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What are the two classifications for FTT?
- Organic: caused by disease processes
- Nonorganic: lack of parental bonding, psycho-social issues
What are the clinical manifestations for FTT?
- unresponsive to cuddling
- <5% growth chart for weight and possibly height
- Avoidance of eye contact
- No stranger anxiety
- Delayed development
- Feeding disorders
What is rumination, what is a clinical sign, and how is it managed?
- Rumination is voluntary regurgitation
- The infant will improve in a nurturing environment with increased caloric intake
- Long term involvement with home visits to ensure support
- Nonjudgmental attitude is necessary and all systemic/congenital disorders should be ruled out
How would you assess for FTT?
- Complete history of problem and diet
- Feeding, stooling, and sleeping pattern
- Psychosocial history
- Parent-child interactions
- H to T physical assessment and growth chart
- Developmental assessments and milestones
- SAFETY (is it safe for this child to be at home???)
How is FTT treated?
- Nutritional Supplementation (vits, minerals, caloric boosters, protein increased)
- Offer support-home visits
- Psycho-social therapy/parenting class
- Daily/weekly weights
What are kwashiokor and Marasmus?
- Kwashiokor: protein deficiency
- Marasmus: Protein and caloric deficiency
What are Rickets, scurvy, beriberi, and pellagra?
- Rickets: Vit D (all infants should have 200 mg vit D daily), Calcium & Phosphorus deficiency
- Scurvy: Vit C Deficiency
- Beriberi: B1-Thyamine deficiency
- Pellagra: B3 Vitamin and Anacin deficiency
When thinking about caloric intake, what are some important things to consider?
- Formula normally has 20kcal/oz, so higher caloric formula may be needed
- Improve fluid intake and monitor i/o
- Prevent infection, promote skin integrity, and sensory stimulation
Discuss the importance of fluids to an infant
- A premature infant is 90% water, while a term infant is 75-80% water, a child is 65% water
- Infants have a higher amount of extracellular fluid and 1/2 of it is exchanged every day
- Glomerular filtration reaches adult rate by 2 y/o (infants have dilute urine)
- Increased resp rate leads to increased insensible fluid loss
- Greater fluid loss thru skin due to greater body surface per kg
What is the average urine output for an infant and school age child?
- Infant: 5-10 ml/hr
- 1-10 yrs: 10-25 ml/hr
- 11+: 35 ml/hr
What are causes of diarrhea and Gastroenteritis in the infant? What is the main risk?
- Can be caused by dehydration, lactose intolerance, or infection (gastroenteritis)
- Infectious agents include Salmonella, Shigella, E. Coli, rotavirus, giardia, and c. diff
- *Main complication is dehydration
What is the primary type of dehydration in children?
- Isotonic is the primary form of dehydration in children
- This is a balanced loss of both water and electrolytes
- The major loss is in ECF, leading to decreased circulating blood
- Major complication is hypovolemic shock
- Sodium labs will be normal at 130-150 meq/L
What is hypotonic dehydration?
- Losing more electrolyte than water, leading fluid to enter the cells
- May occur if electrolytes are not replaced during fluid loss (giving only water)
- Also decreases circulating blood (fluid goes into ICF) and risk of hypovolemic shock
- Sodium labs will be BELOW 130-150 meq/L
What is hypertonic dehydration?
- Losing more water than electrolytes, due to either loss of water or increase in electrolyte replacement
- Fluid shifts from ICF to ECF
- Neurological changes
- Sodium labs HIGHER than 130-150 meq/L
- *When introducing replacement fluids, monitor for cerebral edema and water toxicity
Describe mild dehydration
- 3-5% wt loss in infants
- Vitals normal and tears present with thirst
- Decreased UO
- May be pale in color
- Mucus Membranes and fontanels normal
- Cap refill >2sec
- Increased urine specific grav
- Normal behavior
Describe moderate dehydration in the infant
- 609% wt loss
- Slight tachycardia and hypertension
- Cap refill 2-4 sec with decreased skin turgor
- Gray in color
- Dry mucous membranes with decreased tearing
- Mod thirst
- Oliguria with increase in urine specific gravity
- Anterior fontanel may be sunken
- Irritable in nature
Describe severe dehydration in the infant
- >10% wt loss
- Cool, mottled skin with tenting
- Cap refill >4sec
- Pulse is rapid and thready with orthostatic BP
- Absent tears with sunken eyes and fontanels
- Mucus membranes are dry and cracked
- Oliguria or anuria
- Hyperirritable or lethargic in nature
What complications can arise from dehydration?
- Hypokalemia, hypocalcemia, and hyponatremia
- Hypovolemic shock
What are the early signs of hypovolemic shock in the infant?
- Mild tachycardia with Normal BP
- Irritability and apprehension
- Decreased UO
- Min UO 1-2ml/kg/hr
- Decreased cap refill in hands and feet
What are the clinical manifestations of hypovolemic shock in infants?
- Tissue Hypoxia
- Increased resp rate to compensate for metabolic acidosis
- Skin is cold and clammy
- Decreased central venous pressure
- Altered LOC
- Decreased glomerular filtration rate
- If UO decreases below 1-2ml/kg/hr, renal failure will occur
What interventions can be done for rehydration of an infant?
- Mild dehydration: Oral Rehydration Solution 40-50 ml/kg over 4 hrs
- Mod Dehydration: ORS 100 ml/kg over 4 hrs
- Severe Dehydration: IV LR 40 ml/kg/hr until pulse and LOC return to normal
- *ORS is 75-90 meq Na/L
How do you replace stool loss for rehydration in the infant?
- Replace 1:1 if stool losses are known
- Infants: 10ml/kg for each diarrhea stool
- Child: 100-150 ml for each diarrhea stool
- *Daily volume maintenance hydration should not exceed 150ml/kg/day
How do you calculate maintenance fluids for the infant?
- 100 ml/kg/day up to 10 kg
- Add 50ml for each additional kg up to 20 kg
- If greater than 20 kg, 1500ml and then add 20ml for every additional kg over 20
How is dehydration diagnosed?
- Elevated HCT
- Decreased Potassium & Sodium
- Elevated BUN due to decrease in renal circ
- CBC may be increased with infection
- Stool sample show low pH with increased sugar
- Stool sample may show leukocytes if caused by an enteroinvasive organism
What nursing interventions and medications can be given for dehydration? What interventions should not be used?
- Strict I/O and daily weights
- maintenance and replacement fluids
- Reintroduce fluids slowly if NPO for bowel rest
- Pedialyte for children under 2 yrs
- If infant tolerates pedialyte, may mix with formula to make 1/2 strength
- If child is over 2, ORS, weak tea, flat soda, or reg diet may be used
How can diarrhea be prevented in the infant?
- teach personal hygiene as most diarrhea is by agents spread by fecal oral route
- Clean water supply protected from contamination
- Careful food prep
- hand washing!!!!
What is colic? What is it commonly related to? What medications and interventions can be used?
- Colic: paroxysms of irritability, fussing, or crying that starts and stops with no obvious cause (3hr + for 3 days/wk)
- Colic is self limiting
- Common with allergies such as dairy (in mom's milk) so rule out all allergies
- Medications include simethicone drops PO to relieve intestinal gas
- Change infant's position frequently
What is gastroesophageal reflux?
- This occurs in everyone but frequency and persistence make it abnormal
- GERD has tissue damage
- 50% of infants 2mo ave GER that usually resolves within 12 mo
- usually occurs from relaxation of the lower esophageal sphincter
- Inflammation from acids causes symptoms
What is GER diagnosed? How is it different from GERD?
- GER is diagnosed y hst and PE
- Upper Gi series can detect pyloric stenosis, malrotation, hiatial hernia, or strictures
- 24hr Intra-esophageal ph monitoring study may be done
- GER does not occur with tissue damage, unlike GERD
How is GER treated?
- Ger is symptomatically treated by mixing 1tsp-1tbs of rice cereal per oz of formula
- Upright position maintained after feedings
- Prone position may be indicated if severity of GER outweighs risk of SIDS
- tagamet, zantac, pepcid, prevacid, and prilosec may be given
- Nissen fundoplication: surgical procedure that wraps the gastric fundus around the esophagus to prevent reflux
Define anemia. What are the common types of anemia found in children?
- Anemia is common in childhood and may result from inadequate RBC production or hemoglobin or excessive loss or both
- Iron Deficiency Anemia
- Hemorrhagic Anemia
- Hemolytic Anemia (congenital or acquired)
- *chronic anemias can cause CHF, growth restriction and decreased sexual maturation
Why is iron deficient anemia common in infants? How is it diagnosed? How can be prevented and how is it treated?
- Fetal iron stores only last 5-6mo
- Most common from 12-36mo
- After 1yr, infants that drink dairy milk interferes with oral iron absorption
- Diagnosed by a Hemoglobin <11g/dl and Hct <33%
- treated by increased oral intake with iron fortified ceral and formula (give with vit c)
- Also treated with oral ferrous sulfate (can stain teeth!)
- Severe anemia requires Imferon IV or IM or blood transfusions
Which children are at risk for Sickle Cell anemia?
- It is a heredity disease common to people of African American descent along with Hispanics
- When both parents are carriers of the sickle cell trait, the child has a 25% chance of developing sickle cell anemia
Why is sickle cell generally not seen at birth and therefore requires newborn screening?
- Fetal hemoglobin (HgbF) decreases during the first year of life
- HgbF does not sickle and therefore masks the disease
- newborn screening can be done to detect SCA
Describe the pathophysiology of sickle cell anemia
- Hypoxia causes RBCs to scikle causing obstruction, RBC destruction, and further hypoxia
- Vaso-occlusion results in pain, tissue ischemia, and infarction
- This can lead to tissue or organ enlargement,tissue death, and scarring
What are the s/s of a sickle cell crisis?
- Vaso-occlusive crisis are incredibly painful
- Sequestian Crisis is a pooling of red blood cells in the liver and spleen leading to splenomegaly and hepatomegaly
- Aplastic crisis- diminished RBC production
- Hyper hemolytic crisis is an accelerated destruction of RBCs
- CVA can occur due to blockages in the major blood vessels in the brain
- Acute chest syndrome is similar to pneumonia
- Infection is one of the main causes of a sickle cell crisis and s/s of infection may also be present!!
How is sickle cell anemia diagnosed?
- newborn screening
- Sickledex from finger stick will be positive for SCA will not show carrier or SCD. Positive Sickledex is an indication for electrophoresis
- HgB electrophoresis to determine if carrier or SCD
How is SCD treated and what is the prognosis?
- Hydroxyurea may be used to maintain hemodilution
- Opioids RTC and PRN on PCA pump for pain (such as morphine)
- Adequate hydration and rest with possible O2 use
- Electrolyte replacement with transfusions to treat anemia (may need kelation therapy for iron build up)
- Antibiotics to treat any existing infection (prophylactic penicillin)
- *child without w/w can participate in reg activities, but may have physical and sexual delays. Infection is the major complication in children under 5 y/o
What are nursing interventions for SCD?
- Educate the family and the child to seek early intervention with a fever of 101 F or if infection is suspected
- Give prophylactic antibiotics (such as penicillin)
- Recognize s/s of splenic sequestration requiring splenectomy
- Treat the child normally
- Stress the importance of adequate hydration!!
- Depression, anxiety, and other psych disturbances are common due to pain and other restrictions
Describe acute nasopharyngitis, the s/s, and its treatment
- Acute Nasopharyngitis is the common cold often caused by rhinovirus, RSv, adenovirus, or influenza virus
- In children over 3 mo they may have a high fever, but younger children may be afebrile
- May be accompanied with /v/d due to accumulated mucus drainage in the GI
- Treatment includes rest, increasing fluids, NS nose drops, bulb suction and measures for fever reduction (no ASA!)
- Decongestant nose drops may be given to infants older than 6mo for 3 days or less
- May progress to OM due to nasal congestion
Why is ASA avoided in children with viruses?
Associated with Reyes Syndrome
Describe acute otitis media, its s/s, dx, and treatment
- One of the most common infectious disease in infants due to the short, wide, and straight nature of the Eustachian tubes
- Can be caused RSV,influenza, Hib
- s/s include bulging red or yellow eardrum, purulent drainage if ruptured with pain
- Infant will have acute acute pain with irritability and tugging on ears
- Amoxicillin may be given for 10-14 days
- Myringotomy may be performed to relieve middle ear pressure
What is OME and how is it dx and treated?
- Fever and bulging tampanic membrane with little or no pain
- Tm will be immobile with an orange discoloration
- Anitbiotics only if the effusion >3 mo
- Tympanostomy (tubes) to equalize pressure and drain fluid from middle ear
What should parents be taught if their child has OME?
- Complete the full course of antibiotics
- Tylenol or warm/cold packs
- temporary hearing loss during infection and for up to months after
- Use ear plugs when exposed to water if tympanostomy tubes are present
- Prevent OM by not propping bottles,smoke free environment, and avoiding allergens
What is acute bronchiolitis?
- Frequently seen in the first 6 mo of life and rarely after 2 yrs of age
- RSV responsible for 80%
- Most common on winter/early spring
- Bronchioles swollen with mucus and exudate
- Obstruction leads to hyperinflation, obstructive emphysema, and patchy atelectesis
What are the s/s of acute bronchiolitis?
- Begins as an URI
- OM and conjunctivitis may be present
- Tight cough, retractions, cyanosis, barrel chest, may become dehydration
- X-rays show hyperinflation
- Apnea may eb present
- Increased PaCO2 leads to resp acidosis
- Hypoxemia (Decrease O2 sat)
How is acute bronchiolitis dx and treated?
- NSS instilled into nostril and aspired for RSV testing
- Treated with fluids,rest, humidified O2
- Periodic suctioning
- Contact isolation and hand washing!!!
- Ribavarin (Virazole) aerosol to treat virus (very controversial and only used for high risk)
How can RSV be prevented?
- Palivizumab- monoclonal antibody in monthly IM injections preferred for most high risk children, infants with bpd, and those with congential heart disease
- RSV Prophylaxis is recommended for all infants born <32 wks gestation and is given from Nov - Mar when RSV is most common
What type of bacterial pneumonia is most common in infant and children? When is it most likely to occur?
- Pneumococcal Pneumonia is the most common in infants and children (incidence decreased by vaccination)
- Usually bronchial rather than lobular
- Often occurs secondary to URI
What are the clinical manifestations of bacterial pneumonia and how is it treated?
- Abrupt, high fever
- marked resp distress with flaring, retractions, circumoral cyanosis
- tachycardia, tachypnea
- Cough, chest pain, meningeal symptoms
- Pain can be referred to abdomen
- Abd distension due to swallowed air or paralytic ileus
- Treated by antibiotics
- O2 and IV fluids
- Cluster Care for rest
- Antipyretics and suctioning
- Elevate HOB
- Support Family
What is Sudden Infant Death Syndrome? What are some suspected causes?
- "The death of an infant under 1 yr of age which remains unexplained after a complete postmortem examination, including an investigation of the death scene and review of case history"
- Cause is unknown, but may be brainstem abnormalities, overheating, suffocation, and smoking in the home
What are the characteristics commonly associated with SIDS?
- Frequently age between 2-3 mo
- Low birth weight
- Lower socioeconomic
- Mother under 20 y/o
- Mother smokes
- Not the first born
- Sleeping in the prone position
What are some common findings in infants who have died from SIDS?
- Infant often found in a disheveled bed with blankets over head an huddled in corner
- Mouth may be frothy, blood tinged fluid
- Infant lying face down
- Diaper full of urine and stool
- Hands may be clutching sheet
- Autopsy may reveal mild resp distress
What are some considerations nurses should take when interacting with a family who has suffered a loss from SIDS?
- Family is in shock and guilt can be overwhelming
- Grieving is a process and family may project feelings
- Only ask factual questions
- Allow parents to say goodbye to the infant
- Follow up with home visits; SIDs printed info
- Support group referral
What are Apparent Life Threatening Events (ALTE)?
- Apnea of infancy >20sec
- Color Change- pallor or cyanosis
- Chocking or gagging
- Slight increased risk for SIDs
- Relate to other disorders
- Continue home monitoring and make sure parents know CPR
Describe Hydrocele, cryptorchidism, and orchiopexy
- Hydrocele: collection of peritoneal fluid that accumulates in the scrotum (surgery if persists past 1 yr)
- Cryptorchidism: undescended testicles (if not corrected, sterility can result)
- Orchiopexy: surgical procedure to bring testes down, usually done between 1-2 years of age
Describe a UTI in the infant, the tx, and tips for prevention
- Fairly common in diaper age, more so in females due to anatomy. E coli most common cause
- Fever, n/v, irritability, darkened urine, frequency
- Clean catch urine specimen to culture
- Treated with antibiotics at home
- Prevent by keeping perineal area clean, changing diapers on time, washing hands, and poss cranberry supplements
What is Wilm's tumor? What should you never do if Wilm's tumor is suspected?
- An Adenosarcoma in the kidney region and is one of the most common of the abdominal neoplasms in early childhood
- Never palpate as it may burst!
- Treatment includes removal of kidney, chemo & radiation
What are febrile seizures and how are they treated?
- Seizures associated with a febrile illness in the absence of CNS infection or electrolyte imbalance
- Most common between 6-36 mo when temp >101.8
- Seizure precautions are most important during an event
- IV or rectal valium is the drug of choice
- Tylenol may bring fever down but does not prevent or stop seizures
- If seizure lasts >5min, the parents should call 911
What nursing interventions should be performed for a child with seizures?
- Make sure infant is in a safe place
- Turn onto side to prevent aspiration
- Have 02 and suction equipment ready
- Ambu bag should be kept at bedside
- Pad the crib rails
- Document the type of movements, the duration, pulse & resp, color, eye deviation, and postictal state
What are some common head traumas in infants? What are some complications from head trauma?
- Common head traumas in infants include skull fractures, contusions, and hematomas
- Complications include increased ICP, cerebral edema, infection, brain damage, hemorrhage and death
When should a parent seek treatment after head trauma?
- Significant fall or loss of consciousness
- Amnesia or severe HA
- Fluids leaking from ears or nose (+ for glucose means CSF fluid)
- Vomiting 3x+
- Confusion, unsteady gait, change in vision
- Neck pain
- Bruising below eyes (basilar fracture)
- Pupils dilated, unequal, or fixed (neuro emergency!!)
What assessments are essential for head trauma?
- Stabilize spine
- Clean any abrasions
- NPO then advance to clears if normal LOC
- Assess for pain (cannot give meds)
- Assess neuro q4hr
What are some common skin and mucous membrane disorders of the infant? How are they treated?
- Miliaria Rubra: prickly heat rash. No tx
- Diaper Rash: tx with zinc cream
- Candidiasis: Yeast infec treated with anti-fungal such as nystatin
- Seborrheic Dermatitis: also called cradle cap. Due to excessive sebaceous glands. Leave oil on head overnight to loosen crusts
- Impetigo: characterized by yellow crusts. Crusts removed by Barlows solution and treated with antibiotics
- Acute Infantile Eczema: also called atopic dermatitis. Treated with creams and lotions