Peds Unit 1- Care of the Infant

• • GAINS 5-7 OUNCES WEEKLY FOR 1ST 5-6 MO.
• • DOUBLES BIRTH WEIGHT BY 6 MO.
• • TRIPLES BIRTH WEIGHT BY 12 MO
• • BIRTH LENGTH INCREASES 50% BY 12 MO.
• • HEAD SIZE INCREASES 33% BY 12 MO
• • BRAIN INCREASES IN WEIGHT BY 2 ½TIMES
• • ORGAN SYSTEMS BEGIN TO MATURE
• • GROWTH CHARTS ARE MOST ACCURATE ASSESSMENT OF CHILD’S GROWTH

• •HEAD CONTROL ESTABLISHED @ 4-6 MONTHS
• •TURNS ABD. TO BACK @ 4-5 MONTHS
• •TURNS BACK TO ABD. @ 6-7 MONTHS
• •SITS WITHOUT SUPPORT  @ 8-9 MO.
• •CRAWLS AND PULLS UP @ 8-9 MO.
• •STANDS ALONE @ 10-12 MO.
• •WALKS W/ ONE HAND HELD 10-12 M
• •WALKS INDEPENDENTLY 12-15 MO.

-Head lag at 6 months of age should have a developmental/ neurological evaluation

-developmental delay does not always mean there is cognitive delay

• •1 MONTH - HANDS FISTED – PALMAR GRASP
• •3 MONTHS - CAN HOLD RATTLE
• •4-5 MONTHS – BEGINS REACHING & GRASPING WITH PALMS
• •6-7 MONTHS – PICKS UP OBJECT WELL -TRANSFERS OBJECTS FROM HAND TO HAND
• •8-9 MONTHS - PINCHER GRASP, REACHES FOR TOYS– PINCER GRASP DEVELOPS
• •10-12 MONTHS – RELEASES CUBE INTO CUP AFTER
• DEMO. – PINCER GRASP COMPLETE

• •SMILES RESPONSIVELY @ 3 MO.
• •SHOWS FEAR AND ANGER @ 4-5 MO.
• •SMILES AT SELF IN MIRROR @ 6-7 MO.
• •PLAYS PEEK-A-BOO @ 6-7 MO.
• •STRANGER ANXIETY HEIGHT@ 8-9 MO.
• •QUIETS SELF @ 10-12 MO.

HAS MOOD CHANGES @ 10-12 MO

• •RESPONDS TO SOUNDS @ BIRTH
• •COOS @ 3 WEEKS
• •BABBLING COMMON @ 4-5 MONTHS
• •BELLY LAUGHS & TALKS TO TOYS 6-7 MO.
• •ECHOLALIA (IMITATES SPEECH SOUNDS) 8-11
• MONTHS
• •CAN SAY 3-5 WORDS WITH MEANING BY 1 YEAR

•TRUST VS. MISTRUST – THE BASIC DEVELOPMENTAL TASK OF INFANCY

–TRUST OF SELF, OTHERS , AND THE WORLD

• –TRUST DEVELOPS WHEN INFANT’S NEEDS ARE
• CONSISTENTLY MET

• –IF NEEDS NOT CONSISTENTLY MET MISTRUST OF
• WORLD DEVELOPS

-RESULT OF THIS TASK FORMS CORNERSTONE OF INFANT’S PERSONALITY

• SENSORIMOTOR STAGE–Birth to 2 years

–INITIALLY RELATES TO WORLD THROUGH REFLEXES

–ORGANIZES SENSORIMOTOR ACTIONS IN RESPONSE TO ENVIRONMENT OVER TIME

“OBJECT PERMANENCE”  IS THE KEY COGNITIVE TASK IN THE 1ST YEAR, OCCURS @ 9-10 MO

• –FOUR STAGES DURING INFANCY
• 1. USE OF REFLEXES
• –Sucking, rooting, grasping

• 2.PRIMARY CIRCULAR RESPONSE (1-4
• months)
• –Replacement of reflexive behaviors with voluntary acts
• *sucking or grasping becomes deliberate responses
• *Recognizes the stimulus that produces a certain action
• *Previously cried until nipple in mouth but Now associates nipple with parent’s voice- will stop crying once hears parent's voice

• 3. SECONDARY CIRCULAR RESPONSE
• -Continuation of primary lasts until 8 months
• *primary reactions are repeated or prolonged
• *Grasping and holding now becomes shaking, banging , and pulling
• *The quality and quantity of an act becomes more evident

• 4.COORDINATION OF SECONDARY SCHEMAS
• –Use previous behavioral achievements primarily as the foundation for adding new intellectual skills
• *Coordination of secondary schemas- increased motor skills allow greater exploration of the environment
• *Associate certain symbols with events- bye bye means daddy is going to work

•Parallels sensorimotor development

•As physical needs are met they feel comfort and satisfaction with their body

•Messages conveyed by caregivers reinforce these feelings

•Object permanence is basic to development of self image

• •By the end of the first year they realize they are distinct from their parents
• –At the same time is increased interest in their image
• –Smile at themselves in the mirror
• -When infants smile they receive emotional satisfaction from those who smile back

•DTaP SERIES

•HEPATITIS B SERIES

•POLIO SERIES

• STREP PNUEMOCOCCUS SERIES (Prevnar)

•H. INFLUENZA B- HIB SERIES

• •BOOSTERS
• –DTAP
• –PNUEMOCOCCUS
• –HIB

•MMR

•VARICELLA

•HUMAN MILK MOST DESIRABLE COMPLETE DIET FOR THE FIRST 6 MONTHS

•BREAST MILK OR FORMULA UNTIL 12 MONTHS

•IRON SUPPLEMENTS @ 6MO FOR BOTH BREAST AND FORMULA BABIES D/T DEPLETED IRON STORES

•NO BOTTLES IN MICROWAVE TO HEAT

• •ADDITION OF SOLID FOODS NOT RECOMMENDED UNTIL 4-6 MONTHS
• –EARLY EXPOSURE TO SOLIDS CAN PRODUCE ALLERGIES
• –EXTRUSION REFLEX IS STRONG IN YOUNG INFANTS

•IRON FORTIFIED RICE CEREAL USUALLY FIRST

•FRUIT JUICES CAN BE ADDED AFTER 6 MONTHS

•STRAINED VEGETABLES USUALLY NEXT

•FOLLOWED BY STRAINED FRUITS, THEN MEATS

• •EGGS, COW’S MILK,  AND CITRUS ARE THE MOST
• COMMON INFANT ALLERGENS.  DELAY
• INTRODUCTION UNTIL INFANT 12 MONTHS OLD

• • NO COWS MILK UNTIL 12 MONTHS ( WHOLE MILK) THEN 2% AT 2 YEARS OF AGE
• COWS MILK EARLIER THAN 12 MOTHS CAN CAUSE IRON DEFICIENCY ANEMIA

•INTRODUCE WHEN INFANT IS HUNGRY

• •BEGIN BY PUSHING FOOD TO BACK OF TONGUE
• BECAUSE OF EXTRUSION REFLEX

•USE A SMALL SPOON WITH A STRAIGHT HANDLE

• •BEGIN WITH 1-2 TEASPOONS OF FOOD, INCREASE
• GRADUALLY

• •INTRODUCE FOODS ONE AT A TIME WITH 4-7 DAYS
• BETWEEN ADDING NEW FOODS

•AS AMOUNT OF SOLID FOOD INCREASES, DECREASE AMOUNT OF FORMULA TO PREVENT OVERFEEDING

•DO NOT INTRODUCE FOODS BY MIXING WITH FORMULA IN THE BOTTLE

• EARLY FEEDING EXPERIENCES ARE SLOPPY

• •CHILDREN CAN’T BE PRESSURED INTO EATING
• NEATLY UNTIL THEY HAVE MANIPULATIVE SKILLS

•SOLITARY OR ONE-SIDED PLAY

•NARCISSISTIC

•OVER THE YEAR BECOMES MORE SOPHISTICATED AND INTERDEPENDENT

•SENSORY STIMULATION IS VERY IMPORTANT

• •INFANTS NEED TO BE PLAYED WITH, NOT MERELY
• ALLOWED TO PLAY
• -CHILDREN WHO ARE NEGLECTED HAVE SHOWN TO HAVE COGNITIVE AND developmental DELAY

•MULTIFACTOR ETIOLOGY

•TENDS TO RUN IN FAMILIES

•ENVIRONMENTAL TERATOGENS MAY PLAY A ROLE

•CHROMOSOMAL ANOMALIES OFTEN HAVE CLEFTS AS A FEATURE

•MATERNAL SMOKING IN 1ST TRIMESTER ASSOCIATED WITH 10 % OF CASES

• •APPEARS MOST OFTEN IN ASIAN AND NATIVE
• AMERICAN INFANTS - LEAST IN AFRICAN-AMERICAN

• •PATHOPHYSIOLOGY- FAILURE OF THE MAXILLARY AND PREMAXILLARY PROCESSES TO MEET AND FUSE. 
• NOTHING IS MISSING, ALL THE PIECES ARE THERE.

•CAN BE INCOMPLETE OR COMPLETE

• •CLEFT LIP CAN BE UNILATERAL OR BILATERAL
• –EXTENT OF CLEFT AND NASAL DEFORMITY IS VARIABLE

•CAN HAVE CLEFT LIP OR CLEFT PALATE OR BOTH

•INCIDENCE OF CLEFT LIP IS 1 IN 800 LIVE BIRTHS

• •INCIDENCE OF CLEFT PALATE IS 1 IN 200O LIVE
• BIRTHS

•CLEFT PALATE CAN BE MISSED.  FULL VISUALIZATION AND PALPATION OF THE PALATE NEEDED DURING NEWBORN EXAMINATIONS

• •SURGICAL TREATMENT
• –CLEFT LIP REPAIRED DURING 1ST MONTH OF LIFE TO PROMOTE BONDING
• –CLEFT PALATE REPAIRED AT 12-18 MO.

• •MULTIDISCIPLINARY TEAM APPROACH D/T PROBLEMS WITH SPEECH, ORTHODONTIA AND EARS/SINUSES
• -CAN HAVE PROBLEMS WITH NASOPHARYNX, IMPROPER TOOTH ALIGNMENT, HEARING LOSS

• •NURSING CARE- CLEFT LIP REPAIR
• –PREOP- DEAL WITH FEEDING PROBLEMS
• –ENCOURAGE PARENT/INFANT BONDING
• –Z-PLASTY REPAIR OF LIP MINIMIZES NOTCHING
• –POST OP- PREVENT INFANT CRYING, CLEAN SUTURE LINE, MAINTAIN SUPINE POSITIONING, MAINTAIN ELBOW RESTRAINTS AND LIP BOW (LOGAN BOW)

• *DECREASED ABILITY TO SUCK = PROBLEMS WITH BREAST OR BOTTLE FEEDING
• *LIQUID TAKEN INTO MOUTH TENDS TO ESCAPE VIA THE CLEFT THROUGH THE NOSE

• •NURSING CARE- CLEFT PALATE REPAIR (12 TO 18
• MONTHS)
• –PERFORMED BEFORE FAULTY SPEECH HABITS OCCUR
• –PREOP- DEAL WITH FEEDING PROBLEMS
• –POST OP- PREVENT INFANT CRYING, ASSESS FOR PAIN, PREVENT CHILD FROM INSERTING HARD OR POINTED OBJECTS IN MOUTH AND AVOID HARD FOODS
• –ALLOWED TO LIE ON ABDOMEN IN THE IMMEDIATE POSTOP PERIOD
• –NEED TO MONITOR RESPIRATORY STATUS CLOSELY

• OBSERVE FEEDING ONCE RESUMED- I & O
• *ORAL PACKING MAY BE USED – REMOVED 2- 3 DAYS POSTOP

• •PATHOPHYSIOLOGY:
• •FAILURE OF THE ESOPHAGUS TO FORM AS A CONTINUOUS PASSAGE

•THE PROXIMAL SEGMENT TERMINATES INTO A BLIND POUCH

• •THE DISTAL SEGMENT IS CONNECTED TO THE
• TRACHEA OR THE PRIMARY BRONCHUS BY A SHORT FISTULA

–EXCESSIVE SALIVATION AND DROOLING

–THE THREE “C’s”= COUGH, CHOKING AND CYANOSIS

–APNEA

–RESPIRATORY DISTRESS WITH FEEDS

ABDOMINAL DISTENTION

–PREVENTION OF ASPIRATION AND PNEUMONIA

•NPO  AND IV FLUIDS

•“POUCH TUBE” TO REMOVE SECRETIONS

•ELEVATE HEAD

•GASTROSTOMY TO DRAIN STOMACH CONTENTS

SURGICAL CORRECTION

–IF SUSPECTED MAKE INFANT NPO

– ELEVATE HEAD

• –CLEAR SECRETIONS WITH CONTINUOUS
• SUCTION

–OXYGEN FOR RESPIRATORY DISTRESS

–PLACEMENT OF GASTROSTOMY TUBE IF A STAGED REPAIR IS NECESSARY

•NURSING CARE- POST OP

–MAINTAIN GASTROSTOMY TUBE

–SLOW RETURN OF ORAL FEEDS

–DISCHARGE AFTER ORAL FEEDINGS RESUMED AND G-TUBE REMOVED

•FAILURE OF DIAPHRAGM TO CLOSE PRENATALLY ALLOWING ABDOMINAL ORGANS TO BE DISPLACED INTO THE ABDOMEN

•OCCURS IN 1 IN 3000-4000 LIVE BIRTHS

• •DEFECT ON IS USUALLY ON THE LEFT SIDE.  BOWEL ENTERS THE CHEST CAVITY AND PUSHES
• HEART TO THE RIGHT.  IMPEDES GROWTH OF
• THE LUNG

• •AFTER BIRTH THE BOWEL FILLS WITH AIR WHICH
• FURTHER COMPROMISES BREATHING AND CIRCULATION

• •CLINICAL MANIFESTATIONS
• –HEART SOUNDS LOUDER ON THE RIGHT
• –SCAPHOID ABDOMEN
• –BOWEL SOUNDS IN CHEST
• –INCREASING RESPIRATORY DISTRESS

• •STABILIZATION PRE-OP
• –RESUSCITATED WITH ET TUBE NOT MASK
• –ELEVATE HEAD OF  BED
• –AFFECTED SIDE DOWN
• –NPO AND GASTRIC DECOMPRESSION (NG TUBE)

*MAY REQUIRE ECMO (EXTRACORPOREAL MEMBRANE OXYGENATION) UNTIL LUNGS FUNCTIONING AFTER SURGERY

• •IMBALANCE BETWEEN PRODUCTION AND ABSORPTION OF CSF CAUSING ACCUMULATION IN VENTRICLES
• –Communicating (impaired absorption within the subarachnoid space)
• –Noncommunicating (obstruction to the flow of the CSF within the ventricles (ventricles do not communicate) –
• most cases associated with developmental malformations

•FOUND EARLY ON WELL EXAMS BY SERIALLY MEASURING AND GRAPHING HEAD CIRCUMFERENCES

•VERY OFTEN ASSOCIATED WITH MYELOMENINGOCELE

• •EARLY PHYSICAL SIGNS
• –BULGING FONTANELS
• –DILATED SCALP VEINS
• –SEPARATED SUTURE LINES

• •LATE PHYSICAL SIGNS
• –SETTING SUN SIGN- SCLERA VISIBLE ABOVE IRIS
• –SHRILL HIGH PITCHED CRY DUE TO ICP
• –OPISTHOTONOS

Can result in brain damage if not detected and treated early

•VENTRICULAR-PERITONEAL  SHUNT USUALLY NEEDED (VP shunt)

•Infection is greatest hazard

•Monitor closely for signs of infection and ICP

•Pain management

•Educate parents on signs of infection and increased ICP

•Teach parents how to change dressing

• •SPINAL BIFIDA OCCULTA
• –DEFECT PRESENT IN VERTEBRA
• –NO SAC PRESENT
• –NO OBVIOUS  DEFICITS BUT “SOFT” SIGNS MAY BE PRESENT

•Meningocele

•Sac contains meninges and spinal fluid but no neural elements

•Not associated with neurological defect

•Sac contains meninges, spinal fluid, and nerves

•Manifestations relate to degree of defect, which is determined by the level of the lesion

•CAN BE DETECTED BY ULTRASOUND

•CAN BE DETECTED BY AFP

• •INITIAL CARE
• –PREVENTION OF INFECTION
• –NEUROLOGIC ASSESSMENT
• –DEALING WITH IMPACT ON FAMILY
• *C-section usually required

• •MULTIDISCIPLINARY  APPROACH
• –NEUROLOGICAL AND NEUROSURGICAL EVALUATION
• –ORTHOPEDIC EVALUATION
• –GENITOURINARY EVALUATION
• –GASTROINTESTINAL  (BOWEL CONTROL) EVALUATION

• •After birth:
• –Prone positioning
• –Radiant warmer to maintain temp without clothing
• –Application of moist, nonadherent sterile dressing over sac
• –Prevent infection

•Post op care same as any surgical procedure

•Latex allergy precautions

•Family support

Education

•HIP JOINT INSTABILITY

•MULTIFACTORAL ETIOLOGY

• •FRANK BREECH PRESENTATION HAS HIGH
• ASSOCIATION WITH D.D.H.

• *hormonal influence- estrogen laxity in fetal joints
• Mechanical factors of intrauterine posture- frank breech

•DIAGNOSTIC EVALUATION

–POSITIVE BARLOW OR ORTOLANI MANEUVERS DURING ASSESSMENTS

–RESTRICTED ABDUCTION

–ASYMMETRICAL SKIN FOLDS ON POSTERIOR THIGHS

–APPARENT FEMUR SHORTENING

Galeazzi Test - difference in knee heights

*early Diagnosis is vital – treatment needs to be initiated within the first two months.  The longer the delay the more severe the deformity and the less favorable the prognosis

–“DOUBLE DIAPER”

–PAVLIK HARNESS

–HIP SPICA CAST

•AVOID INDENTING WET CAST WITH FINGERS. USE FLATS OF HANDS - Indents in cast can cause pressure points

•DO NOT PULL ON ABDUCTION BAR

•PROTECT CAST FROM SOILING

•FOOT TWISTED OUT OF NORMAL POSITION

•INCIDENCE IS 1 OF 1000 LIVE BIRTHS

•EXACT CAUSE NOT KNOWN

•UNILATERAL CLUB FOOT IS MORE COMMON

•IF MILD TREATED WITH EXERCISES

•IF MORE INVOLVED SERIAL CASTING IS PERFORMED

•IF MAXIMUM CORRECTION IS NOT ACHIEVED 3-6 MO., SURGERY FOLLOWS

•LONG-TERM FOLLOW UP INDICATED

•Serial casting is begun immediately

•Correction usually takes 8 to 12 weeks

• •Severe case or cases in which casting does not correct deformity require surgery
• –Done between 4 months and 1 year of age

• •Assessments
• –Circulation
• –Sensation
• –Movement

• •Interventions
• –Elevate limb
• –Avoid indenting the cast while it is drying
• –Parent education