prevention by decreasing the medical and psychological effects of STIs; conducting support groups for adolescents with HIV, HSV, and HPV infections; and assisting pregnant adolescents in obtaining adequate prenatal screening and treatment of STIs.
Pelvic Inflammatory Disease PID is an infectious process that most commonly involves the uterine tubes, uterus, and rarely the ovaries and peritoneal surfaces. Multiple organisms have been found to cause PID and common agents include Neisseria gonorrhoeae, C. trachomatis, and a variety of other aerobic and anaerobic bacteria. It is estimated that each year 800,000 women of reproductive age experience an episode of PID, with high cases occurring in adolescents (Trent, 2013). Women younger than 25 years old have a 1 in 8 chance of experiencing PID compared with those older than 25 years old, whose risk is 1 in 80 (Trent, 2013).
Women who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. Other problems associated with PID include dyspareunia, pyosalpinx, tubo-ovarian abscess, and pelvic adhesions.
Presenting symptoms in adolescents may be generalized, but pain is a common symptom in all
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infections. The pain can be dull, cramping, intermittent, persistent, and incapacitating. Women may also report fever, chills, abdominal pain, nausea and vomiting, increased vaginal discharge, urinary tract symptoms, and irregular bleeding. A pelvic examination is indicated for every sexually active woman who complains of lower abdominal pain to evaluate for the possibility of PID.
Prevention is the primary concern of health care professionals. Primary prevention includes education in avoiding contracting STIs; secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. Barrier contraceptive methods, such as condoms, are critical. Treatment for mild to moderately severe PID may be oral (e.g., ceftriaxone plus doxycycline with or without metronidazole) or parenteral (e.g., cefotetan or cefoxitin plus doxycycline [oral]), and regimens can be administered in inpatient or outpatient settings. Pregnant women should be hospitalized and given parenteral antibiotics. Women should be counseled to comply with therapy and complete all medication, even if symptoms have disappeared. Follow up after treatment should include endocervical cultures to test for cure.
Sexual Assault (Rape) Typically, stranger rape is what comes to mind when one thinks of sexual assault; however, more than half of assaults are committed by someone known to the survivor. Although both males and females can be sexually assaulted, females are at greatest risk. Adolescents are at high risk for sexual assault; other high-risk groups include survivors of childhood sexual or physical abuse; persons who are disabled; persons with substance abuse problems; sex workers; persons who are poor or homeless; and persons living in prisons, institutions, or areas of military conflict. Sexual assault remains underreported for multifactorial reasons.
An understanding of the legal definitions of sexual assault, rape, acquaintance rape, and statutory rape is essential for the nurse to identify, treat, and manage adolescent victims (Box 16-2).
Box 16-2 D e f i n i t i o n s o f S e x u a l A s s a u l t s Sexual assault: Comprehensive term that includes various types of forced or inappropriate sexual
activity. Sexual assault includes both physical and psychological coercion as well as touch, penetration, and other sexual contact.
Rape: Forced sexual intercourse that occurs by physical force or psychological coercion. Rape includes vaginal, anal, or oral penetration by body parts or inanimate objects.
Acquaintance rape (date rape): Applied to situations in which the assailant and victim know each other.
Statutory rape: Consensual sexual contact by a person 18 years old or older with a person under the age of consent or unable to consent because of developmental disability. Age of consent varies by state.
Statutory rape laws have been revised in many states across the country. The motivation for tougher laws and greater enforcement is to decrease teen pregnancy, increase male responsibility, and decrease welfare dependency. Traditionally, statutory rape laws have been concerned with the protection of girls. In the past 20 years, many laws have been rewritten to be gender neutral. Statutory rape laws require reporting to child protective services or local law enforcement. One risk of strict statutory rape enforcement is that girls may not seek health care for reproductive care, prenatal care, or domestic violence. Young people may fear not only for themselves but also for their partners. However, sexual coercion of teens by adults remains a problem and results in STIs and adolescent pregnancy.
In the United States, it is illegal for anyone to have sexual intercourse with a child ranging in age of 12 to 18 years old (Oudekerk, Guarnera, and Reppucci, 2014). These laws protect the health and safety of children incapable of protecting themselves. When consensuality is considered in statutory rape laws and cases, it implies that adolescents are morally and socially responsible for sexual contact that occurs with adults. This does not afford adolescents the same protections provided to
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children younger than 12 years old (Oudekerk, Guarnera, and Reppucci, 2014). Nurses can obtain information about their state statutory rape reporting responsibilities from
state or local child protective services agencies, legal counsel, rape crisis organizations, state or local law enforcement agencies, or the state nurses' association. The limits of confidentiality should be clearly reviewed with each adolescent patient before beginning the interview about sexual activity.
Diagnostic Evaluation Rape victims may exhibit a variety of reactions (Box 16-3), and the circumstances of the initial medical evaluation may be frightening and stressful. The initial contact with the rape victim must be supportive, because the interrogation and associated activities have the potential to add to the trauma of the sexual assault. First of all, the victim needs to know that she (or he) is (1) all right, and (2) not being blamed for the situation.
Box 16-3 C l i n i c a l M a n i f e s t a t i o n s o f R a p e Vi c t i m s May display a variety of emotions and behaviors, such as:
• Hysterical crying
• Giggling
• Agitation
• Feelings of degradation
• Anger and rage
• Helplessness
• Nervousness
• Rapid mood swings
• Appearing calm and controlled (masking inner turmoil)
• Confused
• Self-blame
• Fear—of the rape and of injury
Evidence of physical force from the following:
• Roughness
• Non-brutal beating (slapping)
• Brutal beating (slugging, kicking, beating repeatedly with fists)
• Choking or gagging
Medical examination provides evidence of:
• Penetration
• Ejaculation
• Use of force
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It is important to obtain a clear account of the circumstances of an alleged rape without forcing the victim to relive a painful experience. Information includes the date, time, location, and an accurate description of any type of sexual contact. The physical examination is carried out as soon as possible because physical evidence deteriorates rapidly. The victim should not bathe or shower before the examination.
N u r s i n g A l e r t It is common for rape victims to delay seeking help, especially in cases of acquaintance or date rape. Nurses can be most supportive by acknowledging the painful and sometimes confusing feelings that surround such experiences and by focusing on the fact that the victim is seeking assistance now.
The young person is always told in advance in understandable terms exactly what to expect in the way of tests and procedures and the explanation is accompanied by strong emotional support. The victim is examined thoroughly, including nongenital areas, for evidence of injury that might substantiate the use of force.
The forensic examination of a sexual assault victim must follow strict legal requirements. The medical record may provide key evidence for the legal case. Practitioners specially trained for rape examination should be used when possible. Nurses are often members of this group and are known as sexual assault nurse examiners (SANEs). Evaluation for STIs is an important part of the evaluation. The following procedures are recommended for the initial examination: nucleic acid amplified testing (NAAT) for chlamydia and gonorrhea; wet mount and culture or point-of-care testing of a vaginal swab specimen for trichomoniasis; and a serum sample for HIV infection, hepatitis B, and syphilis. Decisions to perform these tests should be made on an individual basis. Repeat testing for chlamydia and gonorrhea can be done at 2 weeks if prophylactic treatment was not administered. Serologic tests for syphilis and HIV infection can be repeated 6 weeks, 3 months, and 6 months after the assault if infection in the assailant could not be ruled out (Workowski, Berman, and Centers for Disease Control and Prevention, 2010).
Prophylactic treatment for chlamydia, gonorrhea, and trichomoniasis is recommended. Vaccination for hepatitis B should be administered if the patient has not been previously vaccinated. Follow-up doses of vaccine should be administered 1 to 2 and 4 to 6 months after the first dose. Female victims should be provided with emergency contraception. The recommendation for HIV prophylaxis varies depending on the geographic area, the circumstances of the assault, and the known HIV status of the perpetrator. The CDC (Workowski, Berman, and Centers for Disease Control and Prevention, 2010) maintains updates and recommendations for treatment of STIs incurred as a result of sexual assault.*
Therapeutic Management Adolescents who have been raped arrive at the emergency department or practitioner's office under a variety of circumstances. They are usually brought by parents, friends, or police officers, but some may seek medical help on their own. It is advisable to obtain parental consent for examination, but the examination may be performed without parental consent if the adolescent is mature and the parents are unavailable. A female observer or chaperone should be present during the history and examination of female victims who are examined by a male practitioner. Whether a parent should be present during the examination is determined on an individual basis. The parent's presence is usually encouraged if the parent is supportive and the young person agrees.
Nursing Care Management Many of the approaches that have been described for sexually abused children (see Chapter 13) also apply to adolescents. Sexual assault is a devastating experience with long-lasting effects. The primary goal of nursing care is to avoid inflicting further stress on the adolescent, who is often angry, confused, frightened, embarrassed, and filled with self-blame. The nurse must do everything possible to reduce the stress of the interrogation and examination. Although most health professionals and law enforcement officers are sensitive to the needs of adolescents and attempt to make the process as non-stressful as possible, the nurse should be alert to cues that indicate the victim is being overstressed.
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Follow-up care of the rape victim is essential and extends over a long period. The health- compromising responses to sexual assault include PTSD, anxiety, and depression. PTSD is the most common mental health sequelae of sexual violence with rates of 37% to 53% among children and adolescents (Cummings, Berkowitz, and Scribano, 2012). Aside from the universal need for emotional support, the needs of rape victims vary widely and depend on the nature of the incident, the victim's age when the rape occurred, the physical and emotional injuries sustained by the victim, the legal actions being considered as a result, the resources available for informal support, and the anticipated reactions of persons in the informal support network (see Family-Centered Care box).*
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F a m i l y - C e n t e r e d C a r e Supporting the Rape Victim's Parents
In addition to the needs of the adolescent rape victim, the nurse should also be sensitive to the needs and reactions of the adolescent's parents. Some parents will be angry and blame the adolescent; others will feel guilty and embarrassed. Many reactions can be expected at the time of the incident, ranging from despair to extreme agitation. Frequently, the parents require as much support and reassurance as the victim. Agitated, angry, or incapacitated parents are unable to provide support for their adolescent. Meeting their needs can foster their ability to support the teenager during the crisis.
Nutrition and Eating Disorders Obesity Few problems in childhood and adolescence are so obvious to others, are so difficult to treat, and have such long-term effects on health as obesity. Several different definitions have been proposed for obesity and overweight. Obesity has been defined as an increase in body weight resulting from an excessive accumulation of body fat relative to lean body mass. Overweight refers to the state of weighing more than average for height and body build. Currently, the body mass index (BMI) measurement is recommended as the most accurate method for screening children and adolescents for obesity. The BMI measurement is strongly associated with subcutaneous and total body fat and with skinfold thickness measurements. It is also highly specific for children with the greatest amount of body fat. Pediatric growth charts that include BMI for age and gender are available from the CDC.* Children with BMIs between the 85th and 95th percentiles are considered overweight, and obesity is defined by a BMI greater than or equal to the 95th percentile (Gahagan, 2016). It is important to note that for children with high levels of muscle mass (e.g., athletes), the BMI measurement may misclassify these youth into overweight/obesity classifications. Clinical judgment is needed to understand if these youth are at risk for obesity.
Regardless of the definition used, the number of overweight children in the United States has reportedly reached epidemic status (Spruijt-Metz, 2011). Approximately 12.7 million children are overweight or obese (Centers for Disease Control and Prevention, 2014a). Numerous studies dating back to the early 1960s have documented childhood overweight through comprehensive evaluations of dietary intake, physical activity, and anthropometric measures (Centers for Disease Control and Prevention using the various National Health and Nutrition Examination Surveys [NHANESs], I, II, III, and IV) (Ogden, Carroll, Kit, et al, 2014; Ogden, Carroll, and Flegal, 2008; Ogden, Kuczmarski, Flegal, et al, 2002; Ogden, Troiano, Briefel, et al, 1997). In the 1960s and 1970s, childhood overweight remained fairly constant at approximately 4% to 5.5%. However, surveys during the 1990s and early 2000s demonstrated a steady climb to reach 17% in both children and adolescents (Ogden, Carroll, Kit, et al, 2014; Flegal, Carroll, Kit, et al, 2012). This prevalence remains stable since 2003 but overall, the incidence remains high (Ogden, Carroll, Kit, et al, 2014). African- American and Hispanic children and youth are disproportionately represented by a higher prevalence of overweight and obesity (23.7% and 23.9%, respectively) compared with non-Hispanic white children (16.1%) (Flegal, Carroll, Kit, et al, 2012). Overall, adolescent Mexican-American boys and non-Hispanic black girls are at greatest risk with overweight/obesity prevalence rates of 46% and 45.1% respectively (Flegal, Carroll, Kit, et al, 2012).
Because adult obesity is associated with increased mortality and morbidity from a variety of complications, both physical and psychological, adolescent obesity is a serious condition. For the first time in United States history, the current generation of children will have a shorter life expectancy than their parents (American Heart Association, 2014). Overweight children and adolescents are at risk for continuing to be obese as adults, and they experience health and social consequences of obesity much earlier than children and adolescents of normal weight (Van Cleave, Gortmaker, and Perrin, 2010). Parental obesity increases the risk of overweight by twofold to threefold (Altman and Wilfley, 2015). The probability that overweight children will become obese adolescents is significant. In a large longitudinal study, overweight kindergartners were four times more likely to become obese by 14 years old than normal weight kindergartners (Cunningham,
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Kramer, and Narayan, 2014). Obesity in childhood and adolescence has been related to elevated blood cholesterol, high blood
pressure, respiratory disorders, orthopedic conditions, cholelithiasis, some types of adult-onset cancer, nonalcoholic fatty liver disease (NAFLD), and type 2 diabetes mellitus. The incidence of metabolic syndrome was 30% in obese children (Kiess, Kratzsch, Sergeyev, et al, 2014). Common emotional consequences of obesity include low self-esteem, social isolation, anxiety, depression, and an increased risk for the development of eating disorders (Altman and Wilfley, 2015).
Etiology and Pathophysiology Obesity results from a caloric intake that consistently exceeds caloric requirements and expenditure and may involve a variety of interrelated influences, including metabolic, hypothalamic, hereditary, social, cultural, and psychological factors (Fig. 16-2). Because the etiology of obesity is multifactorial, the treatment requires multilevel interventions.
FIG 16-2 Complex relationships in obesity.
A balance between energy intake and energy expenditure is a critical factor in regulating body weight. For example, eating one small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. Factors that raise energy intake or decrease energy expenditure by even small amounts can have a long-term impact on the development of overweight and obesity.
Genetic influence is an epidemiologic consideration in regard to children's weight. Genetic mutations, such as FTO (fat mass and obesity) are rare but can predispose individuals to becoming overweight or obese (Gahagan, 2016). Studies have also suggested a tendency for a combination of genetic and environmental factors. Parental BMI is a more potent predictor of obesity than genetics, suggesting that behaviors and environment play a greater role in obesity (Morandi, Meyre, Lobbens, et al, 2012). The increasing rates of obesity within genetically stable populations suggest that environmental, some perinatal factors (e.g., bottle feeding), and possible intrauterine factors (e.g., maternal gestational weight gain and stress) are contributors to the current increases in childhood obesity (Li, Magadia, Fein, et al, 2012). More research is needed to better understand the influences of family behavior and adolescent overweight.
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Fewer than 5% of the cases of childhood obesity can be attributed to an underlying disease. Such diseases include hypothyroidism; adrenal hypercorticoidism; hyperinsulinism; and dysfunction or damage to the central nervous system (CNS) as a result of tumor, injury, infection, or vascular accident. Obesity is a frequent complication of muscular dystrophy, paraplegia, Down syndrome, spina bifida, and other chronic illnesses that limit mobility.
A major focus of obesity research has been on appetite regulation. The expression of appetite is chemically coded in the hypothalamus by distinctive circuitry involved in drive and motivation. Orexigenic substances produce signals that increase appetite, and anorexigenic substances promote the cessation of eating behaviors. Feedback loops between signals have been identified where one signal peptide is able to alter the secretion of another signal peptide. No one signal has been identified as the gatekeeper of appetite. It is apparent that an entire network of signals, including their frequency and amplitude, is responsible for triggering eating behaviors.
There is little evidence to support a relationship between obesity and low metabolism. Small differences may exist in regulation of dietary intake or metabolic rate between obese and nonobese children that could lead to an energy imbalance and inappropriate weight gain, but these small differences are difficult to accurately quantify. Obese children tend to be less active than lean children, but it is uncertain whether inactivity creates the obesity or obesity is responsible for the inactivity. The tendency toward obesity is manifested whenever environmental conditions are favorable toward excessive caloric intake, such as an abundance of food, limited access to low-fat foods, reduced or minimum physical activity, and snacking combined with excessive screen time (computer, television, video games, cell phone). Family and cultural eating patterns as well as psychological factors play important roles; many families and cultures consider fat to be an indication of good health. It is common for obese children to have families that emphasize large meals, admonish children for leaving food on their plates, or use food as a reward or punishment. Parents may have an exaggerated concept of the amount of food children require and expect them to eat more than they need.
Disparities in obesity rates exist among racial/ethnic minorities, immigrant and refugee communities, and socioeconomic status (SES) with differences often becoming apparent before 6 years old. Lower socioeconomic groups have a greater prevalence of obesity, especially in girls. Youth immigrating to the United States tend to have lower initial weight statuses, but on a population level, immigrant youth have higher BMIs than their native-born counterparts after one generation of living in the United States. This is particularly true for Hispanic immigrants (Singh and Yu, 2012). Physical activity may also be influenced by sociocultural factors. Studies have shown that activity and inactivity patterns differ by ethnicity, and minority adolescents (non-Hispanic African-Americas, Hispanics, and Filipinos) engage in less physical activity and more inactivity than their non-Hispanic Caucasian counterparts (Gortmaker, Lee, Cradock, et al, 2012).
Some community factors that influence eating and activity patterns include a lack of built environment (food deserts, community gardens, farmers markets, sidewalks, parks, bike paths) or affordable and accessible facilities for low-income youth to be active, thus limiting their opportunities to participate in physical activities or healthful eating. Social policies also contribute to obesity. The increased availability of energy-dense foods, pricing strategies that promote unhealthy food choices, and overzealous food advertising that targets children and adolescents with high-fat and high-sugar foods are some examples (Schwartz and Ustjanauskas, 2012).
Institutional factors also influence patterns of obesity and decreased physical activity. Many school policies allow students to leave school for lunch. Vending machines in school often are filled with high-fat and high-calorie foods and soft drinks. Although well-balanced, nutritious school lunches may be available to students, they often opt for less nutritious choices, such as high-fat and high-sugar snacks.
Physical inactivity has also been identified as an important contributing factor in the development and maintenance of childhood overweight. There is little doubt that physical activity has decreased in elementary and secondary schools in the United States. In 2010, 44% of 9th-grade students attended physical education class daily, but only 28% of 12th-grade students participated in daily physical education (Eaton, Kann, Kinchen, et al, 2012). Consequently, most of children's physical activity must occur within the family or outside of school, which is often limited due to community factors (e.g., unsafe neighborhoods). Decreased physical activity within the family is a powerful influence on children because children imitate their parents and other adults.
The growing attraction and availability of many sedentary activities, including television, video games, computers, and the Internet, have greatly influenced the amount of exercise that children
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get. Studies have shown the association between screen time and obesity among children (De Jong, Visscher, Hirasing, et al, 2013; Thorn, DeLellis, Chandler, et al, 2013). The American Academy of Pediatrics (2011b) issued a policy statement encouraging parents to limit media viewing in children to 2 hours or less per day.
Psychological factors also affect eating patterns. Infants experience relief from discomfort through feeding and learn to associate eating with a sense of well-being, security, and the comforting presence of a nurturing person. Eating is soon associated with the feeling of being loved. In addition, the pleasurable oral sensation of sucking provides a connection between emotions and early eating behavior. Many parents use food as a positive reward for desired behaviors. This practice may become a habit, and the child may continue to use food as a reward, a comfort, and a means of dealing with depression or hostility. Many individuals eat when they are not hungry or in response to stress, boredom, loneliness, sadness, depression, or tiredness. Difficulty in determining feelings of satiety can lead to weight problems and may compound the factor of eating in response to emotional rather than physical hunger cues.
Frequency of family meals has consistently been shown to be a protective factor for obesity (Hammons and Fiese, 2011; Neumark-Sztainer, Larson, Fulkerson, et al, 2010). Family meals tend to provide access to a variety of nutrient-rich foods, particularly fruits and vegetables. This is also a time when parents can model healthy behaviors. Parental modeling of eating and physical activity and food availability in the home are predictors of excess weight gain during childhood and adolescence (Tandon, Zhou, Sallis, et al, 2012).
Diagnostic Evaluation A careful history is obtained regarding the development of obesity, and a physical examination is performed to differentiate simple obesity from increased fat that results from organic causes. A family history of obesity, diabetes, coronary heart disease, and dyslipidemia should be obtained for all children who are overweight or at risk for overweight. Specific information from the patient and family about the effects of obesity on daily functioning—for example, problems with nighttime breathing and sleep, daytime sleepiness, joint pain, ability to keep up with family activities and peers at school—is helpful. The physical examination should focus on identifying comorbid conditions and identifiable causes of obesity. For some, psychological assessment, by interviews and standardized personality tests, may provide insight into the personality and emotional problems that contribute to obesity and that might interfere with therapy.
It is useful to estimate the degree of obesity to determine the component of body weight that can be modified. All of the following methods have been used to assess obesity: BMI, body weight, weight–height ratios, weight–age ratios, hydrostatic weight, dual-energy x-ray absorptiometry (DXA), skinfold measurements, bioelectrical analysis, computed tomography (CT), magnetic resonance imaging (MRI), and neutron activation. Each of these methods has advantages and disadvantages. Hydrostatic weighing provides the most accurate measurement of lean body weight.
BMI is currently considered the best method to assess weight in children and adolescents. The calculation is based on the individual's height and weight. In adults, BMI definitions are fixed measures without regard for sex and age. The BMI in children and adolescents varies to accommodate age- and gender-specific changes in growth. The formula for BMI calculation is weight in kilograms divided by height in meters squared—weight (kg) ÷ (height [m]2). BMI measures in children and adolescents are plotted on growth charts that enable health care professionals to determine BMI for age for the patient.
The initial assessment of obese children and adolescents should include screening to evaluate for comorbidities. The history is an important guide to determine the workup. A complete physical examination is important. Some areas to focus on include (1) skin for stretch markings and discolorations (e.g., acanthosis nigricans), (2) joints for swelling and evidence of pain, and (3) airway for evidence of obstruction and enlarged tonsils. Basic laboratory studies include a fasting lipid panel, fasting insulin level, fasting glucose hepatic enzymes, including gamma-glutamyl
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transferase (GGT), and in some institutions, hemoglobin A1c. Other studies, such as a polysomnogram (sleep study), metabolic studies, and radiographic evaluations, may be added based on the history and physical examination. These assessments may determine whether the patient needs a referral to specialty services for more focused evaluation and treatment, such as endocrinology (insulin resistance, diabetes), hepatology (elevated liver enzymes, NAFLD), orthopedics (Blount disease), or pulmonary medicine (sleep-disordered breathing, continuous positive airway pressure [CPAP]).
Therapeutic Management The best approach to the management of obesity is a preventive one. Early recognition and control measures are essential before the child or adolescent reaches an obese state. Health care providers need to educate families about the medical complications of obesity.
Currently, the only treatments recommended for children are diet, exercise, behavior modification, and in some situations pharmacologic agents, such as orlistat. The treatment of obesity is difficult. Many approaches do not achieve long-term success. The average individual only loses about 5% to 10% of his or her weight with available therapies. Losing weight can have a significant positive effect on many comorbidities, but unfortunately, the lost weight is frequently regained in a year or two. A number of multidisciplinary programs offer interventions combining medical, dietary, exercise, and psychological support. This therapy is labor intensive and fairly costly. Diet modification is an essential part of weight reduction programs. Dietary counseling focuses on improving the nutritional quality of the diet rather than on dietary restriction. Children and adolescents should avoid fad diets. Most dietitians and nutrition experts recommend a diet with no trans fats, low-saturated fat, moderate total fat (≤30%), low sodium, and at least nine servings of fruits and vegetables, consistent with the My Plate* food guide for children. Also, promoting high-fiber foods and avoiding highly refined starches and sugars decrease caloric intake. Many programs recommend using a food diary as a helpful tool to increase awareness of food choices and eating behaviors. The goal is to encourage the individual to make healthy choices in food selection and discourage using food by habit or to appease boredom. Box 16-4 contains helpful suggestions.
Box 16-4 R e c o m m e n d e d B e h a v i o r s f o r P r e ve n t i n g O b e s i t y In counseling adolescents whose body mass index (BMI) is between the 5th and 84th percentiles, physicians and health care providers should recommend the following steps to prevent obesity:
• Limit consumption of sugar-sweetened beverages.
• Consume recommended quantities of fruits and vegetables.
• Limit screen time to no more than 2 hours per day.
• Remove television and computer screens from primary sleeping areas.
• Eat breakfast daily.
• Limit eating at restaurants.
• Have frequent family meals in which parents and youth eat together.
• Limit portion sizes.
Adapted from Davis DM, Gance-Cleveland B, Hassink S, et al: Recommendations for prevention of childhood obesity, Pediatrics 120(suppl):S229-S253, 2007.
In patients with severe obesity, strict diets have been used, such as the protein-sparing modified fast, hypocaloric diet, or ketogenic diet (Sukkar, Signori, Borrini, et al, 2013; Castaldo, Palmieri, Galdo, et al, 2015). These diets are designed to provide enough protein to minimize loss of lean body mass during weight loss. Such diets need to be closely monitored and should be used only
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with multidisciplinary teams that include a physician, nutritionist, and behavioral therapist. Generally, the diet consists of 1.5 to 2.5 g of protein per kilogram. The intake of carbohydrates is low enough to induce ketosis. The benefits of the diet are relatively rapid weight loss and anorexia induced by ketosis. Potential complications include protein losses, hypokalemia, hypoglycemia, inadequate calcium intake, orthostatic hypotension, and increased risk for osteoporosis. Supplements containing vitamins, minerals, and trace minerals, along with therapeutic doses of vitamin D can minimize these complications (Kossoff, Zupec-Kania, and Rho, 2009). It is difficult to sustain these diets over the long term, and the long-term outcomes of using these diets have not been established.
Researchers continue searching for medications that will successfully treat obesity. Orlistat, a lipase inhibitor, has been approved for use in children 12 years old and older; however, side effects of the drug include fatty or oily stools and possible malabsorption of fat-soluble vitamins (Kanekar and Sharma, 2010). There are currently no drugs approved for use in overweight or obese children younger than 12 years old.
Behavioral modification approaches to weight loss are based on the observation that obese individuals have abnormal eating practices that can be altered. Attention is focused not on food but on the social and behavioral aspects surrounding food consumption. Successful behavior modification weight programs help adolescents identify and eliminate inappropriate eating habits and include a problem-solving component that enables adolescents to identify problems and determine solutions. Combining behavioral modifications with pharmacologic therapy in children 12 years old and older have produced mixed results referent to total weight loss maintained over a significant period of time (Barton and US Preventive Services Task Force, 2010). Programs including family-based behavioral modification, dietary modification, and exercise have been shown to be successful in reducing obesity in some children (Altman and Wilfley, 2015). Behavior modification is an important part of multidisciplinary intervention programs.
Surgical techniques (bariatric surgery) that bypass portions of the intestine or occlude a segment of the stomach to produce a marked diet restriction and weight loss are hazardous and cause many metabolic complications. These complications include severe water and electrolyte depletion, persistent diarrhea, vitamin deficiency, internal herniation, and fatty infiltration and degeneration of the liver. Bariatric surgery may be the only practical alternative for increasing numbers of severely overweight adolescents who have failed organized attempts to lose or maintain weight loss through conventional nonoperative approaches and who have serious life-threatening conditions. Physicians must define clear, realistic, and restrictive guidelines to apply with younger patients when surgery is considered. Candidates for surgery should be referred to centers that offer a multidisciplinary team experienced in the management of childhood and adolescent obesity. The surgery should be performed by surgeons who have participated in subspecialty training in bariatric medical and surgical care as detailed by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery.
Nursing Care Management Nurses play a key role in the adherence and maintenance phases of many weight reduction programs. Nurses assess, manage, and evaluate the progress of many overweight adolescents. They also play an important role in recognizing potential weight problems and assisting parents and adolescents in preventing obesity.
The presence of obesity may not be obvious from appearance alone. Regular assessment of height and weight and computation of the BMI facilitate early recognition of risk. Evaluation includes a height and weight history of the adolescent and family members, eating habits, appetite and hunger patterns, and physical activities. A psychosocial history is also helpful in understanding the impact of obesity on the child's life.
Before initiating a treatment plan, it is important to be certain that the family is ready for change. Lack of readiness may result in failure, frustration, and reluctance to address the problem in the future. The nurse should explore with adolescents the reasons behind the desire to lose weight because motivation to lose weight is the key to success. Adolescents need to take personal responsibility for their dietary habits and physical activity. Young persons who are forced by their parents to seek help are seldom motivated, become rebellious, and are unwilling to control their dietary intake.
Nutritional counseling.
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Preventing an increase in body fat during growth is a realistic approach. This is often accomplished by adjusting four aspects of eating: (1) reducing the quantity eaten by purchasing, preparing, and serving smaller portions; (2) altering the quality consumed by substituting low-calorie, low-fat foods for high-calorie foods (especially for snacks); (3) eating regular meals and snacks, particularly breakfast; and (4) altering situations by severing associations between eating and other stimuli, such as eating while watching television. Nutrition counseling incorporates health behavior theories to help motivate and maintain behavior change. The most successful changes are those that are attainable, reasonable, and sustainable. The emphasis of counseling should be on health outcomes, not weight. Studies have shown focusing on weight can be detrimental to therapies and may promote eating disorders (Altman and Wilfley, 2015).
Teach adolescents and parents how to incorporate favorite foods into their diet and to select satisfying substitutes. To maintain a healthy diet, it is necessary to encourage the consumption of high-nutrient foods, such as fruits, vegetables, whole grains, and low-fat dairy protein products. Keep calories and fat to a healthy level without being significantly restricted. To be successful, a dietary program should be nutritionally sound with sufficient satiety value, produce the desired weight loss, and be accompanied by nutrition education and continued support. Davis, Gance- Cleveland, Hassink, and colleagues (2007) describe steps to approaching behavior change with youth (Box 16-5).
Box 16-5 Pe d i a t r i c O b e s i t y P r e ve n t i o n P r o t o c o l f o r P r i m a r y C a r e Step 1: Assess
Explain and conduct assessments of:
• Weight, height, and body mass index (BMI) percentile
• Dietary intake (fruit, vegetables, sweetened beverages, and fast food)
• Activity (screen time, moderate to vigorous activity)
• Eating behaviors (breakfast, portion sizes, family meals)
Provide and elicit feedback on BMI and behaviors found to be inside and outside the optimal range.
Step 2: Set Agenda
Explore interest in changing behaviors not in the optimal range.
Agree on target behaviors with the patient and caregiver.
Step 3: Assess Motivation and Confidence
With regard to interest in changing weight status or behaviors, assess:
• Willingness/ability to make change
• Perceived importance
• Confidence in having success
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Probe the patient regarding ratings of willingness, perceived importance, and confidence to explore the advantages and disadvantages of changing.
Step 4: Summarize and Probe Possible Changes
Summarize the advantages and disadvantages of change.
Query possible next steps. Allow the adolescent to suggest ideas.
Provide guidance for getting started in making a change as needed. Encourage achievable goals.
Summarize the change plan.
Provide positive feedback.
Step 5: Schedule Follow-up Visit
If a change plan is made, agree on a follow-up appointment within a specified number of weeks or months.
If no change plan is made, agree to revisit the topic within a specific number of weeks or months.
Adapted from Davis DM, Gance-Cleveland B, Hassink S, and others: Recommendations for prevention of childhood obesity, Pediatrics 120(suppl):S229-S253, 2007.
Behavioral therapy. Altering eating behavior and eliminating inappropriate eating habits are essential to weight reduction, especially in maintaining long-term weight control. Most behavioral modification programs include the following concepts: • A description of the behavior to be controlled, such as eating habits • Attempts to modify and control the stimuli that govern eating • Development of eating techniques designed to control speed of eating • Positive reinforcement for these modifications through a suitable reward system that does not
include food • Create environments where the healthy choice is the easy choice
Group involvement. Commercial groups (e.g., Weight Watchers) or diet workshops composed primarily of adults may be helpful to some teenagers; however, a peer group is often more effective. Adolescent groups include summer camps designed for obese young people and conducted by health professionals, school groups organized and led by a school nurse or health professional, and groups associated with special clinics.
These groups are concerned not only with weight loss but also with the development of a positive self-image and the encouragement of physical activity. Nutrition education, diet planning, and the improvement of social skills are essential components of these groups. Improvement is determined by positive changes in all aspects of behavior.
Family involvement. There is a definite connection among family environment, interaction, and obesity. The nurse needs to educate parents in the purposes of the therapeutic measures and their role in management. The family needs nutrition education and counseling regarding the reinforcement plan, alterations in the food environment, and ways to maintain proper attitudes. They can support their child in efforts to change eating behaviors, food intake, and physical activity.
Physical activity. The current recommendation for physical activity for children and adolescents is to participate in a combined total of 60 minutes of physical activity daily; this can be moderate- to vigorous-intensive exercise or activity (Centers of Disease Control and Prevention, 2015). Regular physical activity is
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incorporated into all weight reduction programs. Recommendations for physical activity need to consider the current health status and developmental level of the child or adolescent. The best choice for exercise is any form that is enjoyable and likely to be sustainable. Light exercises, such as walking, may provide an opportunity for the family to increase time together and increase caloric expenditure. Weight training can increase the basal metabolic rate and replace fat mass with muscle mass. However, weight training is not generally recommended for prepubertal children until they have reached physical and skeletal maturity. In prepubertal children, increasing outdoor playtime is likely to be beneficial. Limiting sedentary activities such as television viewing while eating snacks is very beneficial.
Prevention. Gradual accumulation of adipose tissue during childhood establishes a pattern of eating that is difficult to reverse in adolescence. Prevention of obesity should begin in early childhood with the development of healthy eating habits, regular exercise patterns, and a positive relationship between parents and children. Prevention of adolescent obesity is best accomplished by early identification of obesity in the preschool, school-age, and preadolescent periods. Health care professionals should encourage frequent health care visits for children who are overweight or obese and incorporate a dietary history and counseling into each well-infant, well-child, and well-adolescent visit.*
Anorexia Nervosa and Bulimia Nervosa Anorexia nervosa (AN) is an eating disorder characterized by a refusal to maintain a minimally normal body weight and by severe weight loss in the absence of obvious physical causes. It is a disorder with social, psychological, behavioral, cultural, and physiological components that result in significant morbidity and mortality. The disorder is a clinical diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR) (American Psychiatric Association, 2013). Individuals with AN are described as perfectionists, academically high achievers, conforming, and conscientious.
Bulimia (from the Greek meaning “ox hunger”) refers to an eating disorder similar to AN. Bulimia nervosa (BN) is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise (American Psychiatric Association, 2013). The binge behavior consists of secretive, frenzied consumption of large amounts of high- calorie (or “forbidden”) foods during a brief time (usually ≈2 hours). The binge is counteracted by a variety of weight control methods (purging). These binge–purge cycles are followed by self- deprecating thoughts, a depressed mood, and an awareness that the eating pattern is abnormal.
Eating disorder not otherwise specified (EDNOS) is an additional diagnosis for eating disorders. These disorders have components of both AN and BN that are not characteristics of the established diagnostic criteria for AN and BN. Binge eating disorder (BED) is a type of EDNOS. Binge eating disorder (BED) is a distinct diagnostic category that is very similar to BN, with the exception that purging is not involved. Eating disorder not otherwise specified (EDNOS) is an additional diagnosis for eating disorders in the DSM. EDNOS includes subthresholds of the aforementioned disorders, as well as purging disorder, night eating syndrome, and a residual category for clinically significant problems meeting the definition of a feeding or eating disorder but not satisfying the criteria for any other disorder or condition (American Psychiatric Association, 2013).
The incidence of AN in adolescent females in the United States has been estimated at 0.5%, and between 1% and 5% meet the criteria for BN, with up to 10% cases attributable to males (Rosen, 2010). These prevalences will likely climb as practitioners begin to use the new DSM criteria. A nationally representative study found no differences in the prevalence of AN between adolescent boys and girls, but did find higher prevalences of BN among girls compared to boys (Swanson, Crow, Le Grange, et al, 2011). BED is more common among males (Smink, van Hoeken, and Hoek, 2012). Young people under the age of 12 years old are the fastest growing group of youth who report eating disorder tendencies (Funari, 2013).
Etiology and Pathophysiology The etiology of these disorders remains unclear. A combination of genetic, neurochemical, psychodevelopmental, sociocultural, and environmental factors appear to cause the disorder (Stice, South, and Shaw, 2012). Dieting and body dissatisfaction appear to be common to the initiation of
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both AN and BN. Also characteristic is a childhood preoccupation with being thin reinforced by sociocultural and environmental factors, supporting the concepts of an ideal body shape. The dominant aspects of AN are a relentless pursuit of thinness and a fear of fatness, usually preceded by a period of mood disturbances and behavior changes.
There is no strong empirical data to indicate that one particular family prototype is responsible for the development of an eating disorder. However, many experts have associated the development of an eating disorder with family characteristics, such as an adolescent perception of high parental expectations for achievement and appearance, difficulty managing conflict, poor communication styles, enmeshment and occasionally estrangement among family members, devaluation of the mother or the maternal role, marital tension, and mood and anxiety disorders. Adolescents whose parents focus on weight report higher levels of disordered eating (Berge, Maclehose, Loth, et al, 2013). Families struggling with an eating disorder have been characterized as often having difficulties responding positively to the changing physical and emotional needs of the adolescent. Family stress of any kind may become a significant factor in the development of an eating disorder (Berge, Maclehose, Loth, et al, 2013).
Individuals with eating disorders commonly have psychiatric problems, including affective disorder, anxiety disorder, obsessive-compulsive disorder (OCD), and personality disorder. Adult women with eating disorders were found to have higher rates of obsessive-compulsive behavior traits in their childhoods. Persons with eating disorders have also been found to have higher reported rates of substance abuse, with alcohol problems being more common in those with BN than AN (Wildes and Marcus, 2013). It is important to note that many of the clinical findings are directly related to the state of starvation and improve with weight gain. Research continues in an effort to better understand the etiology and pathogenesis of eating disorders.
Many sports and artistic endeavors that emphasize leanness (e.g., ballet and running) and sports in which the scoring is partly subjective (e.g., figure skating and gymnastics) or where weight class is prerequisite to participation (e.g., wrestling) have been associated with a higher incidence of eating disorders (Bratland-Sanda and Sundgot-Borgen, 2013). The term female athlete triad, characterized by an eating disorder, amenorrhea, and osteoporosis, has been applied to young women with restrictive eating disorders and amenorrhea (Deimel and Dunlap, 2012).
Diagnostic Evaluation Diagnosis is made on the basis of clinical manifestations (Box 16-6) and conformity to the criteria established by the American Psychiatric Association (2013). Characteristics of BN and AN are listed in Table 16-3.
Box 16-6 C l i n i c a l M a n i f e s t a t i o n s o f A n o r e x i a N e r v o s a • Severe and profound weight loss
• Secondary amenorrhea (if menarche attained)
• Primary amenorrhea (if menarche not attained)
• Sinus bradycardia
• Low body temperature
• Hypotension
• Intolerance to cold
• Dry skin and brittle nails
• Appearance of lanugo hair
• Thinning hair
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• Abdominal pain
• Bloating
• Constipation
• Fatigue
• Lightheadedness
• Evidence of muscle wasting (cachectic appearance)
• Bone pain with exercise
TABLE 16-3 Characteristics of Individuals With Eating Disorders
Factors Anorexia Nervosa Bulimia Food Turns away from food to cope Turns to food to cope Personality Introverted Extroverted
Avoids intimacy Seeks intimacy Negates feminine role Aspires to feminine role
Behavior “Model” child Often acts out Obsessive-compulsive Impulsive
School High achiever Variable school performance Control Maintains rigid control Loses control Body image Body image distortion Less frequent body image distortion Health Denies illness Recognizes illness
Health fluctuates Weight Body weight <85% of expected norm Within 2.3 to 7 kg (5 to 15 lbs.) of normal body weight or may be overweight Sexuality Usually not sexually active Often sexually active
A complete history and physical examination are important to rule out other causes of weight loss. The medical assessment of an eating disorder focuses on the complications of altered nutritional status and purging. A careful history assesses weight changes, dietary patterns, and the frequency and severity of purging and excessive exercise. Purging behaviors include vomiting or other methods, such as abuse of laxatives, enemas, diuretics, anorexic drugs, caffeine, or other stimulants. Measure the patient's weight and height and evaluate it for appropriateness according to standard weight for height, age, and sex determined according to the percentile of his or her expected body weight or BMI.
Particularly important parts of the physical examination are vital sign measurement (heart and blood pressure, both supine and standing, and temperature). Hypotension, bradycardia, and hypothermia are often seen in association with extremely low weight. Prolongation of the QT interval may be detected in some patients. Dry skin, lanugo, acrocyanosis, and breast atrophy are findings that have been associated with AN. Distinctive hand lesions (Russell sign) have been observed; the backs of the hands are often scarred and cut from repeated abrasion of the skin against the maxillary incisors during self-induced vomiting.
The diagnosis of eating disorder is made clinically, but additional laboratory diagnostic tests may be obtained to identify malnutrition or other associated complications. Laboratory assessment may include a complete blood count to evaluate for anemia and other hematologic abnormalities; erythrocyte sedimentation rate or C-reactive protein to detect evidence of inflammation; electrolytes as well as calcium, magnesium, phosphorus, blood urea nitrogen, and creatinine; and urinalysis, including specific gravity to detect water loading. In patients with prolonged amenorrhea, human chorionic gonadotropin is assessed to determine the presence of pregnancy. Other tests for patients with amenorrhea include thyroid function tests and measurement of serum prolactin and follicle- stimulating hormone to help rule out prolactinoma (hormone-secreting pituitary tumor), hyperthyroidism, hypothyroidism, or ovarian failure. A bone density study may be ordered to detect bone loss, which is a complication of AN. In addition, a comprehensive cardiac evaluation is often recommended in those with AN. Further diagnostic tests may be required based on the history and findings from these diagnostic tests.
Screening tools. All patients in high-risk categories for eating disorders should be screened during routine office visits. The medical history is most important for diagnosing eating disorders because the physical
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examination findings may be normal, especially early in the illness. A number of screening questionnaires are available to assist with the interview. For example, with the SCOFF Questionnaire, 1 point is scored for every “yes.” A score of 2 or more indicates a likely case of AN or BN. The questions related to the mnemonic SCOFF are (Trent, Moreira, Colwell, et al, 2013):
1. Do you make yourself sick because you feel uncomfortably full?
2. Do you worry that you have lost control over how much you eat?
3. Have you recently lost more than 6.4 kg (14 pounds or one stone) in a 3-month period?
4. Do you believe yourself to be fat when others say that you are too thin?
5. Do thoughts and fears about food and weight dominate your life?
Therapeutic Management The treatment and management of AN involve three major goals: (1) reinstitution of normal nutrition or reversal of the severe state of malnutrition, (2) resolution of disturbed patterns of family interaction, and (3) individual psychotherapy to correct deficits and distortions in psychological functioning. Treatment of eating disorders requires interventions of an interdisciplinary team composed of a primary practitioner, nurse, dietitian, and mental health provider with pediatric and adolescent health care experience. Because of the psychogenic nature of the disorder, the treatment may be long.
Most adolescents with AN are treated on an outpatient basis, but those with problems requiring immediate medical attention, such as severe malnutrition, electrolyte disturbances, vital sign abnormalities, or psychiatric disturbances (e.g., severe depression or suicidal ideation), may require hospitalization. Persons with BN may benefit from cognitive behavioral therapy, psychotherapy, family-based therapy, and nutritional counseling (Kreipe, 2016).
Nutrition therapy. The most important goal is to treat any life-threatening malnutrition and to restore dietary stability and weight gain. This may require intravenous or tube feedings if the malnutrition is severe. The patient should avoid rapid weight gain because it has been associated with severe metabolic abnormalities in some patients, such as refeeding syndrome, which consists of cardiovascular, neurologic, and hematologic complications that occur when nutritional replacement is given too rapidly. This syndrome can be avoided with slow refeeding and the addition of phosphorus when total body phosphorus is depleted. Treatment goal weights are individualized and based on age, height, stage of puberty, premorbid weight, and previous growth charts. In young women who have reached menarche, resumption of menses is an objective measure of return to biologic health.
Dietary interventions are combined with behavioral therapy to improve the underlying psychological misconceptions about weight loss. Another aspect of treatment is to relieve the anxiety related to eating and the depression that accompanies the disorder. Weight gain alone cannot be considered a cure for the disease and is an unreliable sign of progress. Relapses are frequent as the person may revert to previous eating patterns when removed from the therapeutic environment.
Behavioral therapy. Behavioral modification, usually through cognitive behavior therapy or motivational interviewing, has met varying degrees of success. The goal is to increase the patient's feelings of control and responsibility toward achieving recovery. Providing privileges or activities for weight gain or positive eating behaviors may be successful, but treatment should also address the conflict precipitating the disorder. Individual psychotherapy is aimed at helping the young person resolve the adolescent identity crisis, particularly as it relates to a distorted body image. If the disorder is related to a dysfunctional family situation, therapy is most successful when it is started soon after the onset of illness and directed toward disengagement and redirection of malfunctioning processes in the family.
The team responsible for the management of young people with AN arranges a carefully structured environment. First, there must be consistency. The team decides on an approach and
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adheres to it. The plan is structured with reality testing regarding caloric intake and body image perception as an essential component. The team members provide a unified front to avoid any possibility of manipulation or inconsistency. Second, all team members are involved; responsibility for the program cannot be left to one person. The role and boundaries of each member are clearly spelled out. Third, continuity of team members is important; it is helpful to have the same team members all the time. Fourth, communication among team members is essential. Communication with the patient regarding what is expected is also important. Sometimes the limit setting may seem unreasonable. If the adolescent does not understand the rationale for the limits, he or she may sabotage the entire program. It is also important to communicate with the family. Fifth, the plan must provide for support of the adolescent, the family, and team members. Support the adolescent's efforts, and provide positive feedback for accomplishments made in normalizing eating habits. Meetings are held to discuss the feelings and concerns of the patient, immediate caregivers, and team members.
Pharmacotherapy. Pharmacotherapy in the treatment of AN has been disappointing so far. Although some comorbidities have been shown to decrease, low recovery rates of the disorder are maintained (Flament, Bissada, and Spettigue, 2012). The few studies that have been done have primarily evaluated medications' efficacy in the treatment of comorbid disorders, such as OCDs and depression. Anxiolytic medications may be helpful before meals to relieve some patients' anxiety.
Tricyclic antidepressants and fluoxetine belong to a group of medications known as SSRIs, which have been more successful when used with BN. There is also some evidence that tricyclic antidepressants such as desipramine, imipramine, and amitriptyline; monoamine oxidase inhibitors; and buspirone are more effective compared with a placebo in decreasing binging and vomiting in patients with BN. Topiramate, an antiepileptic agent, and the selective serotonin antagonist ondansetron have demonstrated some benefit in treating patients with BN. The American Psychiatric Association's guidelines have discouraged using medication as the only therapy. Clearly more research is needed to clarify whether medications have a role in the treatment of eating disorders (Flament, Bissada, and Spettigue, 2012).
Psychotherapy. Psychotherapy is central to the treatment of eating disorders. Patients need to be active participants in the treatment process to better understand the impulses, feelings, and needs that have resulted in their eating disorder. The goal is to increase the patient's feelings of control and responsibility toward achieving recovery. Eating disorders are complex and multifaceted. If possible, treatment should match patients' readiness to change (Geller, Srikameswaran, Zelichowska, et al, 2012). It is important to treat eating disorder patients with respect and support preservation of their self- esteem to promote a successful recovery (Ozier and Henry, 2011). Family therapy addresses dysfunctional roles, conflicts, alliances, and patterns that the eating disorder is precipitating or maintaining, while helping family members deal with the eating disorder.
Nursing Care Management Nurses need to adopt and maintain a kind and supportive yet firm manner in managing the care of the adolescent with eating disorders without creating a passive-dependent attitude. The individual requires sustained support and reassurance to cope with ambivalent feelings related to body concept and the desire to be seen as cooperative, reliable, and worthy of receiving kindness. Encouraging the adolescent with education and activities that strengthen self-esteem facilitates the resocialization process and promotes social acceptance among peers.
It is important for nurses to be aware of the physical side effects of AN. Patients with AN frequently limit their fluid intake. Urinary tract problems are common, and ketones and protein may be detected in the urine as a result of breakdown of fat and protein. Vital sign instability can be severe and can include orthostatic hypotension; the pulse becomes irregular, and the rate decreases markedly. Bradycardia and hypothermia can result in cardiac arrest (see Critical Thinking Case Study box).
C r i t i c a l T h i n k i n g C a s e S t u d y
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Anorexia Nervosa
Jane is a 13-year-old girl whose grades have been excellent and whom the teachers describe as a “model student.” Recently, Jane's teacher told the nurse practitioner that Jane's parents were in the middle of a “messy divorce.” In addition, several of Jane's friends told the nurse practitioner that they are concerned about Jane because she runs every day at lunchtime and seldom eats lunch with them. Jane told her friends that she gained weight over the winter months and that she is running because she wants to qualify for the track team this spring. At the time of her routine health interview and sports physical examination, the nurse practitioner notes that Jane's oral temperature is 36° C (96.8° F) and that she weighs 34 kg (75 pounds). Jane has lost 9 kg (20 pounds) since her last sports physical. Jane tells the nurse practitioner that she has not had her menstrual period for 3 months.
Questions
1. Evidence: Is there sufficient evidence to draw any conclusions about Jane's behavior?
2. Assumptions: Describe some underlying assumptions about the following:
a. Personality characteristics of individuals with AN
b. Factors influencing the development of AN
c. Clinical manifestations of AN
d. Treatment of AN
3. What priorities for nursing care should be established for Jane at this time?
4. Does the evidence support your conclusion?
AN, Anorexia nervosa.
Nursing care of the adolescent with BN is similar to care of the patient with AN. Acute care involves careful monitoring of fluid and electrolyte alterations and observation for signs of cardiac complications. Nutritional consultation and follow-up care are essential. The nurse should encourage the adolescent and family members to structure the environment to reduce the binging behavior. Avoiding and eliminating trigger foods that would result in binges; restricting eating to one room of the house to avoid hiding and the shame related to overeating; being mindful and not engaging in other activities while eating; and substituting exercise, crafts, visualization, and relaxation techniques prior and during urges to binge are helpful interventions.
Nurses, patients, and families can find assistance and information from several organizations. The National Association of Anorexia Nervosa and Associated Disorders* provides counseling, referral, and self-help programs for young people with AN. The National Eating Disorders Association† provides information and support services for both patients and families.
Lactose Intolerance Lactose intolerance refers to the inability to digest lactose, a sugar found in milk and dairy products. It involves a deficiency of the enzyme lactase, which is needed for the hydrolysis or digestion of lactose in the small intestine; lactose is hydrolyzed into glucose and galactose.
There are four types of lactase deficiency that leads to lactose intolerance. Congenital lactase deficiency occurs soon after birth after the newborn has consumed lactose-containing milk (human milk or commercial formula). This inborn error of metabolism involves the complete absence or severely reduced presence of lactase, is extremely rare, and requires a lifelong lactose-free or extremely reduced lactose diet. Developmental lactase deficiency refers to the relative lactase
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deficiency observed in preterm infants younger than 34 weeks of gestation and is usually reversible with time. Primary lactase deficiency is the most common type of lactose intolerance and is usually manifested by 2 years old, although the time of onset is variable. Ethnic groups with a high incidence of primary lactase deficiency include Asians, African Americans, and American Indians; individuals of northern European descent tend to have the lowest incidence (Carter and Attel, 2013). Secondary lactase deficiency occurs secondary to damage of the intestinal lumen, which decreases or destroys the enzyme lactase. Cystic fibrosis, sprue, celiac disease, kwashiorkor, and infections (such as giardiasis or rotavirus) may cause a temporary or permanent lactose intolerance.
The primary symptoms of lactose intolerance include abdominal pain, abdominal bloating, flatulence, diarrhea, and nausea after the ingestion of lactose. The onset of symptoms occurs within 30 minutes to several hours of lactose consumption. Lactose intolerance is often perceived as an allergy or IBS; however, a dairy allergy is often immediate and accompanied by a skin rash or hives, and IBS is triggered by ingestion of fat, caffeine, sorbitol, and fructose in addition to lactose (Carter and Attel, 2013).
Lactose intolerance may be diagnosed on the basis of the history and improvement with a lactose- reduced diet. The breath hydrogen test is used to positively diagnose the condition. After ingesting 50 grams of a lactose solution, breath samples in lactose-deficient individuals will yield a higher percentage of hydrogen (≥20 ppm [parts per million] above baseline). In infants, lactose malabsorption may be diagnosed by evaluating fecal pH and reducing substances after ingesting a lactose load; however, fructose, gastric motility, and water excretion can alter the sensitivity of the test (Carter and Attel, 2013).
Treatment of lactose intolerance is elimination of offending dairy products; however, some advocate decreasing amounts of dairy products rather than total elimination. Most individuals with lactose intolerance can tolerate a single serving of lactose (12 grams) per day, especially when consumed with food (Shaukat, Levitt, Taylor, et al, 2010). The enzyme, lactase, can be added to foods or beverages to promote the breakdown of lactose. One concern is that dairy avoidance in children and adolescents with lactose intolerance will contribute to reduced bone mineral density (Setty-Shah, Maranda, Candela, et al, 2013). It is recommended that individuals with lactose maldigestion who do not experience lactose intolerance symptoms continue to consume small amounts of dairy products with meals to prevent reduced bone mass density and subsequent osteoporosis. A systematic review of interventions to reduce lactose intolerance symptoms found insufficient evidence on the use of probiotics (Shaukat, Levitt, Taylor, et al, 2010). Because dairy products are a major source of calcium and vitamin D, supplementation of these nutrients is needed to prevent deficiency. Yogurt contains inactive lactase enzyme, which is activated by the temperature and pH of the duodenum; this lactase activity substitutes for the lack of endogenous lactase. Fresh, plain yogurt may be tolerated better than frozen or flavored yogurt; hard cheeses, lactase-treated dairy products, and lactase tablets taken with dairy products are also viable options.
Nursing Care Management Nursing care is similar to the interventions discussed for cow's milk allergy in Chapter 10 and includes explaining the dietary restrictions to the family; identifying alternate sources of calcium, such as yogurt and calcium supplementation; explaining the importance of supplementation; discussing sources of lactose, especially hidden sources, such as its use as a bulk agent in certain medications; and recognizing ways of controlling the symptoms. Parents are advised to check with the pharmacist regarding the possibility of lactose when obtaining medication for the child.
Adolescent Disorders with a Behavioral Component Substance Abuse Although experimentation with drugs during childhood and adolescence is widespread, most children and teens do not become high-risk users. Monitoring the Future has been providing long- term research about the rates of substance use among adolescents, young adults, and adults since 1975 (Johnston, O'Malley, Miech, et al, 2015). The 2014 survey found that marijuana use and acceptance of marijuana use among 12th graders increased from 2006 to 2011 and then leveled from 2011 to 2013. Binge drinking (five or more alcoholic drinks at least once in the prior 2 weeks) has been on the decline since the early 1980s and reached historically low levels in 2014. Cigarette use has been on a steady decline from the mid-1990s until 2004, which followed a leveling off through
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2014. More teens used e-cigarettes in 2014 than any other tobacco product, with a prevalence of 13.6% among 12th graders (Johnston, O'Malley, Miech, et al, 2015). The use of illicit drugs other than marijuana has shown minimal change from the late 1990s until 2014 (Johnston, O'Malley, Miech, et al, 2015).
Drug abuse, misuse, and addiction are culturally defined and are voluntary behaviors. Drug tolerance and physical dependence are involuntary physiologic responses to the pharmacologic characteristics of drugs, such as opioids and alcohol. Consequently, an individual can be addicted to a narcotic with or without being physically dependent. A person can also be physically dependent on a narcotic without being addicted (e.g., patients who use opioids to control pain).
Motivation Most drug use begins with experimentation. The drug may be used only once, may be used occasionally, or may become part of a drug-centered lifestyle. Children and adolescents initiate drug use out of curiosity. Adolescents who use drugs may fall into one of two broad categories— experimenters and compulsive users—or they may fall into a third category somewhere on the continuum between these extremes, referred to as recreational users, principally of drugs such as marijuana, cocaine, alcohol, and prescription drugs. For many, the goal is peer acceptance; these users fit more closely with the experimenting, intermittent users. For others, the goal is intoxication or the sustained intense effects from using a particular drug; these users resemble the compulsive users. These users may engage in periodic heavy use, or binges. The groups of greatest concern to health care workers are those whose patterns of use involve high doses or mixed drugs with the danger of overdose and compulsive users with the threat of dependence, withdrawal syndromes, and altered lifestyle.
Types of Drugs Abused Any drug can be abused, and most are potentially harmful to adolescents still going through formative life experiences. Although rarely considered drugs by society, the chemically active substances frequently abused are the xanthines and theobromines contained in chocolate, tea, coffee, and colas. Ethyl alcohol and nicotine are other drugs that are legal and socially sanctioned. Any of these substances can produce mild to moderate euphoric or stimulant effects and can lead to physical and psychological dependence.
Drugs with mind-altering abilities that are available on the “street” and are of medical and legal concern are the hallucinogenic, narcotic, hypnotic, and stimulant drugs. In addition, health professionals are concerned about the use of alcohol and volatile substances that are inhaled to achieve altered sensation (e.g., gasoline, antifreeze, plastic model cement, organic solvents). Cough and cold preparations such as NyQuil, Coricidin, and Robitussin are common substances abused by adolescents and young adults. The abuse of prescription and synthetic drugs such as oxycodone, alprazolam (Xanax), and amphetamine-dextroamphetamine (Adderall), has reached epidemic proportions among adolescents and young people (Maxwell, 2011). Many of the prescription drugs are available at a decreased cost compared with the more exotic drugs of abuse and are often found in the medicine or kitchen cabinet at home. Websites also promote the “safe use” of some psychoactive drugs and supply information on new “designer” drugs that are not detectable on a standard urine drug screening test.
Tobacco. Cigarette smoking has been on a slow decline since the peak in 1999 despite multiple efforts, including increased costs, changes in community attitudes about smoking, media campaigns with counter-advertising, and tobacco-free environments. Use of all tobacco products among youth has not significantly changed between 2004 and 2014 (Johnston, O'Malley, Miech, et al, 2015).
Cigarette smoking is still considered a chief avoidable cause of death. The hazards of smoking at any age are undisputed; however, a preventive approach to teenage smoking is especially important. Because of its addictive nature, smoking begun in childhood and adolescence can result in a lifetime habit, with increased morbidity and early mortality.
The effects of secondhand smoke exposure are well known and include increased incidence of low birth weight and subsequent illness, increased incidence of sudden infant death syndrome (maternal smoking during and after pregnancy), increased incidence of lower respiratory tract infections and ear infections, exacerbation of asthma attacks, sleep disturbances, and intellectual
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impairment (Homa, Neff, King, et al, 2015; Al-Sayed and Ibrahim, 2014).
Etiology. Teenagers begin smoking for a variety of reasons, including imitation of adult behavior, peer pressure, a desire to imitate behaviors and lifestyles portrayed in movies and advertisements, and a desire to control weight, especially among young women. Teenagers who do not smoke usually have family members and friends who do not smoke or who oppose smoking. Most teens who refrain from smoking have a desire to succeed in academics or athletics and plans to go to college (see Community Focus box). Although smoking among college students has increased in recent years, rates of smoking are highest among adolescents who do not complete high school.
C o m m u n i t y F o c u s Early Sexual Maturation, Alcohol, and Cigarettes
Smoking cigarettes and drinking alcohol among adolescents are complex behaviors that are not explained by any one cause or factor. Some theorists and investigators believe there is a relationship between biological maturation and risk-taking behaviors. For example, young girls who are sexually mature at an earlier age than their peers are often attracted to older girls and boys who may engage in risk-taking behaviors. If older teens smoke, drink, and drive while under the influence of alcohol with no adverse consequences (e.g., no motor vehicle crashes), young girls may believe that they, too, will be safe while smoking, drinking, or riding in an automobile with friends who are drinking.
Although parents and nurses cannot influence the time of biological maturation, they can identify young girls who are at risk for the initiation of risk-taking behaviors because of early puberty. Parents need to understand that an early-maturing daughter might be uncomfortable with her body, and they should take advantage of opportunities to build her self-esteem. Parental sensitivity to the importance of peer group acceptance and parental support of a teenage daughter who feels left out or different are crucial. School nurses can provide anticipatory guidance to these girls and help them to role-play coping strategies for situations that involve offers to smoke and drink. In addition, school nurses can provide information about physical development during puberty and emphasize the fact that not all teenagers mature at the same time or rate.
Teachers, coaches, and community and church leaders can provide opportunities for these girls to “fit in” with their same-age peers through activities that stress mutual goals. For example, an early-maturing girl is typically taller than her age mates and can be an asset in sports, such as basketball and track-and-field events.
Smokeless tobacco. The term smokeless tobacco refers to tobacco products that are placed in the mouth but not ignited (e.g., snuff and chewing tobacco). This substitute for cigarettes continues to pose a hazard to adolescents, although use had steadily declined by about 50% since the peak prevalence in 1995. Children and adolescents continue to recognize the risk of smokeless tobacco and have expressed high rates of disapproval (Johnston, O'Malley, Miech, et al, 2015). These products have also been proven to be carcinogenic, and regular use can cause dental problems, foul-smelling breath, and tooth erosion or loss.
Nursing care management. Prevention of regular smoking in teenagers is the most effective way to reduce the overall incidence of smoking. A variety of methods have been used. Posters, charts, displays, statistics, and the use of examples of actual damaged lungs to communicate the hazards of smoking all have their supporters and doubters. Some schools also use films and demonstrations in science classes.
For the most part, smoking prevention programs that focus on the negative, long-term effects of smoking on health have been ineffective. Youth-to-youth programs and those emphasizing the immediate effects are more effective but primarily in improving teenagers' attitudes toward not smoking. Because smoking and smoking-related behaviors are social symbols, antismoking campaigns must address the norms of potential smokers. Anything that ridicules or threatens the social norms of the peer group can be unproductive or counterproductive. Investigators have found
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that teaching resistance to peer pressure to smoke is effective in early adolescence. Although the effects of these programs may decrease with time, the effects can be enhanced in older adolescents by presenting information in class instead of simply handing out written material to the students.
Two areas of focus for antismoking programs are peer-led programs and use of media in smoking prevention (e.g., CDs, videotapes, and films). Peer-led programs emphasizing the social consequences of smoking have proved most successful. If a significant number of influential peers can “sell” their classmates on the idea that the habit is not popular, the followers will imitate their behavior. Such programs emphasize short-term rather than long-term consequences (e.g., the effects of smoking on personal appearance, such as unattractive stains on teeth and hands and unpleasant odor of breath and clothing).
The impact of school-based antismoking programs can be strengthened by expanding these programs to include parents, mass media, youth groups, and community organizations. For example, mass media efforts that involve antismoking radio campaigns have been identified as the most cost-effective mass media intervention.
Smoking bans in schools also accomplish several goals including discouraging students from starting to smoke, reinforcing knowledge of the health hazards of cigarette smoking and exposure to environmental tobacco smoke, and promoting a smoke-free environment as the norm (see Community Focus box).
C o m m u n i t y F o c u s Considerations Nonsmoking Strategies
Nurses who work in schools, hospitals, and community agencies can take advantage of all opportunities to provide education about the dangers of smoking, to discourage smoking initiation by children and adolescents, to encourage smoking cessation, and to promote smoke-free environments. In particular, school nurses must be alert to the vulnerability of young preteens when they enter junior high or middle school. These nurses are in an ideal position to assess stress, personal conflict, weight concerns, peer pressures, and other factors that place preteens at risk for smoking initiation. Nurses should serve as counselors to student, teacher, and parent groups and as advocates for antismoking legislative efforts. The following additional strategies are recommended*:
• Provide only brief information about long-term health consequences (e.g., cardiovascular, cancer risks).
• Discuss immediate physiological consequences (e.g., changes in heart rate, blood pressure, respiratory symptoms, and blood carbon monoxide concentrations).
• Mention alternatives to smoking that also establish a self-image that appears independent, mature, or sophisticated (e.g., weightlifting; jogging; dancing; joining a boys or girls club; volunteering for a hospital or political, religious, or community group).
• Mention the negative effects in detail (e.g., earlier wrinkling of skin; yellow stains on teeth and fingers; tobacco odor on breath, hair, and clothing).
• Mention the increasing ostracism of smokers by nonsmokers, both legal and informal, in the workplace and in public places.
• Mention the increasing evidence that secondhand smoke is injurious to the health of nonsmokers who are regularly exposed, especially small children.
• Acknowledge that many adults who were enticed to start smoking as teenagers because of its social benefits, now wish they could stop smoking.
• Give cooperative adolescents effective arguments to deal with peer pressure (e.g., by not smoking, a teenager demonstrates independence and nonconformity, traits normally prized by youth).
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• Request posters or pamphlets from local agencies (e.g., American Cancer Society, American Heart Association, American Lung Association) to display in prominent places at school.
*The Centers for Disease Control and Prevention has information on the effects of tobacco, smoking cessation, and tobacco control programs: 1600 Clifton Rd., Atlanta, GA 30333; 800-232-4636; email: [email protected]; http://www.cdc.gov/tobacco.
Alcohol. Acute or chronic abuse of alcohol (ethanol) is responsible for many acts of violence, suicide, accidental injury, and death. Alcohol drinking is likely to begin in the middle school years and increase with age. By 18 years old, 80% to 90% of adolescents have tried alcohol. Ethanol is a depressant that reduces inhibitions against aggressive and sexual acting out. Severe physical and psychological symptoms accompany abrupt withdrawal, and long-term use leads to slow tissue destruction, especially of the brain and liver cells. The most noticeable effects of alcohol occur within the CNS and include changes in cognitive and autonomic functions, such as judgment, memory, learning ability, and other intellectual capacities. Young people with alcoholism often drink alone and cannot control their use of alcohol. They often rely on the substance as a defense against depression, anxiety, fear, or anger. Not all of these characteristics are observed in adolescents who are abusing alcohol, but if several signs are evident, the child or adolescent should be considered at risk. Referral to a health care professional and detoxification therapy may be necessary. Information about alcohol and answers to questions are available through the Alcohol Hotline.* Other groups that provide support and counseling for families are Al-Anon, Alateen, Alatot, and Alcoholics Anonymous (an organization that has listings in all local directories).
Cocaine. Although cocaine is not pharmacologically considered a narcotic, it is legally categorized as such. Cocaine is available in two forms: water-soluble cocaine hydrochloride, which is administered by “snorting” or intravenous injection, and non-soluble alkaloid (freebase) cocaine, which is used primarily for smoking. Crack, or “rock,” is a purer, more menacing form of the drug. It can be produced cheaply and smoked in either water pipes or mentholated cigarettes.
Cocaine creates a sense of euphoria, or an indefinable high. Withdrawal does not produce the dramatic symptoms observed in withdrawal from other substances. The effects are those commonly seen in depression, including lack of energy and motivation, irritability, appetite changes, psychomotor delay, and irregular sleep patterns. More serious symptoms include cardiovascular manifestations and seizures. Physical withdrawal should not be confused with the so-called crash after a cocaine high, which consists of a long period of sleep. Answers to questions about the risks of using cocaine are available at the National Cocaine Hotline,† which also provides referrals to support groups and treatment centers.
Narcotics. Narcotic drugs include opiates, such as heroin and morphine, and opioids (opiate-like drugs), such as hydromorphone (Dilaudid), hydrocodone, fentanyl, meperidine (Demerol), and codeine. These drugs produce a state of euphoria by removing painful feelings and creating a pleasurable experience and a sense of success accompanied by clouding of the consciousness and a dreamlike state. Physical signs of narcotic abuse include constricted pupils, respiratory depression, and, often, cyanosis. Needle marks may be visible on the arms or legs in chronic users. Physical withdrawal from opiates is extremely unpleasant unless controlled with supervised tapering doses of the opioid or substitution of methadone.
As important as the physical effects are the indirect consequences related to the illegal status of narcotic use and the problems associated with securing the drug (e.g., the time-consuming searches to obtain the drug and the often illegal methods used to meet the high cost of purchasing it). Health problems also result from self-neglect of physical needs (nutrition, cleanliness, dental care), overdose, contamination, and infection, including HIV and hepatitis B and C infection.
Central nervous system depressants. CNS depressants include a variety of hypnotic drugs that produce physical dependence and withdrawal symptoms on abrupt discontinuation. They create a feeling of relaxation and sleepiness
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but impair general functioning. Drugs in this category include barbiturates, nonbarbiturates, and alcohol. Barbiturates combined with alcohol produce a profound depressant effect. Flunitrazepam (Rohypnol), known as the “date rape drug,” is a hypnotic drug abused by adolescents. Many women and men report being raped after unknowingly being given Rohypnol in a drink. Rohypnol is 10 times more powerful than diazepam (Valium). It produces prolonged sedation, a feeling of well-being, and short-term memory loss.
Central nervous system stimulants. Amphetamines and cocaine do not produce strong physical dependence and can be withdrawn without much danger. However, psychological dependence is strong, and acute intoxication can lead to violent aggressive behavior or psychotic episodes characterized by paranoia, uncontrollable agitation, and restlessness. When combined with barbiturates, the euphoric effects are particularly addictive.
Methamphetamine can be snorted, injected, swallowed, or smoked and produces a burst of energy in its users, along with intense, alternating attacks of boldness and paranoia. It provokes excitement far more intense than that caused by cocaine. The drug, with the street names crank, meth, and crystal, is inexpensive and has a longer period of action than cocaine. Instead of a short (few minutes) high, as achieved with cocaine, a user can remain “up” for hours on a similar dose of crank.
Health care professionals are concerned about the use of various volatile substances, or inhalants such as gasoline, model cement, and organic solvents; these substances are inhaled by the user to achieve an altered sensation, and the most recent surveillance has indicated a modest increase in use after nearly a decade of decline. Adolescents breathe or place these substances into paper or plastic bags or soda cans from which they rebreathe the fumes to produce a feeling of euphoria and altered consciousness. These substances contain chemical solvents and are extremely hazardous. Dusters contain Freon, a substance that can cause fatal cardiac arrhythmias. Inhalants are the only substance that has a higher incidence of use among young adolescents. This is probably related to the fact that the products are readily available and may be the only substances available for young teens. Many young children are unaware of the dangers of “sniffing” or “huffing.” In addition to rapid loss of consciousness and respiratory arrest, these substances may cause visual scanning problems, language deficiencies, motor instability, memory deficits, and attention and concentration problems.
Mind-altering drugs. Hallucinogens (psychedelics, psychotomimetics, psychotropics, or illusionogenics) are drugs that produce vivid hallucinations and euphoria. These drugs do not produce physical dependence, and they can be abruptly withdrawn without ill effect. However, the acute and long-term effects are variable, and in some individuals, the dissociative behavior may be prolonged. Cannabis (marijuana, hashish) and lysergic acid diethylamide (LSD) are also included in this category of drugs.
Nursing Care Management and Therapeutic Management Nurses who have contact with children and adolescents are in an excellent position to provide information about substance abuse and to serve as patient advocates. Nurses most often encounter young drug abusers when they are (1) experiencing overdose or withdrawal symptoms, (2) manifesting bizarre behavior or confusion secondary to drug ingestion, (3) worried that they are or will become addicted, or (4) worried about a friend or family member who is addicted.
In particular, nurses who care for hospitalized adolescents need to know if these youths use drugs compulsively. Drug withdrawal can seriously complicate other illnesses. Nurses should be alert for any physical or behavioral clues that indicate the onset of withdrawal or the effects of drugs. School nurses and nurses who work in the community play an essential role in identifying children, adolescents, and families with substance abuse problems. The school nurse may be the first to identify a child or adolescent who has ingested a particular drug by the child's erratic behavior in class or on the school grounds (see Critical Thinking Case Study box). Early identification of those at risk for substance abuse problems is an essential aspect of prevention. Pediatric health care professionals also prevent substance abuse by creating trusting relationships so that children and adolescents feel comfortable asking questions about drugs, and health
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professionals can alert them to websites and other aspects of society that encourage experimentation with drugs.
C r i t i c a l T h i n k i n g C a s e S t u d y Prescription Medication Abuse in Adolescence
An 8th-grade teacher calls the school nurse, Sally, to her classroom and reports that a girl is behaving “strangely;” the girl slept most of the period before lunch and has not participated in class discussions. Sally, the RN, takes the girl to her office and performs an initial assessment. Upon assessment, the girl demonstrates short-term memory lapse and has slightly slurred speech, and her pupillary reaction to light is delayed; her blood pressure is 112/68 mm Hg, respirations are 14 breaths/min and regular, and heart rate is 102 beats/min. She denies taking any pills or liquid initially but then states she had a migraine on arrival to school and a friend gave her two blue pills to help with the headache. She refuses to say who gave her the pills and does not know what they were but thought they were Tylenol. She states that she does not know where her mother and father are but thinks they are at work.
Questions
1. Evidence: Is there sufficient evidence for Sally to implement a plan of care for this adolescent?
2. What should Sally's next course of action involve? What is her professional responsibility in this case?
3. Assumptions: Describe the underlying assumptions about the following:
a. The school nurse's physical assessment findings
b. The misuse of prescription medications by adolescents
4. What nursing priorities and implications for care can be made at this time? What type of care should the eighth grader receive?
RN, Registered nurse.
Acute care. Adolescents experiencing toxic drug effects or withdrawal symptoms are usually seen initially in the emergency department. Experienced emergency department personnel are familiar with the management of acute drug toxicity and the signs, symptoms, and behavioral characteristics associated with a variety of substances. When the drug is questionable or unknown, knowledge of these factors facilitates management and treatment. Often, observation or description of the child's or adolescent's behavior is more valuable than reports by patients or their friends.
The treatment for drug toxicity or withdrawal varies according to the drug and the method used. Every effort is made to determine the type, time of ingestion, amount of drug taken, mode of administration, and factors related to the onset of presenting symptoms. It is helpful to know the individual's pattern of use. For example, if two types of drugs are involved, they may require different treatments. Historically, gastric lavage has been used when the drug has been ingested recently and the cough reflex is intact, but it is of little value when the drug has been administered by the intravenous (“mainlined”) or intranasal (“sniffed”) route. More commonly, the administration of a drug antidote such as naloxone and the early (within 1 to 2 hours of ingestion) administration of activated charcoal may be used for opioid overdose. Because the actual content of most street drugs is highly questionable, other pharmaceutical agents are administered with caution, except perhaps the narcotic antagonists in cases of suspected opiate overdoses. It is also necessary to assess for possible trauma sustained while the patient was under the influence of the drug.
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Long-term management. A major factor in the treatment and rehabilitation of young drug users is careful assessment in the nonacute stage to determine the function that the drug plays in the adolescent's life. The motivation phase is directed toward exploring the factors that influence drug use. It also involves establishing a feeling of self-worth and a commitment to self-help in the teen.
Rehabilitation begins when adolescents decide they can and are willing to change. Rehabilitation involves fostering healthy interdependent relationships with caring and supportive adults and exploring alternate mechanisms for problem solving, while simultaneously reducing or eliminating drug use. Persons working with troubled youth must be prepared for recidivism, or the tendency to relapse, and maintain a plan for reentry into the treatment process.
Family support. Most treatment programs for substance abusers are based on adult 12-step models, such as Alcoholics Anonymous. Research is needed to determine whether these adult models are effective for adolescents. Tough Love* is one program that is based on the conviction that parents have the right and responsibility to be the policymakers in the family, to set limits on the behavior of their children, and to take control of the household from out-of-control adolescents. The premise is that allowing teenagers to experience the negative consequences of their behavior will bring them closer to accepting help or changing their behavior. Another group that provides support and counseling for families experiencing substance abuse and seeking strategies to cope with their children is Parents Anonymous.† Another source of information is the Substance Abuse and Mental Health Services Administration's National Clearinghouse for Alcohol and Drug Information.‡
Prevention. Nurses play an important role in education efforts, as well as in individual observation, assessment, and therapy related to substance abuse. In recent years, a variety of educational programs have been applied with promising results. The most effective prevention strategies are those that are part of a broader, more general effort to promote overall health and success. Health-compromising behaviors are often interconnected and have common antecedents. Prevention efforts that focus on changing only one behavior (e.g., alcohol, other drug use) are less likely to be successful. Successful programs are those that have promoted parenting skills, social skills among distractible children, academic achievement, and skills to resist peer pressure.
Peer pressure is a powerful tool and can be used effectively in substance abuse prevention. A group that has had some success in reducing injury from drunk driving is Students Against Destructive Decisions (SADD).§ Techniques used by this group include peer counseling, parental guidelines for teenage parties, and community awareness. Nurses should encourage the formation of SADD chapters in the high schools in their communities.
Suicide Suicide is defined as the deliberate act of self-injury with the intent that the injury results in death. Most experts distinguish among suicidal ideation, suicide attempt (or parasuicide), and suicide.
Suicidal ideation involves a preoccupation with thoughts about committing suicide and may be a precursor to suicide. Although it is common for adolescents to experience occasional suicidal thoughts, expressions of preoccupation with suicide should be taken seriously, and an assessment should be conducted for appropriate referral. A suicide attempt is intended to cause injury or death. The term parasuicide is used to refer to behaviors ranging from gestures to serious attempts to kill oneself. Parasuicide is a preferred term, because it makes no reference to intent and because a person's motive may be too difficult or complex to determine. However, all parasuicidal activity should be taken seriously.
N u r s i n g A l e r t A history of a previous suicide attempt is a serious indicator for possible suicide completion in the future. Studies of adolescent suicides have found that as many as half of the adolescents had made previous attempts.
Results from the Youth Risk Behavior Surveillance (2011) indicated that 7.8% of students
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nationwide had attempted suicide at least once during the 12 months preceding the survey; the range of suicide attempts by adolescents across the states varied from 3.6% to 11.3% (Eaton, Kann, Kinchen, et al, 2012). The overall incidence of youth suicide has decreased since 1992, yet the Centers for Disease Control and Prevention and other experts note that the incidence is still too high. Approximately 12.8% of the students in this survey reported that they had made a specific plan to attempt suicide in the 12 months preceding the survey. Suicide is currently the third leading cause of death during the teenage years, surpassed only by death from motor vehicle crashes and homicides (see Chapter 1).
Etiology Individual, family, and social or environmental factors have all been implicated in suicide. The single most important individual factor is the presence of an active psychiatric disorder (depression, bipolar disorder, psychosis, substance abuse, or conduct disorder). Alcohol use in particular has been self-reported with more than 75% of suicide attempts among adolescents (Schilling, Aseltine, Glanovsky, et al, 2009). For some teens, suicide becomes the final pathway for release from their psychiatric and social problems. Child and adolescent suicide victims are reported to have higher rates not only of depression but also of conduct disorders; bipolar disorders; substance abuse; interpersonal problems with parents; and a family history of depression, substance abuse, and suicidal behavior.
Family factors influencing suicide include parental loss; family disruption; a family history of suicide, depression, substance abuse, or emotional disturbance; child abuse or neglect; unavailable parents; poor communication and isolation within the family; family conflict; and unrealistically high parental expectations or parental indifference with low expectations. Families who respect individuality, are cohesive and caring, balance discipline with a supportive and understanding relationship, have good systems of communication, and have at least one attentive and caring parent available to the child protect adolescents from suicidal outcomes. Social or environmental risk factors include incarceration, isolation, acute loss of a boyfriend or girlfriend, lack of future options, and availability of firearms in the home.
Methods Firearms are by far the most commonly used instruments in completed suicides among males and females (American Academy of Pediatrics, Dowd, Sege, et al, 2012). For adolescent males, the second and third most common means of suicide are hanging and overdose, respectively; for females, the second and third most common means are overdose and strangulation, respectively.
The most common method of suicide attempt is overdose or ingestion of a potentially toxic substance, such as drugs. The second most common method of suicide attempt is self-inflicted laceration.
N u r s i n g A l e r t Given what is known about youth suicide, nurses should ask parents, especially those with at-risk teenagers, if firearms are available in the house and, if so, recommend their removal. Parents must ensure that their children—especially those who are depressed, have poor problem-solving skills, or use drugs or alcohol—do not have access to firearms. Parents must also be educated on the warning signs of suicide (Box 16-7).
Box 16-7 Wa r n i n g S i g n s o f S u i c i d e • Preoccupation with themes of death—focuses on morbid thoughts
• Wants to give away cherished possessions
• Talks of own death, desire to die
• Loss of energy, loss of interest, listlessness
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• Exhaustion without obvious cause
• Changes in sleep patterns—too much or too little
• Increased irritability, argumentativeness, or stubbornness
• Physical complaints—recurrent stomachaches, headaches
• Repeated visits to physician, nurse practitioner, or emergency department for treatment of injuries
• Reckless behavior
• Antisocial behavior—engages in drinking, uses drugs, fights, commits acts of vandalism, runs away from home, becomes sexually promiscuous
• Sudden change in school performance—lowered grades, cutting classes, dropping out of activities
• Resists or refuses to go to school
• Remains distant, sad, remote—flat affect, frozen facial expression
• Describes self as worthless
• Sudden cheerfulness following deep depression
• Social withdrawal from friends, activities, interests that were previously enjoyed
• Impaired concentration
• Dramatic change in appetite
Motivation Suicidal ideation is common in adolescents. It represents numerous fantasies, such as relief from suffering, a means of gaining comfort and sympathy, or a means of revenge against those who have hurt them. Adolescents have the erroneous perception that the act of suicide will evoke remorse and pity and that they will be able to return and witness the grief. Angry children or adolescents who are unable to directly punish those who have injured or insulted them may take revenge on those who love them through self-destruction (e.g., “They'll be sorry when they find me dead;” “They'll be sorry they were mean to me”).
For adolescents who are severely depressed, suicide seems to be the only release from their despair. These adolescents rarely provide evidence of their intent and frequently conceal their suicidal thoughts. Many adolescents, however, tell their peers of their suicidal thoughts or plans but avoid telling adults. Social isolation is a significant factor in distinguishing adolescents who will kill themselves from those who will not. It is also more characteristic of those who complete suicide than of those who make attempts or threats.
The frequency of contagion, or copycat suicides (i.e., an increase in youth suicide that occurs after the suicide of one teenager is publicized) is disturbing and may indicate that teenagers perceive suicide as glamorous. In addition, young people may not realize the finality of suicide because they have become desensitized from constantly viewing violence and death on television.
Diagnostic Evaluation Depression is common among adolescents who attempt suicide. Depression is characterized by both subjective symptoms and objective signs that reflect the adolescent's sadness and despair. Adolescents describe feelings of sadness, despair, helplessness, hopelessness, boredom, loss of interest, and isolation. They may also feel self-reproach, self-deprecation, and guilt. Subjective symptoms of depression or specific changes in behavior place an adolescent at risk for suicide.
Therapeutic Management
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Threats of suicide should always be taken seriously. There has been a tendency to dismiss suicide attempts as impulsive acts resulting from temporary crises or depression. If a suicide attempt fails to draw attention to his or her problems or makes them worse, the child or adolescent may conclude that suicide is the only answer. Children and adolescents need to know that someone cares and must be provided with swift and efficient crisis intervention. Although ordinary practitioners can manage an acute depressive reaction without difficulty, the adolescent who has made a serious attempt or has a specific plan for suicide should receive immediate attention and competent psychiatric care.
Youths who are actively suicidal need inpatient care, monitoring, and treatment. Medications for depression and bipolar disorder often take several weeks to reach therapeutic dosages. The time until medications and therapy begin to take effect can be trying for the adolescent and the family. It is important to encourage families to support their teen in adherence to the regimen prescribed. The SSRIs are often prescribed for depression, but teens who are taking such medications need careful, frequent monitoring.
N u r s i n g A l e r t Adolescents who express suicidal feelings and have a specific plan should be monitored at all times. They should not have access to firearms, prescription or over-the-counter drugs, belts, scarves, shoestrings, sharp objects, matches, or lighters. If they are intoxicated, they must be restrained or placed in a protective environment until a psychiatrist or psychologist can assess them.
Nursing Care Management Nurses play a pivotal role in reducing adolescent suicide. Nurses have the opportunity to provide anticipatory guidance to parents and adolescents. They can teach parents to be supportive and to develop positive communication patterns that help teens feel connected with and loved by their families. To foster healthy development, parents can be encouraged to provide teens with creative outlets and to assist young people in accepting strong emotions—pain, anger, and frustration—as a normal part of the human experience.
Care of suicidal adolescents includes early recognition, management, and prevention. The most important aspect of management is the recognition of warning signs that indicate that an adolescent is troubled and might attempt suicide. The nurse must take any suicidal remarks seriously and not leave the young person alone until the degree of suicidality is assessed. A mnemonic for the assessment process is SLAP: Specificity, Lethality, Accessibility, and Proximity. The first step (specificity) is to ask adolescents whether they feel suicidal or as though they would like to take their own lives. If so, have they chosen a means of suicide, and do they have a specific plan? The second stage of assessment (lethality) involves determining the lethality of the methods available to them. Do they plan to use a gun or knife? Have they chosen highly lethal medications, hanging, or carbon monoxide poisoning? The third stage (accessibility) involves determining the availability of the means of suicide, and the fourth stage (proximity) involves assessing whether they have determined a time to commit suicide and when.
Health professionals must be alert to the signs of depression, and anyone who exhibits such behavior should be referred for thorough psychological assessment. Depression is manifested differently in children and adolescents than in adults. In teens, it may be masked by impulsive aggressive behaviors. Defiance, disobedience, behavior problems, and psychosomatic disturbances can indicate underlying depression, suicidal ideation, and impending suicide attempts.
N u r s i n g A l e r t No threat of suicide should be ignored or challenged. Threats are a symptom that must be taken seriously. Too often, suicidal threats or minor attempts are confused with bids for attention. It is also a mistake to be lulled into a false sense of security when an adolescent's depression is apparently relieved. The improvement in attitude may mean that the adolescent has made the decision and found the means to carry out the threat.
Peers and other confidants are valuable observers and excellent sources of information about
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potential suicide attempts. They may not be able to diagnose depression, but they are able to sense when a friend has undergone a marked personality change. It is important to emphasize that the peer who detects any changes in a friend is a potential rescuer and should not remain silent about the observations. Friendship does not imply collusion. A peer who believes that a friend may be suicidal should alert someone who can help (e.g., a parent, teacher, guidance counselor, school nurse).
Routine health assessments of adolescents should include questions that assess the presence of suicidal ideation or intent. The following questions can be asked (Greydanus and Pratt, 1995):
1. Do you consider yourself more a happy person, an unhappy person, or somewhere in the middle?
2. Have you ever been so unhappy or upset that you felt like being dead?
3. Have you ever thought about hurting yourself?
4. Have you ever developed a plan to hurt yourself or kill yourself?
5. Have you ever attempted to kill yourself?
If adolescents answer “yes” to questions 2, 3, or 4, they should be asked if they feel that way now to assess for current suicidality. If teens say they have attempted suicide in the past, assess the number of times and ask them to describe what they were feeling, which method they used, what happened, if they would make a similar attempt, and how they would handle their despair now. Any previous suicide attempt indicates an increased risk for a future attempt. The risk of a suicide attempt in the near future increases as the frequency of suicidal ideation increases.
N u r s i n g A l e r t The National Suicide Prevention Lifeline (800-273-TALK [8255]; in Spanish, 888-628-9454) offers someone to talk to 24/7.
If children or adolescents express suicidal intent, nurses can make a contract, asking them to sign an agreement that they will not attempt suicide during an agreed-on period and that they will call the 24-hour crisis line immediately if they feel that they cannot keep to their contract. The amount of time an adolescent feels comfortable contracting to is usually an indication of his or her risk and stability.
Because a suicide attempt is frequently an outgrowth of family distress, it is essential to intervene with the family. It is important to assess family interactions and to recognize disturbed relationships. The most effective approach is recognition of susceptible adolescents during the early stages of family distress so that family counseling can be started. Prevention must be directed toward improving childrearing practices through support and education of parents and changing societal conditions that generate defeat, despair, and maladaptive behavior.
Although confidentiality is an essential part of adolescent counseling, in the case of self- destructive behaviors, confidentiality cannot be honored. Suicidal behavior is reported to the family and other professionals, and adolescents are informed that this will be done. Such action conveys an important message to the youth: that the professionals understand and care.
Many schools have instituted suicide prevention programs. These programs include services such as drop-in counseling and a peer counseling telephone line. Information can also be obtained from the American Association of Suicidology.*
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NCLEX Review Questions 1. Which of the following should the nurse discuss with a 14-year-old adolescent female taking
isotretinoin (Accutane) for the treatment of acne? Select all that apply. a. Birth control methods b. Feelings of depression c. Sudden thoughts about hurting oneself d. Blurred vision e. Mood swings
2. Joanna, a 19-year-old pregnant female, is at the clinic for her first prenatal care visit. She is in her first trimester. Joanna has been recently diagnosed with HIV and is concerned about the health of her unborn fetus. The nurse counsels Joanna that treatments are available to prevent or minimize perinatal transmission of HIV. The current evidence-based recommendations to prevent perinatal transmission of HIV are to: a. Administer intravenous zidovudine 24 hours before delivery b. Start a combination of antiviral drugs as soon as possible c. Avoid giving antiretroviral drugs until the 28th week of gestation d. Wait until the infant is born because perinatal transmission before delivery is very rare
3. Which of the following conditions may lead to the development of obesity in children and adolescents? Select all that apply. a. Hereditary low metabolism b. Physical inactivity c. Socioeconomic status d. Use of food as a positive reinforcer of desired behaviors e. Availability of energy-dense foods and drinks f. Positive self-esteem
4. A 15-year-old female diagnosed previously with anorexia nervosa (AN) is admitted to the emergency department. Her mother states that her daughter has not voided in 24 hours and has been lethargic for the last 12 hours. The patient appears cachectic and pale, and her weight is recorded as 78 pounds. She is minimally responsive to painful stimulation. A number of diagnostic tests are obtained. Which one of these represents the most immediate threat to her life requiring intervention? a. Serum sodium of 149 mEq b. Serum potassium of 2.6 mEq c. Hemoglobin of 6.8 mg d. Arterial pH of 7.30
5. Almost one half of all cases of pelvic inflammatory disease (PID) in the United States are caused by: a. Neisseria gonorrhoeae b. Chlamydia trachomatis c. Treponema pallidum d. Human papillomavirus (HPV)
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Correct Answers 1. a, b, c, e; 2. b; 3. b, c, d, e; 4. b; 5. b
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Van Cleave J, Gortmaker SL, Perrin JM. Dynamics of obesity and chronic health conditions among children and youth. JAMA. 2010;303(7):623–630.
Wampler SM, Llanes M. Common scrotal and testicular problems. Prim Care. 2010;37(3):613– 626.
Wildes JE, Marcus MD. Alternative methods of classifying eating disorders: models incorporating comorbid psychopathology and associated features. Clin Psychol Rev. 2013;33(3):383–394.
Workowski KA, Berman S. Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR–12):1–110.
*http://www.cdc.gov/std/treatment/. *For information about local organizations, contact National Organization for Victim Assistance, 510 King St., Suite 424, Alexandria, VA 22314; 800-879-6682 or 703-535-6682; http://www.trynova.org. *http://www.cdc.gov/growthcharts. *www.choosemyplate.gov. *For additional information on prevention of obesity in childhood, visit the Institute of Medicine website, www.iom.edu/obesityyoungchildren. *Helpline 630-577-1330, available 9 AM to 5 PM Central Time, Monday to Friday; email: [email protected]; http://www.anad.org. †Referral helpline 800-931-2237, available 9 AM to 9 PM Eastern Time, Monday to Thursday and 9 AM to 5 PM, Friday; http://www.nationaleatingdisorders.org/. *Toll free 800-331-2900. †800-COCAINE (800-262-2463). *http://www.toughlove.com. †675 W. Foothill Blvd., Suite 220, Claremont, CA 91711; 909-621-6184; http://www.parentsanonymous.org.
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‡Choke Cherry Road, Rockville, MD 20857; 877-SAMHSA-7; http://www.samhsa.gov/ §255 Main St., Marlborough, MA 01752; 877-SADD-INC; http://www.sadd.org. *5221 Wisconsin Ave. NW, Washington, DC 20015; 202-237-2280; http://www.suicidology.org.
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U N I T 7 Family-Centered Care of the Child with Special Needs
OUTLINE 17 Quality of Life for Children Living with Chronic or Complex Diseases 18 Impact of Cognitive or Sensory Impairment on the Child and Family
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Quality of Life for Children Living with Chronic or Complex Diseases Sharron L. Docherty, Raymond Barfield, Debra Brandon
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Perspectives on the Care of Children and Families Living with or Dying From Chronic or Complex Diseases Scope of the Problem Advances in medical and nursing care, such as the increasing viability of extremely preterm infants, the portability of life-sustaining technology (e.g., total parental nutrition, ventilatory support), and life-extending treatments for children with conditions that previously would have led to an early death (e.g., malignancies, genetic conditions), have led to an exponential rise in the prevalence of children with complex and chronic diseases (Burke and Alverson, 2010; Simon, Berry, Feudtner, et al, 2010). These children have complex conditions involving several organ systems and require multiple specialists, technologic supports, and community services to assist them to function to their healthiest potential. The complex, high level of skill required to meet their daily health care needs and the continuous nature and potential volatility of their conditions sets this group apart from the broader population of children with special health care needs (Cohen, Kuo, Agrawal, et al, 2011; Simon, Berry, Feudtner, et al, 2010; Kuo, Cohen, Agrawal, et al, 2011). A range of terms, such as complex chronic condition, medically complex, technology dependent, and multiply handicapped, have been used to describe this vulnerable population of children (Carnevale, Rehm, Kirk, et al, 2008; Cohen, Friedman, Nicholas, et al, 2008; Cohen, Kuo, Agrawal, et al, 2011; Feudtner, Feinstein, Zhong, et al, 2014). Frequent and prolonged hospitalizations; complex and multisystem health and developmental needs; and reliance on technology and care that cross hospital, clinic, and home settings are the key characteristics that all of these terms seek to signify about the children they are used to represent (Berry, Hall, Hall, et al, 2013; Cohen, Kuo, Agrawal, et al, 2011; Feudtner, Feinstein, Zhong, et al, 2014).
The nature and severity of childhood chronic and complex conditions is widely heterogeneous. Table 17-1 is a non-exhaustive sampling of conditions organized by specialty. However, these children and families are similar in the vulnerability that they experience due to the health and developmental consequences of these diagnoses on the child, such as ongoing functional impairment, neurodevelopmental disability, dependence on medical technology, and the need for ongoing skilled, supportive care from health care providers and family members. Although many authors have described the rise in prevalence that has come about because of advances in medical care (Burns, Casey, Lyle, et al, 2010; Council on Children with Disabilities, 2005; Simon, Berry, and Feudtner, et al, 2010), accurate estimates of the numbers of affected families are not known (Carnevale, Rehm, Kirk, et al, 2008). However, the impact of chronic and complex illness in children is wide ranging. The family experiences significant challenges necessitated by the child's care requirements (Goudie, Narcisse, Hall, et al, 2014; Kratz, Uding, Trahms, et al, 2009; Kuo, Cohen, Agrawal, et al, 2011; MacDonald and Callery, 2008). A child's activity level and developmental opportunities can be affected. Days can be lost from school. Children with complex chronic conditions may be at increased risk for behavior or emotional problems. Parents may lose days from work, experience financial strain, and be challenged both emotionally and physically as they cope with care of the child.
TABLE 17-1 Chronic Conditions of Childhood
Specialty Examples of Chronic Conditions Cardiology Complex congenital heart disease, congestive heart failure, cardiac dysrhythmias, Kawasaki disease, rheumatic fever, hyperlipidemia Endocrinology Diabetes, congenital adrenal hyperplasia, Cushing syndrome Gastroenterology Short bowel syndrome, biliary atresia, inflammatory bowel disease, hepatitis, cirrhosis, peptic ulcer disease, celiac disease Hematology Sickle cell anemia, thalassemia, aplastic anemia, hereditary anemias, hemophilia Immunology Immune deficiency, human immunodeficiency virus, Wiskott-Aldrich syndrome, severe combined immunodeficiency disease Nephrology Prune belly syndrome, renal disease Neurology Cerebral palsy, ataxia telangiectasia, muscular dystrophy, seizure disorder, spina bifida, traumatic brain injury Oncology Brain tumor, leukemia, lymphoma, solid tumors, bone tumors, rare tumors Pulmonology Asthma, chronic lung disease, cystic fibrosis, tuberculosis Rheumatology Systemic lupus erythematosus, juvenile rheumatoid arthritis, dermatomyositis
Siblings are also affected by having a “different” brother or sister, and they may simultaneously feel guilt, anger, or jealousy toward their ill sibling. Clinicians need to know that siblings of children with chronic illnesses are at risk for negative psychological effects (Hartling, Milne, Tjosvold, et al, 2014). Parents need encouragement and assistance with understanding the reactions
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of siblings to having a chronically ill family member (e.g., behavioral regression, anxiety, withdrawal, apathy). Additionally, secondary losses (such as the ability to participate in extracurricular activities or social events) occur because of routines imposed by the affected child's chronic condition.
Trends in Care Developmental Focus Focusing on the child's developmental level rather than chronologic age or diagnosis emphasizes the child's abilities and strengths rather than disabilities. Attention is directed to normalizing experiences, adapting the environment, and promoting coping skills. Nurses often are in vital positions to redirect attention from the pathological model with its focus on weaknesses and problems to the developmental model to meet the unique needs of the child and family.
A developmental focus also considers family development. The life cycle of the family unit reflects changing ages and needs of family members, as well as changing external demands. A family member's serious illness can cause significant stress or crisis at any stage of the family life cycle. Just as with individual development, family development may be interrupted or even regress to an earlier level of functioning. Nurses can use the concept of family development to plan meaningful interventions and evaluate care (see Developmental Theory, Chapter 3).
Family-Centered Care Children's physical and emotional health, as well as their cognitive and social functioning, is strongly influenced by how well their families function (Dunst and Trivette, 2009; Treyvaud, 2014; Kuhlthau, Bloom, Van Cleave, et al, 2011). The importance of family-centered care—a philosophy that considers the family as the constant in the child's life—is especially evident in the care of children with special needs (see also Family-Centered Care, Chapter 2). As parents learn about the child's health care needs, they often become experts in delivering care. Health care providers, including nurses, are adjuncts to the child's care and need to form partnerships with parents. Effective communication and negotiation between parents and nurses are essential to forming trusting and effective partnerships and finding the best ways to meet the needs of the child and family (Corlett and Twycross, 2006; Kuo, Houtrow, Arango et al, 2012). Collaborative relationships are characterized by communication, dialogue, active listening, awareness, and acceptance of others' differences (Kuhlthau, Bloom, Van Cleave, et al, 2011).
Family–Health Care Provider Communication The disclosure of a serious chronic or complex condition of a child is one of the most stressful aspects of communication between families and health care professionals. Often, parents have suspected for some time that something is wrong with their child and believe that their concerns were minimized or ignored by health care professionals (Smaldone and Ritholz, 2011; Thomlinson, 2002; Whitehead and Gosling, 2003). After a diagnosis is made, factors that influence parent dissatisfaction with the way in which information is communicated include disrespectful attitudes, breaking bad news in an insensitive manner, withholding information, and changing a treatment course without preparing the child and family (Barnes, Gardiner, Gott, et al, 2012; Hsiao, Evan, and Zeltzer, 2007). Conversely, parents report satisfaction when they perceived health care providers to be available, demonstrate competence, and engage the child and parent in care decision making (Barnes, Gardiner, Gott, et al, 2012; Hsiao, Evan, and Zeltzer, 2007; Kuo, Sisterhen, Sigrest, et al, 2012). Similar factors are important in communication of changes in the child's condition throughout the course of the illness.
Providing information to families with a chronically ill child should be a process of repeated discussions to allow the family to process the information and their reactions to that information and allow them to ask for clarification and further information. Nurses play an important role in ensuring that families' needs are met during discussions related to the child's diagnosis, condition, and treatment (Kavanaugh, Moro, and Savage, 2010). This requires assessment regarding how much information the family is comfortable with, what they understand of the information already given to them, and how they are coping with the information both cognitively and emotionally. Nurses should ensure that the appropriate health care professionals address any concerns or further questions that families may have.
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Establishing Therapeutic Relationships Another important aspect of family-centered care of children with chronic and complex conditions is establishing a therapeutic relationship with the child and family, which has been shown to predict improved health-related outcomes (Kuhlthau, Bloom, Van Cleave, et al, 2011). Families, most often the mother, take on enormous responsibility in providing technical care and symptom management of their child's condition outside of the health care institution (Goudie, Narcisse, Hall, et al, 2014; Raina, O'Donnell, Rosenbaum, et al, 2005). To build successful therapeutic relationships with families, it is necessary for nurses to recognize parents' expertise with regard to their child's condition and needs. Health care environments for children with serious illnesses are fraught with obstacles that serve as barriers to successful therapeutic relationships with families. Individual discussions, especially with the case manager, primary nurse, clinical nurse specialist, or nurse practitioner, help establish a consistent and flexible care plan that can prevent conflicts or deal with these conflicts before they disrupt care.
The Role of Culture in Family-Centered Care Issues of culture, ethnicity, and race affect access to services, utilization, and follow-through with referrals and recommendations (Coker, Rodriguez, and Flores, 2010; Toomey, Chien, Elliott, et al, 2013). For some ethnic and minority populations, cultural understandings of illness, the structure of family life, social roles for individuals with disabilities, and other factors related to the perception of children may differ from those of mainstream American culture.
Although culture cannot completely explain how an individual will think and act, understanding cultural perspectives can help the nurse anticipate and understand why families may make certain decisions. Cultural attributes such as values and beliefs regarding illness or chronic condition and its causation, social roles for people who are ill or disabled, family structure, the role of children, childrearing practices, self versus group orientation, spirituality, and time orientation also affect a family's response to illness or chronic condition in a child (Carnevale, Alexander, Davis, et al, 2006; Dell'Api, Rennick, and Rosmus, 2007; Wiener, McConnell, Latella, et al, 2013).
When parents are informed of their child's chronic illness, interpreters familiar with both culture and language should be used. Children, family members, and friends of the family should not be used as translators, because their presence may prevent parents from openly discussing the issues. When working with people of cultural backgrounds different from their own, nurses must listen carefully with an initial goal of understanding and articulating the family's perspective. The ability to interpret the mainstream medical culture to the family is also important. Furthermore, every effort is made to incorporate traditional cultural beliefs of a family into treatment plans. It is important to keep in mind that “cultural norms” may not always apply to every family from a shared background. Developing a care plan in conjunction with the family, considering their preferences and priorities, is an important first step in formulating a plan that best meets the family's needs, no matter what their cultural background (Coker, Rodriguez, and Flores, 2010; Thibodeaux and Deatrick, 2007; Wiener, McConnell, Latella, et al, 2013).
Shared Decision Making Shared decision making among the child, family, and health care team can result from open, honest, culturally sensitive communication and the establishment of a therapeutic relationship among the family and health care providers. In a shared decision-making model, the health care professionals provide honest, clear information regarding diagnosis, prognosis, treatment options, and risk– benefit assessment. The patient and family then share information with the health care team regarding important family values, acceptable levels of discomfort or inconvenience, and the ability to comply with treatments being recommended (Kon, 2010; Wiener, McConnell, Latella, et al, 2013; Wyatt, List, Brinkman, et al, 2015). This process allows them to discuss all options in terms of the risks and benefits to the child and family, the prognosis or expected course of the illness, and the impact on the family's resources (Box 17-1). Together, the parents and health care team can make decisions that are best for the family and child at the time the decision is made (Kon, 2010).
Box 17-1 F a c i l i t a t i n g S h a r e d D e c i s i o n M a k i n g
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• Continually assess the impact of the child's illness and treatment on the family.
• Provide honest, accurate information regarding the trajectory of the disease, anticipated complications, and prognostic information.
• Discuss what the family desires for the child's quality of life.
• Avoid personal opinion or judgment of the family's questions and decisions.
• Be aware of nurses' personal and cultural assumptions and the ways these assumptions impact communication, decision making, and judgment.
Normalization Normalization refers to the efforts family members make to create a normal family life, their perceptions of the consequences of these efforts, and the meanings they attribute to their management efforts (Knafl, Darney, Gallo, et al, 2010). For chronically ill children, such efforts may include attending school, pursuing hobbies and recreational interests, and achieving employment and a level of independence. For their families, it may entail adapting the family routine to accommodate the ill or disabled child's health and physical needs (Kratz, Uding, Trahms, et al 2009; Kuo, Cohen, Agrawal, et al, 2011).
Children with chronic and complex conditions and their families face numerous challenges in achieving normalization. Families move between the “normal” of living with the experience of chronic childhood illness and the “normal” of the healthy outside world; they often redefine “normal” based on their particular experiences, needs, and circumstances (Knafl, Darney, Gallo, et al, 2010; Nelson, 2002). Normalization may be an important mediator of illness-related stressors (e.g., treatment demands, uncertainty) on family outcomes.
Nurses can assist families in normalizing their lives by assessing the family's everyday life, social support systems, coping strategies, family cohesiveness, and family and community resources. Interventions include encouraging families to reduce stress through delegation of care and family tasks, identifying ways to incorporate care into current routines, structuring the home environment to encourage the child's engagement in age-appropriate activities, and ensuring families have access to appropriate community support services (Jokinen, 2004; Knafl and Santacroce, 2010). Being supportive of the child's illness and treatment and actively including the family in all aspects of care will improve their self-esteem and promote further development (Jones and Prinz, 2005; Knafl and Santacroce, 2010).
Home care represents the return to a system and set of priorities in which family values are as important in the care of a child with a chronic health problem as they are in the care of other children. Home care seeks to achieve goals that are consistent with the developmental model (Stein, 1985): • Normalize the life of the child, including those with technologically complex care, in a family and
community context and setting. • Minimize the disruptive impact of the child's condition on the family. • Foster the child's maximum growth and development.
With appropriate training and support, families provide complex procedures and treatments in the home. Parents are challenged to retain a homelike setting among monitors, ventilators, and other sophisticated equipment. Throughout the text, home care is discussed as appropriate for specific conditions. The process of transition from hospital to home is elaborated on in Chapters 19 and 20.
Paralleling normalization and home care is the process of mainstreaming, or integrating children with disabilities into regular classrooms. Children who attend school have the advantages of learning and socializing with a wide group of peers. There is an increased focus on individualization as plans are made to meet the academic needs of these children along with those of the rest of the students.
A variety of supplemental programs have been designed in the school system to accommodate special needs, both at school age and younger, through early intervention, which consists of any sustained and systematic effort to assist developmentally vulnerable or disabled children from birth to 3 years old. Increased opportunities for normalization for children with disabilities has resulted
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in large part from the passage of (1) the Education for All Handicapped Children Act of 1975 (Public Law 94-142) and its 1990 amendments (Public Law 101-476), which changed the name of the Act to the Individuals with Disabilities Education Act (IDEA); (2) the Education of the Handicapped Act Amendments of 1986 (Public Law 99-457), which directs states to develop and implement statewide comprehensive, coordinated, multidisciplinary interagency programs of early intervention services for infants and toddlers with disabilities, as well as support services for their families; and (3) the Americans with Disabilities Act of 1990. Nurses can provide parents with information about these laws and in some cases may participate in the development of Individualized Educational Programs (IEPs) or Individualized Family Service Plans (IFSPs) for children with disabilities.
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The Family of the Child with a Chronic or Complex Condition A major goal in working with the family of a child with chronic or complex illness is to support the family's coping and promote their optimal functioning throughout the child's life. Long-term, comprehensive care involves forming parent–professional partnerships that can support a family's adaptation across the trajectory of the illness to the many changes that may be necessary in day-to- day life, determine expectations of and for the child, and provide a long-term perspective (Box 17- 2).
Box 17-2 A d a p t i ve Ta s k s o f Pa r e n t s H a v i n g C h i l d r e n w i t h C h r o n i c C o n d i t i o n s 1. Accept the child's condition.
2. Manage the child's condition on a day-to-day basis.
3. Meet the child's normal developmental needs.
4. Meet the developmental needs of other family members.
5. Cope with ongoing stress and periodic crises.
6. Assist family members to manage their feelings.
7. Educate others about the child's condition.
8. Establish a support system.
From Canam C: Common adaptive tasks facing parents of children with chronic conditions, J Adv Nurs 18:46-53, 1993.
Often the impact of a child's medical or developmental condition is first experienced as a crisis at the time of diagnosis, which may occur at birth, after a long period of diagnostic testing, or immediately after a tragic injury. But the impact may also be felt before the diagnosis is made, when parents are aware that something is wrong with their child but before medical confirmation (Smaldone and Ritholz, 2011; Thomlinson, 2002; Whitehead and Gosling, 2003).
The diagnosis and initial discharge home are critical times for parents (Coffey, 2006). Several factors can make this particularly difficult, including a long duration of uncertainty in the diagnostic process, negative perceptions of chronic illness, insufficient information, and lack of mutual trust between parents and their child's health care team (Huang, Kenzik, Sanjeev, et al, 2010; LeGrow, Hodnett, Stremler, et al, 2014; Monterosso, Kristjanson, Aoun, et al, 2007; Nuutila and Salanterä, 2006). Parental feelings of shock, helplessness, isolation, fear, and depression are common (Coffey, 2006; Nuutila and Salanterä, 2006). Throughout the first year, parents struggle to accept the child's diagnosis, care, and uncertainty of the future (Coffey, 2006). Optimal support at the time of diagnosis and initial discharge home can be encouraged by providing explicit and uncomplicated information to parents in an empathic way (Nuutila and Salanterä, 2006); assessing the family's daily routine, living conditions, background knowledge, skills and abilities, and coping behaviors; and evaluating the family's understanding of the information. It is also necessary to reassess parents' needs for information and support on a routine basis (Nuutila and Salanterä, 2006).
Other critical times include the exacerbation of the child's physical symptoms, which increases parental care. These crises often involve medical intervention and rehospitalization. Frequently, the child does not return to his or her precrisis level of functioning, and parents and family must adapt to new care needs and schedules. Instability may also follow transition points on the illness trajectory. Supporting parents, respecting their stress and emotions, and acknowledging their role
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as team members in the care of their child are important aspects of nursing care (Coffey, 2006; Nuutila and Salanterä, 2006; Panicker, 2013).
Impact of the Child's Chronic Illness Each member in the family of a child with a chronic or complex illness is affected by the experience (Goudie, Narcisse, Hall, et al, 2014; Kuo, Cohen, Agrawal, 2011; Sullivan-Bolyai, Sadler, Knafl, et al, 2003). The effects on the parents and their responses may be so intense that they directly influence the other members' reactions and the child's own coping.
Parents In addition to the stress of grieving for the loss of hope for a perfect child, parents are affected by whether or not they receive positive feedback from interactions with their child. Many parents feel satisfaction and fulfillment from the parenting role. For others, parenting may be a series of unrewarding experiences that contribute to feelings of inadequacy and failure (Box 17-3). These responses may be most evident in parents who are responsible for the child's care. For example, parents may become preoccupied with their ability to carry out certain procedures, overlooking the child's personal comfort and satisfaction, or failing to offer praise for anything less than perfect cooperation or performance. They may pursue a frustrating activity until they achieve “success”— long after the child has become irritable and uncooperative. As a result, parents can become caught in a pattern of interaction that is mutually unrewarding and minimally productive. This situation may become exacerbated by disagreements or lack of support from other family members and judgment from caregivers and others in the community. For these parents, several strategies may be helpful, including education regarding what can reasonably be expected of their child, assistance in identifying the child's strengths, praise for a parental job well done, and respite care so that parents can renew their energies.
Box 17-3 A n t i c i p a t e d Pa r e n t a l S t r e s s P o i n t s Diagnosis of the condition: Parents require considerable education while dealing with an
emotional response.
Developmental milestones: Times that children normally achieve walking, talking, and self-care are delayed or impossible for the child.
Start of schooling: Particularly stressful are situations in which appropriate schooling will not be in a regular class placement.
Reaching the ultimate attainment: Parents must handle situations such as realizing that ambulation will be impossible or that the child will not learn to read.
Adolescence: Issues such as sexuality and independence become prominent.
Future placement: Decisions about placement must be made when the child becomes an adult or when the parents can no longer care for the child.
Death of the child
Parental Roles Parenting a child with a complex chronic condition requires attending to the routine aspects of parenting with the added responsibility of performing complex technical care, symptom management, advocating for their child, and seeking and coordinating health and social services for their ill or disabled child (Kirk, Glendinning, and Callery, 2005). These added responsibilities must then be balanced with the needs of other family members, extended family and friends, and personal health and obligations to minimize consequences to the overall functioning of the family (Coffey, 2006).
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Often one parent or partner remains at home to manage existing family responsibilities while the other remains with the ill child. The partner who is not included in the caregiving activities may feel neglected because all of the attention is directed toward the child and be resentful that he or she is not sufficiently informed to be competent in the care. Without active participation in the child's care, the parent has little appreciation of the time and energy involved in performing these activities. When this partner does attempt to participate, the other parent may criticize the less skillful efforts. As a result, communication and support for each other may be adversely affected.
The nurse can assist parents in avoiding role conflicts by providing anticipatory guidance early on. Teaching should address stressors often identified as having an impact on the marriage, including (1) the burden of care at home assumed by primarily one parent, (2) the financial burden, (3) the fear of the child dying, (4) pressure from relatives, (5) the hereditary nature of the disease (if applicable), and (6) fear of pregnancy. Other causes of tension may center on the inconveniences associated with care, such as long waits for an appointment, lack of parking near care facilities, or lack of overnight accommodations.
Mother–Father Differences Mothers and fathers of a child with a complex condition often adjust and cope differently. Mothers are often the primary caregiver and are more likely than fathers to give up their jobs to care for their children, often resulting in social isolation (Coffey, 2006). Mothers often have greater needs for social support and positive appraisal of the situation than fathers.
Fathers of children with disabilities struggle with issues that may be distinct from those of the mothers (Swallow, Macfadyen, Santacroce, et al, 2012). Fathers may think that their role as protector is challenged, because they do not know how to help and cannot protect their family from the seemingly overwhelming recurring problems. The extensive stresses in the family can leave fathers feeling depressed, weak, guilty, powerless, isolated, embarrassed, and angry. Fearful that they will lose control or be viewed as weak or ineffectual, however, fathers often hide their feelings and display an outward confidence that may lead others to believe that everything is fine. Fathers worry about what the future holds for their children, their ability to manage the increasing financial burden, and the daily disruptions of the entire family (Davies, Gudmundsdottir, Worden, et al, 2004; Swallow, Macfadyen, Santacroce, et al, 2012).
Single-Parent Families Single-parent families are of special concern. As the only parent of a child who may require extensive, sophisticated, and lifelong care, the single parent may feel an enormous burden. Available financial and emotional resources may already be stretched to the limit. A special effort should be made to assist the single parent in finding financial and support services that can ease the burden of care. Nurses can also assist the single parent in identifying helping roles that may be acceptable to relatives and friends.
Siblings Results of studies are less clear regarding the ways that siblings are affected by having a brother or sister with a complex condition (Anderson and Davis, 2011; Barlow and Ellard, 2006; Hartling, Milne, Tjosvold, et al, 2014; O'Brien, Duffy, and Nicholl, 2009). Most evidence shows a negative effect on siblings of children with chronic illnesses compared with siblings of healthy children (Gold, Treadwell, Weissman, et al, 2011; Hartling, Milne, Tjosvold, et al, 2014). Siblings of children with chronic illnesses report psychosocial problems more often than their peers (Gold, Treadwell, Weissman, et al, 2011; O'Brien, Duffy, and Nicholl, 2009). A number of factors increase the risk of negative effects for siblings of ill children. Responsibility for caregiving, differential treatment by parents, and limitations in family resources and recreational time are often the experiences of siblings of ill or disabled children (Lobato and Kao, 2002) (Box 17-4).
Box 17-4 S u p p o r t i n g S i b l i n g s o f C h i l d r e n w i t h S p e c i a l N e e d s Promote Healthy Sibling Relationships
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Value each child individually and avoid comparisons. Remind each child of his or her positive qualities and contribution to other family members.
Help siblings see the differences and similarities between themselves and the child with special needs. Create a climate in which children can achieve successes without feeling guilty.
Teach siblings ways to interact with the child.
Seek to be fair in terms of discipline, attention, and resources; require the affected child to do as much for himself or herself as possible.
Let siblings settle their own differences; intervene only to prevent siblings from hurting one another.
Legitimize reasonable anger. Even children with special needs behave badly sometimes.
Respect a sibling's reluctance to be with or to include the child with special needs in activities.
Help Siblings Cope
Listen to siblings to let them know that their thoughts and suggestions are valued.
Praise siblings when they have been patient, have sacrificed, or have been particularly helpful. Do not expect siblings to always act in this manner.
Acknowledge the personal strengths siblings have and their ability to cope with stress successfully.
Provide age-appropriate information about the child's condition and update it when appropriate.
Let teachers know what is happening so that they can be understanding and helpful.
Recognize special stress times for siblings and plan to minimize negative effects.
Schedule special time with siblings; have a friend or family member substitute when parent is unavailable.
Encourage siblings to join or help establish a sibling support group.
Use the services of professionals when needed. If parent feels that such a service is necessary, it should be provided in as vigorous a manner as a service for the child with special needs.
Involve Siblings
Seek out ways to realistically include siblings in the care and treatment of the child with special needs.
Limit caregiving responsibilities and give recognition when siblings perform them.
Develop a library of children's books on special needs.
Invite siblings to attend meetings to develop plans for the child with special needs (e.g., individualized educational program [IEP], individualized family service plan [IFSP]).
Discuss future plans with them.
Solicit their ideas on treatment and service needs.
Have them visit professionals who work with the child.
Help them develop competencies to teach the child new skills.
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Provide opportunities for siblings to advocate for the child.
Allow siblings to set their own pace for learning and involvement.
Data from Powell T, Ogle P: Brothers and sisters—a special part of exceptional families, Baltimore, 1985, Paul H Brooks; Spokane Washington Deaconess Medical Center, Pediatric Oncology Unit: Tips for dealing with siblings, Candlelighters Childhood Cancer Found Q Newslett 11(3,4):7, 1987; and Carlson J, Leviton A, Mueller M: Services to siblings: an important component of family- centered practice, ACCH Advocate 1(1):53-56, 1993.
An important factor in sibling adjustment and coping is information and knowledge regarding their brother's or sister's illness or complex condition. What siblings piece together or overhear is often much worse than the truth. Often they imagine gruesome things regarding the experiences related to the illness, treatment, and hospitalization (Knafl and Santacroce, 2010). Latino siblings have reported less accurate information about their siblings' condition than non-Latino siblings (Lobato, Kao, and Plante, 2005). Parents are usually in the best position to impart information, although they are often overwhelmed with the medical crisis at hand (Fleitas, 2000). Nurses can encourage parents to talk with the siblings about how they perceive their sick brother or sister and to be accepting of the siblings' feelings. Nurses can be ideal educators and counselors of siblings during the course of their brother's or sister's illness.
Coping with Ongoing Stress and Periodic Crises Professionals can help families cope with stress by providing anticipatory guidance, providing emotional support, assisting the family in assessing and identifying specific stressors, aiding the family in developing coping mechanisms and problem-solving strategies, and working collaboratively with parents so that they become empowered in the process (Anderson and Davis, 2011).
Concurrent Stresses within the Family The ability to deal with the overwhelming stress of a chronic illness is challenged further when additional stresses are present. Stressors may be situational or developmental. They may be related to marital difficulties, sibling needs, homelessness, or social isolation. Some families may simultaneously be struggling with a family member's alcohol or other drug problem. Even relatively minor stressors, such as arranging care for siblings, managing the home, and traveling to distant treatment centers, can challenge a family's ability to cope successfully.
Most families, regardless of their income or insurance coverage, have financial concerns. The costs of caring for a child with a complex illness can be overwhelming. Nurses and social workers can help a family review various options for financial assistance, including insurance, managed care, or health maintenance organization policies; Medicaid; Supplemental Security Income; Women, Infants, and Children program; the state Program for Children with Special Health Needs; disease-related associations; and local philanthropic organizations.
Coping Mechanisms Coping mechanisms are behaviors aimed at reducing the tension caused by a crisis. Approach behaviors are coping mechanisms that result in movement toward adjustment and resolution of the crisis. Avoidance behaviors result in movement away from adjustment and represent maladaptation to the crisis. Several approach and avoidance behaviors used in coping with a chronic illness are listed in the Nursing Care Guidelines box. Each behavior must be viewed in the context of all of the variables affecting the family. For example, the observation of several avoidance behaviors in an emotionally healthy family may denote significantly less risk to the successful resolution of the crisis than an equal number of avoidance behaviors in an individual who has few available supports.
N u r s i n g C a r e G u i d e l i n e s Assessing Coping Behaviors
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Approach Behaviors
Asks for information regarding diagnosis and child's present condition
Seeks help and support from others
Anticipates future problems; actively seeks guidance and answers
Endows the chronic illness or complex condition with meaning
Shares burden of disorder with others
Plans realistically for the future
Acknowledges and accepts child's awareness of diagnosis and prognosis
Expresses feelings (such as sorrow, depression, and anger) and realizes reason for the emotional reaction
Realistically perceives child's condition; adjusts to changes
Recognizes own growth through passage of time, such as earlier denial and non-acceptance of diagnosis
Verbalizes possible loss of child
Avoidance Behaviors
Fails to recognize seriousness of child's condition despite physical evidence
Refuses to agree to treatment
Intellectualizes about the illness but in areas unrelated to child's condition
Is angry and hostile to members of the staff regardless of their attitude or behavior
Avoids staff, family members, or child
Entertains unrealistic future plans for child with little emphasis on the present
Is unable to adjust to or accept a change in progression of disease
Continually looks for new cures with no perspective toward possible benefit
Refuses to acknowledge child's understanding of disease and prognosis
Uses magical thinking and fantasy; may seek “occult” help
Places complete faith in religion to point of relinquishing own responsibility
Withdraws from outside world; refuses help
Punishes self because of guilt and blame
Makes no change in lifestyle to meet needs of other family members
Resorts to excessive use of alcohol or drugs to avoid problems
Verbalizes suicidal intents
Is unable to discuss possible loss of child or previous experiences with death
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Parental Empowerment Empowerment can be seen as a process of recognizing, promoting, and enhancing competence. For parents of children with chronic conditions, empowerment may occur gradually as strength and capabilities are drawn on to master the child's care, manage family life, and plan for the future. Advocating for the child and developing parent–professional partnerships are part of taking charge (Panicker, 2013).
Assisting Family Members in Managing Their Feelings Although some previous research has postulated stages of adaptation to a chronic illness, there is a great deal of individual variation in responses to the diagnosis, adjustments made, and time frames for coming to terms with a diagnosis. It is important that professionals recognize and respect a wide range of reactions and coping mechanisms. In fact, members of the family of a child with a complex chronic condition may experience a number of difficult emotions, including fear, guilt, anger, resentment, and anxiety. Learning to manage these emotions promotes adaptive coping (see Nursing Care Guidelines box). Support from professionals, other family members, and friends can assist family members in managing their feelings. The following discussion examines some common phases of adjustment and emotional reactions.
Shock and Denial The initial diagnosis of a chronic illness or complex condition is often met with intense emotion and is characterized by shock, disbelief, and sometimes denial. Denial as a defense mechanism is a necessary cushion to prevent disintegration and is a normal response to grieving for any type of loss. Probably all family members experience various degrees of adaptive denial as they learn of the impact that the diagnosis has on their lives.
Shock and denial can last from days to months, sometimes even longer. Examples of denial that may be exhibited at the time of diagnosis include: • Physician shopping • Attributing the symptoms of the actual illness to a minor condition • Refusing to believe the diagnostic tests • Delaying consent for treatment • Acting happy and optimistic despite the revealed diagnosis • Refusing to tell or talk to anyone about the condition • Insisting that no one is telling the truth, regardless of others' attempts to do so • Denying the reason for admission • Asking no questions about the diagnosis, treatment, or prognosis
Generally, these mechanisms should be respected as short-term responses that allow individuals to distance themselves from the tremendous emotional impact and to collect and mobilize their energies toward goal-directed, problem-solving behaviors.
In children, the importance of denial has repeatedly been demonstrated as a factor in their positive coping with the diagnosis. Denial allows the child to maintain hope in the face of overwhelming odds and to function adaptively and productively. Similar to hope, denial may be an adaptive mechanism for dealing with loss that persists until a family or patient is ready or needs other responses.
Denial is probably the least understood and most poorly dealt-with reaction. If denial is labeled as maladaptive, it can lead to inappropriate attempts to strip away the reaction by repeated and sometimes blunt explanations of the prognosis. However, denial becomes maladaptive only when it prevents recognition of treatment or rehabilitative goals necessary for the child's optimal survival or development.
Adjustment For most families, adjustment gradually follows shock and is usually characterized by an open admission that the condition exists. This stage may be accompanied by several responses, which are normal parts of the adaptation process. Probably the most universal of these feelings are guilt and self-accusation. Guilt is often greatest when the cause of the disorder is directly traceable to the
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parent, as in genetic diseases or accidental injury. However, it can occur even without any scientific or realistic basis for parental responsibility. Frequently, the guilt stems from a false assumption that the child's condition is a result of personal failure or wrongdoing, such as not doing something correctly during pregnancy or the birth. Guilt may also be associated with cultural or religious beliefs. Some parents are convinced that they are being punished for some previous misdeed. Others may see the illness as a trial sent by God to test their religious strength and faith. With correct information, support, and time, most parents master guilt and self-accusation.
Children, too, may interpret their serious illness as retribution for past misbehavior. The nurse should be particularly sensitive to the child who passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment. It is vital that parents and health care professionals reassure children that their illnesses are not their fault.
Other common and normal reactions to a diagnosis are bitterness and anger. Anger directed inward may be evident as self-reproaching or punitive behavior, such as neglecting one's health and verbally degrading oneself. Anger directed outward may be manifested in either open arguments or withdrawal from communication and may be evident in the person's relationship with any number of individuals, such as the spouse, the child, and siblings. Passive anger toward the ill child may be evident in decreased visiting, refusal to believe how sick the child is, or an inability to provide comfort. Health care providers are among the most common targets for parental anger. Parents may complain about the nursing care, the insufficient time physicians spend with them, or the lack of skill of those who draw blood or start intravenous infusions.
Children are apt to respond with anger as well, and this includes the affected child and the well siblings. Children are aware of the loss engendered by their illness or complex condition and may react angrily to the restrictions imposed or the feelings of being different. Siblings may also feel anger and resentment toward the ill child and parents for the loss of routine and parental attention. It is difficult for older children and almost impossible for younger children to comprehend the plight of the affected child. Their perception is of a brother or sister who has the undivided attention of their parents, is showered with cards and gifts, and is the focus of everyone's concern.
During the period of adjustment, four types of parental reactions to the child influence the child's eventual response to the disorder: • Overprotection: The parents fear letting the child achieve any new skill, avoid all discipline, and
cater to every desire to prevent frustration. • Rejection: The parents detach themselves emotionally from the child but usually provide
adequate physical care or constantly nag and scold the child. • Denial: The parents act as if the disorder does not exist or attempt to have the child
overcompensate for it. • Gradual acceptance: The parents place necessary and realistic restrictions on the child, encourage
self-care activities, and promote reasonable physical and social abilities.
Reintegration and Acknowledgment For many families, the adjustment process culminates in the development of realistic expectations for the child and reintegration of family life with the illness or complex condition in a manageable perspective. Because a large portion of this phase is one of grief for a loss, total resolution is not possible until the child dies or leaves home as an independent adult. Therefore one can regard adjustment as “increased comfort” with everyday living rather than a complete resolution.
This adjustment phase also involves social reintegration in which the family broadens its activities to include relationships outside of the home with the child as an acceptable and participating member of the group. This last criterion often differentiates the reaction of gradual acceptance during the adjustment period from total acceptance or perhaps is more descriptive of the acknowledgment process.
Many parents of children with chronic illnesses experience chronic sorrow, which are feelings of sorrow and loss that recur in waves over time. As the child's condition progresses, parents experience repeated losses that represent further declines and new caregiving demands. Consequently, families must be assessed on an ongoing basis and offered appropriate support and resources as their needs change over time (Bettle and Latimer, 2009; Gordon, 2009). This represents a critical period of time because the manner in which the nursing and medical team approach and provide support can directly impact the experience of complicated grief after the death of the child.
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Complicated grief, which is characterized as persistent distress and chronic stress response, may last 6 months or longer after the death of a child and has a significant impact on quality of life of the family left behind (Meert, Shear, Newth, et al, 2011). Persistent complex bereavement disorder is a new diagnostic entity included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychological Association, 2013).
Establishing a Support System The diagnosis of a child with a complex chronic condition is a major situational crisis that affects the entire family system. However, families can experience positive outcomes as they successfully deal with the many challenges that accompany a child with chronic illness (Hungerbuehler, Vollrath, and Landolt, 2011).
One nursing goal is to assess which families are at risk for succumbing to the effects of the crisis. Several variables—available support system, perception of the event, coping mechanisms, reactions to the child, available resources, and concurrent stresses within the family—influence the resolution of a crisis. Although most families cope well, the needs of families at risk are great. If they receive emotional support and guidance early, there is an increased likelihood that they will also cope successfully.
Although it is easy to assume that families of children with the most severe illnesses or disabilities would have the poorest adjustment, the severity of the condition reflects only one part of the overall picture. The level of adjustment is significantly influenced by the functional burden on the family (Stein, 1985). This concept considers the issues related to caring for and living with the child in relation to the family's resources and ability to cope (Box 17-5). The family of a child with a high level of technology dependence demanding complex care yet having many resources and coping skills may adjust more successfully to the child's situation than the family of a child with a less serious condition and few resources to counterbalance.
Box 17-5 C o n c e p t o f F u n c t i o n a l B u r d e n Impact of the Child with Special Needs
The child's need for medical and nursing care
The child's fixed deficits
The child's age-appropriate dependency in activities of daily living
The disruptions in the family routine caused by the care
The psychological burden of the prognosis on the family
Family Resources and Ability to Cope
The family's physical resources
The family's emotional resources
The family's educational resources
The family's social supports and available help
The competing demands for family members' time and energy
Data from Stein REK: Home care: a challenging opportunity, Child Health Care 14(2):90-95, 1985.
Intrafamilial resources, social support from friends and relatives, parent-to-parent support, parent/professional partnerships, and community resources interweave to provide a flexible web of
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support for families of children with chronic conditions.
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The Child with a Chronic or Complex Condition The child's reaction to chronic illness depends to a great extent on his or her developmental level, temperament, and available coping mechanisms; on the reactions of family members or significant others; and, to a lesser extent, on the condition itself. A child's conceptual understanding of his or her own illness is based not only on age and developmental level but also on the duration and type of experience accumulated with the disease. Knowledge of these variables is essential in providing the kind of information and support needed by these children to cope with an often overwhelming situation.
Developmental Aspects The impact of a complex chronic illness is influenced by the age at onset. Chronic illness affects children of all ages, but the developmental aspects of each age group dictate particular stresses and risks for the child. The nurse must also recognize that children need to redefine their condition and its implications as they develop and grow. For example, appearance, skills, and abilities are highly valued by peers (Fig. 17-1). A teenager who is limited in any of these qualities is subject to rejection. This is especially marked when an illness interferes with sexual attractiveness.
FIG 17-1 Children with any type of impairment should have the opportunity to develop their skills. (Courtesy of Poyo/Hinton Photography.)
Children's developmental concepts of illness are discussed in Chapter 19. An understanding of these developmental factors facilitates planning care to support the child and minimize the risks. Developmental aspects of chronic illness on children are described in Table 17-2.
TABLE 17-2 Developmental Effects of Chronic Illness or Disability on Children
Developmental Tasks Potential Effects of Chronic Illness or Disability Supportive Interventions Infancy Develop a sense of trust Multiple caregivers and frequent separations,
especially if hospitalized Encourage consistent caregivers in hospital or other care settings.
Deprived of consistent nurturing Encourage parental presence, “rooming in” during hospitalization, and participation in care. Bond, or attach, to parent Delayed because of separation; parental grief for loss
of “dream” child; parental inability to accept the condition, especially a visible defect
Emphasize healthy, perfect qualities of infant. Help parents learn special care needs of infant for them to feel competent.
Learn through sensorimotor experiences
More exposure to painful experiences than pleasurable ones
Expose infant to pleasurable experiences through all senses (touch, hearing, sight, taste, movement).
Limited contact with environment from restricted movement or confinement
Encourage age-appropriate developmental skills (e.g., holding bottle, finger feeding, crawling).
Begin to develop a sense of separateness from parent
Increased dependency on parent for care Encourage all family members to participate in care to prevent over involvement of one member. Over involvement of parent in care Encourage periodic respite from demands of care responsibilities.
Toddlerhood Develop autonomy Increased dependency on parent Encourage independence in as many areas as possible (e.g., toileting, dressing, feeding). Master locomotor and language skills
Limited opportunity to test own abilities and limits Provide gross motor skill activity and modification of toys or equipment, such as modified swing or rocking horse.
Learn through sensorimotor
experience; beginning
Increased exposure to painful experiences Give choices to allow simple feeling of control (e.g., choice of what book to look at, what kind of
sandwich to eat).
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Recognize that negative and ritualistic behaviors are normal. Provide sensory experiences (e.g., water play, sandbox play, finger painting).
Preschool Age Develop initiative and
purpose Master self-care skills
Limited opportunities for success in accomplishing simple tasks or mastering self-care skills
Encourage mastery of self-help skills. Provide devices that make tasks easier (e.g., self-dressing).
Begin to develop peer relationships
Limited opportunities for socialization with peers; may appear “like a baby” to age mates
Protection within tolerant and secure family, causing child to fear criticism and withdraw
Encourage socialization (e.g., inviting friends to play, daycare experience, trips to park). Provide age-appropriate play, especially associative play opportunities. Emphasize child's abilities; dress appropriately to enhance desirable appearance.
Develop sense of body image and sexual identification
Awareness of body centering on pain, anxiety, and failure
Sex-role identification focused primarily on mothering skills
Encourage relationships with same-sex and opposite-sex peers and adults.
Learn through preoperational thought (magical thinking)
Guilt (thinking he or she caused the illness or disability or is being punished for wrongdoing)
Help child deal with criticisms; realize that too much protection prevents child from realities of world.
Clarify that cause of child's illness or disability is not his or her fault or a punishment. School Age Develop a sense of accomplishment
Limited opportunities to achieve and compete (e.g., many school absences, inability to join regular athletic activities)
Encourage school attendance; schedule medical visits at times other than school; encourage child to make up missed work.
Form peer relationships Limited opportunities for socialization Educate teachers and classmates about child's condition, abilities, and special needs. Encourage sports activities (e.g., Special Olympics). Encourage socialization (e.g., Girl Scouts, Campfire, Boy Scouts, 4-H Club; having a best friend or
club membership). Learn through concrete operations
Incomplete comprehension of the imposed physical limitations or treatment of the disorder
Provide child with information about his or her condition. Encourage creative activities (e.g., VSA Arts).
Adolescence Develop personal and sexual identity
Increased sense of feeling different from peers and reduced ability to compete with peers in appearance, abilities, special skills
Help child realize that many of the difficulties the teenager is experiencing are part of normal adolescence (rebelliousness, risk taking, lack of cooperation, hostility toward authority).
Achieve independence from family
Increased dependency on family; limited job or career opportunities
Provide instruction on interpersonal and coping skills. Encourage increased responsibility for care and management of the disease or condition (e.g.,
assuming responsibility for making and keeping appointment [ideally alone], sharing assessment and planning stages of health care delivery, contacting resources).
Discuss planning for future and how condition can affect choices. Form heterosexual relationships
Limited opportunities for heterosexual friendships; less opportunity to discuss sexual concerns with peers
Increased concern with issues such as why did he or she get the disorder and whether he or she will marry and have a family
Encourage socialization with peers, including peers with special needs and those without special needs.
Encourage activities appropriate for age (e.g., attending mixed-sex parties, sports activities, driving a car).
Be alert to cues that signal readiness for information regarding implications of condition on sexuality and reproduction.
Emphasize good appearance and wearing stylish clothes, use of makeup. Understand that adolescent has same sexual needs and concerns as any other teenager.
Learn through abstract thinking
Decreased opportunity for earlier stages of cognition impeding achievement of level of abstract thinking
Provide instruction on decision making, assertiveness, and other skills necessary to manage personal plans.
Coping Mechanisms Children with chronic conditions tend to use five distinct patterns of coping (Box 17-6). Children with more positive and accepting attitudes about their chronic illness use a more adaptive coping style characterized by optimism, competence, and compliance. They show fewer behavior problems at home and at school. The two maladaptive coping patterns—“Feels different and withdraws” and “Is irritable, is moody, and acts out”—are associated with poorer adaptation; children using these strategies have poorer self-concepts, more negative attitudes about their conditions, and more behavior problems at home and at school.
Box 17-6 C o p i n g Pa t t e r n s U s e d b y C h i l d r e n w i t h S p e c i a l N e e d s Develops competence and optimism: Accentuates the positive aspects of the situation and
concentrates more on what he or she has or can do than on what is missing or on what he or she cannot do; is as independent as possible
Feels different and withdraws: Sees self as being different from other children because of the chronic health condition; views being different as negative; sees self as less worthy than others; focuses on things he or she cannot do and sometimes over restricts activities needlessly
Is irritable, is moody, and acts out: Uses proactive and self-initiated coping behaviors, although usually counterproductive in that the behaviors are not ego enhancing or socially responsible and do not result in desired outcomes; acts out irritability, which may or may not be associated with condition's symptoms
Complies with treatment: Takes necessary medications, treatments; adheres to activity restrictions; also uses behaviors that indicate developing independence (e.g., assumes responsibility for taking medication)
Seeks support: Talks with adults, children, physicians, and nurses; develops plans to handle problems as they occur; uses downward comparison (i.e., realizes that others have it worse)
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Modified from Austin J, Patterson J, Huberty T: Development of the coping health inventory for children, J Pediatr Nurs 6(3):166- 174, 1991.
Well-adapted children gradually learn to accept their physical limitations and find achievement in a variety of compensatory motor and intellectual pursuits. They function well at home, at school, and with peers. They have an understanding of their disorder that allows them to accept their limitations, assume responsibility for their care, and assist in treatment and rehabilitation regimens. They express appropriate emotions, such as sadness, anxiety, and anger, at times of exacerbations but confidence and guarded optimism during periods of clinical stability (Fig. 17-2). They are able to identify with other similarly affected individuals, promoting positive self-images and displaying pride and self-confidence in their ability to master a productive, successful life despite their illnesses.
FIG 17-2 Periods of sadness and anger are appropriate in the child's adjustment to a chronic illness or disability, especially during exacerbations of the disorder.
Hopefulness Children, particularly adolescents, are sensitive to the presence or absence of hope. Hopefulness is an internal quality that mobilizes humans into goal-directed action that may be satisfying and life sustaining. A sense of hopefulness can produce increased participation in health-seeking behaviors and an improved sense of well-being (Ritchie, 2001).
Health Education and Self-Care Health education is an intervention that promotes coping. Children need information about their condition, the therapeutic plan, and how the disease or the therapy might affect their particular situation. Children nearing puberty also need to understand the maturation process and how their chronic illness may alter this event. For example, a youngster with Crohn disease should understand that this disorder is associated with growth failure and delayed puberty, a child with diabetes needs to know that hormonal changes and increased growth needs will alter food and insulin requirements at this time, and a sexually active girl with sickle cell anemia or systemic lupus erythematosus needs to be aware of the risks of pregnancy. The information should not be given all at once but should be timed appropriately to meet their changing needs, and it should be described and repeated as often as the situation demands.
Responses to Parental Behavior Parental behavior toward the child is one of the most important factors influencing the child's adjustment. Children's perceptions of their mothers' support and maternal perceptions of the psychosocial impact of the child's chronic illness on the family were shown to be two of the greatest predictors of children's psychological adjustment (Immelt, 2006). In addition, family organization, illness-related support, and involvement of the parents influence children's adjustment to chronic illness (Schor, 2003). They often display pride and confidence in their ability to cope successfully with the challenges imposed by their disorder. Anticipatory guidance by the nurse and
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encouragement of normalizing practices may assist parents in facilitating positive adjustment in their children.
Type of Illness or Condition The type of illness or condition also influences the child's emotional response. Interestingly, children with more severe disorders often cope better than those with milder conditions. However, the presence of multiple conditions may place a child at risk for more behavioral problems (Newacheck and Halfon, 1998). Because of children's cognitive ability and the timing of onset of abstract thinking in adolescence, an obvious condition may be easier for them to accept because its limitations are concrete.
The onset of a disabling condition may generate a state of confusion for children, who may have trouble differentiating between actual bodily functions and their image of their bodies. They may also experience problems in identifying themselves and those extensions of self (e.g., wheelchairs, braces, crutches, other mechanical or prosthetic devices) and may have difficulty in accepting functional aids.
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Nursing Care of the Family and Child with a Chronic or Complex Condition Assessment Because the nurse may meet a family during any phase of the adjustment process, several assessment areas are important. The family's ability to cope with previous stresses influences the current situation, and answers to questions about their usual coping skills are enlightening. Knowledge of concurrent stresses, such as financial, marital or nonmarital, and career or unemployment, helps identify families who may have fewer resources to cope with the child's needs.
Finally, awareness of the family members' reactions to the child and the illness or condition is important. Sample questions that the nurse and family can use to evaluate the support system, perception of the illness, coping mechanisms, resources, and concurrent stresses are listed in Table 17-3. Because factors affecting the family's response may change at any point during the illness, assessment must be a continuous process.
TABLE 17-3 Assessment of Factors Affecting Family Adjustment
Factors Affecting Adjustment Assessment Questions Available Support System Status of marital relationship To whom do you talk when you have something on your mind? (If answer is not the spouse, ask for the reason.) Alternate support systems When something is worrying you, what do you do?
What helps you most when you are upset? Ability to communicate Does talking seem to help when you feel upset? Perception of the Illness or Disability Previous knowledge of disorder Have you ever heard the word (name of diagnosis) before? Tell me about it (if answer is yes). Imagined cause of disorder What are your thoughts about the causes of the disorder? Effects of illness or disability on family How has your child's illness or disability affected you and your family?
How has your lifestyle changed? Coping Mechanisms Reactions to previous crises Tell me one time you've had another crisis (problem, bad time) in your family. How did you solve that problem? Reactions to the child Do you find yourself being a little more cautious with this child than with your other children? Childrearing practices Do you feel as comfortable disciplining this child as your other children? Influence of religion Has your religion or faith been of help to you? Tell me how (if answer is yes). Attitudes How is this child different from the siblings or other children of similar age?
Describe your child's personality. Is it easy, difficult, or in between? When you think of your child's future, what thoughts come to mind?
Available Resources What parts of your child's care are causing the most difficulty for you or your family? What services are available to help? What services do you need that currently are not available?
Concurrent Stresses What other problems are you facing now? (Be specific; ask about financial, marital, sibling, and extended family or friends concerns.)
Special challenges exist in assessing the child's feelings about having a chronic condition. Chapter 4 presents several approaches to encourage children to discuss their feelings about their conditions. The nurse should use a variety of communication techniques, such as drawing and play, as assessment tools rather than relying solely on parental reports. Often, children are neglected partners in their care, and their unique needs are not identified (Dixon-Woods, Young, and Heney, 1999; Young, Dixon-Woods, Windridge, et al, 2003).
The needs of working parents and siblings also should be assessed; this is a goal that requires flexibility in scheduling appointments. When working parents know that their input is valuable, they will often change their work schedule to meet with a health professional. Because siblings can be of any age, the use of appropriate communication strategies for assessment must be considered. Nonverbal techniques, such as those discussed in Chapter 4 should be considered for these children.
Provide Support at the Time of Diagnosis The diagnosis is a critical time for parents and can influence how they perceive their health care providers across the trajectory of care. Although they may not hear or remember all that is said to them, they frequently sense a certain attitude of acceptance, rejection, hope, or despair that may influence their ability to absorb the shock and begin adapting to the family's altered future.
Parents may be encouraged to be together when they are informed of their child's condition, thus avoiding the problem of one parent having to interpret complex information and deal with the
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initial emotional reaction of the other. The informing session should take place in a private, comfortable setting free of distractions and interruptions in an atmosphere in which the parents feel free to express their emotions (Fig. 17-3). Their emotional needs are acknowledged by showing acceptance of expressions, such as crying, sadness, anger, and disappointment. Emotional support is offered by having tissues available if a family member cries and demonstrating through facial and body language that indeed this is a difficult and painful period. Although touching is a powerful expression of empathy, it must be used wisely. For example, it can prematurely terminate free expression of feelings, especially when combined with statements, such as “Everything will be all right.” Nurses should also be aware of cultural issues regarding touching (see Chapter 4).
FIG 17-3 Information sessions should take place in a private, comfortable setting free of distractions and interruptions.
Parents should receive the kind of information they desire. This can be assessed by asking questions, such as “Do you prefer to hear detailed information?” Parents or other family members may have different preferences regarding the amount of information that they wish to hear. Most parents want a clear, simple explanation of the diagnosis; a prediction of possible futures for the child; advice on what to do next; an opportunity to ask questions; a warm, sympathetic listener; and, most important, time. Understanding of explanations is elicited with questions, such as “Do you see what I mean?” or “Is this clear to you?” Technical terms are used with simple definitions. If the parents are unaware of the term, they are given written literature or at least a written summary of the diagnosis.
Finally, the informing conference does not end with the presentation of devastating news. Instead, the child's strengths, appealing behaviors, and potential for development are stressed, as are available rehabilitation efforts or treatments. Parents can be encouraged to view their experiences as a series of challenges that they are capable of handling, particularly with available professional feedback. The parents are assured that the nurse will be available to answer questions and to provide further assistance as needed.
The preceding discussion relates primarily to the initial informing interview. However, because of the need for long-term follow-up, it is only one in a series of continuing discussions. In all interactions, the family's input is solicited and incorporated into the care plan. Some situations require consideration of special problems (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Situations Requiring Special Consideration
Congenital Anomaly
Tension in the delivery room conveys the sense that something is seriously wrong. Communication is often delayed while the physician is involved with the mother's care. The manner in which the infant is presented may well set the tone for the early parent–child relationship.
Clarify role with physician in regard to revealing information to enable immediate parental
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support.
Explain to parents briefly in simple language what the defect is and something concerning the immediate prognosis before showing them the infant. Later more information can be given when they are more ready to “hear” what is said.
Be aware of nonverbal communication. Parents watch facial expressions of others for signs of revulsion or rejection.
Present infant as something precious.
Emphasize well-formed aspects of infant's body.
Allow time and opportunity for parents to express their initial response.
Encourage parents to ask questions and provide honest, straightforward answers without undue optimism or pessimism.
Cognitive Impairment
Unless cognitive impairment (or mental retardation) is associated with other physical problems, it is often easy for parents to miss clues to its presence or to make defensive excuses regarding the diagnosis.
Plan situations that help parents become aware of the problem.
Encourage parents to discuss their observations of child but withhold diagnostic opinions.
Focus on what the child can do and appropriate interventions to promote progress (e.g., infant stimulation programs) to involve parents in their child's care while helping them gain an awareness of the child's condition.
Physical Disability
If loss of motor or sensory ability occurs during childhood, the diagnosis is readily apparent. The challenge lies in helping the child and parents over the period of shock and grief and toward the phase of acceptance and reintegration.
Institute early rehabilitation (e.g., using a prosthetic limb, learning to read braille, learning to read lips).
Be aware that physical rehabilitation usually precedes psychological adjustment.
When the cause of the disability is accidental, avoid implying that parents or child was responsible for the injury but allow them the opportunity to discuss feelings of blame.
Encourage expression of feelings (see Communication Techniques, Chapter 4).
Chronic Illness
Realization of the true impact may take months or years. Conflict over parents' versus child's concerns may result in serious problems. When condition is inherited, parents may blame themselves or child may blame the parents.
Help each family member gain an appreciation of the others' concerns.
Discuss hereditary aspect of condition with parents at time of diagnosis to lessen guilt and accusatory feelings.
Encourage child to express feelings by using third-person technique (e.g., “Sometimes when a person has an illness that was passed on by the parents, that person feels angry or bitter toward
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them”).
Multiple Disabilities
The child or parent may require additional time for the shock phase and may be able to attend to only one diagnosis before hearing significant information regarding other disorders.
Acknowledge parents' understanding and acceptance of all diagnoses, especially when an obvious and more hidden disability coexists.
Appreciate the devastating consequences of more than one disability for a child, especially if they interfere with expressive-receptive abilities.
Terminal Illness
Parents require much support to deal with their own feelings and guidance in how to tell the child the diagnosis. They may want to conceal the diagnosis from the child. They may believe that the child is too young to know, will not be able to cope with the information, or will lose hope and the will to live.
Approach the subject of disclosure in a positive way by asking, “How will you tell your child about the diagnosis?”
Help parents understand the disadvantages of not telling the child (e.g., deprives child of the opportunity to discuss feelings openly and ask questions, incurs the risk of child learning the truth from outside and sometimes less tactful sources, may lessen child's trust and confidence in the parents after learning the truth).
Guide parents to see the potential problems involved in fostering a conspiracy.
Offer parents guidelines for how and what to tell the child about the disease or the possibility of death. Explanations should be tailored to child's cognitive ability, be based on knowledge child already has, and be honest. Honesty must be tempered with concern for child's feelings.
Assure parents that telling a child the name of the illness and the reason for treatment instills hope, provides support from others, and serves as a foundation for explaining and understanding subsequent events.
Acknowledge that being honest is not always easy because the truth may prompt the child to ask other distressing questions, such as “Am I going to die?” However, even this difficult question must be answered.
Support the Family's Coping Methods For the family to meet the stresses of optimally adjusting to the child's condition, each member must be individually supported so that the family system is strong. Although the family can indefinitely support a member who is in need of assistance, its greatest strength lies in every member supporting each other. The nurse should bear in mind that the family member in greatest need is not necessarily the affected child but may be a parent or sibling who is dealing with stresses that require intervention.
Parents The nurse can provide support by being attentive to families' responses to their children. Mothers and fathers need to experience success, joy, and pride in their children to give the support they need. It is important for nurses to examine their attitudes to determine their ability to engage in parent–professional partnerships. An essential characteristic is the belief that parents are equal to professionals and are experts regarding their child (see Nursing Care Guidelines box).
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N u r s i n g C a r e G u i d e l i n e s Developing Successful Parent–Professional Partnerships
Promote primary nursing; in nonhospital settings, designate a case manager.
Acknowledge parents' overall competence and their unique expertise with their child.
Respect parents' time as having value equal to that of other members of child's health care team.
Explain or define any medical, technical, or discipline-specific terms.
Tell families, “I am not sure” or “I don't know” when appropriate.
Facilitate family's effectiveness in team meetings (e.g., provide parents with same information as other participants).
Parents can be encouraged to discuss their feelings toward the child, the impact of this event on their marriage, and associated stresses such as financial burdens. For most families, regardless of their income or insurance coverage, financial concerns exist. The costs of caring for a child with special needs can be overwhelming. In addition, one or both parents may have to sacrifice job opportunities to remain close to a medical facility or to avoid losing insurance benefits. Numerous volunteer and community resources are available that provide assistance, rehabilitation, equipment, and funding for a variety of health problems. National and local disease-oriented organizations may provide needed assistance and support to families that qualify. Many of these are discussed elsewhere in the text under the specific diagnosis. State and federal departments of health, mental health, social service, and labor may be able to help locate appropriate regional resources. For example, state programs for Children with Special Health Needs provide financial assistance for children with many disabling conditions. Local and national sources of respite care and medical daycare may be useful to families. Nurses should become acquainted with those in their communities and with vocational programs for special groups.
Parent-to-Parent Support Just being with another parent who has shared similar experiences is helpful. It may not need to be a parent of a child with the same diagnosis, because parents in the process of adjusting to a child with special needs—or finding respite services, educational or rehabilitative services, special equipment vendors, and financial counseling—tread a common path. If the agency does not have a parent staff position, the nurse can contact parent groups that will often send a representative. Another strategy is to ask another parent to talk to the parents. The nurse should seek out a parent who is a good listener, has a nonjudgmental approach to differences in families, and possesses good advocacy and problem-solving skills.
The parent self-help group can promote parent-to-parent support.* Group members feel less alone and have the opportunity to observe both coping and mastery role modeling from other members. Parent groups are rich resources for information. Even if parents are unable to attend meetings, they can still benefit from group newsletters and other literature that often accompany membership. Nurses can assist in starting a group by identifying one or two parents as leaders; sharing with them the names, telephone numbers, and addresses of other families who have expressed both an interest and a willingness to release their phone number and address; and guiding them in how to initiate a first meeting.
Advocate for Empowerment Nurses can advocate for methods that foster opportunities for parent empowerment. For example, nurses can suggest reimbursement for travel and child care plus stipends to enable parents' voices to be heard at meetings and conferences. They can encourage parent membership on committees and advisory boards. They can keep parents informed of pending legislation on child health issues or take action when parents inform them.
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The Child Through ongoing contacts with the child, the nurse (1) observes the child's responses to the disorder, ability to function, and adaptive behaviors within the environment and with significant others; (2) explores the child's own understanding of his or her illness or condition; and (3) provides support while the child learns to cope with his or her feelings. Children are encouraged to express their concerns rather than allowing others to express them for them because open discussions may reduce anxiety (see Nursing Care Guidelines box).
N u r s i n g C a r e G u i d e l i n e s Encouraging Expression of Emotion
Describe the behavior: “You seem angry at everyone.”
Give evidence of understanding: “Being angry is only natural.”
Give evidence of caring: “It must be difficult to endure so many painful procedures.”
Help focus on feelings: “Maybe you wonder why this happened to you.”
One of the most important interventions is alleviating the child's feeling of being different and normalizing his or her life as much as possible (see Nursing Care Guidelines box). Whenever possible, the nurse assists the family in assessing the child's daily routine for indications of a need for normalizing practices. For example, the child who remains in a bedroom all day requires a restructured daily routine to provide activities in different parts of the house, such as eating in the kitchen or dining room with the family. Such children may also be deprived of social, recreational, and academic activities that can be better accommodated by applying normalization practices. For example, home and out-of-home health-related treatments should be planned at times that least interfere with normal daily activities.
N u r s i n g C a r e G u i d e l i n e s Promoting Normalization
Preparation: Prepare child in advance for changes that may occur from the chronic or complex condition.
Example: Tell the child in advance the possible side effects of drug therapy.
Participation: Include child in as many decisions as possible, especially those relating to his or her care regimen.
Example: The child is responsible for taking medications or scheduling home treatments.
Sharing: Allow both family members and child's peers to be a part of the care regimen whenever possible.
Examples: Give the child his or her medication when the other siblings receive their vitamins.
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The parent cooks the same menu for the whole family.
If the child is invited to another's home, the parent advises the family of the child's dietary restrictions.
Control: Identify areas where child can be in control so that feelings of uncertainty, passivity, and helplessness are decreased.
Example: The child identifies activities that are appropriate to his or her energy level and chooses to rest when fatigued.
Expectation: Apply the same family rules to the child with a complex chronic illness as to the well siblings or peers.
Example: The child is disciplined, is expected to fulfill household responsibilities, and attends school in accordance with abilities.
Children who are concerned that their condition detracts from their physical attractiveness need attention focused on the normal aspects of appearance and capabilities. Health professionals help strengthen and consolidate the self-image by emphasizing the normal while allowing children to express anger, isolation, fear of rejection, feelings of sadness, and loneliness. The children need positive reinforcement for compliance and any evidence of improvement. Anything that might improve attractiveness and contribute to a positive self-image is used, such as makeup for a teenager with a scar, clothing that disguises a prosthesis, or a hairstyle or wig to cover a deformity or lost hair.
Siblings The presence of a child with special needs in a family may result in parents paying less attention to the other children. Siblings may respond by developing negative attitudes toward the child or by expressing anger in different forms. The nurse can help by using anticipatory guidance, questioning the parents about what they believe is the best way to have siblings respond to the child, and guiding them through ways to meet their other children's needs for attention. This questioning should take place before serious negative effects occur.
Siblings may also experience embarrassment associated with having a brother or sister with a chronic or complex condition. Parents are then faced with the difficulty of responding to this embarrassment in an understanding and appropriate manner without punishing the siblings for how they feel. Parents are encouraged to talk with the siblings about how they view their affected sibling. For example, siblings of a child with developmental disabilities may express fears about their ability to bear normal children. Adolescents in particular may not be able to discuss these vital issues with their parents and may prefer to consult with the nurse. Many siblings benefit from sharing their concerns with other young people who are experiencing a similar situation. Support groups for siblings can help decrease isolation, promote expression of feelings, and provide examples of effective coping skills.
Many parents express concern about when and how to inform the other children in the family about a sibling's illness or disability. The answer depends on each child's level of sophistication and understanding. However, it is usually best to inform the siblings before a neighbor or other nonfamily member does so. Uninformed siblings may fantasize or develop apprehensions that are out of proportion to the child's actual condition. Furthermore, if parents choose to be silent or deceptive about the issue, they are setting a negative precedent for the siblings to follow rather than encouraging the siblings to cope with the experience in a healthy and nurturing way.
The nurse is sensitive to the reactions of siblings and whenever possible intervenes to promote more positive adjustment. For example, siblings often mention that they are expected to take on additional responsibilities to help the parents care for the child. It is not unusual for them to express
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a positive reaction to assuming the extra duties but a negative response to feeling unappreciated for doing so. Such feelings can often be minimized by encouraging siblings to discuss this with the parents and by suggesting to parents ways of showing gratitude, such as an increase in allowance, special privileges, and, most significantly, verbal praise.
Educate About the Disorder and General Health Care Educating the family about the disorder is actually an extension of revealing the diagnosis. Education involves not only supplying technical information but also discussing how the condition will affect the child. Parents may only be able to process limited information at any one time. It may be helpful to provide essential information and then follow by asking, “What else would you like to know about your child's condition?” Responding to parents' questions and concerns ensures that their information needs are met.
Activities of Daily Living Parents also need guidance in how the condition may interfere with or alter activities of daily living, such as eating, dressing, sleeping, and toileting. One area frequently affected is nutrition. Common problems are undernutrition resulting from food being inappropriately restricted or loss of appetite, vomiting, or motor deficits that interfere with feeding; overnutrition may also occur, usually because of a caloric intake in excess of energy expenditure because of boredom and lack of stimulation in other areas. Although the child requires the same basic nutrients as other children, the daily requirements may differ. Special nutritional considerations are discussed as appropriate throughout the text.
Safe Transportation Modifications may also be needed regarding car safety. Children with conditions such as low birth weight (see Discharge Planning and Home Care, Chapter 8) or orthopedic, neuromuscular, or respiratory impairments often cannot safely use conventional car restraints. For example, children with hip spica casts cannot sit properly in child safety seats (see Developmental Dysplasia of the Hip, Chapter 29). Modifications can be made to some commercial models, and for older children, a special vest is available that secures the child to the back seat in a lying-down position.*
If a child requires a wheelchair, the family should consult the wheelchair manufacturer for specific instructions regarding safe car transportation. Considerations for wheelchairs used with vehicle transportation must address securing both the wheelchair and the occupant in the wheelchair. Wheelchairs should be secured facing forward with tie downs at four points. The tie- down system should be dynamically crash tested, as should the occupant securement system that secures the child in the wheelchair. For example, use of trays is not recommended for transportation. With children who must travel with additional medical equipment, this equipment (e.g., oxygen, monitors, or ventilators) should be anchored to the floor or underneath the vehicle seat or wheelchair. Soft padding should be added around the equipment to reduce movement. A second adult should be present to monitor the condition of a medically fragile child while traveling.
Primary Health Care Children with special needs require all the usual health care recommended for any child. Attention to injury prevention, immunizations, dental health, and regular physical examinations is essential. Nurses can play an important role in reminding parents of these aspects of care that are so often neglected when the concern is focused on the child's chronic condition. Specific discussions of nutrition, sleep and activity, dental health, and injury prevention are presented in the chapters on health promotion for specific age groups. Immunizations are discussed in Chapter 9.
Parents also need to be aware of the importance of communicating the child's condition in the event of a medical emergency. Young children are unable to give information about their disorders, and although older children may be reliable sources, after an accident, they may be physically unable to speak. Therefore all children with any type of chronic condition that may affect medical care should wear some type of identification, such as a MedicAlert bracelet,* or carry a card in their wallet that lists the medical condition and a phone number for emergency medical records and other personal information.
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Promote Normal Development Aside from knowledge of the condition and its effect on the child's abilities, the family must be guided toward fostering appropriate development in their child. Although each stage may take longer to achieve, parents are guided toward helping the child fully realize his or her potential in preparation for the next developmental stage. Table 17-2 outlines developmental aspects of complex conditions and supportive interventions. With appropriate planning and knowledge of strategies to improve the child's functional abilities, most children can live fulfilling and productive lives.
One important aspect of promoting normal development is to encourage the child's self-care abilities in both activities of daily living and the medical regimen. An assessment of the child's age and physical, emotional, and mental capacities, as well as the support and structure provided by the family, should be considered in determining the appropriate level of self-care in the medical regimen. Even toddlers can be involved in their own care by holding supplies for the parent during a procedure. Over time, children should be encouraged toward greater autonomy in the self-care arena.
Early Childhood During infancy, the child is achieving basic trust through a satisfying, intimate, consistent relationship with his or her parents. However, affected children's early existence may be stressful, chaotic, and unsatisfying. Consequently, they may need more parental support and expressions of affection to achieve trust. Likewise, the parents require assistance in finding ways to meet the infant's needs, such as how to hold a rigid or flaccid infant, how to feed a child with tongue thrust or episodes of dyspnea, and how to stimulate a child who seems incapable of achieving any skills. If hospitalizations are frequent or prolonged, every effort is made to preserve the parent–child relationship (see also Chapter 19).
During early childhood, the goal is to adapt to periods of separation from parents, autonomy, and initiative. However, the natural parental response to having a sick child is overprotection (Box 17- 7). Parents need help in realizing the importance of brief separations of the child from them and from others involved in the child's care and of providing social experiences outside the home whenever possible. Respite care, which provides temporary relief for family members, can be essential in allowing caregivers time away from the daily burdens.
Box 17-7 C h a r a c t e r i s t i c s o f Pa r e n t a l O ve r p r o t e c t i o n Sacrifices self and rest of family for the child
Continually helps the child even when the child is capable
Is inconsistent with regard to discipline or uses no discipline; frequently applies different rules to the siblings
Is dictatorial and arbitrary, making decisions without considering the child's wishes, such as keeping the child from attending school
Hovers and offers suggestions; calls attention to every activity; overdoes praise
Protects the child from every possible discomfort
Restricts play, often because of fear that the child will be injured
Denies the child opportunities for growing up and assuming responsibility, such as learning to give own medications or perform treatments
Does not understand the child's capabilities and sets goals too high or too low
Monopolizes the child's time, such as sleeping with the child, permitting few friends, or refusing participation in social or educational activities
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Young children also need the opportunity to develop independence. Frequently, the child is able to learn self-help skills, such as finger feeding, and removing simple articles of clothing, but the parent continues to perform the act. The nurse can provide parents with anticipatory guidance as to the usual milestones expected from the child. When a child is unable to perform a skill independently, functional aids should be used. With innovation, many adaptations can be implemented in children's environments to increase their mobility and independence and allow them to play like other children their age. For example, with slight modifications, a child with physical limitations may be able to ride a tricycle (Fig. 17-4).
FIG 17-4 A modified tricycle with block pedals, self-adhesive straps for support, and a modified seat and handle bars can help a child with disabilities gain mobility.
Another critical component for normal child development is discipline. Discipline and guidance serve several purposes, such as providing children with boundaries on which to test out their behavior and teaching them socially acceptable behavior. Resentment and hostility can arise among siblings if different standards are applied to each child. The nurse's responsibility is to help parents learn successful methods of managing a child's behaviors before they become problems (see Limit Setting and Discipline, Chapter 2).
School Age For school-age children, the major tasks are entry into school and achieving a sense of industry. Although the importance of school in the life of all children is well known, school absences are significantly higher among children with chronic illnesses than among their healthy peers. The more school absences the child experiences, the more difficult it is to resume attendance, and school phobia may result. The child should return to school as soon as possible after diagnosis or treatments.
Preparation for entry into or resumption of school is best accomplished through a team approach with the parents, child, teacher, school nurse, and primary nurse in the hospital. Ideally, this planning should begin before hospital discharge, provided that the child is well enough to resume usual activities. A structured plan should be developed, with attention to aspects of care that must be continued during school hours, such as administration of medication or other treatments.
Children also need preparation before entering or resuming school. Having a tutor in the hospital or home as soon as children are physically able helps them realize that school will continue and gives them time to consider this prospect (Fig. 17-5). They need to investigate possible answers to the many questions others will ask. One method of anticipatory preparation is to role-play, with the child as the “returned pupil” and the nurse or parent as “other schoolmates.” If the child returns to school with some obvious physical change (such as hair loss, amputation, or a visible scar), the nurse might also ask questions about these alterations to prompt preparatory responses from the
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child.
FIG 17-5 Children with disabilities should continue their schooling as soon as their condition permits.
Classroom peers also need preparation, and a joint plan created by the teacher, nurse, and child is best. At a minimum, classmates should be given a description of the child's condition, prepared for any visible changes in the child, and allowed an opportunity to ask questions. The child should have the option of attending this session. As the child's condition changes, particularly if the illness is potentially fatal, school personnel, including the students, need periodic appraisal of the child's status and preparation for what to expect.
Children with special needs are encouraged to maintain or reestablish relationships with peers and to participate according to their capabilities in any age-appropriate activities. Alternative activities may be substituted for those that are impossible or that place a strain on the child's condition. Programs, such as the Special Olympics,* offer children an opportunity to compete with their peers and to achieve athletic skill. Summer camps† allow children to associate with peers and develop a wide variety of skills. Children with special needs can derive enormous benefits from expressive activities, such as art, music, poetry, dance, and drama. With adaptive equipment and imagination, children can participate in a variety of activities. Organizations such as VSA Arts allow children to celebrate and share their accomplishments.‡ Children need the opportunity to interact with healthy peers and to engage in activities with groups or clubs composed of similarly affected age-mates. Organizations such as ostomy clubs, diabetes clubs, and cerebral palsy groups share information and provide support related to the special problems the members face.
Adolescence Adolescence can be a particularly difficult period for the teenager and family. All of the needs discussed previously apply to this age group as well. Developing independence or autonomy, however, is a major task for the adolescent as planning for the future becomes a prominent concern. Although the emphasis in the past has been on achieving independence from physical assistance, recent developments in the fields of special education, adolescent development, and family systems suggest redefining autonomy in terms of individuals' capacities to take responsibility for their own behavior, to make decisions regarding their own lives, and to maintain supportive social relationships. Given this understanding, even individuals with severe impairments can be viewed as autonomous if they perceive their own needs and take responsibility for meeting them, either directly or by engaging the assistance of others. As adolescents become more autonomous, the nurse can help them articulate their needs, participate in developing their own care plans, and discover and express how others can be of greatest assistance.
Physical symptoms are high on teenagers' list of health-related concerns. Because adolescence is a time of enormous physical and emotional changes, it is important for the nurse to distinguish
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between body changes that are related to the child's complex condition and those that are a result of normal body development. It can be a great comfort for teenagers with disabling conditions to know that many of the changes they experience are normal developmental outcomes.
A sense of feeling different from peers can lead to loneliness, isolation, and depression. Participation in groups of teenagers with chronic conditions or disabilities can alleviate feelings of isolation and smooth the transition to a meaningful relationship with one person in adulthood.
Establish Realistic Future Goals One of the most difficult adjustments is setting realistic future goals for the child that are based on the child's own goals and values.
Planning for the future should be a gradual process. All along, the parents should cultivate realistic vocations for the child. For example, if children have physical disabilities, they can be directed toward intellectual, artistic, or musical pursuits. Children with developmental disabilities can be taught manual skills. In this way, the child's development proceeds in the direction of self- support through gainful employment.
With prolonged survival, young people with chronic illnesses must deal with new decisions and problems, such as marriage, employment, and insurance coverage. With appropriate guidance, individuals with disabilities can attain gainful employment, marriage, and a family. For those whose conditions are genetic, counseling is needed regarding future offspring. Prospective spouses often benefit from an opportunity to discuss their feelings regarding marriage to an individual with continued health needs and possibly a limited life span. Health insurance coverage is a critical issue for chronically ill children because of their enormous health care costs over time. The Affordable Care Act allows young adults to remain on their parents insurance until they are 26 years old and prevents private insurance carriers from denying them coverage. Life insurance is another dilemma, especially when children have serious conditions, such as congenital heart anomalies.
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Perspectives on the Care of Children at the End of Life Although most childhood illnesses and many injuries and other trauma respond favorably to treatment, some do not. When a child and family face a prolonged and life-limiting illness, health professionals must confront the challenge of providing the best possible care to meet the physical, psychological, spiritual, and emotional needs of the child and family during the uncertain course of the illness and at the time of death. When death is sudden and unexpected, nurses are challenged to respond to grief and shock in families and provide comfort and support in the absence of a prior relationship.
Many factors affect the causes of death that nurses are likely to encounter in children, including developmental factors, medical advances and technology, and changing social patterns. In infants, the leading causes of death are congenital anomalies, respiratory distress syndrome, disorders related to short gestation and low birth weight, and sudden infant death syndrome (Kochanek, Murphy, Xu, et al, 2014) (see Chapter 1). The leading causes of death in children 5 to 9 years old include injuries (accidents), malignant neoplasms, congenital anomalies, assault (homicide), and heart disease. In children 10 to 14 years old, suicide is the third leading cause of death after injuries (accidents) and malignant neoplasms. In youths 15 to 19 years old, assault (homicide), suicide, malignant neoplasms, and heart disease follow accidents as the most prevalent causes of death (Anderson and Smith, 2005).
A child who is diagnosed with a life-threatening illness or who is suffering serious, life- threatening trauma needs medical diagnosis and intervention, as well as nursing assessment and care—sometimes for a short time and sometimes over a lengthy period. When cure is no longer possible and life-prolonging measures result in pain, suffering, and distress to the child, parents need information about care options that are available to assist them in deciding how they want the remaining time with their child to be managed by the health care team. It is important that families are reassured that although their child cannot be cured, active care will continue to be provided to maintain the child's comfort. Support is provided to assist the child and family during the dying process. As a result, nurses may care for children and families who are making the difficult transition from curative or restorative treatments to palliative care.
Principles of Palliative Care Palliative care involves a multidisciplinary approach to the care of children living with or dying from chronic, complex, or potentially life-limiting conditions with a primary focus on symptom control, supportive care, and quality of life rather than on cure or life prolongation in the absence of the possibility of a cure (Field and Behrman, 2004). The World Health Organization (1996) defines palliative care as the “active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families.” This goal is certainly compatible with care for patients who are pursuing curative or life-prolonging therapy. Therefore there should be a distinction between palliative care and end-of-life care. End-of-life care is a part of palliative care, but the goals of palliative care extend to all aspects of a patient's quality of life and can be established early in the trajectory of a patient's disease. The World Health Organization (1998) amended the definition of palliative care for children to include: • Palliative care for children is the active total care of the child's body, mind, and spirit and involves
giving support to the family. • It begins when illness is diagnosed and continues regardless of whether or not a child receives
treatment directed at the disease. • Health providers must evaluate and alleviate the child's physical, psychological, and social
distress. • Effective palliative care requires a broad multidisciplinary approach that includes the family and
makes use of available community resources; it can be successfully implemented even if resources are limited.
• It can be provided in tertiary care facilities, in community health centers, and even in children's
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homes. Palliative care interventions do not serve to hasten death. Rather, they provide pain and
symptom management, attention to issues faced by the child and family with regard to death and dying, and promotion of optimal functioning and quality of life during the time the child has remaining. The implementation of neonatal and pediatric palliative care consulting services within hospitals has led to enhanced quality of life and end-of-life care for children and their families and support for their care providers (Blume, Balkin, Aiyagari, et al, 2014; O'Quinn and Giambra, 2014). Several principles are hallmarks of palliative care.
The child and family are considered the unit of care. The death of a child is an extremely stressful event for a family, because it is out of the natural order of things. Children represent health and hope, and their death calls into question the understanding of life. A multidisciplinary team of health care professionals consisting of social workers, chaplains, nurses, personal care aides, and physicians skilled in caring for dying patients assist the family by focusing care on the complex interactions among physical, emotional, social, and spiritual issues.
Palliative care seeks to create a therapeutic environment as homelike as possible, if not in the child's own home. Through education and support of family members, an atmosphere of open communication is provided regarding the child's dying process and its impact on all members of the family (see Translating Evidence into Practice box).
T r a n s l a t i n g E v i d e n c e i n t o P r a c t i c e Pediatric Pain and Symptom Management at the End of Life
Ask the Question PICOT Question In children, what is the pain and symptom experience at the end of life?
Search for the Evidence Search Strategies Published studies from using the subject terms child, palliative care, pain, and symptoms were identified and examined. Retrospective descriptive studies dominated the findings describing infants' and children's end-of-life experiences through the use of medical record reviews and provider and parental surveys.
Databases Used PubMed, CINAHL
Critically Analyze the Evidence Children experienced an average of 11 symptoms during their last week of life (Drake, Frost, and Collins, 2003). Pain, dyspnea, and fatigue were the most frequently documented symptoms experienced by most children at the end of life (Bradshaw, Hinds, Lensing, et al, 2005; Carter, Howenstein, Gilmer, et al, 2004; Drake, Frost, and Collins, 2003; Hongo, Watanabe, Okada, et al, 2003). Children and their parents report high distress with pain and symptoms at the end of life. Parents reported pain and suffering as one of the most important factors in deciding to withhold or withdraw life support from their child in the pediatric intensive care unit (Meert, Thurston, and Sarnaik, 2000).
Documentation was scarce related to symptom management. Morphine was the most commonly prescribed pain medication (Drake, Frost, and Collins, 2003; Hongo, Watanabe, Okada, et al, 2003). Parents reported their children as experiencing high levels of pain near the end of life (Contro, Larson, Scofield, et al, 2002). Physicians were more likely than nurses or parents to report that a child's pain and symptoms were well managed at the end of life, but the majority of both provider groups believed the child's physical management was difficult (Andresen, Seecharan, and Toce, 2004; Wolfe, Grier, Klar, et al, 2000).
Barriers to the adequate provision of pediatric palliative care include developmental issues specific to infants and children; symptoms, their causes, how they are related, and effective treatment strategies; lack of education; and reimbursement issues (Harris, 2004). Physicians report reliance on trial and error as they learn to care for children at the end of life and the need for
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specialty consults with palliative care service providers (Hilden, Emanuel, Fairclough, et al, 2001).
Apply the Evidence: Nursing Implications There is moderate-quality evidence with a strong recommendation (Guyatt, Oxman, Vist, et al, 2008) for better pain management at the end of life. Although the philosophy of palliative care encompasses pain and symptom management for infants and children who may not outlive their disease, the provision of that care to ease suffering and provide comfort to those who will die continues to lag. Studies show that children experience significant pain and other distressing symptoms at the end of life that are not well managed. Discrepancies in perceptions of infants' and children's pain and suffering continue to exist between providers and parents. Barriers to the provision of pediatric palliative care exist. Improvements are needed in the management of pain and symptoms at the end of life for infants and children.
Quality and Safety Competencies: Evidence-Based Practice* Knowledge
Differentiate clinical opinion from research and evidence-based summaries.
Describe common symptoms experienced at the end of life.
Skills
Base individualized care plan on patient values, clinical expertise, and evidence.
Integrate evidence into practice by carefully assessing pain and other symptoms in children at the end of life.
Attitudes
Value the concept of evidence-based practice as integral to determining best clinical practice.
Appreciate strengths and weakness of evidence for symptom assessment and management at the end of life.
References Andresen EM, Seecharan GA, Toce SS. Provider perceptions of child deaths. Arch Pediatr
Adolesc Med. 2004;158(5):430–435. Bradshaw G, Hinds PS, Lensing S, et al. Cancer-related deaths in children and adolescents. J
Palliat Med. 2005;8(1):86–95. Carter BS, Howenstein BS, Gilmer MJ, et al. Circumstances surrounding the deaths of
hospitalized children: opportunities for pediatric palliative care. Pediatrics. 2004;114(3):361– 366.
Contro N, Larson J, Scofield S, et al. Family perspectives on the quality of pediatric palliative care. Arch Pediatr Adolesc Med. 2002;156(1):14–19.
Drake R, Frost J, Collins JJ. The symptoms of dying children. J Pain Symptom Manage. 2003;26(1):594–603.
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926.
Harris MB. Palliative care in children with cancer: which child and when? J Natl Cancer Inst Monogr. 2004;32:144–149.
Hilden JM, Emanuel EJ, Fairclough DL, et al. Attitudes and practices among pediatric oncologists regarding end-of-life care: results of the 1998 American Society of Clinical Oncology Survey. J Clin Oncol. 2001;19(1):205–212.
Hongo T, Watanabe C, Okada S, et al. Analysis of the circumstances at the end of life in children with cancer: symptoms, suffering and acceptance. Pediatr Int. 2003;45(1):60–64.
Meert KL, Thurston CS, Sarnaik AP. End-of-life decision-making and satisfaction with care: parental perspectives. Pediatr Crit Care Med. 2000;1(2):179–185.
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Wolfe J, Grier HE, Klar N, et al. Symptoms and suffering at the end of life in children with cancer. N Engl J Med. 2000;342(5):326–333.
*Adapted from the Quality and Safety Education for Nurses website at http://www.qsen.org/.
Decision Making at the End of Life Discussions concerning the possibility that a child's illness or condition is not curable and that death is an inevitable outcome cause everyone involved a great deal of stress. Physicians, other members of the health care team, and families must consider all information regarding the child's situation and make decisions that all parties agree to and that will have a profound impact on the child and family.
Ethical Considerations in End-of-Life Decision Making A number of ethical concerns arise when parents and health care professionals are deciding on the best course of care for the dying child. Many parents and health care providers are concerned that not offering treatment that would cause potential pain and suffering but might extend life would be considered euthanasia or assisted suicide. To eliminate such concerns, it is necessary to understand the various terms. Euthanasia involves an action carried out by a person other than the patient to end the life of the patient suffering from a terminal condition. The intent of this action is based on the belief that the act is “putting the person out of his or her misery.” This action has also been called mercy killing. Assisted suicide occurs when someone provides the patient with the means to end his or her life and the patient uses that means to do so. The important distinction between these two actions involves who is actually acting to end the person's life.
The American Nurses Association Code of Ethics for Nurses (2015) does not support the active intent on the part of a nurse to end a person's life. However, it does permit the nurse to provide interventions to relieve symptoms in the dying patient even when the interventions involve a substantial risk of hastening death. When the prognosis for a patient is poor and death is the expected outcome, it is ethically acceptable to withhold or withdraw treatments that may cause pain and suffering and provide interventions that promote comfort and quality of life.
Physician–Health Care Team Decision Making Decisions by physicians regarding care are often made on the basis of the progression of the disease or amount of trauma, the availability of treatment options that would provide cure from disease or restoration of health, the impact of such treatments on the child, and the child's overall prognosis (Pousset, Bilsen, Cohen, et al, 2010). Often the main determinants prompting physicians to discuss end-of-life issues and options for children with critical illnesses include the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life (Pousset, Bilsen, Cohen, et al, 2010). When the physician discusses this information openly with families, a shared decision-making process can occur regarding do not attempt resuscitation (DNaR) orders and care that is focused on the comfort of the child and family during the dying process (Giannini, Messeri, Aprile, et al, 2008).
Unfortunately, many families are not given the option of terminating treatment and pursuing care that is focused on comfort and quality of life when cure is unlikely, and staff may be reluctant to raise the question of DNaR orders. This occurs for a number of reasons, including the belief that not being able to “save” a child is a “failure.” Also, the physician and other members of the health care team may lack knowledge of and experience with the principles of palliative care (Baker, Torkildson, Baillargeon, et al, 2007; Price, Dornan, Quail, 2013).
Parental Decision Making Rarely are families prepared to cope with the numerous decisions that must be made when a child is dying. When the death is unexpected, as in the case of an accident or trauma, the confusion of emergency services and possibly an intensive care setting presents challenges to parents as they are asked to make difficult choices. If the child has either experienced a life-threatening illness (such as cancer) or lived with a chronic illness that has now reached its terminal phase, parents are often
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unprepared for the reality of their child's impending death (see Family-Centered Care box). Numerous studies have found that families facing the impending death of a child depend on information provided to them by the health care team, particularly an honest appraisal of the child's prognosis, to make difficult decisions regarding care options for their children (Lipstein, Brinkman, and Britto, 2012; Hinds, Oakes, Furman, et al, 2001; James and Johnson, 1997; Wolfe, Friebert, and Hilden, 2002).
F a m i l y - C e n t e r e d C a r e Family of the Dying Child
As the group of health professionals that is most involved with families, nurses are in an excellent position to ensure that families are presented with the options available to them. The nurse's first responsibility is to explore the family's wishes. This is best done in concert with the physician but at times may need to be initiated by the nurse. Statements (such as, “Tell me about your thoughts for the type of care you want your child to receive when he is dying” or “Have you considered the types of interventions you would like us to use when your child is near death?”) can begin discussion of this sensitive but critical aspect of terminal care.
The Dying Child Children need honest and accurate information about their illness, treatments, and prognosis. This information needs to be given in clear, simple language. In most situations, this best occurs as a gradual process over time that is characterized by increasingly open dialogue among parents, professionals, and the child (Barnes, Gardiner, Gott, et al, 2012; Beale, Baile, and Aaron, 2005; Young, Dixon-Woods, Windridge, et al, 2003). Providing an atmosphere of open communication early in the course of an illness facilitates answering difficult questions as the child's condition worsens. Providing appropriate literature about the disease, as well as the experience of illness and possible death, is also helpful. Exactly how and when to involve children in decisions regarding care during their dying process and death is an individual matter. The child's age or developmental level is an important consideration in the process (Table 17-4). In general, parents should be asked how they would like their child to be told of his or her prognosis, and they should be included in his or her care. Some parents may request that their child not be told that he or she is dying even if the child asks. This often places health care providers in a difficult situation. Children, even at a young age, are perceptive. Even if they are not told outright that they are dying, they realize that something is seriously wrong and that it involves them. Often, helping parents understand that honesty and shared decision making between them and their child are important to the child's and family's emotional health will encourage parents to allow discussion of dying with their child. Parents may require professional support and guidance in this process from a nurse, social worker, or child life specialist who has a good relationship with the child and family.
TABLE 17-4 Children's Understanding of and Reactions to Death
Concepts of Death Reactions to Death Nursing Care Management Infants and Toddlers Death has least significance to children
younger than 6 months old. After parent–child attachment and trust
are established, the loss, even if temporary, of the significant person is profound.
Prolonged separation during the first several years is thought to be more significant in terms of future physical, social, and emotional growth than at any subsequent age.
Toddlers are egocentric and can only think about events in terms of their own frame of reference—living.
Their egocentricity and vague separation of fact and fantasy make it impossible for them to comprehend absence of life.
Instead of understanding death, this age group is affected more by any change in lifestyle.
With the death of someone else, they may continue to act as though the person is alive.
As children grow older, they will be increasingly able and willing to let go of the dead person.
Ritualism is important; a change in lifestyle could be anxiety producing. This age group reacts more to the pain and discomfort of a serious illness
than to the probable fatal prognosis. This age group also reacts to parental anxiety and sadness.
Help parents deal with their feelings, allowing them greater emotional reserves to meet the needs of their children.
Encourage parents to remain as near to child as possible yet be sensitive to parents' needs.
Maintain as normal an environment as possible to retain ritualism.
If a parent has died, encourage having consistent caregiver for child.
Promote primary nursing.
Preschool Children Preschoolers believe their thoughts are
sufficient to cause death; the consequence is the burden of guilt,
If they become seriously ill, they conceive of the illness as a punishment for their thoughts or actions.
They may feel guilty and responsible for the death of a sibling.
Help parents deal with their feelings, allowing them greater emotional reserves to meet the needs of their children.
Help parents understand behavioral reactions of their children.
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shame, and punishment. Their egocentricity implies a tremendous
sense of self-power and omnipotence. They usually have some understanding
of the meaning of death. Death is seen as a departure, a kind of
sleep. They may recognize the fact of physical
death but do not separate it from living abilities.
Death is seen as temporary and gradual; life and death can change places with one another.
They have no understanding of the universality and inevitability of death.
Greatest fear concerning death is separation from parents. They may engage in activities that seem strange or abnormal to adults. Because they have fewer defense mechanisms to deal with loss, young
children may react to a less significant loss with more outward grief than to the loss of a very significant person. The loss is so deep, painful, and threatening that the child must deny it for a time to survive its overwhelming impact.
Behavior reactions such as giggling, joking, attracting attention, or regressing to earlier developmental skills indicate children's need to distance themselves from tremendous loss.
Encourage parents to remain near the child as much as possible to minimize the child's great fear of separation from parents.
If a parent has died, encourage having a consistent caregiver for child.
Promote primary nursing.
School-Age Children Children still associate misdeeds or bad
thoughts with causing death and feel intense guilt and responsibility for the event.
Because of their higher cognitive abilities, they respond well to logical explanations and comprehend the figurative meaning of words.
They have a deeper understanding of death in a concrete sense.
They particularly fear the mutilation and punishment that they associate with death.
They personify death as the devil, a monster, or the bogeyman.
They may have naturalistic or physiologic explanations of death.
By 9 or 10 years old, children have an adult concept of death, realizing that it is inevitable, universal, and irreversible.
Because of their increased ability to comprehend, they may have more fears, for example:
• The reason for the illness • Communicability of the disease to themselves or others • Consequences of the disease • The process of dying and death itself Their fear of the unknown is greater than their fear of the known. The realization of impending death is a tremendous threat to their sense of
security and ego strength. They are likely to exhibit fear through verbal uncooperativeness rather than
actual physical aggression. They are interested in post-death services. They may be inquisitive about what happens to the body.
Help parents deal with their feelings, allowing them greater emotional reserves to meet the needs of their children.
Encourage parents to remain near child as much as possible yet be sensitive to parents' needs.
Because of children's fear of the unknown, anticipatory preparation is important.
Because the developmental task of this age is industry, interventions of helping children maintain control over their bodies and increasing their understanding allow them to achieve independence, self-worth, and self-esteem and avoid a sense of inferiority.
Encourage children to talk about their feelings and provide aggressive outlets.
Encourage parents to honestly answer questions about dying rather than avoiding the subject or fabricating euphemisms.
Encourage parents to share their moments of sorrow with their children.
Provide preparation for post-death services.
Adolescents Adolescents have a mature
understanding of death. They are still influenced by remnants of
magical thinking and are subject to guilt and shame.
They are likely to see deviations from accepted behavior as reasons for their illness.
Adolescents straddle transition from childhood to adulthood. They have the most difficulty in coping with death. They are least likely to accept cessation of life, particularly if it is their own. Concern is for the present much more than for the past or the future. They may consider themselves alienated from their peers and unable to
communicate with their parents for emotional support, feeling alone in their struggle.
Adolescents' orientation to the present compels them to worry about physical changes even more than the prognosis.
Because of their idealistic view of the world, they may criticize funeral rites as barbaric, money making, and unnecessary.
Help parents deal with their feelings, allowing them greater emotional reserves to meet the needs of their children.
Avoid alliances with either parent or child. Structure hospital admission to allow for maximum self-control
and independence. Answer adolescents' questions honestly, treating them as
mature individuals and respecting their needs for privacy, solitude, and personal expressions of emotions.
Help parents understand their child's reactions to death and dying, especially that concern for present crises (such as loss of hair) may be much greater than for future ones, including possible death.
If given the opportunity, children will tell others how much they want to know. Nurses can help children set limits on how much truth they can accept and cope with by asking questions, such as “If the disease came back, would you want to know?” or “Do you want others to tell you everything even if the news isn't good?” or “If someone were not getting better [or more directly, were dying], do you think he would want to know?” Children need time to process feelings and information so that they can assimilate and ideally accept the reality of impending death.
Care of dying adolescents requires the nurse to become knowledgeable about any possible delays or alterations in normal growth and development. Legal and ethical issues also come to the forefront with respect to the age at which an adolescent should have autonomy in decision making with regard to care and treatment. Effective communication among the patient, family, and health care team is an important part of optimal care for dying adolescents (Barnes, Gardiner, Gott, et al, 2012).
Treatment Options for Terminally Ill Children Based on the child and family's decision regarding their wishes for terminal care, they have several options from which to choose.
Hospital Families may choose to remain in the hospital to receive care if the child's illness or condition is unstable and home care is not an option or the family is uncomfortable with providing care at home. If a family chooses to remain at the hospital for terminal care, the setting should be made as homelike as possible. Families are encouraged to bring familiar items from the child's room at home. In addition, there should be a consistent and coordinated care plan for the comfort of the child and family.
Home Care Some families prefer to take their child home and receive services from a home care agency. Generally, these services entail periodic nursing visits to administer a treatment or provide medications, equipment, or supplies. The child's care continues to be directed by the primary physician. Home care is often the option chosen by physicians and families because of the traditional view that a child must be considered to have a life expectancy of less than 6 months to be referred to hospice care. Fortunately, a number of hospice organizations are expanding their
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services to children based on the presence of a life-limiting disease process for which cure is not possible, rather than on the sole criteria of a limited time-projected prognosis.
Hospice Care Parents should be offered the option of caring for their child at home during the final phases of an illness with the assistance of a hospice organization. Hospice* is a community health care organization that specializes in the care of dying patients by combining the hospice philosophy with the principles of palliative care. Hospice philosophy regards dying as a natural process and care of dying patients as including management of the physical, psychosocial, and spiritual needs of the patient and family. Care is provided by a multidisciplinary group of professionals in the patient's home or an inpatient facility that uses the hospice philosophy. Hospice care for children was introduced in the 1970s, and a number of community hospice organizations now accept children into their care (Keim-Malpass, Hart, and Miller, 2013; Siden, Chavoshi, Harvey, et al, 2014). However, access to free standing pediatric hospice services continues to be highly variable (Kassam and Wolfe, 2013). Collaboration between the child's primary treatment team and the hospice care team is essential to the success of hospice care. Families may continue to see their primary care physicians as they choose.
Hospice care is based on a number of important concepts that significantly set it apart from hospital care: • Family members are usually the principal caregivers and are supported by a team of professional
and volunteer staff. • The priority of care is comfort. The child's physical, psychosocial, and spiritual needs are
considered. Pain and symptom control are primary concerns, and no extraordinary efforts are used to attempt a cure or prolong life.
• The family's needs are considered to be as important as those of the patient. • Hospice is concerned with the family's post-death adjustment, and care may continue for a year or
more. The goal of hospice care is for children to live life to the fullest without pain, with choices and
dignity, in the familiar environment of their home, and with the support of their family. Hospice care is covered under state Medicaid programs and by most insurance plans. The service provides home visits from nurses, social workers, chaplains, and, in some cases, physicians. Medications, medical equipment, and any necessary medical supplies are all provided by the hospice organization providing care.
With children, the home has been the more common environment for implementing the hospice concept, and this benefits the family in a variety of ways. Children who are dying are allowed to remain with those they love and with whom they feel secure. Many children who were thought to be in imminent danger of death have gone home and lived longer than expected. Siblings can feel more involved in the care and often have more positive perceptions of the death. Parental adaptation is often more favorable, demonstrated by their perceptions of how the experience at home affected their marriage, social reorientation, religious beliefs, and views on the meaning of life and death.
If the home is chosen for hospice care, the child may or may not die in the home. Reasons for final admission to a hospital vary but may be related to the parents' or siblings' wish to have the child die outside the home, exhaustion on the part of the caregivers, and physical problems such as sudden, acute pain or respiratory distress.
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Nursing Care of the Child and Family at the End of Life Regardless of where the child is cared for during the terminal stage of illness, both the child and the family usually experience fear of (1) pain and suffering, (2) dying alone (child) or not being present when the child dies (parent), and (3) actual death. Nurses can help families by lessening their fears through attention to the care needs of the child and family.
Fear of Pain and Suffering The presence of unrelieved pain in a terminally ill child can have detrimental effects on the quality of life experienced by the child and family. Parents feel that having their child in pain is unendurable and results in feelings of helplessness and a sense that they must be present and vigilant to get the necessary pain medications. Persistent pain also has an impact on the family as a whole. Nurses can alleviate the fear of pain and suffering by providing interventions aimed at treating the pain and symptoms associated with the terminal process in children.
Pain and Symptom Management Pain control for children in the terminal stages of illness or injury must be given the highest priority. Despite ongoing efforts to educate physicians and nurses on pain management strategies in children, studies have reported that children continue to be under-medicated for their pain (Wolfe, Grier, Klar, et al, 2000). Nearly all children experience some amount of pain in the terminal phase of their illness. The current standard for treating children's pain follows the World Health Organization's (1996) analgesic stepladder, which promotes tailoring the pain interventions to the child's level of reported pain. Children's pain should be assessed frequently and medications adjusted as necessary. Pain medications should be given on a regular schedule, and extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such as morphine should be given for severe pain, and the dose should be increased as necessary to maintain optimal pain relief. Techniques, such as distraction, relaxation techniques, and guided imagery (Lambert, 1999), should be combined with drug therapy to provide the child and family strategies to control pain (see Chapter 5 for further discussion of pain management strategies).
In addition to pain, children experience a variety of symptoms during their terminal course as a result of their disease process or as a side effect of medicines used to manage pain or other symptoms. These symptoms include fatigue, nausea and vomiting, constipation, anorexia, dyspnea, congestion, seizures, anxiety, depression, restlessness, agitation, and confusion (Hellsten, Hockenberry, Lamb, et al, 2000; von Lützau, Otto, Hechler, et al, 2012; Wolfe, Friebert, and Hilden, 2002). Each of these symptoms should be aggressively managed with appropriate medications or treatments and with interventions such as repositioning, relaxation, massage, and other measures to maintain the child's comfort and quality of life.
Occasionally, children require very high doses of opioids to control pain. This may occur for several reasons. Children on long-term opioid pain management can become tolerant of the drug, meaning that it is necessary to give more drugs to maintain the same level of pain relief. This should not be confused with addiction, which is a psychological dependence on the side effects of opioids. Addiction is not a factor in managing terminal pain in children. Other obvious reasons for requiring increased doses of opioids include progression of disease and other physiologic experiences of pain. It is important to understand that there is no maximum dose that can be given to control pain. However, nurses often express concern that administering doses of opioids that exceed what they are familiar with will hasten the child's death. The principle of double effect (Box 17-8) addresses such concerns. It provides an ethical standard that supports the use of interventions intended to relieve pain and suffering even though there is a foreseeable possibility that death may be hastened (Rousseau, 2001). In cases in which the child is terminally ill and in severe pain, using large doses of opioids and sedatives to manage pain is justified when no other treatment options are available that would relieve the pain but make the risk of death less likely (Hawryluck and Harvey, 2000; Jacobs, 2005). See Chapter 5 for an extensive discussion of pain assessment and management.
Box 17-8
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E t h i c a l P r i n c i p l e o f D o u b l e E f f e c t An action that has one good (intended) and one bad (unintended but foreseeable) effect is permissible if the following conditions are met:
• The action itself must be good or indifferent. Only the good consequences of the action must be sincerely intended.
• The good effect must not be produced by the bad effect.
• There must be a compelling or proportionate reason for permitting the foreseeable bad effect to occur.
Parents' and Siblings' Need for Education and Support Parents are the primary caregivers when the child is at home, and nurses providing care to the child and family need to teach the family about the medications being given to the child, how to administer medications, and the use of non-pharmacologic techniques. This empowers parents and provides a sense of control over the child's comfort and well-being, reducing their fear that their child will be in pain or suffering as he or she is dying. Additionally, better bereavement outcomes (e.g., adaptive coping, family cohesion, and less anxiety, stress, and depression) have been reported by parents who were actively involved in the care of their child (Goodenough, Drew, Higgins, et al, 2004; Lauer, Mulhern, Schell, et al, 1989). The grief work of fathers in particular seems to be facilitated when their child dies in the home setting. This finding may be related to the increased opportunity of working fathers to provide care to and spend time with their child at home versus the hospital setting.
Siblings may feel isolated and displaced during the time that their brother or sister is dying. Parents devote the majority of their time to the care and comfort of the dying child, causing siblings to feel left out of the parent–sick child relationship. Siblings may become resentful of their sick sibling and begin to feel guilty or ashamed about such feelings (Murray, 1999). Nurses can assist the family by helping the parents identify ways to involve siblings in the caring process, perhaps by bringing some supplies or favorite toy, game, or food item. Parents should also be encouraged to schedule time focusing on the siblings. Helping parents identify a trusted friend or family member who can sit with the ill child for a short period will allow them to attend to their own needs or those of their other children.
Fear of Dying Alone or of Not Being Present When the Child Dies When a child is being cared for at home, the burden of care on parents and family members can be great. Often, as the child's condition declines, family members begin the “death vigil.” Rarely is a child left alone for any length of time. This can be exhausting for family members, and nurses can assist the family by helping them arrange shifts so that friends or family members can be present with the child and allow others to rest. If the family has limited resources, community organizations, such as hospice or churches, often have volunteers who are willing to visit and sit with children. It is important that whoever is sitting with the child be aware of when the parent(s) would like to be notified to return to the child's bedside (Fig. 17-6).
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FIG 17-6 For a dying child, there is no greater comfort than the security and closeness of a parent.
When a child is dying in the hospital, the parents should be given full access to the child at all times. If the parents need to leave, they should be provided with a pager or other means of immediate communication and alerted if staff members note any change in the child that may indicate imminent death. Nurses should advocate for parents' presence in intensive care and emergency departments and attend to the parents' needs for food, drinks, comfortable chairs, blankets, and pillows.
Fear of Actual Death Home Deaths The majority of children receiving hospice care die at home; they often die in their own room with family, pets, and loved possessions around them. The physical process of dying can be distressing to parents because often the child slowly becomes less alert in the days before the actual death. The nurse can assist the family by providing them with information about what changes will occur as the child progresses through the dying process (Box 17-9). During this time, nursing visits often become more frequent and longer in duration to provide the family with additional support as the death nears. The most distressing change for parents to observe is the change in the respiratory pattern. In the final hours of life, the dying patient's respirations may become labored, with deep breaths and long periods of apnea, referred to as Cheyne-Stokes respirations. Families should be reassured that this is not distressing to the child and that it is a normal part of the dying process. However, the use of opioids can slow the respirations to make the child breathe more easily, and scopolamine, usually applied as a topical patch, can help reduce noisy respirations known as the “death rattle.” Noisy respirations are more likely to occur if the child is overhydrated.
Box 17-9 P h y s i c a l S i g n s o f A p p r o a c h i n g D e a t h Loss of sensation and movement in the lower extremities, progressing toward the upper body
Sensation of heat, although the body feels cool
Loss of senses:
• Tactile sensation decreasing
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• Sensitivity to light
• Hearing the last sense to fail
Confusion, loss of consciousness, slurred speech
Muscle weakness
Loss of bowel and bladder control
Decreased appetite and thirst
Difficulty swallowing
Change in respiratory pattern:
• Cheyne-Stokes respirations (waxing and waning of depth of breathing with regular periods of apnea)
• “Death rattle” (noisy chest sounds from accumulation of pulmonary and pharyngeal secretions)
Weak, slow pulse; decreased blood pressure
All families have the option of admitting their child to the hospital if they feel unable to deal with the death. The child who dies at home must be pronounced dead. Hospice programs typically have provisions so that this proceeds smoothly. In some circumstances, the police may be notified, with an explanation of the circumstances to prevent unnecessary concern regarding abuse. Providing the police with the number of the responsible practitioner is usually all that is necessary to confirm the cause of death.
Hospital Deaths Children dying in the hospital who are receiving supportive care interventions experience a similar process. Death resulting from accident or trauma or acute illness in settings, such as the emergency department or intensive care unit, often requires the active withdrawal of some form of life- supporting intervention, such as a ventilator or bypass machine. These situations often raise difficult ethical issues (Sullivan, Monagle, and Gillam, 2014), and parents are often less prepared for the actual moment of death. Nurses can assist these parents by providing detailed information about what will happen as supportive equipment is withdrawn, ensuring that appropriate pain medications are administered to prevent pain during the dying process and allowing the parents time before the start of the withdrawal to be with and speak to their child. It is important that the nurse attempt to control the environment around the family at this time by providing privacy, asking if they would like to play music, softening lights and monitor noises, and arranging for any religious or cultural rituals that the family may want performed.
After the child's death, the family should be allowed to remain with the body and hold or rock the child if they desire. After the nurse has removed all tubes and equipment from the body, the parents should be given the option of assisting with the preparation of the body, such as bathing and dressing. It is important for the nurse to determine whether the family has any specific needs because many cultures have adopted specific methods for coping with and mourning death, and impeding these practices may interfere with the grieving process (Clements, Vigil, Manno, et al, 2003).
At some point, the nurse discusses whether the family has made preparations for the burial service and whether the staff can help in any way. Parents often have concerns about the funeral, such as siblings' involvement in the death rituals. Although no absolute answers exist regarding the
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question of siblings attending the funeral or burial services, the consensus is that the surviving children benefit from being involved in these events. However, children need preparation for post- death services. They should be told what to expect, particularly how the deceased person will look if the coffin is open; allowed their private time to say good-bye; and permitted to stay as long as they wish. Ideally, the parents should prepare the siblings. If the parents' grief prevents this communication, a significant family member or friend should substitute.
Organ or Tissue Donation and Autopsy For some families, organ or tissue donation may be a meaningful act—one that benefits another human being despite the loss of their child. Unfortunately, initiating a discussion about tissue donation is often stressful for staff, and there may be confusion regarding whose responsibility this is. In centers in which transplants are performed, a full-time transplant coordinator is usually available to inform the family about organ donation and to take care of details. If such services are not available, the staff needs to determine which members should discuss this topic with the family. Ideally, the person who knows the family best, knows when the death is expected, or has the opportunity to spend time with the family when the death is unexpected takes the role. Often nurses are in an optimal position to suggest tissue donation after consultation with the attending physician. When possible, the topic should be raised before death occurs. The request should be made in a private and quiet area of the hospital and should be simple and direct with questions, such as “Are you a donor family?” or “Have you ever considered organ donation?”
Many states have legislated a mandatory request for organ or tissue donation when a child dies, especially if the patient is brain dead. Written consent from the family is required before donation can proceed. When requests for organ donation are made, health care practitioners must address common misunderstandings families have about brain death and organ donation (Franz, DeJong, Wolfe, et al, 1997). Training health care professionals on sensitive approaches to requests for organ donation has been shown to increase families' willingness to consent to organ donation (Evanisko, Beasley, Brigham, et al, 1998; Workman, Myrick, Meyers, et al, 2013). The option to donate organs should always be separate from the communication of impending or actual death.
Nurses need to be aware of common questions about organ donation to help families make an informed decision. Healthy children who die unexpectedly are excellent candidates for organ donation. Children with cancer, chronic disease, or infection and those who have suffered prolonged cardiac arrest may not be suitable candidates, although this is individually determined. The nurse should ask whether organ donation was discussed with the child or whether the child ever expressed such a wish. Any number of body tissues or organs can be donated (skin, corneas, bone, kidney, heart, liver, pancreas), and their removal does not mutilate or desecrate the body or cause any suffering. The family may have an open casket, and there is no delay in the funeral. There is no cost to the donor family, but organ donation does not eliminate funeral or cremation responsibilities. With the exception of Orthodox Judaism, most religions permit organ donation as long as the recipient benefits from the transplant. In cases of unexplained death, violent death, or suspected suicide, autopsy is required by law. In other instances, it may be optional, and parents should be informed of this choice. The procedure, as well as forms that require signing, should be explained. The family should know that the child can be in an open casket after an autopsy.
Grief and Mourning Grief is a process, not an event, of experiencing physiologic, psychological, behavioral, social, and spiritual reactions to the loss of a child. Grief is highly individualized, encompassing a broad range of manifestations from person to person. It is a natural and expected reaction to loss. It is neither orderly nor predictable. Grieving in any form is necessary for healing to occur. When death is the expected or a possible outcome of a disorder, the child and family members may experience anticipatory grief. Anticipatory grief may be manifested in varying behaviors and intensities and may include denial, anger, depression, and other psychological and physical symptoms.
Anticipatory guidance may assist grieving family members. Health care professionals should emphasize that grief reactions such as hearing the dead person's voice, feeling distant from others, or seeking reassurance that they did everything possible for the lost person are normal, necessary, and expected. They in no way signify poor coping, insanity, or an approaching mental breakdown. On the contrary, such behaviors signify that the survivor is working through the acute grief.
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Anticipatory guidance regarding the mourning process may help families recognize the normalcy of their experiences.
It is important to recognize that some family members may experience complicated grief. Complicated grief reactions (>1 year after the loss) include such symptoms as intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feelings of excessive loneliness and emptiness, unusual sleep disturbance, and maladaptive levels of loss of interest in personal activities (Meert, Shear, Newth, et al, 2011). Bereaved persons experiencing such prolonged and complicated grief should be referred to an expert in grief and bereavement counseling.
Another important aspect of grief is the individual nature of the grief experience. Each member of the family will experience the grief of the child's death in his or her own way based on the particular relationship with that child. This can create potential conflict for families, because each family member has expectations that the other family members should feel and grieve as they do. Nurses caring for families experiencing grief should be aware of the different grieving styles and help the family learn to recognize and support the uniqueness of each other's grief.
Parental Grief Parental grief after the death of a child has been found to be the most intense, complex, long-lasting, and fluctuating grief experience compared with that of other bereaved individuals. Although parents experience the primary loss of their child, many secondary losses are felt, such as the loss of part of one's self, hopes and dreams for the child's future, the family unit, prior social and emotional community supports, and often spousal support. It is common for parents of the same child to experience different grief reactions.
Studies with bereaved parents have shown that grieving does not end with the severing of the bond with the deceased child but rather involves a continuing bond between the parent and the deceased child (Klass, 2001). Parental resolution of grief is a process of integrating the dead child into daily life in which the pain of losing a child is never completely gone but lessens. There are occasions of brief relapse but not to the degree experienced when the loss initially occurred. Thus parental grief work is never completed and is a timeless process of accommodating the new reality of being without a child as it changes over time (Davies, 2004). A child's death can also challenge the marital relationship in several ways. Maternal and paternal reactions often differ (Hendrickson, 2009; Moriarty, Carroll, and Cotroneo, 1996; Scholtes and Browne, 2015; Vance, Najman, Thearle, et al, 1995). Different grieving styles between the couple may hinder communication and support for each other. Differing needs and expectations can place a strain on the marriage.
Sibling Grief Each child grieves in his or her own way and on his or her own timeline. Children, even adolescents, grieve differently than adults. Adults and children differ more widely in their reactions to death than in their reactions to any other phenomenon. Children of all ages grieve the loss of a loved one, and their understanding and reactions to death depend on their age and developmental level. Children grieve for a longer duration, revisiting their grief as they grow and develop new understandings of death. However, they do not grieve 100% of the time. They grieve in spurts and can be emotional and sad in one instance and then, just as quickly, off and playing. Children express their grief through play and behavior. Children can be exquisitely attuned to their parents' grief and will try to protect them by not asking questions or by trying not to upset them. This can set the stage for the sibling to try to become the “perfect child.” Children exhibit many of the grief reactions of adults, including physical sensations and illnesses, anger, guilt, sadness, loneliness, withdrawal, acting out, sleep disturbances, isolation, and search for meaning. Again, nurses should be attentive for signs that siblings are struggling with their grief and provide guidance to parents when possible.
At times, family members may need assistance in their grieving (see Nursing Care Guidelines box). Communication with the bereaved family is essential, but often nurses do not know what to say and feel helpless in offering words of comfort. The most supportive approach is to avoid judging the family's reactions or offering advice or rationalizations and to focus on feelings. Perhaps the most valuable supportive measure the nurse can perform for families is to listen. Families understand that no words will relieve their pain; all they want is acceptance, understanding, and respect for their grief.
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N u r s i n g C a r e G u i d e l i n e s Supporting Grieving Families*
General
Stay with the family; sit quietly if they prefer not to talk; cry with them if desired.
Accept the family's grief reactions; avoid judgmental statements (e.g., “You should be feeling better by now”).
Avoid offering rationalizations for the child's death (e.g., “Your child isn't suffering anymore”).
Avoid artificial consolation (e.g., “I know how you feel,” or “You are still young enough to have another baby”).
Deal openly with feelings such as guilt, anger, and loss of self-esteem.
Focus on feelings by using a feeling word in the statement (e.g., “You're still feeling all the pain of losing a child”).
Refer the family to an appropriate self-help group or for professional help if needed.
At the Time of Death
Reassure the family that everything possible is being done for the child if they want lifesaving interventions.
Do everything possible to ensure the child's comfort, especially relieving pain.
Provide the child and family with the opportunity to review special experiences or memories in their lives.
Express personal feelings of loss or frustrations (e.g., “We will miss him so much,” “We tried everything; we feel so sorry that we couldn't save her”).
Provide information that the family requests and be honest.
Respect the emotional needs of family members, such as siblings, who may need brief respites from the dying child.
Make every effort to arrange for family members, especially the parents, to be with the child at the moment of death if they want to be present.
Allow the family to stay with the dead child for as long as they wish and to rock, hold, or bathe the child.
Provide practical help when possible, such as collecting the child's belongings.
Arrange for spiritual support based on the family's religious beliefs; pray with the family if no one else can stay with them.
Post Death
Attend the funeral or visitation if there was a special closeness with the family.
Initiate and maintain contact (e.g., sending cards, telephoning, inviting them back to the unit, making a home visit).
Refer to the dead child by name; discuss shared memories with the family.
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Discourage the use of drugs and alcohol as a method of escaping grief.
Encourage all family members to communicate their feelings rather than remaining silent to avoid upsetting another member.
Emphasize that grieving is a painful process that often takes years to resolve.
*“Family” refers to all significant persons involved in the child's life, such as the parents, siblings, grandparents, and other close relatives or friends.
It is important for families to understand that mourning takes a long time. Whereas acute grief may last only weeks or months, resolving the loss is measured in years. Holidays and anniversaries can be particularly difficult, and people who previously had been supportive may now expect the family to have “adjusted.” Consequently, prolonged mourning is often silent and lonely.
Many families never receive the support and guidance that could help them resolve the loss. A plan for regular follow-up with bereaved families can be beneficial. At minimum, one follow-up phone call or meeting with the family should be arranged. Families can also be referred to self-help groups. When such groups are not available, nurses can be instrumental in bringing families together or facilitating parent and sibling groups. Formal bereavement programs or bereavement counseling can be helpful as well.
Nurses' Reactions to Caring for Dying Children The death of a patient is one of the most stressful aspects of nursing.* Nurses experience reactions to the death of a patient that are very similar to the responses of family members, including denial, anger, depression, guilt, and ambivalent feelings.
Strategies that can assist nurses in maintaining the ability to work effectively in these settings include maintaining good general health, developing well-rounded interests, using distancing techniques such as taking time off when needed, developing and using professional and personal support systems, cultivating the capacity for empathy, focusing on the positive aspects of the caregiver role, and basing nursing interventions on sound theory and empiric observations. Attending shared-remembrance rituals assists some nurses in resolving grief (Davis and Eng, 1998). Similarly, attending the funeral services can be a supportive act for both the family and the nurse and in no way detracts from the professionalism of care.
F a m i l y - C e n t e r e d C a r e A Dying Child: A Nurse's Perspective
Claire was unresponsive with slow, gasping breathing. Her mother asked me what I thought was happening. I replied honestly, “Your baby is dying because of her brain tumor.” The mother put her arms around me and cried. We arranged for Claire to be baptized.
Honesty. As painful as the loss of a child is, my job is to assist the family through this experience. Although I usually wait until a private moment (such as driving home), I found tears streaming down my face as family and friends gathered for Claire's baptism. I went into the kitchen to compose myself, only to find several of my colleagues crying as well. Saying good-bye to a dying child will always be a difficult but shared experience.
Jeanne O'Connor Egan, RN, MSN Pediatric Clinical Specialist, Children's Hospital Washington, DC
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NCLEX Review Questions 1. When caring for a 4-year-old with a disability, the nurse notes that while encouraging the child to
take part in his care, the mother constantly gives into the child, allowing him to have his own way. What anticipatory guidance can the nurse give to promote normalization in this relationship? a. “Giving in” is not a detriment to the child when he or she has a disability and limitations. b. Explain that when parents establish reasonable limits, children are likely to develop
independence that is appropriate for their age and achievement equal to their limitations. c. Advise the parent to wait to explain any procedure to the child until they are at the health care
setting or just before the procedure to avoid unduly upsetting the child. d. Have the parent realize that it would be unfair to the siblings to expect similar rules to apply to
all of the children in the family. 2. Children with disabilities or chronic illness and their families may have different methods of
coping than those of healthy children. Often they have a resilience that is to be admired. Which of these statements reflect ways that they foster this resilience? Select all that apply. a. Protect the child from having to learn about his or her disability or illness on a repeated basis. b. Develop relationships with other children and their families with similar circumstances to
build support. c. The parents set long-term goals to create a sense of hope. d. Focus on the child's strengths and encourage independence. e. Accept that chronic illness is part of living.
3. Which of the following factors should a nurse consider when managing the pain of a terminally ill child? Select all that apply. a. Pain medications are given on an as-needed schedule, and extra doses for breakthrough pain
are available to maintain comfort. b. Opioid drugs, such as morphine, are given for severe pain, and the dosage is increased as
necessary to maintain optimum pain relief. c. Addiction is a factor in managing terminal pain in a child, and the nurse plays an important
role in educating parents that their child may become addicted. d. Nurses often express concern that administering dosages of opioids that exceed those with
which they are familiar will hasten the child's death; (principle of double effect). e. In addition to pain medication, techniques such as music therapy, distraction, and guided
imagery should be combined with medications to provide the child and family strategies to control pain.
4. It is important to consider the child's developmental understanding of death when working with that child. Which option is the preschool child's developmental stage? a. Children of this age believe their thoughts are sufficient to cause death. b. They are still very much influenced by remnants of magical thinking and are subject to feelings
of guilt and shame. c. They have a deeper understanding of death in a concrete sense. d. They can perceive events only in terms of their own frame of reference—living.
5. As the nurse caring for a culturally diverse population, it is important to understand cultural health beliefs of families. This can best be accomplished by: a. Asking the parents how their extended families feel about their child's illness b. Exploring the use of alternative medicines and therapies c. Understanding the parents' perception of the seriousness or severity of the illness or disability,
as well as concerns and worries they have about the condition d. Acknowledging that language constraints may make it necessary for the health care team to
make some decisions
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Correct Answers 1. b; 2. b, d, e; 3. a, b, d, e; 4. a; 5. c
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