Paediatric Medicine Lecture Notes

Nusing 1 Dr Anderson A. C

CHAPTER ONE

INTRODUCTION TO CHILD HEALTH

Learning Objectives:
After studying the material in this unit, the students will be

able to describe:

- Safe mother hood in relation to child health

- Age and disease patterns

- Health priorities in children

1.1 Introduction

Throughout the world, poor women and children are the most

vulnerable and the least served. In the less developed areas

of the world, disease and death take the highest toll among

mothers and children who make up over two-thirds of the

population. Perinatal mortality may be as much as ten times

higher than that of infants born in industrialized countries; the

infant mortality rate may be six to twenty times greater than

that the industrialized regions of Europe and North America;

the death rate among pre-school children is also up to ten

times high. Furthermore, in underdeveloped countries, half of

the total mortality may occur in children under 5 years of age

compared to only 5% in countries such as United Kingdom

and Sweden. In technically advanced countries, the child

survival rate is over 97% while in less developed countries

over 50% of total deaths are of children under the age of 5,

and the average life span is about 35 years. In scientifically

advanced countries, only 5% of the total mortality occurs

among the under 5; and the average life span is over 70

years. Before the advent of scientific medicine, it was taken

for granted that a large proportion of children born alive would

die in childhood, and the parents felt it necessary to have

many children in the hope that some would survive, that few

of them paid much attention to childhood diseases

1.2. Safe mother hood in relation to child

health

High Neonatal Mortality Rates are preventable Proven,

simple, low cost solutions exist; up to 70% of neonatal deaths

could be prevented through intervention for the mother.

Impact of mother baby package interventions on neonatal

death (WHO mother –baby package 1994).

A. Antenatal Care:
ƒIn the first visit

• History taking

• Physical examination

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• Laboratory examination (Blood for RH, anemia, urine for

albumine..)

• Treatment of minor ailment

• In the second and subsequent visit

• Measuring BP, fundal height, weight

• Maternal immunization with tetanus toxoid

• Nutritional support including iron/ folate supplementation

• Birth planning

• Counseling on breast feeding

• Presumptive malaria treatment where appropriate

• Syphilis screening and treatment where appropriate

• Voluntary counseling and testing for HIV, where

appropriate

• Recognition of danger signs; treatment & referral as

needed.

Detecting for high risk pregnancy:

• Age <18 and > 35 years

• Primigravida

• Previous Cesarean section (C/S)

• Instrumental deliveries (vacuum, forceps)

• Destructive deliveries

• Previous prenatal death

• Previous still birth

• Previous ante partum hemorrhage (APH)

• Previous post partum hemorrhage (PPH)

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• Grand multiparty

• Preeclamsia, eclampsia

• Cardiac disease

• Renal disease

• Diabetes mellitus

• Multiple pregnancy

B. Labor and delivery Care:

Trained health worker during labor and delivery should attend

Mother and baby. Delivery should be conducted under

hygienic condition. Clean hand, delivery surface, clean cordcutting and tying, clean environment, and
clean perineum.

Skilled attendant at delivery. Recognition of danger signs

(mother and baby); treatment and referral as needed.

Age and disease patterns:

C. Essential Newborn Care:

ƒImmediate assessment

ƒCare of the new-born baby should be guided by the

following principles

ƒDry the new-born as soon as possible

ƒWrap the new-born in a dry towel to prevent heat loss

from the body

ƒPlace the new-born next to the mother to get the breast

and warmth (rooming in).

ƒCut the cord when it becomes thin and white. Apply

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tetracycline eye ointment 1% to both eyes to prevent eye

infection. Delay washing of the new-born for 12-24 hours

to avoid unnecessary chilling. Nothing should be applied

to the cord except gentian violet.

1.3. Age and disease and patterns:

To define the task better, it is important to look in more details

at the types of diseases that are prominent at childhood. The

following list summarizes the most important diseases that will

be encountered at different ages.

• Birth to 1 month-neonatal period

• Obstetric complications and birth injuries

• Asphyxia (failure to breathe at birth)

• Low birth weight babies (prematurity)

• Infection leading to septicemia

• Tetanus (from infected cord)

• Death of mother – the new born baby is likely to die of

starvation, (or gastroenteritis, if bottle-fed) unless another

woman can be found to breast feed him.

A. First year of life- infancy

• Respiratory diseases- pneumonia, whooping cough, etc.

• Diarrheal diseases ( Especially likely if the baby is bottle

fed

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• Malaria, measles marsmus, due to either lack of an

adequate diet or a chronic disease

• Vit A deficiency

• Vit D deficiency

B. Second to the fifth year of life

• Malnutrition (Marasmus or kwashiorkor) some times both

together

• Pneumonia often caused by measles or whooping cough

• Diarrhea diseases

• Measles

• Malaria

• Anemia, some times accused by hook worm

• Tuberculosis

• Accidents

• Streptococcal tonsillitis

2. After 5 years

• Infectious diseases( Hook worm round worm)

• Malnutrition

• Malaria
• Skin diseases

• Respiratory diseases and other age specific diseases (

E.g: rheumatic fever, Streptococcal pharengitis and post

streptococcal acute glumelonephritis are not common

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before five years of age)It is obvious from this list that

most of these child hood diseases are preventable. This

why such a great emphasis must be put on preventive

programs including nutrition education, immunization and

environmental sanitation

1.4. Health Priorities in children

Child health Indicators:

A. Perinatal mortality rate:- the total number of still-births

plus the number of deaths under one week old, per 1000 birth

or the sum of late fetal and early neonatal deaths. The causes

of Perinatal mortality are generally attributed to trauma and

stress of labor, toxemia ante partum hemorrhage, maternal

disease (particularly malaria and malnutrition), congenital

anomalies, infection and induced abortions. Rates and causes

of perinatal mortality are less well documented in developing

areas. Available data indicate that in some areas like Addis

Ababa, Ethiopia, the perinatal mortality rate was documented

as high as 66 per 1000 live births.

B. Neonatal mortality rate: - The number of deaths under 28

days of age per 1000 live births. The neonatal death reflects

not only the quality of care available to women during

pregnancy and childbirth but also the quality of care available

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to the newborn during the first months of life. Immaturity of the

infant is the chief cause of these early deaths. Approximately

80 % of infants who die within 48 hours of birth weigh less

than 2500 g.

C. Post-natal mortality rate: - The number of deaths over 28

days but under one year of age per 1000 live births.

D. Infant mortality rate: - The number of infant under one

year of age dies per 1000 live births. It is the sum of neonatal

and postnatal deaths. The primary cause is immaturity and

the second leading cause is gastroenteritis, which can be

prevented by putting the newborn immediately with the mother

and advocating breast-feeding.

E. Child mortality rate: - The number of deaths between 1

and 4 years in a year per 1000 children. This rate reflects the

main environmental factors affecting the child health, such as

nutrition, sanitation, communicable diseases and accidents

around the home. It is a sensitive indicator of socioeconomic

development in a community and may be 25 times higher in

developing countries compared to developed countries.

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1.5 Care of the Under-Fives

In most countries of the world, there is a relative neglect of the

children of pre-school age. They are a vulnerable or special

risk group in any population. The reasons why they need

special health care are:

• Large numbers: constitute 15 – 20% of population in

developing countries.

• High mortality: Apart from infant mortality which is more

than 100/1000 live birth in developing countries, the

mortality in age groups 1-4 years is not less than 40/1000

as compared to 0.5 in developed countries. The major

causes of death in this group are due to malnutrition and

infection, both preventable.

• Morbidity: The major diseases which affect this

preschool age group are: diphtheria, whooping cough

tetanus, diarrhea, dysentery, malnutrition, accidents all

are preventable etc...

A) Major childhood problems:

• Pneumonia

• Diarrhea

• Malaria

• Tuberculosis

• HIV ( mother to child transmission)

• Perinatal infection

• Malnutrition

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B) Major child health programs/activities:

• CDD see the section on IMCI case management of

Diarrhea

• ARI see the section on IMCI case management of ARI

• Malaria control see the section on IMCI case

management of fever

• HIV control activities (mother to child transmission

prevention) see the section in HIV prevention.

C) Antenatal and deliver care:

Every child begins as a fetus, and the months before delivery

are some of the most important in his life. Pregnant mothers

should be checked regularly and advised on their nutrition and

any other difficulties they have. Every mother should receive

tetanus immunization to protect her new baby. Finally, skilled

help during labor and delivery will provide the final step for a

good start in life.

D) EPI (Immunization):

Tuberculosis, diphtheria, whooping cough, tetanus, polio and

measles can all be prevented by Immunization. These are

some of the main causes of sickness and death among

children. These methods of primary prevention are available

and effective and should be given to every child.

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E) Under Five Clinic:

• The aims and objectives of the under-fives clinic are to

provide curative, preventive and promotive health

services within the resources available in the country such

as:

• Well baby care

• Care in illness

• Adequate nutrition

• Immunization

F) Traditional Practice:

Everyone is greatly influenced by the traditional customs of

his family, tribe, and country. Some of these traditional

practices are good for health, such as breast feeding or the

acceptance of modern medicine, should be supported. Those

traditional practices and beliefs, which are bad (cutting of

uvula, female genital mutilation etc ) need to be gradually

changed. This is another important area in which health

workers can have a strong influence in improving health.

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Study Questions

1. Discuss the components of safe motherhood that can

contribute to the reduction of neonatal morbidity and

mortality.

2. What are the immediate essential newborn cares?

3. What are the major components of child health program

activities?

4. Discuss advantages and disadvantages of traditional

practices in relation to child health

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CHAPTER TWO

HISTORY TAKING AND PHYSICAL

EXAMINATION

Learning Objectives

After studying the material in this unit, the students will be

able to:

- Take relevant/proper pediatric history

- Perform systematic physical examination

- Interprate history and physical examination to arrive at

differential diagnosis

- Out line Lab. Work up and management

2.1 History taking and approach

A) The Chief complaint: is the symptom the patient presents

himself with. It can be stated briefly as e.g. fever, cut wound,

or vomiting etc.

B) History of the present illness: this is a chronologic

description and duration of the chief complaint. We try to

answer the following questions;

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• Duration of disease onset

• Severity

• Aggravating and alleviating factors

• Associated symptoms

• Any treatment and response to treatment

• History of contact with similar illness

• Relevant pediatric history (like history of immunizations)

related to chief complaints or history present illness

C) Past medical history: this is made up of the illness the

patient has had in the past. Past medical history section of

pediatrics contains (Past illness, child hood illness, Prenatal

history, birth history). Find out if your patient has been

hospitalized previously and for what conditions. Do the

symptoms he/she has now resemble the one he had in

connection with these past conditions, if so then they might be

due to the same illness.

In the case of children ask about what childhood diseases

they have had. If a child has a rash now which resembles

measles you do not have to worry about this condition if he

has already had measles or if he has been immunized against

measles.

D) Social and family history:

The social history should include the parents’ occupation as

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well as the current living condition. Poverty and ignorance are

major sources of ill health. You may have to educate a poor

mother with malnourished baby that the best treatment for her

baby is to be breast-fed exclusively till the age of one or more.

If a mother feeds the baby food containing unbilled water the

baby may get diarrhea. Teach the mother to boil water used

for preparing food to infants.

E) Immunization status:

Immunization is a way of protecting children against the major

diseases of childhood, which harm, cripple or kill thousands of

children.

Ask the mother about immunization status and if he/she is not

properly immunized, take the opportunity of a minor illness to

prevent major diseases by advice and vaccination.

NB. No proper history can be obtained without observation of

the child and the mother.

Some rules in history taking:

Be an intelligent observer (while you are waiting for the

undressing of the child or while you are taking with the

mother)

Situation your action in history taking

The very sick child try to find out quickly what is causes

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The Symptoms of disease (e.g. respiratory distress,

dehydration, pain, anxiety). This will direct your history taking.

The healthy looking child whose mother believes he is ill. See

how the proposed illness affects the general wellbeing or

growth of the child. History taking does not have to be long if

he looks well. Inappropriate reaction of the mother the recent

history may be irrelevant. Social history may be more

important to get.

ƒAbnormal reaction of the child towards

What is happening around him

history may be directed towards CNS

2. Listen to the mother’s description of the complaints

carefully and get the main symptoms.

• How did the disease start, which symptoms followed?

• Get the time factor. When the disease starts? Has the

child had the same kind of symptoms before?

• Ask about the condition of other members of the family?

• How is the child eating at present? How was his appetite

in the last month?

• How is he doing between the attacks of illness? Is he

weak and inactive or strong and active?

• It may be necessary to obtain the social history in certain

conditions such as malnutrition.

• Get the ‘story’. Where has the child gone for help before?

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What sort of local treatment has he had? What are the

mother’s beliefs about his illness/disease?

• Always try to evaluate the weight progress of the child.

This is best done by looking at the weight chart which the

mother preferably should have and bring to outpatients’

department at every visit.

• Ask about vaccinations done.

• When the symptoms are vague and nonspecific, e.g.

tiredness, abdominal pain etc. review the different

systems of the body.

2.2 Review of Systems:

The review of system is essentially the same as in the adult

history. It is best organized from the head to down to the

extremities. In the child, however, there should be increased

emphasis on the symptoms related to the respiratory,

gastrointestinal, and genitourinary systems. The high

incidence of symptoms and diseases related to these

symptoms obligate the interviewer to focus in this area.

To get the important points:

The patient usually comes with his mother and the task is to

pick out from all the different information the mother is giving

what is important.

• Try to make good contact with her and with the child

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• Treat them as human beings who have come for help and

advice and do not look upon them as 'cases' only.

• Always believe what the mother tells, but try to be realistic

about the importance the symptoms she is mentioning.

• If he is not well nourished and not properly immunized,

take the opportunity of a minor illness to prevent major

diseases by advice and vaccination.

• Use communication skill (APAC: Ask ,Praise, Advice and

check ones understanding)

2.3 Physical Examination:

A) Principles and techniques of physical examination:

The principles and techniques of physical examinations in the

case of a small children you should make it habit to undress

the child and examine the whole child. To examine the whole

body we start with the head and end at feet in older children

and adults. In order not to frighten small children it is best to

examine things that are uncomfortable or frightening to them

last so as not to loose their cooperation. This means the last

thing to do in a child is auscultation of the heart, inspection of

the ears with an auriscope and inspection of the throat with a

throat stick. We use our eyes, ears and hands in addition to a

few special items of equipment to perform the physical

examination.

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1. Chronological steps of physical examination:

This consists of three parts:

a. General appearance:

This is what you observe while examing your patient

The mental state of the patient

• is he acting normally?

• is he confused?

• is he drowsy, stuporous or even comatose? etc.

The general physical state of the patient

• general state of health

• weight and body build

• colors

• respiration

• signs of dehydration

• edema

b. Vital signs:-

These are:

• Temperature

• Pulse rate

• Respiratory rate

• Blood Pressure

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The temperature:

All sick children should have their temperature measured

(rectally, orally, and axially) The normal temperature is about

37•

C. A temperature below 36•

C is abnormally low and may

be a sign of infection in a small baby.

A temperature above 37.5•

C is fever. When there is a fever it

usually means an infection is present and you must try to

locate the site of the infection and decide whether it needs

treatment and with what.

The pulse:-

The pulse can be felt and count in children radically for fifteen

seconds multiply by four. In the infant it is sometimes easiest

to count the heart rate with the stethoscope apically.

Normal pulse rate:

• babies 100-140 beats per minute

• children 80-100 beats per minute

In fever the pulse rate generally rises. In dehydration the

pulse rate may be very rapid and weak.

The respiratory rate:-

Normal respiratory rate:

• < 2 month ,< 60 breath per minute

• 2-12 months < 50 breath per minute

• 12 month-5years< 40 breath per minute

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A rapid respiration of 60 or more in a small, feverish child is a

very good indicator of pneumonia

c. Anthropometric measurement:

• Weight

• Height/Length

• head circumference

• mid-arm circumference

• Chest circumstances

Weight:

The best way to assess nutritional status is to take body

weight. The weight should be charted on a weight chart. Most

weight charts have three curves. The upper line shows the

average weight of healthy well nourished children and this is

an ideal growth curve. The middle shows the lowest weight

that is still considered to be within limits of normal and the

weights on this line are 80 % of the weights on the upper line.

The lower curve shows 60 % of the ideal weight. According to

Gomez classification any child whose weight is below this line

is marasmic.

Height: Height (length) is also used but more difficult to

measure than weight especially in infants. It is a less sensitive

measure than weight because it does not decrease during

malnutrition, it only stops increasing. This means that height is

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not affected much for the first six months in malnutrition and is

therefore more a measurement of longstanding malnutrition.

d. Evaluation of various body system:

For various body system evaluation we use our

• eyes for inspection

• hands for palpation

• ears for auscultation

• HEENT (hair color and texture, pallor, oral lesions, ear

discharge, eye discharge, neck swellings…) inspection.

• Chest (Inspection, Palpation/ Percussion, Auscultations)

• CVS (Inspection, Palpation/, Auscultations )

• Abdomen(Inspection, Palpation/ Percussion,

Auscultations )

• GUS (Costo-vertebral angle (CVA) tenderness,

Suprapubic tenderness, and inspection of external

genitalia)

• Musculoskeletal system( joint swelling or tenderness or

deformity, bone swelling or tenderness, muscles)

• Intugementory /skin ( color, lesions )

• CNS( Level of consciousness, reflexes,(motor and

sensory )and meningeal Signs

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Study Questions
1. What are the essential components of history taking?

2. What are the principles and techniques of physical

examination in a small child?

3. What methods can you use when evaluating the body

system?

4. What techniques would you use to get information about

the sick child?

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CHAPTER THREE

ESSENTIAL CARE FOR

HOSPITALIZED CHILDREN

Learning Objectives

After studying the material in this unit, the students will be

able to:

- Administer drugs for hospitalized children through

different routs

- Identify indications and use NG-tube feeding

- Identify indications and administer Oxygen as ordered

- Identify the need and carryout resuscitation

- Care for a child under specific conditions

3.1 Administration of Drugs:

The giving of medication to a child is a serious responsibility

of a nurse. The need for accuracy in pouring and giving

medication is greater than with adult patients. The dose varies

with the size, surface area, the age of the child and the nurse

has no standard dose as is customary for adult patients. Since

the dose is relatively small, a slight mistake in amount of drug

given makes a greater proportional error in terms of the

amount ordered than with the adult dose.

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Since the possibility of error is greater in the giving of

medication to children than to adults, and since a child’s

reaction to a dose ordered by a physician is less predictable

than adult’s reaction, the nurse must be alert to recognize

undesired effects of the medication given.

A) Oral administration:

Infants will generally accept the medication put into their

mouth, provided that it is in a form which they can deadly

swallow. The medication should be given slowly in order to

prevent choking. The nurse should sit-down and hold infant or

if he cannot be removed from his crib, raises him to sitting

position or if this is contraindicated elevate his head and

shoulders. There is then less danger of his choking.

Medication can be given from medication glass, the tip of

teaspoon or rubber-tipped medicine dropper. If the medication

is immediately vomited, the physician should be notified. The

child as young as two years of age can be taught to swallow

drugs. The child should be told to place the tablet near the
back of his tongue and to drink the water, fruit juice, milk

offered him in order to wash down the tablet. In younger

seriously sick children, tablets crushed and dissolved in water

can be given by spoon or through Naso- gastric tube

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B) Intramuscular Injections:

The procedure of using an intramuscular injection is the same

as for the adults. In children and infants anterior lateral thigh is

often used for IM injection to reduce the risk of vascular and

peripheral nerve (sciatic) injuries. The needle used for

intramuscular injection must be long enough so that the

medication should be given deeply into the muscle tissue in

order to be absorbed properly.

C) Intravenous Administration:

When a patient’s gastrointestinal tract can not accept food,

nutritional requirements are often met intravenously. Parental

administration may include high concentrations of glucose,

protein or fat to meet nutritional requirements. Many

medications are delivered intravenously, either by infusion or

directly into the vein. Because intravenous administrations

circulate rapidly. The ability to gain access to the venous

system for administering fluid and medications is an expected

nursing skill in many settings. They are responsible for

selecting the appropriate venipuncture site and being

proficient in the technique of vein entry. Ideally, both arms and

hands should be carefully inspected before a specific

venipuncture site is chosen.

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The following are considered when selecting a site for

venipuncture.

• Condition of the vein

• Type of fluid/ medication to be infused

• Duration of the therapy

• Patients age and size

• Skill of the health provider

Possible Sites:

• Scalp veins

• Femoral Veins

• External jaguar Veins

• Antecubital –fossa

3.2 Indications and use of NG-tube:

Gavage feeding (nasogastric or NG-tube feeding) is a means

of supplying adequate nutrition to an infant who is unable or

tires too easily to suck or to an older child who can not drink.

To prepare for Gavage feedings, the space from the bridge of

the infant’s nose to the earlobe to a point halfway between the

xiphoid process and the umbilicus is measured against a No 8

or 10 Gavage tube for children over one year measure from

the bridge of the nose to the earlobe to the xiphoid process.

The tube is marked at this point by a small Kelly clamp or

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piece of tape to ensure that it reaches the stomach after it is

passed. The tip of the catheter may be lubricated by water. An

oil lubricant should never be used. Although the tube is

passed into the stomach, it is occasionally passed into the

trachea accidentally, oil left in the trachea could lead to lipoid

pneumonia, a complication that a child already burdened with

disease may not be able to tolerate.

Once you are assured that the catheter is in the stomach,

attach a syringe or special feeding funnel to the tube. Be

certain that the child’s head and chest are slightly elevated to

encourage fluid to flow downward into the stomach. Then feed

with funnel or syringe and allow it to flow by gravity into the

child’s stomach. When the total feeding has passed through

the tube, the tube is reclamped securely and then gently and

rapidly withdrawn to reduce the risk of aspiration. If the tube is

to be remain in place, it should be flashed with 1 to 5 ml of

sterile water and cupped to seal out air.

Indications for NG tube:

• Prematurity

• Neurologic disorders

• Respiratory distress
• Severe protein energy malnutrition

• Cleft palate

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3) Resuscitation:

Respiratory arrest means that there is no apparent respiratory

activity. The child will be unresponsive, pale and dead like.

Cardiac arrest follows quickly after respiratory arrest as soon

as the heart muscle is affected by the anoxia, which occurs.

The outcome for the child will depend to great extent on the

speed with which resuscitation is began. The steps for

resuscitation can be remembered as “A, B, C, D” where A is

for airway, B for breathing and C is for circulation and D is for

drug administration. These three techniques (clearing the

airway, ventilating the lungs, and circulating the blood by

cardiac compression) will provide adequate oxygenation to

major body organs for an extended period of time (A: clear

airway, position, suction), (B: bagging, oxygen administration),

(C: Cardiac compression, secure IV line), (D –drugs

(epinephrine).

Oxygen administration: Oxygen administration elevates the

arterial saturation level by supplying more available oxygen to

the respiratory tract. Nursing care must be planned carefully

when children are in tents:

• The tent should be open as little as possible so that as

high an oxygen concentration as possible can be

maintained.

• Oxygen may be delivered to an infant by use of plastic

mask. This tight fitting plastic can keep oxygen

concentration at nearly 100 %.

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• A nasal catheter used with an oxygen flow of 4 L/ min

provides a concentration of about 50 %. Most children do

not like nasal catheter because it is irritant; assess the

nostrils of the infant carefully when using nasal catheter.

The pressure of catheter can cause areas of necrosis,

particularly on the nasal septum.

• Oxygen must be administered warmed and moistened, no

matter what the route of delivery; dry oxygen will dry and

thicken, not loosen secretions.

• Oxygen must be administered with the same careful

observation and thoughtfulness as any drug.

• If concentrations are too low, oxygen is not therapeutic

• In concentrations greater than those desired, oxygen

toxicity can develop.

• If newborns are subjected to a Pao2 of over 100-mm/Hg

for an extended time, retinopathy of prematurely can

occur.

4. Administering Enemas:
Enemas are rarely used with children unless a part of

preoperative preparation or are required for radiological study.

The usual amount of enema solution used are as follows:

• Infant: less than 250 ml

• Preschooler: 250-350 ml

• School age child: 300-500 ml

• Adolescent: 500 ml

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For an infant:

• Use a small soft catheter (no 10 to 12 French) in place of

an enema tip.

• Infants and children up to ages 3 years or 4 years are

unable to retain enema solutions, so they must rest on a

bed pan or baby pan during the procedure

• Pad the edge of the pan so that it is not cold or sharp.

• Place a pillow under the infants or the young child’s upper

body for positioning and comfort.

• Lubricate the catheter and insert it only 2 to 3 inches (5cm

– 7cm ) in children and only 1 inch ( 2.5 cm ) in infants.

• Be certain to hold the solution container no more than 12-

15 inch above the bed surface so the solution flows at

controlled rate.

• If the child experiences intestinal cramping, clamp the

tubing to halt the flow temporarily and wait until the

cramping passes before instilling any more fluid

• If the enema solution is to be retained, such as an oil

solution, hold the child’s buttocks together after

administration

• Tape water is not used because it is not isotonic and

causes rapid fluid shifts of water in body compartments,

leading to water intoxication.

• Normal saline ( 0.9 sodium chloride ) is the usual solution

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3.3 Care of child under specific conditions:

Fever: Fever in children is common and can have many

causes. In many cases you will make the diagnosis of nonspecific virus infection. This may be true, but such
a diagnosis

is difficult to prove and should never be made without taking a

careful history and performing a proper examination in any

child with fever. Young children appear to tolerate fever better

than adults but some develop convulsions. Remember to ask

for any contact with infectious diseases. Think of malaria and

take a blood film. If you still do not have a definite cause for

the fever, rule out (Malaria, Early measles, Pneumonia,

meningitis)

A) Features of Febrile convulsions:

• Begin between 6 month and 5 years of age

• Incidence is 3 % by 5 years of age

• Epilepsy develop in 3 % of cases

• % are neurologically abnormal

• 30 % of cases develop further seizure with fever

• Febrile seizures lasting over 30 minutes are more serious

• Repeated convulsions may damage the brain. The best

treatment is controlling and preventing high fever rather

than giving continuous anticonvulsants.

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General management of children with fever:

a. If the fever is high (over 39 degree centigrade)

• Tepid sponging with ordinary water will help to reduce but

ice cold water is harmful because it causes constriction of

blood vessel in the skin and prevents heat loss.

• Antipyretics (paracetamol) 10 –15 mg /kg

• Use a fun to increase water evaporation and hence skin

cooling and reduction in body temperature.

b. Feverish children should never be wrapped in warm

blankets. Children must be able to get rid of the heat,

otherwise febrile convulsions can be precipitated

c. children who have fever need to take extra fluids, so make

sure that they have plenty to drink.

• If they are too sick to take, give fluids by NG tube

• If they are obviously dehydrated, they need intravenous or

intraperitoneal infusion

• Room ventilation
• Re-assess the child for fever later

• Attempts should be made to identify and treat underlying

causes

B) Coma:

Coma is a state of unconsciousness from which patient

cannot be aroused by any stimulation.

• This might be the result of a recent convulsions

• Coma can be caused by local damage to the brain by

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infection (brain absces, encephalitis, TB. or other types of

meningitis)

• coma can be caused by abnormal function of the brain

cells due to:

1. uremia

2. high blood pressure as in acute glomerulonephritis

3. drugs or poisons

4. hypoglycemia as in malnourished children or diabetics

after too much insulin

5. hyperglycemic diabetic coma

6. dehydration with electrolyte disturbances

7. liver failure

8. toxic coma as in typhoid fever and septicemia

Management of coma:

1. Take care the airway does not become blocked by the

tongue or secretions by placing the patient in the coma

position with the mouth downwards and using suction

p.r.n.( A,B,C, D of life saving measures)

2. Find and treat the cause, if possible or refer to hospital. A

malaria blood film, a lumbar puncture, dextrostix in blood

or clinistix in urine, measuring blood pressure, and a

thorough history and examination will usually reveal the

cause. If not: treat as malaria in any case. In case of a

feverish, toxic, comatose child, also start treatment with

penicillin and chloramphenicol and refer to hospital.

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3. Turn the patient every 2 hourly

4. Check the bladder regularly for retention

5. Insert NGT for feeding

C) Convulsive seizure: Convulsions are much commoner

during the first two or three years of life than at any other

period. This is not only due to congenital malformation or

perinatal injury to the central nervous system but also the

frequency of “febrile“ convulsions in response to a rapid rise of

temperature at the onset of acute infective illnesses

1. Management of Convulsion in children:

• (A,B,C,D) of life saving measures

• Give 20 % glucose ( IV or PO)

• Give Diazepam, ( Rectal, IV,NGT) if convulsion does not

stop

• Give Phenobarbitone or Phenytine if convulsion does not

stop

• Give General anesthesia

2. Nursing Management during seizure:

• Provide privacy

• Protect head injury by placing pillow under head and neck

• Loosen constrictive clothing’s

• Remove any furniture from patient side

• Remove denture if any

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• Place padded tongue blade between teethes to prevent

tongue bit

• Do not attempt to restrain the patient during attack

• If possible place patient on side

3. Nursing Management after seizure:

• Prevent aspiration by placing on side

• On awaking re-orient the patient to the environment

• Re-assure and calm the patient

3.4 Tracheostomy Care (Care of a child under

Tracheostomy):

A tracheotomy is a procedure in which an opening is made

into the trachea. When an indwelling tube is inserted into the

trachea, the term tracheostomy is used. A trachestomy may

be either temporary or permanent.

A trachestomy is performed to by pass an upper airway

obstruction, to remove tracheoborncheal secretions, to

prevent aspiration of oral or gastric secretions in the

unconscious or paralyzed patient and to replace an

endotracheal tube. There are many disease processes and

emergency conditions that make a tracheostomy necessary.

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37

Procedure:

The procedure is performed in the operating room or in an

intensive care unit, where the patients condition can be well

controlled an optimal aseptic technique can be maintained. An

opening is made in the second or third tracheal rings. After the

trachea is (opened) exposed a tracheostomy tube of

appropriate size is inserted.

The tracheostomy tube is held in place by tapes fastened

around the patients neck usually, a square of sterile gauze is

placed between the tube and the skin to absorb drainage and

prevent infection.

Complications:

Early complications immediately after the trachestomy is

performed include:

• bleeding

• pneumothorax
• air embolism

• aspiration

• subcutaneous or mediastinal emphysema

• recurrent laryngeal nerve damage or

• posterior tracheal wall penetration.

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Long-term complications include:

ƒair way obstructions due to accumulation of secretions.

• infection

• dysphasia

• tracheo-esophageal fistula

• tracheal dilation

• tracheal ischemia and necrosis

• tracheal stenosis after removal of tracheostomy tube.

Immediate Postoperative Nursing care:

• The patient requires continuous monitoring and

assessment.

• The opening must be kept patent by proper suctioning of

secretions.

• After the vital signs are stable, the patient is placed in

semi-fowler’s position to facilitate ventilation, promote

drainage, minimize edema and prevent strain on the

suture lines.

• Analgesic and sedative drugs are administered with

caution because it is undesirable to depress the cough

reflex.

• Paper and pencil, and the patient call light are kept within

reach of patient to ensure a means of communication.

• Psychosocial care

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Tracheostomy tube and skin care:

• Inspect tracheostomy dressing for moisture or drainage

• Wash hands

• Explain procedure to pt.

• Wear clean gloves, remove soiled dressing and discard.

• Prepare sterile supplies (hydrogen peroxide, normal

saline, or sterile water, cotton tipped applicators, dressing

materials).

• Put on sterile gloves.

• Cleanse wound and tracheostomy tube with sterile

applicators moistened with hydrogen peroxide and rinse

with sterile saline.

• If old tapes of outer cannula are soiled change it with care

and secure with a knot.

• Remove old tapes and discard.

• Use sterile tracheostomy dressing and fit securely to

cover the incision.

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Study Questions

1. What are the indications for Oxygen administration?

2. What are similarities and difference in giving IM

medication to children and adults?

3. Discuss about the indications for NG tube feeding.

4. Discuss about the possible causes of fever in children and

its management.

5. Discuss about the care of a child admitted to hospital in

state of coma.

6. List the possible causes of convulsion in children.

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CHAPTER FOUR

CARE OF THE NEW BORN

Learning Objectives:

After studying the material in this unit, the students will be

able to:

- Provide basic delivery room care for the new born

- Identify high risk new born as early as possible and able

to undertake basic neonatal resuscitation

- Provide proper nursing care for the normal neonate

immediately after birth

- Perform assessment of the newborn before discharge

- Detect and manage the common neonatal problems

- Refer neonates with serious problems as soon as

possible to higher facilities

4.1 Care of Normal Newborn:

A) Care at birth:

• Clear air way ( suction mouth and pharynx)

• Temperature control ( dry and wrap with dry cloth)

• clamping the cord immediately after the birth of baby app.

2.5 cm from abdomen

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• provide appropriate eye care to prevent Ophthalmia

Neonatorum( TTC eye ointment)

• Identification of newborn with mothers name

• Vitamin K injection to prevent hemorrhagic disease of the

newborn

• Measurement (Weight, Height, Head circumference)

• Encourage rooming-in immediately after delivery

Assessment of APGAR score:

• 7-10 well adjusted

• 5-7 mild asphyxia

• 3-4 moderate asphyxia

• < 3 severe asphyxia

B) Care in the Postnatal Ward:

• Handle the baby gentle

• Avoid infection (hand washing)

• Keep the baby warm

• Encourage and initiate exclusive breast feeding -4 months

of age

• Encourage care of umbilical stump

• Give immunization ( BCG & OPV0)

C) Assessment of the newborn before discharge:

• Take vital sign

• Check for sign infections (eye , cord ,skin)

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• Check for birth trauma (cephalohematoma, fracture..)

• Check for anomalies ( spina-bifda, imporforate anus, club

foot…)

• Carryout systematic examinations ( head to foot)

D) Classification of the newborn:

Newborns are classified based on their gestational age and

birth weight.

Gestational age defined as:

ƒPreterm defined as gestational age below 37 complete

weeks

ƒTerm defined as gestational age above 37-42 weeks

ƒpost term defined as gestational age above 42 weeks

Classification of Newborn by birth weight:

Low birth weight (LBW- is defined as birth weight < 2.5 kg ,

they may be Preterm or small for gestational age (SGA)

Very LBW - birth weight < 1500gm

Large for gestational age (LGA)- birth weight above 90th

percentile.

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Appropriate for gestational age (AGA)- birth weight

between and 10th and 90th percentile

Small for gestational age-(SGA) – birth weight below 10th

percentile

4.2 Causes of Low Birth Weight (LBW):

Fetal:

1. Fetal distress

2. Multiple pregnancies

3. Erythroblastosis fetalis

Placental:

i. Premature separation

ii. Placenta previa

Uterine: Incompetent cervix

Maternal:

1. Pre-eclampsia

2. Chronic illness

3. Infection

4. PROM (prematurerapture ofmembrane)

5. Poly hydrominous >1500ml

6. Nutrition status of the mother

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A) Management of low birth weight:

ƒClean air way

ƒInitiate breathing

ƒEstablish circulation

ƒKeep Warm

ƒAdminister Vit. K

ƒAdminister Silver nitrate or TTC ointment to the eyes

ƒApply gentian Violet to the cord

ƒFeeding- Breast feeding

ƒNGT feeding

ƒParental feeding

ƒTreat anticipated problems (infection)

ƒHypothermia (cold injury). If Rectal temperature is < 350C

ƒHyperthermia temperature >38.50C

Normal temperature:

ƒRectal 36.5 - 37.20C

ƒAxillary 36.5 - 370C

ƒHyperthermia caused by

ƒExcessive environmental temperature

ƒInfection

ƒDehydration (loss of ECF, Evaporation)

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B) Potential Deaths Averted:

Cause percentage Number

Diarrhea 40-60 24,000-36,000

Tetanus 80 450,000

Pneumonia 40 300,000

Sepsis/ meningitis 40-60 110,000-250,000

Where should the focus be for Perinatal/neonatal

programs?

• Globally most births occur at home

• Most prenatal / neonatal deaths at home within the first

week

• Sick babies are rarely identified by families or health

workers referred to facilities in time to prevent death

Few health facilities are available to provide sophisticated

neonatal care

Focus for prenatal and neonatal programs:

• In relation to neonatal mortality reduction, preventive

approaches will be more effective and more feasible than

curative care

• Many of the known proven interventions could be

provided by skilled attendants and by informed family

members.

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Immediate Newborn care:

• Drying, wrapping, close contact with mother

• Immediate breast feeding

• Prophylactic eye care, where appropriate

Routine Newborn Care:

• Exclusive breast feeding, counseling for problems

• Maintenance of body temperature

• Clean cord care

• Early postpartum visit for mother and baby (within 3 days)

• Recognition of danger signs; treatment and referral as

needed

• Immunization

Special Newborn Care:

• Special care for the sick children

• Recognition and management of birth asphyxia

• Recognition and management of infection

• Special care for the LBW infant

• Skin – to- skin / kangaroo mother care

• Close surveillance for signs of infections and feeding

difficulties

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Common causes of infants and childhood morbidity:

ƒPerinatal period: From 28 wks of gestation - one week of

life after birth

Cause of morbidity:
• Perinatal asphyxia - Respiratory distress

• LBW

• Birth trauma

• Perinatal infection

1. Common Neonatal Problems

A. Due to maternal origin

• Amniotic fluid infection

• Obstructed labor

• Congenital syphilis

Placenta previa

• Causeless

• Toxemia of pregnancy

• Recurrent and the bleeding is painless

Gestational Hepatitis

B. Due to fetal and maternal origin

ƒPremature separation of placenta

ƒTrauma Abruption placenta

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ƒCauseless

ƒAccidental

ƒPainful(rigid)

C. Due to fetal origin

• Compression of umbilical cord

• Congenital abnormality
• Obstructed labor /mal presentation

Clinical manifestation:

Apnea - the cessation of respiratory movement for 15 second

Pale or cyanotic

Less than normal tactile movement / stop movement

5 - 7 mild asphyxia

Management

High-risk mother should be identified at ANC to institute

resuscitation measure immediately after delivery.

2. Respiratory distress (RD)

Cause:

• Me conium aspiration

• Congenital pneumonia (By aspiration of Amniotic fluid)

• Metabolic problems (Acidosis, Hypoglycemia,

Hypertension)

• Congenital heart disease

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• Anemia

• Drug (narcotic)

Clinical Manifestations:

• Tachypnoea

• Intercostals muscles retraction

• Flaring of Alai nasi

• Cyanosis
Management:

• Resuscitation

• Oxygen administration

• Fluid administration

• Warm - heat

3. Congenital pneumonia

It is caused by aspiration of amniotic fluid or ascending

infection.

• Predisposing factors:

• Prolonged labor

• Prolonged rupture of membrane

• Difficult labor

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4.3 Perinatal and infant infections:

1. Neonatal sepsis

Causes:

• Streptococcus

• E. coli

• Premature rupture of membrane (PROM)

Four routes of infection:

• Transplacental

• Ascending infection

• Bacterial colonization

• Environmental
Clinical Manifestation:

• Hypothermia

• Apnea, respiratory distress

• Failure to feed

• Vomiting and jaundice

Management:

Antibiotic (Gentamycin 5-7mg (kg) TID for 14)

Neonatal meningitis: is an infection of brain caused by

sepsis or bacteria in the blood stream.

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Management:

• Ampicillin 200mg/kg. 24 hr in 4 divided dose

• Gentamicin 5-7 mg/kg/ 24 hrs TID 14 days

• Neonatal pneumonia: is an infection of lung tissue in

neonatal period.

Route of infection:

• Transplacental

• Amniotic fluid infection

• Environment

• Instrument

Other Neonatal problems:

• Congenital abnormalities

• Prematurity and related problems

• Jaundice
• Birth Trauma

4.4 Post neonatal and infant morbidity:

Causes of infant morbidity:

• Acute upper respiratory infection

• Diarrhea

• Hypertrophy of tonsils and adenoids

• Bronchopneumonia

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• Pyrexia of unknown origin

• Acute Bronchitis

• Malaria

• Inflammatory disease of eye

• Accidents

• Other helemintisis

Toddler (1-3 year)

• ARI

• Diarrhea

• Measles

• Malnutrition

• Preschool

• ARI

• Measles

• Diarrhea

• Malaria
• Malnutrition

• Whooping cough

• Parasitosis

• Skin disease

• TB

• Accident

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4.5. Neonatal resuscitation:

During the initial resuscitation efforts, a 100 % oxygen

concentration is administered to the neonate. As soon as the

infants condition is stabilized, the concentration is adjusted to

maintain the PO2 (partial pressure of oxygen in the blood)

within acceptable limits. This adjustment is essential, since

elevated pao2 levels can cause irreparable damage to retinal

vessels. Furthermore, high oxygen concentrations can directly

injure lung tissue premature infants with immature lungs and

eye vessels are at particular risk for two conditions that are a

direct result of oxygen toxicity: retrolental fibroplasia and

bronchopulmonary dysplasia.

4.6 Fever:

Fever in children is common and can have many causes. In

many cases you will make the diagnosis of non- specific virus

infection. This may be true, but such a diagnosis is difficult to

prove and should never be made without taking a careful

history and performing a proper examination in any child with

fever.

NB. Remember to ask for any contact with infectious

diseases.

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Think of malaria and take a blood film. If you still do not have

a definite cause for the fever, rule out:

A. Malaria: one negative blood film report does not exclude

malaria

B Early measles: look for koplik’s spots

C Pneumonia: look at the child for flaring of nostrils, rate of

breathing, Lower chest in drawing

D Otitis media: check eardrums

E Meningitis: neck stiffness, irritability

F Urinary tract infection: check urine

G Tonsillitis: look at the throat

H Relapsing fever: take blood film for haemo parasite

4.7 Convulsions:

Convulsions are much common during the first two or three

years of life than at any other period. This is not only due to

congenital malformation or perinatal injury to the central

nervous system but also the frequency of “febrile “convulsions

in response to a rapid rise of temperature at the onset of

acute infective illnesses

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Causes:

1. In the neonatal period the major causes of convulsions are

• Congenital defect of the brain

• Cerebral damage occurring during the process of birth

from hypoxia or trauma both account for 90 % of the

cases.

The remaining 10 % includes:

• infection of the brain ( meningitis )

• hypoglycaemia

• hyperbillirubinaemia with kernicterus etc

2. during early childhood (until about the age of 6 years)

• Infections both (intra and extra cranial) are the most

frequent causes of convulsions

• Febrile convulsions between age of 6 months and 3 years

and rare after this period

• At the age of two idiopathic epilepsy begins to accounts

for an increased proportion of cases.

3. at later childhood and adolescence

• 50 % of recurrent convulsions have idiopathic origin

The remainders are organic and most frequently have

originated from some brain injury sustained in the early year

of life

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4.8. Feeding Recommendations during

sickness and health:

Up to 4 months of age

• Breast feed as often as the child wants, day and night, at

least 8 times in 24 hours.

• Do not give other fluid of fluids

• Expose the child to sunshine for 20 to 30 minutes daily

4 months up to 6 months

• Breast feed as often as the child wants, day and night , at

least 8 times in 24 hours

• Add complement foods mashed potatoes softened with

milks cereal and legumes mixed with milk

• Give these foods with cup and spoon 1 or 2 times per day

in addition to breast feed.

• Expose the child to sun shine for 20 to 30 minutes daily.

6 Months up to 12 months.

• Breast-feed as often as the child wants.

• Give adequate servings of shiro fitfit, Merek fitfit, porridge,

made of cereal and legume mixes, mashed potatoes and

carot, mashed gommen, egg and fruits.

• Give adequate servings of:Porridge made of cereal and

legume mixes. Shiro, kik, merek fitfit, mashed potatoes

and carot, gommen,undiluted milk and egg and fruits

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• Add some extra butter or oil to child’s food

• Give these foods:-3 times per day if breastfed 5 times per

day if not breastfed

• Expose child to sunshine

12 months up to 2 years:

• Breast feed as often as the child wants, Give these foods

5 times per day

• Give adequate serving of: porridge made of cereal and

legume mixes. Shiro, kik, merek fitifit mashed potatos and

carrot, gommen, undiluted milk and fruits

• Add some extera butter or oil to child food

• Give these foods 5 times per day

2 years and older:

Give family food at least 3 times each day.

Also twice daily, give nutrious food between meals, such as:

egg, milk, fruits, kita, dabo

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Study Questions

1. List the common causes of low birth weight.

2. Discuss the focus areas to prevent prenatal and neonatal

mortality.

3. What are the common causes of infant and childhood

mortality?
4. What are the common causes of respiratory distress in

newborns?

5. List common routes of infection in neonates?

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CHAPTER FIVE

CONGENITAL ABNORMALITIES

Learning Objectives:

- After studying the material in this unit, the students will be

able to:

- Define congenital abnormality

- Recognize the common types of congenital abnormalities

and check each newborn baby to be sure that there is no

congenital abnormalities

- Recognize the recommended treatment for each type of

congenital abnormality

- provide appropriate care for children with congenital

abnormalities

5.1 Introduction:

Congenital anomalies are structural anomalies present at

birth. They may be obvious on examination of the newborn or

they may be detected by histological structures.

One reason why more deaths occur in the first than during the

remaining months of the first year of life is that many

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congenital abnormalities are compatible with intrauterine life,

but not with extra-uterine life approximately 15 % of death in

the neonatal period care caused by such gross malformations.

5.2 Types of commonest congenital

anomalies

1. Cleft lip and palate

2. Club foot

3. Umbilical hernia

4. Pyloric stenos

5. phemosis and paraphimosis

6. Spina bifida and hydrocephalus.

5.2.1. Cleft lip and palate

Cleft lip and palate are congenital deformities due to the

failure of various parts of the upper lip and palate to fuse in

the normal manner. Both may be present together. Cleft lip is

operated on about the age of three months, cleft palate about

the age of one year before speech detects have developed.

Cleft lip: may be unilateral or bilateral and may be extended

up into nostril. The surgeon pares the age and stitches them

together.

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62

Preparation: The child should be admitted several days

before operation and observed for sighs of a cold, as

operation should be delayed if this is present and throat

swabs should be taken.

The hemoglobin must be 70% before operation is undertaken.

He is trained in spoon feeding, putting the feeds well to the

back of the tongue.

After care:

The arms must be splinted with card board so that the child

can not touch the wound. Crying must be prevented by good

nursing care and lifting the mother to spend much of her time

with the child. Drugs may be given to keep the child quiet. It

should be ensured that no visitors with colds come to see the

child. The stitches are taken out on the third to fifth days. Soft

feeds are given by spoon well back on the tongue and

followed by sterile water.

Cleft palate: is treated similarly by paring the adages and

suturing after cutting on either side.

Preparation The child should be admitted well before

operation to be accustomed with the environment. He should

be trained on spoon feeding. His general condition must be

improved and he must not be exposed to infection.

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After Care:

Arms must be splinted

Soft feeds are given by spoon placed well back on the tongue
and followed by sterile water.(others similar on cleft lip after

care)

5.2.2 Club foot

Club foot is a foot which has been fell out of shape or position

in uteri and can not be moved to uncorrected position.

The two most common types of club foot are:

Talipes equinovarus

Talipes calcaneovalgal

Both types are usually bilateral. In Talipes equinovarus, the

foot is fixed in palantar fixation and deviates medially i.e. the

heel is elevated.

The child walks on the toes and outer border of the foot. More

than 95% of case of congenital clubfoot are of this type.

In Talipes calcaneovalgal as the foot is dorsiflexed and

deviates laterally, i.e the heel is turned outward, and anterior

part of the foot is elevated on the outer border. The child

walks on the outwardly turned heel and the inner border of the

foot.

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64

Treatment and Responsibility of the Nurse

Treatment should be started as soon as possible. Delay

makes correction more difficult, since the bones and muscles

of the leg develop abnormally, and the tendons will be

shortened.
In infancy, the application of cast to hold the foot in correct

position may be used the nurse may be responsible for

immobilization and holding the child during cast application. If

this measure fails to correct, the surgery on the tendons and

bones may be done in early childhood, and the leg and food

placed in a cast. If the child has undergone operation and cast

has been applied the nurse must watch for evidence of

impairment of circulation or sensation and bleeding, i.e., for

discoloration of the cast over the wound and report these

observations to the physician. The nurses circle the area of

discoloration and write the time this was done on the cast.

After operation it is necessary to change the cast every three

weeks to bring the foot gradually into normal position and

ensure permanent correction. When the cast is no longer

needed exercise may be required and parents need advice to

return for checkup.

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65

5.3 Umbilical Hernia:

An umbilical hernia is a protrusion at a portion of the intestine

through the umbilical ring, muscle, and fascia surrounding the

umbilical cord due to imperfect closure or weakness of the

umbilical ring. The clinical manifestation is a swelling at the

umbilicus which is covered with skin. This protrudes when the

infant cries or strains. It can be reduced by gentle pressure

over the fibrous ring at the umbilicus. The contents of the

hernia are small intestine and omentum.

Treatment and Responsibilities of the Nurse

• Most small umbilical hernias disappear without treatment,

but large ones may require operation. These hernias

rarely cause incarceration or strangulation of the bowel.

• If the physician orders the hernia to be taped, the hernia

is first reduced by gentle pushing the abdominal contents

back through the umbilical ring.

• A 2 inch strip of adhesive tape can be applied to the

abdomen over the skin covering the umbilical hernia.

• Usually operation is not done on an umbilical hernia

unless it becomes strangulated, enlarges or persists to

school age.

• Postoperative nursing care requires no special technique.

The child may be as active as his desire. A normal diet

and fluid may be given; pressure dressing applied at the

time of operation must be kept clean and dry to prevent

wound contamination.

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5.4. Congenital Hypertrophic pyloric stenosis

This is a common surgical condition of the intestinal tract in

infancy. It occurs most frequently in some family strain, in firstborn infants, and in males. Pathologically,
there is an increase

in size of the circular musculature of the pylorus. The

musculature is greatly thickened, and the resulting tumor like

mass constricts the lumen of the pyloric canal. This impedes

emptying of the stomach content through the constricted

pylorus.

Clinical manifestations and x-ray, finding

The symptoms appear in infants 2-4 weeks old. The initial

symptom is vomiting during and after feeding. The vomiting is

at first mild, becomes progressively more forceful until it is

projectile. Since little of the feeding is retained the infant is

always hungry. There is either failure to gain weight or loss of

weight. The signs of pyloric stenosis, dehydration with poor

skin turgor, distention of the epigastrium and an olive-shaped

mass, located by palpation, in the right upper quadrant of the

abdomen. If barium is added to the feeding, an x-ray film will

show the enlargement of the stomach, and the narrowing and

enlargement of the pylorus, increased peristaltic waves, and

an abnormal retention of the barium in the stomach.

Treatment

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Pyloromyotomy involving longitudinal splitting of the

hypertrophied circular muscle of the pylorus without incising

the mucus membrane allow more food to pass through.

Preoperative care

• Correction of fluid and electrolyte imbalance since a

dehydrated infant is at surgical risk.

• After rehydration, whole blood, vitamin B, C and K are

given as needed.

• Just before operation NG tube is passed.

• Feedings must be recorded.

Post operative care

• IV fluids for the first few days

• Position the infant on side or abdomen and prevent

aspiration of vomits.

• Frequent change of position

• Watching for indication of shock (rapid, week pulse, cool

skin, pallor, and restlessness)

• Observing the abdomen for distention

• The mother’s breast milk is expressed and given as soon

as he can tolerate it

• Prevention of wound infection

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Prognosis: The prognosis is excellent complete relief follows

successful surgical repair. The mortality rate is low,

proceeded operation is undertaken before the infant has

become too dehydrated and malnurished.

5.5. Phimosis and paraphimosis

Phimosis is a tight for skin, i.e, a fore skin or prepuce which

has a very small opening, so that it may interfere with the

passage of urine and can not be drown back over the glanis

penis for cleansing. In severe case this will prevent the scape

of urine, so that the fore skin is distended during mictaration,

and the infant screams with pain and strains during the act.

Paraphimosis, a condition due to a tight foreskin being pushed

up and constrict the circulation, causing swelling of the parts

below so that the foreskin cannot be pushed down again, and

requiring operative treatment.

Treatment:

- Circumcision, cutting away the foreskin

- After this operation the wound must be kept clean,

antiseptic dressing applied, and the parts cleansed after

passing of the urine.

- Mild cases of phimosis can be relieved by gradually

stretching the foreskin by pulling it back over the glanis

penis, so that operation is avoided.

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5.6 Spina Bifida

Spina bifida is a malformation of the spina in which the

posterior portion of the laminae of the vertebrae fails to close.

It may occur in almost in any area of the spina but most

common in lumbosacral region.

It is the most common developmental defect of the central

nervous system occurring in about one of 1000 newborn

infant.

The three types are:

1. spinabifida occulta in which the spinalcord and meninges

are normal, the defect being only of the vertebrae,

2. Meningocele, in which the meninges protrude through the

opening in the spinal canal.

3. Meningomylocele, in which both the spinal cord and the

meninges protrude through the defect in the bony rings of

the spinal canal. Meningomyelocele is the most serious

one.

Spina bifida occulta:

The majority of patients with spina bifida occulta have no

symptoms. Some may have a dimple in the skin or growth of

hair over the malformed vertebra. There is no need for

treatment unless neurological symptoms indicate that the

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defect is greater than was thought. If there is possibility that

the spinal cord may be involved in the defect, surgical

treatment is indicated.

Meningocele:

On examination the newborn infant is found to have a defect

on the spinal column large enough to protrude through the

opening. There is generally no evidence of weakness of the

legs, the infant straitens and kicks in normal manner, or if lack

of spincter control, though this is difficult to a certain in the

newborn. The prognosis is excellent if surgical correction is

done on this defects. Hydrocephalus may be an associated

finding or may be aggravated after operation for a

meningocele.

Meningomyelocele:

In this condition an imperfectly developed segment of the

spinal cord as well as the meninges, protrudes through the

spina bifida in the lumbosacral region. There may be a

minimal weakness to a complete flaccid paralysis of the legs

and absence of sensation in the feet.

Operation removes a cosmetically unacceptable deformity,

prevents infection and in many instance improves the

neurological deficit since obstruction is removed from the

nerve path ways.

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Responsibilities of nurse preoperatively in Meningomyelocele

Until the operation is performed the newborn should be kept

flat on his abdomen with sterile pad over the lesion.

No pressure over meningocele sac.

Prompt surgical closure of the skin defect preferably within 24

to 48 hours after birth is done to prevent meningeal irritation.

Responsibilities of Nurse post operatively:

• Observing and reporting of all signs and symptom of the

infant’s condition.

• Temperature, pulse, and respiration (vital signs) must be

noted frequently.

• Symptoms of shock must be noted

• Oxygen must be kept near to bed

• Abdominal distension caused by paralytic illus or

distention of the bladder following most spinal cord

surgery should be reported.

• The surgical dressing must be kept clean and dry.

5.7 Hydrocephalus:

Hydrocephalus is a condition due to inadequate absorption of

cerebrospinal fluid with a corresponding increase of fluid

under pressure within the intracranial cavity to obstruct within

the ventricular system.

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The obstruction inflow cerebrospinal fluid may be due to one

of several causes.

ƒCongenital mal development of the ventricular foramina.

ƒNeoplasm may be present or fibrous residue making it

may occlude the reabsorptive surface.

ƒHemorrhage from trauma may cause hydrocephalus in

the young infant.

The accumulation of fluid in the ventricles generally enlarges

the infants skull, since the suture are not closed and the
bones are soft.

Treatment: should be started as soon as the clinical

manifestations are observed, before damage to the brain

itself. Several shunting procedures are now in use eg.

Ventriculovenostomy (shunting from the ventricle through the

internal juqular vein to the right atrium of the heart), ventriculo

peritoneostomy, ventriculoureterostomy, and lumbar subarachnoid pertoneostomy.

The prognosis is dependant to a great extent on the

promptness of treatment and the kind of operation performed.

Responsibility of the Nurse:

ƒObserving the degree of irritability and changing vital

signs should be reported promptly.

ƒFrequent change of position to prevent hypostatic

pneumonia and danger of pressure sore.

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ƒIf pressure areas develop, great care must be taken to

prevent infection.

ƒWhen lifting head must be supported in order to prevent

trauma.

Postoperative care:

- The temperature, pulse and respiration should be

observed every 15 minutes until the infant is reactive.

- Signs of increased intracranial pressure (irritability,

bulging of the fontanel, lethargy, vomiting, elevated

systolic blood pressure, change in the pulse and

respiration rate, change in body temperature must be

recorded and reported.

- If temperature is elevated tepid sponging may be used or

aspirin may be given.

- IV fluid must be given slowly until the infant can be fed

orally.

- Mucus from nose and mouth should be aspirated to

prevent the danger of aspiration.

- The child should be turned at least every two hourly.

5.8 Neonatal Jaundice:

Jaundice is a yellow discoloration of the skin, sclera and

mucous membranes caused by high serum bilirubin. Bilirubin

is the main pigment formed in humans during the catabolism

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of the hem component of hemoglobin. Either excessive

production or defective elimination of bilirubin causes

jaundice.

ƒPhysiologic jaundice resolves spontaneously by the end

of first week in term infants and 2nd week in premature

infants.

ƒSerum bilirubin is usually under 12 mg/dl in term infants

and less than 15mg/dl in premature babies.

ƒJaundice within 24 hrs of birth; conjugated bilirubin over

12mg/dl; or jaundice beyond 2nd week of life is

pathological

Causes:

ƒABO/RH incompatibility

ƒRed cell membrane defects

ƒRBC enzyme defects

ƒPolycythemia

ƒInfection

Management of pathological jaundice

ƒEnhancing conjugation by induction of glucuronyl

transferase with phenobarbiton

ƒChanging insoluble bilirubin to a water soluble form by

phototherapy

ƒRemoving excess bilirubin by exchange transfusion.

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Study Questions

1. Discuss the role and responsibility of nurse in identifying

and caring for a child with congenital abnormality at birth

2. List the most common congenital abnormalities that can

be detected at birth

3. What measures would you take concerning parents who

had a baby with congenital abnormality?

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CHAPTER SIX

NORMAL GROWTH AND

DEVELOPMENT

Learning Objectives

After studying the material in this unit, the student will be able

to:-

- Identify the difference between growth and development

- Recognize stages of normal growth and development

- Detect deviation from normal growth and development

measures to be taken

- Use growth-monitoring chart to assess nutritional status of

under 5 children

- Recognize needs of the growing child

Definition: Growth means increase in size, Development

means increase of function. Growth and development go

together but at different speeds.

The fetus: during the first trimester the main body systems

are prepared. This is mainly the stage of development, when

the body systems become more efficient

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Harmful environmental factors, such as infections like rubella

(German measles) in the mother, or exposure to certain drugs

or X-rays may interfere with the development of the fetus at

this stage. The child may be born with certain deformities, e.g.
congenital heart disease, deafness, small head and brain.

During the last 6 months the fetus increases greatly in size.

This is mainly stage of growth. Malnutrition or amaemia in the

mother, or other disease of placenta like malaria interfering

with its blood supply, will stop the fetus growing properly. The

baby may thus be born small, not weighing as much as he

should.

The infant: growth and development is a continuous process,

but it often goes fast for a while and slows down before going

fast again. The infant needs a relatively large amount of

water, energy, and protein while growing so fast.

6.1 Growth

The body can grow only if it gets enough good food. The food

must contain enough calories, protein, and other nutrients. If

the body does not grow properly it can not resist diseases

either. The best way to measure growth is by weighing. Other

ways are by measuring length (height) and the arm

circumstances.

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The figures below are average figures for normal growth.

Table 1. Normal growth and development

Age Weight Length Arm

circumference

Birth 3.5 kg 50 cm
½ year 7 kg

1 year 10 kg 75 cm 12.5cm

2 year 12 kg

3 year 14 kg

4 year 16 kg 100 cm

5 year 18 kg

Head circumference:

Below normal range-abnormally small = microcephalus

Above normal range-abnormally large head = usually

hydrocephalus

The infant has relatively larger head than the adult. At birth

the head is a quarter of the whole body length but in an adult

it is only one eight.

Head Circumference: The head grows 12 cm in circumference

in the first 12 months, but 6 cm of this is in the first three

months; during the next three months it grows 3 more cm and

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the rest of the year another 3cm. If the head circumference at

birth is 34 cm it will be 46 cm at the age of 12 months. The

head circumference is measured by taking the greatest

distance around the forehead and the back of the head above

the ears (maximal fronto-occipital circumference)

Arm circumference: The circumference of the middle of the

upper arm remains nearly constant from 1-5 years.

Tooth eruption: Children start teething at the age of 6 months.

A new teeth appears approximately every month. This makes

the number of teeth roughly equal to the age in months minus

six. At the age of 6 years the permanent teeth start to appear.

6.2 Development:

actors promoting development:

Nutrition: Good nutrition is the base for normal growth and

development. Unlike most other organs in the body, the brain

is not fully developed at birth. The first six months of life are

extremely important as the brain may suffer for the rest of life,

if the child is not getting enough food. A malnourished child is

often tired and apathetic and not interested in learning new

things that will promote normal development.

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Emotional Support: The first years of life are the most

important for the development of the child. It is very important

to realize that a child is a growing and developing human

being and he ought to be treated very carefully with love and

respect by everyone so he can develop in harmony. He needs

full emotional support. Here are six important aspects of what

every child needs.

Love: a child who does not feel loved will not develop

properly, and will not learn as quickly as normal children.

Instead he becomes sad, lonely and no longer interested in

what goes on around him.

Security: a child needs to feel safe. He can only feel safe if

his parents show that they love him and take good care of

him. He must know that his parents will look after him and

help him, that they will feed him when he is hungry, play with

him and keep him happy and comfortable. The love and

security the child gets from his parents and family helps him to

feel friendly to people outside his family when he grows up.

Acceptance as individual: the young child needs to know that

his mother and family love him for what he is. They should not

compare him with other children and tell him that he is slow to

do this or that, or that he is not as good as some other child.

They should show him that they respect him as an individual

with his own likes and dislikes, that they realize that he is

different, as all children are different.

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Recognition of achievement: the young child needs to know

that his parents are happy and pleased when he has learned

to do some thing new. His parents help him to do things and

encourage him in his achievement. Wise and consistent use

of authority: children need to know what they can and what

they cannot do. Parents must teach children how they are

expected to behave.

Independence: as the child grows he needs to be allowed to

decide more and more things alone.

Playing: another important factor contributing to the

development of a child is plying. Encourage playing even if it

may be noisy sometimes. It helps physical, mental and social

development and is also good for health. All normal children

like to play. If a young child does not play, he may be ill.

Language training: adults should talk and sing with small

children and encourage them to talk about what they are

thinking. Do not laugh when children are talking; try to

understand how they are thinking and be happy when they

want involve you in their world.

Age periods and developmental milestones:

The development of a child can be assessed from different

points of view.

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- What he can do in the way of moving around (motor

development)

- How he talks and makes his wants known (language)

- How he fits into his family and community (social

behavior)

The various skills the baby and young children learns are

called Milstones. In watching development we notice at what

age the child learns to do certain things, such as smiling at his

mother, sitting without support, grasping objects with his

hands, walking and talking. We may record at what age the

child has reached these various milestones.

All children are different. Some walk early others late. The

average age at which children reach various milestones is

given below. The individual child often differs widely from the

average but is still quite normal.

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Table 2. Summary of normal developmental milestones:

Average age motor

development

Language & social

behaviors

1 month can lift head when

prone

can fix with eyes, often

smiles

3-6 months good head control can follow an object with

eyes, & play with hands

6-9 months can sit

unsupported

grasp actively, makes

loud noise

9-12 months able to stand understand few words,

tries to use
12-18 months able to walk grasp small objects with

thumb and

fingers

2 years able to run around can say several words, or

even as much as he

wants some sentences

3 years actively plying, is

clever in climbing

and jumping

starts talking much

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Study Questions

1 . List factors that affect growth and development of fetus.

2. Discuss the differences between growth and development.

3. List factors that promote normal development in children

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CHAPTER SEVEN

NUTRITION AND NUTRITIONAL

DEFICIENCIES

Learning Objectives:

After studying the material in this chapter the student will be

able to:

- Identify the common causes of infant and child morbidity

and mortality

- State the most common complication of malnutrition and

their management

- List the most common forms of malnutrition in the

developing Countries and their management

- State the purpose of screening and identify children who

need appropriate management

- Perform weighing of babies under 3 years of age and

interpret the weight according to weight for age chart

- Classify nutritional status of children and manage

accordingly including nutrition education.

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7.1 Normal feedings patterns:

The main rule for feedings children

ƒOnly breast milk during the first 4 months start adding

porridge at 4 months.

ƒAdd some protein to every meal after 4-5 months of age.

Plain porridge is not enough for more than a few weeks.

ƒAdd fruits and vegetable to at least one meal every day

start when the child is 4 months old.

ƒGive a child at least three meals /day. Infants may require

four to six small ones.

ƒContinue breast feeding until the child is able to manage

on other foods probably this will be at 18-24 months of

age.

ƒUse the common local carbohydrate food and add a

suitable protein food.

ƒPrepare balanced meals. Make sure that the added

protein is well mixed with the staple

ƒCarbohydrate food and that both are given in a suitable

amount.

A) Breast-Feeding:

The food for babies is undoubtedly human breast milk. Nurses

and midwives should encourage and support mothers to

breast feed even if it is only achieved for a few weeks.

However, if a mother has decided, for what ever the reason,

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to use a milk formula method of bottle feeding she should be

given the same support, understanding, and help as the

mother who breast feeds.

Good Reasons for Breast-feeding:

1. Promote bonding between mother and child.

2. Many infections are far less common in breast fed babies.

3. The fat in human milk is better absorbed than the fat in

cow’s milk

4. The danger of giving an over concentrated or a too diluted

formula milk is avoided

5. The risk of eczema, asthma, and other allergic disorders

is considerably reduced

6. Low birth weight and pre-term infants thrive best on

breast milk

7. It helps for mental development

Preparation for Breast Feeding:

Ideally preparation for breast-feeding should be part of a

health education program for both boys and girls while in

secondary school. This early awareness should be expanded

in antenatal sessions for both parents when baby is expected.

This session should include:

1. Knowledge of the physiology of breast feeding

2. Management and comfort of breast and nipples

3. The importance of a well balanced diet during pregnancy

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and of the need of extra protein and calories while breast

feeding.

4. Practical demonstration and discussion with a breastfeeding mother

Management of Breast-Feeding:

Immediately after birth, while the mother still in the delivery

room, all mothers should have the opportunity to hold the

baby for 10-15 minutes quietly and contently. If the mother

tends to breast-feed, she should suckle her infant for 1-2

minutes at each breast. Skin-to- skin contact and early

suckling are important at this time in promoting “bonding” and

to encourage the release of the prolactine and oxytocine

hormones which stimulate milk secretion and help the uterus

to contract.

B) Weaning Food:

The age at which solid foods can be introduced to the infants

depend upon individual family circumstances. Most authorities

agree, however, that it should be some time between 3 and 6

months of age for the normal healthy infant.

Principles of weaning:

1. Start with one food at one feed time, offering a small

quantity only

2. Introduce new foods one at a time at 3-4 day intervals

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3. Introduce second meal after 3-4 weeks. Include iron

containing foods, e.g. liver, green vegetables

4. As solid foods increased and milk volumes reduced,

remember to offer dilute fruit juice or water from a cup to

infant atleast twice a day particularly during hot weather.

7.2 Assessment of Nutritional Status:

Growth Monitoring:

The first step in appraising the growth of a child is by

comparing the child with others of the same age and sex. A

child, generally, is healthy if she/he grows well and gains

weight. When a child is not growing well, he is probably not

healthy. The causes for this ill health could be infection or

inadequate food intake. Because of these, the growth of a

child will slow down or stop months before clear signs of

protein energy malnutrition (PEM). Thus, measuring the

growth of a child helps to understand if the child is healthy or

not. Growth monitoring is particularly important for follow-ups

for children under 3 years of age. You are advised to refer

growth-monitoring chart.

How to interpret the growth chart:

The first sign of protein energy malnutrition (PEM) is growth

failure. Weighing a child regularly on a growth chart and

understanding the direction of the growth line are the most

important steps in detection of early malnutrition.

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Table 3. Gomeze classification of Nutrition Status

Weight for age/reference

weight

Edema present Edema absent

60-80% Kwashiorkor Underweight

< 60% Marasmic

Kwashiorkor

Marasmus

It is very important to follow subsequent measurements and

plotting, to watch the direction of the line showing the child’s

growth.

Table 4 Interpretation and the findings of growth charts

Indication Child’s

condition

Good gaining

weight

Danger sign

Stagnant

Very Dangerous

Losing weight

Indication of the

growth

Monitoring chart

Interpretation Child is growing

well

Not gaining

weight Find out

why Poor nutrition

infection

Losing weight may

be ill, needs care

Intervention Complement the

mother

Instruct the
mother, support

her

Careful counseling

return soon, admit

or refer

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7.3 Protein Energy Malnutrition

The most common form of malnutrition in the world today is

that associated with diarrhea, as well as an inadequate diet in

the young children. The side effects of malnutrition include

hypoglycemia, hypothermia, hypotonic and mental apathy.

Severe malnutrition (Kwashiorkor and Marasmus) contributes

to high mortality and morbidity of children less than five years

in developing countries and to mental and physical

impairment in those who survive.

A) Kwashiorkor:

The most acute form of malnutrition is generally found in a

child of 10-14 months who has had an excessive

carbohydrate diet containing relatively little protein. Edema

and enlargement of liver may later mask a slight loss of

weight. Coldness of the extremities is well marked and the

child is miserable but apathy when anorexia and/or diarrhea

set in, there is loss of weight in spite of edema. This marsmic

stage may be due to mal absorption rather than deficiency in

caloric intake. Chronic cases show depigmentation of skin and

hair, with the hair losing its luster, becoming straight, dry and

sparse.

Marasmus:

This condition, seen in children whose weight is markedly

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below normal for their length is described as state of

starvation. A general deficiency of protein and energy has

occurred, leading to severe wasting of subcutaneous fat and

muscle tissue. It often occurs between the ages of 6 months

and 18 months. The marasmic child appears as a wizened old

man in appearance, with loss of most fatty tissue, shriveled

buttocks and emaciated limbs. Many of the signs of

kwashiorkor, such as edema, skin rash and hair discoloration

are absent. There is a general slowing of all body processes

in response to the starvation. The marasmic child is often

hungry and willing to eat when offered food.

Treating Severe Malnutrition:

1. Food is the only cure for malnutrition. If a child is to be

cured, he must be able to eat high protein and energy diet

and his family must have enough food for him. If he does

not want to eat, we have to feed him through a tube in

health facilities.

2. The danger signs that show that a malnourished child

needs treatment quickly are edema, apathy and not

eating well.

Initial Treatment

• Give him a capsule of vitamin A

• If necessary rehydrate him

• Keep him warm, either close to his mother or well covered

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• If he is apathy prevent hypoglycemia by IV glucose

administration

• Treat skin or chest infection with an appropriate antibiotic

Later treatment

• Give him high protein foods by mouth later or as soon as

he eats

• Give him iron mixture after the first week of treatment and

continue until his hemoglobin is normal

• Explain the mother the importance of diet treatment and

make sure that she understands that food not medicine is

curing him

• Caring for a malnourished child:

• In addition to diagnosis of PEM there are five things we

have to know

• How severely malnourished is he?

• His weight chart is useful

• What other diseases has he?

Many children with PEM have infections and some lack

Vitamins

Which of the six rules of good nutrition have been broken?

• Breast feeding until at least 18 months

• Start supplementary diet at the fourth month

• Add protein foods to supplementary diet

• Give children four good meals a day

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• Give protective foods to children over four months old

(fruits, vegetables)

• Sick children need more feeding

Why have the rules been broken?

• Poverty?

• Lack of knowledge?

ƒHow could his mother feed him?

Prevention of malnutrition

The following are some of the important approaches in

prevention of malnutrition in children.

• Encouraging and protecting breast-feeding

• Improving weaning practices by using local foods.

• Screening of infants and children at risk for malnutrition

and give them

• Special attention
• Providing nutrition rehabilitation especially in households.

• Integrate nutrition education into primary health care

(PHC).

• Ensure regular supervision in clinics and visiting in homes

by inspection and growth monitoring

E) WHO/IMCI Classification of PEM/Anemia

Look and feel;

• Visible severe wasting

• Look for palmer pallor (some/severe)

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• Look for edema on both feet

• Determine weight for age

Table 5. Classification of malnutrition:

Signs classification

Severe visible wasting or

Severe palmer pallor or

Edema on both feet

severe malnutrition/severe

anemia

Some palmer pallor or

Very low wt. For age anemia or very low weight

7.4 Micro-nutrient/Vitamins deficiencies:

Vitamins are groups of organic substances not synthesized by

the human body but essential as catalysts of cellular

metabolism and thus for normal growth. Since the body doe

not manufacture vitamins small amounts must be included in

the diet. Some are soluble in fat and are ingested in dietary fat

(vitamin A, D, E and K), and some are water soluble (Vitamin

B complex and Vitamin C).

Vitamins; Functions and Deficiency

1. Vitamin A

Normal growth, normal vision, normal reproduction

Maintenance of epithelial cell structure and function

Immunity to infection

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Deficiencies results in:

• xerophthalmia, (night blindness, conjunctiva dryness, Bitot

spots, Keratomalacia, and even eyeball perforation and

blindness)

• Increased risk of infections (Viral is more).

Excess results in:

• Raised intracranial pressure, irritability,dry skin, hair loss,

brittle bones

2. Thiamin (B1)

Carbohydrate metabolism, decarboxylation

Synthesis of fatty acid and Ribose (for RNA)

Deficiency results in: Beriberi manifested by

• Anorexia, emotional disturbances. Parasthesia,

weakness, gastrointestinal symptoms

• Dry beriberi (peripheral neuropathy, mental

confusion,nystagmus)

• wet beriberi ( biventricular cardiac enlargement, systemic

venous hypertension, bounding pulse)

• Infantile beriberi (acute cardiac failure)

3. Riboflavine (B2)

• Coenzyme in oxidative –reduction reaction

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Deficiency results in;

• Angular stomatitis, cracking and fissuring of lips

• Glositis, papillary atrophy

• Scrotal or vulvae dermatitis

• Photophobia, corneal vascularisation

• Anaemia, hair loss , ataxia

• Personality changes, retarded intellectual development

4. Niacin (nicotinic Acid)

• Oxidative –reduction reactions , fat synthesis, glucolysis

• Deficiency results in: Pellagra (dermatitis, diarrhea,

dementia)

• loss of weight, poor appetite, sore mouth, indigestion

• insomina, confusion

• skin erythema, pruritus, discoloration, flaking

5. Pyriodoxine (B6)
• Coenzyme in amino acid metabolism and

• Muscle glucogen phosphorylase

Deficiency results in:

Infants: hyperirritability, convulsions, weakness anemia,

and dermatitis

6. Folic Acid

• Co-enzyme in pyrimidine and purine synthesis (for

DNA,RNA)

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Deficiency results in:

• Megaloblastic anaemia

• Mild peripheral neuropathy, retarded growth

• Psychiatric disturbances, gastrointestinal disturbances

7. Ascorbic Acid (vitamine C)

• Formation of collagen, amino-acid metabolism

• Iron and copper metabolism

• Protection against free radicals (oxidents)

Deficiency results in: Scurvy

• ulceration ,poor wound healing, anemia

• Scurvy: irritability , unproductive cough, bone tenderness,

sub-periosteal hemorrhages

8. Vitamin D:

• Calcium and phosphate homeostasis

• Normal mineralisation of bone and teeth

Deficiency result in:

• Rickets, Osteomalacia

Excess result in:

• Hypocalcaemia, ectopic calcification

• Failure to thrive

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9. Vitamin E (tocopherol):

• Antioxidant (protects against free radicals)

• Preserve cell membrane integrity

Deficiency result in:

• Hemolytic anemia, skin changes

• Encephalomalacia

10. Vitamin K

Synthesis of coagulation factors

Deficiency results in:

• Coagulophathy: haematuria, hematomas, and

heamorragic disease of newborn

• Hemolytic anemia may be caused by the water soluble

form of vitamin K

Iron deficiency Anemia:

Anemia refers to a deficit of red blood cells or hemoglobin in

the blood. It is the most frequent hematological disorder

encounter in children.

Etiology:
• 1.Blood loss

• 2.Impairment of red blood cell production

a. Nutritional deficiency

• Iron deficiency

• Folic acid deficiency

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Vitamin B12 deficiency

b) Decreased erythrocyte production:

• Pure red cell anemia

• Secondary hemolytic anemia’s associated with infection,

renal disease, and chronic disorders Aplastic anemias

Invasion of bone marrow by

A, Leukemia

B, Tumors

3. Increased erythrocyte destruction

a. Drugs and chemicals

b. Infections

c. Antibody reaction

d. Burns

e. Poisons including lead poisoning

f. Abnormalities of the red cell marrow

g. Hemolytic disease of the newborn

h. Abnormal hemoglobin synthesis

e.g. sickle cell disease

Clinical Manifestations:

1. The condition may be acute or chronic

2. Early symptoms

a. Listlessness

b. Fatigability

c. Anorexia

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3. Late symptoms

a. Pallor b. weakness

c. tachycardia d. Palpitation

4. Eventual symptoms

a. Mental and physical retardation

b. Cardiac enlargement and symptoms of congestive

heart failure

c. Inability to carry out the usual childhood activities

5. Prognosis

a. Varies with the type of anemia

b. death may result because of cardiac failure

Nursing Responsibility:

1. Assessment of the child’s condition

Building resistance to infection

Administering blood transfusion as ordered

Nursing management:

1. Administer iron as ordered by the pediatrician

2. Observe for side effects

3. Initiate and reinforce good dietary habits

4. Assist parents to select iron rich foods that are affordable

and culturally acceptable

5. Provide care to the underlying causes

6. Administer antibiotics as prescribed

7. Adminiter folic acid or Vitamin B12 as prescribed

8. Teach parents how to administer medications

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Study Questions

1. How can a nurse contribute to decrease morbidity and

mortality among under five children?

2. What are the important points to observe during screening

in under five clinics?

3. What are some of the important approaches in preventing

malnutrition among under five children's?

4. During growth monitoring intervention what important

points should be considered to promote normal growth

and development?

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CHAPTER EIGHT

ACUTE RESPIRATORY INFECTION

(ARI)
Learning Objectives:

After studying the material in this chapter the student will be

able to:-

- Describe the magnitude of acute respiratory infection

morbidity and mortality among under five children in

Ethiopia

- Identify and use simple clinical signs to classify and treat

a child with acute respiratory infection (ARI)

- Distinguish the clinical manifestations of ARI among

children under 2 months of age and older children

- Identify danger signs of ARI in infants and children and

take appropriate action

- Identify and use commonly available and effective

antibiotics against Common etiologic agents of ARI.

- Give advice to the mother on home treatment of ARI.

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8.1 Introduction

In Ethiopia 20-25 % of morbidity in under fives is due to ARI.

The majority of serious ARI illnesses are due to pneumonia.

Almost all ARI deaths in young children are due to Acute

Lower Respiratory Infections (ALRI), mostly pneumonia.

Acute respiratory infections are anatomically divided into

Acute Upper and Acute Lower Respiratory infections. The

main objective of ARI control program is to reduce mortality

due to pneumonia in children <5 by improving the quality of

ARI case management. Present evidence indicates that

bacteria play a great role as causes of pneumonia in children.

Streptococcus pneumonia and Homophiles influenza

accounts for more than 2/3 of all bacteria isolates. Early

treatment with antimicrobials that are effective against

S.Pneumoniae and H-influenza can prevent deaths from

pneumonia in children with a substantial decrease on

pneumonia mortality. Almost of all the cases where the ARI

may lead to the death of the child can be detected without

radio graph or laboratory tests by use of a few simple clinical

signs, particularly fast breathing and chest in drawing. Fastbreathing helps to categorize children with
cough into two

groups with high and low probability of pneumonia and it is a

better predictor of pneumonia than auscultatory findings

(stethoscope). As pneumonia progresses and becomes more

severe, lung elasticity is gradually reduced and chest in

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drawing develops. The presence of lower chest in drawing

means that the child has severe pneumonia and is at a higher

risk of death. Because of the high probability of bacterial

pneumonia and the reliability of these two diagnostic criteria,

there is a strong justification for the empirical use of

antibacterial based on simple diagnostic criteria.

8.2 Management of Children with ARI

The management of children with ARI comprises three

essential steps.

• Identify children who should be examined for possible

pneumonia

• Identify the case of pneumonia (case classification)

• Institute the appropriate treatment

Examine children <5 for possible pneumonia if they have

cough or difficult breathing

Classification and Diagnostic Criteria:

It is necessary to distinguish between infants under 2 month

of age and older children because the etiology and clinical

manifestations of pneumonia are different in these age

groups.

a) Children 2 months – 4 years old

In these age groups, children with cough or difficult breathing

are classified in to 4 groups.

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• Very severe disease

• Severe pneumonia

• Pneumonia

• No pneumonia

Danger Signs

If any sign indicating complications or severely deteriorated

general condition (danger sign) is present, the child is

classified as having very severe disease

In this age group the danger signs are:

• Not able to drink

• Convulsion

• Abnormally sleepy or difficult to awake

• Strider in a calm child

• Severe under nutrition

In the absence of any danger sign, a child presenting with

chest in drawing is classified as having severe pneumonia.

Since many children have slight intercostals retraction in

absence of severe pneumonia, in order to avoid and over

classification of severe pneumonia and needless referral,

chest in drawing is considered present only when the lower

part of the chest wall (the lower ribs and lower sternum) is

drawn in (or retracts) when the child breathes in. In absence

of any danger sign or chest in drawing a child is classified as

having pneumonia if s/he has fast breathing that is when the

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respiratory rate is above

• 50 per minute (50/m) or more in infants 2-12 months

• 40 per minute (40/m) or more in children 1-4 years

If there are no danger signs, chest in drawing or fast

breathing, the child is classified as having no pneumonia

cough or cold.
b) Young infant under 2 months of age:

Pneumonia in young infant is classified into 3 groups

• Very severe disease

• Severe pneumonia

• No pneumonia

If any sign indicating complications or severely deteriorated

general conditions (danger signs) is present, the child is

classified as having a severe disease.

In this age group the danger signs are:

• Stopping feeding well

• Convulsions

• Abnormally sleepy or difficult to wake

• Stridor in calm child

• Wheezing

• Fever or low body temperature

In the absence of any danger sign, a young infant presenting

with chest in drawing or fast breathing is classified as having

severe pneumonia. Fast breathing is present when the

respiratory rate is 60/min or more (counted twice). Due to the

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higher chest compliance in young infants, the presence of

severe chest in drawing is required to classify an infant below

2 months as having severe pneumonia. There is no

pneumonia if there is no danger signs, no severe chest in

drawing or not fast breathing. It should be noted that young

infants could become sick and die very quickly from

pneumonia. For this reason, any young infant who has signs

of pneumonia (chest in drawing or fast breathing) is classified

as having a severe pneumonia.

c) Treatment of acute lower respiratory disease (ALRI)

Children below 5 years of age with ALRI are divided into 3

therapeutic categories. Children with very severe disease or

severe pneumonia must be refereed to a health center or a

hospital with inpatient capacity where adequate treatment can

be given/provided. Before referral, a first dose of antibiotic

should be given and fever treated if present.

Children with pneumonia must be treated for 5 days on

ambulatory basis with a first line antibiotic recommended by

the program. Other problems (fever, ear infection etc) should

also be treated if present. The child should return after two

days for reassessment. If the child shows sign of a very

severe disease or severe pneumonia she/he must be referred.

If the child does not show signs of a very severe disease or

severe pneumonia but did not improve, different antibiotics

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should be given for other two days. If the child still does not

show improvement, s/he should be referred.

c. A child having cough for more than 30 days (chronic cough)

should be referred for further assessment.

Children with no pneumonia must not be treated with

antibiotic. Advice to the mother should be given on home

care and other problems assessed and treated.

Table 6 a. ARI Clinical Chart: children < 2 months

Signs, cough plus Classification Treatment

Stopping feeding well or

Convulsion

Abnormally sleepy or difficult

to walk or

Strider in calm child or

Wheezing or Fever or low

temperature or Severe chest

in drawing or fast breathing

or

Serious bacterial

infection

- Refer urgently to

hospital

- Give first dose of

antibiotic

- Refer urgently to

hospital

- Give first dose of

antibiotic
-Treat fever if present

Fast breathing but no chest

in drawing

Pneumonia -Advise mother to give

home care

- Give an antibiotic

- Keep young infant warm

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Table 6b. ARI Clinical Chart: children 2 months – 4 years

of age

Signs Classification Treatment

- Not able to drink

or

- Convulsion or

-Abnormally

sleepy or difficulty

to awake or

- Stridor in calm

child or

- Chest in drawing

Severe

pneumonia or

very severe

disease
- Refer urgently to hospital/

admission

- Give first dose of antibiotic

- Treat fever if present

- If cereberal malaria is

possible give ant malarial

drug(s)

-Refer urgently to hospital

- Give first dose of antibiotic

- Treat fever if present

- Fast breathing Pneumonia - Advise mother to give home

care

- Give an antibiotic

- Treat fever if present

- Not fast

breathing and no

chest in drawing

No pneumonia - If there is cough for more

than 30 days refer for

assessment

- Advise mother to give home

care

- Treat fever if present

8.3 Antbiotic Treatment

The commonly available antibiotics most effective against the

main etiologic agents of pneumonia in children are:

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- amoxycillin

- ampicillin

- cotrimoxazole and

- procaine penicillin

8.4 Home Care

Mothers of children treated for pneumonia should return home

knowing how to correctly administer the antibiotic.

Children with no pneumonia and children with pneumonia (in

addition to antibiotic therapy) must receive appropriate home

care. Before leaving the health unit, mothers should receive

the following instructions

- Feed the child during illness and increase the feeding

after illness

- Give the child more fluids to drink. Increase breastfeeding

- Sooth the throat and relieve cough with a safe remedy

- Return quickly to the health unit, if the child develops any

of the following signs

a. breathing becomes difficult

b. breathing becomes fast

c. child is not able to drink or young infant stops feeding well

d. child becomes sicker

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Mothers of young infants should also be told to keep the

infants warm and clear the baby’s nose if it interferes with

feeding.

8.5 Referral Criteria:

Children with a very severe disease or severe pneumonia

must be refereed to HC or hospital. Refer only if it is expected

that the patient will receive better care. If this is not the case,

the child should be treated with the available antibiotics and

needless referral avoided.

Explain to the mother the reason why the child should be

referred. If you think the mother will not take the child to

hospital or the referral will be delayed, whatever the reason,

you should take the following steps:

- If timely referral is likely give first dose of antibiotic

- If there is long referral time give additional doses

- If referral is uncertain give full course

- Treat any other problem present (fever, malaria etc)

8.6 Croup or Obstructive Laryngitis

Croup is an infection of the larynx by viruses or bacteria. If

bacteria are involved they are usually not very sensitive to

pencillin. Because the larynx is rather narrow in childhood

infection leads to obstruction. Therefore, great care is needed

in treating these children.

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Clinical Features:

A) The illness usually follows a cold or accompanies

measles. Then the child suddenly develops a croupy

cough and inspiratory stridor as a result of obstruction in

the area.

B) In some children a large red and infected epiglottis can be

seen.

C) In some the condition becomes worse, retraction of

intercostal space, the supraclavicular space and even of

the ribs themselves become more evident. The child

become restless, pale, shows obvious sign of air hunger

Treatment:

A) Steam: liquefies the dry secretions and results in marked

improvement. A bed sheet over an infant bed makes a

perfect steam tent

B) A humidified oxygen if available can be life saving

C) Make sure the child drinks enough

D) Prednisolone 2mg /kg/day decreases edema

E) Antibiotics: PPF 50,000u/kg with sulphdimidine orally

100mg/kg/day in 3 divided doses for 5 to 7 days

F) Trachetomy or intubationcan be lifesaving

G) Mild sadation with phenergan 1mg/kg/ day can be of help

in:

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8.7 Tonsilitis, Pharyngitis:

Tonsillitis is caused by a variety of bacteria and viruses. Mild

pharyngitise or tonsillitis without much fever, pus, swelling of

lymph glands is almost always a viral disease. This means no

antibiotics. Moderate or severe tonsillitis (usually

accompanied by pharyngitis) with high fever, pus and often

with enlarged lymph glands in neck is more often than not due

to beta-hemolytic streptococci. Beta-hemolytic streptococci

secrete toxic substances into the blood stream that, as an

allergic reaction can cause rheumatic fever or acute

glomerulonephritis. As streptococci are extremely sensitive to

penicillin it is sufficient reason to treat tonsillitis of this type

with penicillin.

Clinical Features:

1. Fever, feeling unwell, sometimes vomiting, diarrhea, and

abdominal pain

2. Refusal of food, difficulty in swallowing, may or may not

complain of sore throat.

3. Tonsilar glands at the angle of the jaw are often swellen

and tender

4. Streptococal tonsilitis has high fever, pus on tonsilar

surface and marked cervical lymp gland swelling

5. Viral tonsilitis has no fever, no pus on tonsilar surface and

no marked cervical lymph gland swelling

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Complications:

A. Otitis media

B. Peritonsilar abscess ( in older children only)

C. Cervical lymphadenitis may develop into abcess

D. Rheumatic fever or acute glomerulonephritis after

streptococcal infection

Treatment:

1. PPF 50 000 u/kg /day for 7 days

2. Viral tonsilitis require no antibiotic treatment

3. Gargles and aspirins may be given for high fever and pain

8.8 Chronic Tonsilitis and Adenoditis

The lymph tissues in the tonsils as well as those behaind the

nasopharnyx serve as a bareier against bacteria trying to

unvade the body via the mouth. In children around 4 years of

age especially these tissues are rather prominent. Sometimes

this mechanism does not function properly and insteady of a

barrier the chronically infected tonsils and adenoids become a

focus of infection

Clinical features

1. Recurrent rhinitis, tonsilitis, otitis media

2. In case of marked adenoids, snoring, sleeping with open

mouth, nasal speech, and pus from infected adenoids

driping into the trachea causing cough

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3. General symptoms of chronich infection (tiredness, poor

appetite are common

Indication for Adenoidectomy or /and tonsilectomy (over 3

years only)

a. Recurrent otitis media, tonsilitis, cervical adenitis= several

times a year

b. Peritonsilar abscess

c. Enlarged adenoid should be removed

i. if giving rise to recurrent infection

ii. if there is loss of hearing

iii. if nose breathing is continuously observed

8.9 Ear Infections:

Ear infections in children are classified into 3 categories:

- Mastoiditis

- Acute ear infection

- Chronic ear infection

A child with painful or tender swelling behind the ear is

classified as having Mastoiditis. In a young infant the swelling

might be above the ear.

- The child should be urgently referred after a first dose of

antibiotic

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Table 7. Assessment of ear problem

Ask Look

- Does the child have ear

pain?

- Does the child have pus

draining from the ear? For

how long?

- Look for pus draining

from the ear or red

immobile ardrum feeling

for tender swelling.

Signs

- Tender swelling behind

the ear

- Pus drainage from

the ear <2 weeks or

ear pain or red

immobile ear drum

Pus draining from the ear

2 weeks or more

Mastoiditis Acute ear infection Chronic ear infection

Treatment

- Refer urgently to

hospital

- Give first dose or

antibiotic

- Paracetamol for pain,

treat fever

- Give oral antibiotic

- Dry the ear by

wicking

- Reassess in five

days

- Treat fever if present

- Paracetamol for pain

- Dry the ear by wicking

- Paracetamol for pain

treat fever

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Study Questions

1. What steps would you take for a child with a very severe

disease or sever pneumonia before referral?

2. What advice would you give to the mother for home

treatment of ARI before she leave the health unit?

3. If you think the mother will not take the child who need

referral or if the referral will be delayed, what steps will

you take?

4. What are the criteria for referring a child with ARI?

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CHAPTER NINE

CONTROL OF DIARRHEA DISEASE

Learning Objectives:

After studying the material in this chapter the student will be

able to:-

- Identify different forms of diarrhea and their management

- Recognize different causes of diarrhea and its prevention

- Assess and classify a child with diarrhea for dehydration

and treat as indicated

- Teach parents and community on the ways of preventing

diarrhea among children

- Recognize different forms of a solution to prevent and

treat dehydration

9.1 Introduction:

Diarrhea means passing of three or more loose or watery

stools in a day. Diarrheal disease is among the leading

causes of morbidity and mortality among children < 5 years of

age in Ethiopia. Diarrhea is most common in children,

especially those between 6 months and 2 years of age. It is

also common in babies under 6 months who are not breastfed.

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9.2 Types of diarrhea:

Diarrhea can be classified by its duration as acute or

persistent and dysentery

- Acute diarrhea – starts suddenly and may continue for

several days but < 2 weeks

- Persistent diarrhea lasts >2 weeks and may vary from day

to day

- If the stool contains blood the diarrhea is called dysentery

9.3 Why is diarrhea dangerous?

Acute diarrhea causes death because of dehydration

Dysentery causes death because of a number of severe and

potentially fatal complications occurring during dysentery such

as

Intestinal perforation

- Toxic mega colon

- Convulsions

- Septicemia

- Prolonged hyponatremia

- Diarrhea is worse in person with malnutrition. Diarrhea

can also cause malnutrition and make it worse because

- Nutrients are lost from the body during diarrhea

- Nutrients are used to repair damaged tissue rather than

for growth

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- A person with diarrhea may not be hungry

- Mothers may not feed children during diarrhea or even for

some days after diarrhea stops

To prevent malnutrition, food should be given to children with

diarrhea as soon as, they eat it.

9.4. How does diarrhea cause dehydration?

The body normally takes in water and salts it needs through

drinks and food. When the bowel is healthy, water and salts

pass from bowel into the blood. When there is diarrhea, the

bowel does not work normally. Less water and salts pass into

the blood, and more passes from the blood into the bowel.

Thus, more than the normal amount of water and salts passed

in the stool results in dehydration. Dehydration also can be

caused by a lot of vomiting, which often accompanies

diarrhea.

9.5. Treating Diarrhea:

The most important measures in treating diarrhea are to:

- Prevent dehydration from occurring if possible

- Treat dehydration quickly and well if it does occur

- Feed the child

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9.6. Prevention of dehydration:

- Drinking extra fluids as soon as diarrhea starts

- Home fluids as well as ORS if available

- Food based fluids containing salt are most effective. eg.

Rice water

- If fluids do not contain salt, give food that is salted to taste

- If dehydration occurs, the child should be treated with

ORS at health institution

- In severe dehydration, first treat with IV fluid, but ORS

should be used in addition as soon as the patient can

drink

- ORS alone when the signs of severe dehydration are

gone

9.7 Feeding:

Feeding during diarrhea episode provides nutrients that the

children need to be strong and grow

- Breast-fed children should be given the breast more

frequently

- Other children should be given their usual feedings

- Children of 6 months or older should be given small

amounts of nutritious and easily digestible foods more

frequently

- After the diarrhea has stopped, an extra meal each day

for 2 weesk to help the child regain weight lost during the

illness

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9.8 Oral rehydration therapy:

Recommended home fluids

- Breast milk

- Cow milk

- Cereal-based gruel (eg.’ Muk’, ‘attimit’)

- Soup (‘shorba’)

- Yogurt (‘ergo’)

- Whey (‘aguat’, ‘arera’)

- Rice water

- Fresh fruit juice

- Plain water with food

Recommended foods

- Milk and milk products

- Eggs

- Porridge (‘genffo’) from mixture of one third legumes and

two third cereal

- ‘Alicha fitfit’

How to prepare ORS:

- Wash your hands with soap and water

- Measure 1 liter of clean water. It is best to boil and cool

the water before use but if this is not possible use clean

drinking water available

- Pour all the powder from one packet of ORS into a clean

container

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- Pour the water into the container. Mix well with a clean
spoon until the powder is dissolved

- Taste the solution so that you would know its taste like

salt

- Then give the child frequent small sips out of a cup or

spoon. If the child vomits, wait for 5-10 minutes, then

continue giving ORS slowly

- Mix fresh ORS each day in a clean container. Keep the

container covered.

9.9 Assessment of a child with diarrhea:

To identify a case of diarrhea ask the mother

Has the child had loose or watery stool?

For how long?

Have there been loose stools with blood?

If the answer to either question is ‘yes’, use the following

management chart to assess, classify and treat the child

Calcifying Dehydration:

- There are three possible calcifications of dehydrations for

a child with diarrhea.

- SEVERE DEHYDRATION

- SOME DEHYDRATION

- NO DEHYDRATION

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Table 8. Chart for assessing dehydration in patients with

diarrhea
Two of the following

signs:

-Lethargic or

unconscious

- Sunken eyes

-Not able to drink or

drinking poorly

-Skin pinch goes back

very slowly.

SEVERE

DEHYDRATI

ON

- If a child has no other severe

classification

- Give fluid for severe dehydration

(plan C) or if a child also has another

server calcification:

- Refer urgently to hospital with

mother giving frequent sips or ORS

on the way. Advise mother to

continue breast-feeding.

Two of the following

signs:

- Restless, irritable

- Sunken eyes
- Drinks eagerly,

thirsty

- Skin pinch goes

back slowly

SOME

DEHYDRATI

ON

Give fluid and food for some

dehydration (Plan B)

If child also has severe clacification:

Refer urgently to hospital with mother

giving frequent sips of ORS on the

way.

Advise the mother to continue breastfeeding.

Advice mother when to return

immediately.

- Follow up in five days if not

improving

Not enough signs to

classify as some or

severe dehydration

NO

DEHYDRATI

ON

- Give fluid and food to treat diarrhea

at home (Plan A).

- Advise mother when to return

immediately

- Follow up in five days if not

improving.

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When going through the assessment chart:

Ask the following questions:

- For how long has the child had diarrhea?

- How many liquid stool, has the child passed in 24 hrs?

- Is there any blood in the stool?

Has the child been vomiting?

- If so, has the child vomited more than a small amount?

- How often has the child vomited in 24 hrs?

ƒIs the child able to drink?

ƒIf so, is the child thirsty than usual?

Look for the following conditions

- What is the child’s general condition?

- Is the child:

- Well and alert?

- Unwell, sleepy or irritable?

- Very sleepy, floppy or unconscious?

- Having fits?

ƒDoes the child have tears when he or she cries?

ƒAre the child’s eyes normal, sunken or very dry

sunken?

ƒAre the child’s mouth and tongue wet, dry or very dry?

ƒIs the child’s breathing normal, faster than normal,

very fast and deep?

ƒWhen water is offered to drink, is it taken normally,

eagerly or is the patient unable to drink?

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Feeling for the following conditions:

When the skin is pinched:

- Does it go back quickly?

- Does it go back slowly?

- Does it go back very slowly? (>2 seconds)

- Pinch the skin over the abdomen and thigh

- Can the pulse be felt? (Normal 100-120/min) faster, or

weak?

- Is the fontanel normal? Depressed or very depressed in

young infants.

- Ask for other problems than dehydration:

- Ask about blood in the stool

If blood is present, treat for 5 days with an oral antibiotic

recommended for shigella in your area.

- See the child again after 2 days if:

- Under 1 year of age

- Initially dehydrated

- There is still blood in stool

- Not getting better

If the stool is bloody after 2 days, change to a second oral

antibiotic recommended for shigella in your area. Give it for 5

days.

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If diarrhea has lasted at least for 14 days:

- Refer to hospital if:

- The child is under 6 months old

- Dehydration is present (refer after treatment of

dehydration)

Otherwise, teach the mother to feed her child as in plan A

Look for severe under nutrition If the child has severe under

nutrition:

- Do not attempt rehydration: refer to hospital for

management

- Provide the mother with ORS solution and show her how

to give it

- A teaspoon every 1– 2 minutes for less than 2 years child

- Frequent sips from a cup for an older child

Ask about fever and take temperature

1. If the temperature is 39, give paracetamol

2. If there is Falciparum malaria in the area and the child has

any fever (38 or above) or history of fever in the past 5

days give anti-malarial treatment according to malaria

program recommendation in your area

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9.10. Treatment of Diarrhea

Decide on appropriate treatment:

After the examination, decide how to treat the child

- if the child has any of the signs in the column labeled “for

other problems” specific treatment is needed in addition to

treatment given for dehydration

- if there is blood in the stool and diarrhea for less than 14

days, the child has dysentry and appropriate antibiotics

should be given

- if there is diarrhea for longer than 14 days with or without

blood in the stool and/or if there is severe under nutrition,

continue feeding the child and refer for treatment.

Determine the degree of dehydration

Look at the upper row, the assessing and classifying chart. If

two or more of the signs listed are present, it means that the

child has severe dehydration

- If two or more signs from upper row are not present, look

at the middle row

- If two or more of the signs listed in this row are present, it

means that the child has some dehydration

- If two or more signs from the middle row or upper rows

are not present, it means that the child has no signs of

dehydration

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Select the appropriate treatment plan based on the degree of

dehydration

- For no signs of dehydration, select treatment plan A to

treat diarrhea at home

- For some dehydration, select treatment plan B to treat

dehydration in ORT corner

- For severe dehydration, select treatment plan C to treat

severe dehydration quickly

9.11. To treat diarrhea at home use treatment

plan A

There are three rules for treating diarrhea in the home

Rule 1: give the child more fluid than usual

- Give the recommended home fluid or food based fluid,

such as (cow milk, ‘shorba’, ‘atmit’, ORS etc)

- If an infant is breast-fed, continue to breast feed and try to

do so more often than usual at least every 3 hours

Rule 2: Continue to feed the child

Feeding during the diarrhea episode provides nutrients the

child needs, helps preventing weight loss, shorten the

duration and decreases the severity of diarrhea

- During and after diarrhea a child should be given

nutritious food frequently. Even if the absorption of

nutrients from food is somewhat decreased during

diarrhea, most of it will be absorbed

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Rule 3: Take your child to the health worker if the child is not

getting better

The mother should take the child to a health worker if the child

does not get better in 3 days or develops one of the following:

- Passes many stools

- Does not eat or drink normally

- Has fever

- Is very thirsty

- Vomits repeatedly

- There is blood or mucus in the stool

- Is not passing urine for > 6-8 hours

- Seems not getting better

Children should be given ORS solution at home if:

They have been on treatment plan B or C

They cannot return to the health worker if the diarrhea

gets worse

Show the mother how much ORS to give after each loose

stool and give her enough packets for 2 days.

Table 9. Amount of estimated ORS solution.

Age Amount of ORS to give

after each loose stool

Amount of ORS to

provide for use at home

< 24 months 50-100ml 500 ml/day

2-10 years 100-200 ml 1000 ml/day

10 years or more As much as wanted 20000/day

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Describe and show the amount to be given after each stool

using a local measure

- Give a teaspoonful 1-2 minutes for a child < 2 years

- Give frequent sips from a cup for an older child

- If the child vomits, wait for 10 minutes, then give the

solution more slowly (a spoonful ORS every 2-3 minutes)

Use the patient’s age only when you do not know the weight

- If the child wants more ORS than shown, give more

- Encourage the mother to continue breast-feeding

- For infants < 6 months children who are not breast fed,

give 100-200 ml clean water during this period

After 4 hours, reassess the child using the assessment chart,

then select plan A,B or C to continue treatment

- If there are not signs of dehydration, shift to plan A

- If signs indicating some dehydration are still present

repeat plan B, but start to offer food, milk and juice as

described in plan A

- If signs indicating severe dehydration have appeared,

shift to plan C

If the mother must leave before completing plan B

- Show her how much ORS to give to finish the 4 hours

treatment at home

- Give her enough ORS Packets to complete rehydration,

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and for 2 more days as shown in plan A

- Show her how to prepare ORS solution

- Explain to her the three rules in plan A:

1. To give ORS or other fluid until diarrhea stops

2. To feed the child

3. To bring the child back to the health worker if necessary

Table 10. Treatment Plan-C To Treat Severe Dehydration

Quickly

Age First give 30

ml/kg IV

Then give 70

ml/kg

Infants (<12 months) 1 hour 5 hours

Older 30 minutes 2 ½ hours

Guidelines for rehyderation therapy for severe

dehydrations
ƒStart IV immediately

ƒIf the patient can drink, give ORS by mouth while the drip

is set up

ƒGive 100 ml/kg Ringers lactate or normal saline in divided

dose as above.

ƒRepeat once if radial pulse is still very weak or not

detectable

ƒReassess the patient every 1-2 hours. If hydration is not

improving give the IV more rapidly.

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ƒAlso give ORS about 5 ml/kg/hr as soon as the patient

can drink; usually after 3-4 hours (infant) or 1-2 hour

(older pts)

ƒReassess after 6 hours infant) or 3 hours (older patients)

and choose the appropriate plan (A,B,C)

ƒIf there are no signs of dehydration use treatment plan A

ƒIf some of the sign of dehydration are still present but the

child is improving, give ORS for another 6 hours specified

in the treatment PlanB.

ƒIf the signs of dehydration are worse or remain

unchanged rehydration therapy with treatment plan C

should be continued.

In particular attention should be given to:

ƒThe number and volume of stool

ƒThe extent of vomiting

ƒThe presence and changes in the sign of dehydration

ƒWhether the rehyderation fluid (oral and or IV) is being

successfully given and is adequate amount.

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Study Questions

1. What are most important points to be considered in

treating diarrhea?

2. How does diarrhea cause dehydration?

3. What important measures should be taken to prevent

dehydration in children with diarrhea?

4. What steps would you follow when assessing a child with

diarrhea?

5. What important pieces of advice would you give to the

mother for home treatment of diarrhea?

6. How would you treat a child with severe dehydration?

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CHAPTER TEN

SYSTEMIC DISEASES

Learning Objectives

After studying the material in this unit the student will be able

to:-

- Identify different forms of systemic diseases affecting

children

- Manage different forms of systemic diseases

- Prevent complications arising from systemic diseases

- Evaluate the effectiveness of care and treatment

- Identify danger signs of systemic diseases and take

appropriate action

10.1. Cardiovascular system (CVS) disorder

Most heart diseases in young children are congenital. Older

children are more likely to have acquired heart diseases such

as rheumatic fever, endomyocardial fibrosis. The heart may

also be affected in many systemic disorders i.e. infections,

malnutrition, anemia etc.

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Symptoms and signs related to cardiovascular diseases:

ƒCyanosis is a bluish discoloration of the skin as result of

reduced amount of hemoglobin in the circulating blood.

Cyanosis can best be detected under the fingernails or on

the mucus membranes of the mouth (lips, under side of

the tongue).

ƒClubbing of fingers and toes often occurs. One of the

main causes of this is chronic under saturation of the

blood with oxygen.

Signs of Cardiac Failure:

ƒTachycardia-rapid pulse
ƒTachyponea-rapid respiration

ƒDyspnea-shortness of breath

ƒEdema and other signs of raised venous pressure

ƒFatigue and failure to thrive

ƒArrhythmia-irregular heart beat

ƒSystolic and more frequently diastolic murmurs

ƒCough

ƒOrthophea

Management:

Any child with congestive heart failure should be referred to

hospital whenever possible. In all cases where you have to

start treatment:

- check weight of the child ,record the pulse and respiration

carefully at 2 hours intervals and indicate the exact time of

any drugs given.

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Treatment:

A. bed rest

B. sedation ( phenobarbitone 5mg/kg/day in 2-3 divided dose

im or rectally)

C. Oxygen if available

D. Diuretics 10 mg in stat in acute cardiac failure.

E. Digitalization is most important

In order to achieve effective blood levels quickly a digitizing

dose is calculated and given over 24 hours.

ƒ1/2 of the calculated dose is given initially

ƒ1/4 8 hours later

ƒ1/4 after another 8 hours

Then continue with the maintenance dose, which is usually ¼

of the digitizing dose

Congenital Heart Disease:

Congenital heart disease is a structural malformation of the

heart or great blood vessels present at birth. In most

congenital heart diseases the cause is unknown. The only

known cause is damage to the fetus by rubella Virus, when

the mother is one to three months pregnant, or by

chromosomal abnormality in children with Down’s syndrome.

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Pathophysiology:

Anatomically the following principal defects may be found.

a. Abnormal communication in the heart or between big

vessels

ƒAtrial septal defect

ƒVentricular septal defect

ƒPatent ductus arteriosus

In these due to the highest pressure in the left heart, there is a

shunt from left to right heart with an increased blood load in

lesser circulation. In this group of disease there is no

cyanosis.

b. Congenital obstruction of the blood flow

ƒpulmonary stenosis

ƒaortic stenosis coarctation of the aorta)

c. Combination of abnormal communication and stenosis

(pallot’s disease is one example)

Clinical Features:

Besides the above-mentioned symptoms, failure of normal

growth and development, repeated attacks of respiratory tract

infections, and a loud murmur is usually present.

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Management:

A. Any child with congestive heart failure should be referred

to hospital whenever possible. In all cases where you

have to start treatment:

ƒcheck weight of the child ,record the pulse and

respiration carefully at 2 hours intervals and indicate

the exact time of any drugs given.

B. Respiratory tract infections are readily treated with

penicillin in normal doses.

C. Give chloroquine in case of fever after taking blood film.

D. Treat anemia if present.

E. Arrange a well-timed comprehensive vaccination

program.
F. Give prophylaxis against subacute bacterial endocarditis

Prognosis: Many children with congenital heart disease die in

early childhood. The prognosis is particularly poor in children

with cyanotic heart disease.

Rheumatic Heart Disease:

Rheumatic fever is an inflammatory disease related to

streptococcal infection affecting mostly the heart and joints,

but also other tissues including the brain and skin. It occurs

most commonly in children between 3 and 15 years.

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Pathogenesis:

Rheumatic fever usually follows about 2 weeks after an

infection of the throat or skin with beta-hemolytic streptococci.

This is due to a specific reaction of tissues, mainly the heart

and the joints, to the streptococcal toxins.

Clinical Features:

Painful swelling of one or more big joints ( knee, ankle, elbow,

shoulder) may last for one day or longer, subside and another

joint may then be affected ( rheumatic polyarthritis)

ƒFever

ƒmalaise

ƒrheumatic carditis (heart become enlarged murmur

develops and sign

ƒOf congestive heart failure may occur.

1) Relapses are very likely to occur

Treatment/ management:

A. bed rest particularly in patients with rheumatic carditis

until signs of active disease disapear (fever, pain…)

B. aspirin 100 mg/kg/day in three divided doses for 4-6

weeks

C. penicillin 1 million units/day for one week to treat

streptococcal infection

D. if cardiac failure occurs referred to hospital whenever

possible.

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Congestive Heart Failure:

Congestive heart failure occurs when the cardiac output is

inadequate to meet the metabolic need of the body and

results in accumulation of excessive blood volume in the

pulmonary and/or systemic venous system.

Etiology:

a) Congenital heart disease ( in the first 3 years of life)

b) Acquired heart disease (rheumatic heart disease)

c) Non cardiovascular causes (anemia, pulmonary disease...)

Clinical manifestations:

1) Dyspnea and tachypnea

2) Tachycardia

3) Orthopnoa, Peripheral edema ( sacral or periorbital)

4) Restlessness

5) Tire easily

6) Pallor

7) Weight gain

8) Diaphoresis

9) Growth failure

10) Nonproductive irrelative cough

11) Neck vein distension

12) Hepatomegally

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Pathophysilogy:

a) For any number of reasons, cardiac output is inadequate

to meet the oxygenation and nutritional requirement of

vital organs

b) various compensatory mechanisms occur (Tachycardia)

c) Cardiac output decreases further as a compensatory

mechanism fail

d) There is diminished blood return to the heart, with venous

congestion and a rise in venous pressure.

Diagnostic evaluation:

a. Palpation (may have weak peripheral pulse)

Auscultation (gallop rhythm, cardiac murmur may or may not

be present)

Chest x-ray (cardiomegally may be present)

Nursing Care:

1. Administer digoxin as ordered to improve myocardial

efficiency

2. Provide uninterrupted rest to reduce energy requirement.

3. Administer diuretics as prescribed to remove accumulated

sodium and fluid and restrict sodium intake.

4. Administer oxygen therapy to improve tissue oxygenation.

5. Provide foods to meet calorie requirement of the child

6. Practice careful hand washing technique to decrease the

dangers of infection

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7. Monitor vital signs frequently and report any significant

changes to observe signs off disease progress or

response to treatment

10.2. Central nervous system Diseases

Meningitis: Meningitis is an inflammation of the meninges

(membranes surrounding the brain and spinal cord) and is

caused by a viral, bacterial or fungal organisms. Meningitis is

further classified as aseptic, septic and tuberculosis

meningitis. Aseptic meningitis refers either viral or other

causes of meningeal irritation such as brain abscess or blood

in the subarachnoid spaces. Septic meningitis refers to

meningitis caused by bacterial organisms such as

meningococcus, Staphylococcus, or influenza bacillus.

Tubercles meningitis is caused by the tubercle bacillus.

Meningeal infections generally originate in one of two ways

either through the blood stream as a consequence of other

infections such as cellulites or by direct extension after

traumatic injury to the facial bones. In a small number of

cases the cause is iatrogenic or secondary to invasive

procedures (e.g. lumbar puncture).

Clinical Manifestations:

The symptom of meningitis results from infection and

increased intracranial pressure (ICP). Headache and fever:

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Are frequently the initial symptoms. Change in level of

consciousness: Are associated with bacterial meningitis. As

the illness progresses, lethargy, unresponsiveness, and coma

may develop. Stiff neck (rigidity): Is an early sign. Any

attempts at flexion of the head are difficult and causes severe

pain. Positive kerning sign: When the patient is lying with the

thigh flexed on the abdomen, the leg cannot be completely

extended. Positive Brudzink’s sign: When the patient’s neck is

flexed, flexion of the knees and hips is produced.

Photophobia: Extreme sensitivity to light is present Seizures

and increased ICP: Seizures occur secondary to focal area of

cortical irritability while increased ICP results from cerebral

edema characterized by headache, vomiting and depressed

level of consciousness.

Diagnostic Evaluation:

A lumbar puncture is carried out by inserting a needle into the

lumbar subarachnoid space through the third and fourth or

fourth and fifth lumbar interspace to withdraw CSF for

diagnostic and therapeutic purposes. The purposes are to

obtain CSF for examination, measure and reduce CSF

pressure determine the presence or absence blood in the

CSF etc.

Assisting with a Lumbar puncture procedure:

1. Assure the patient that inserting the needle into the spine

will not cause paralysis

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2. See that the patient’s bowel and bladder are emptied

3. Position the patient on one side with back towards the

physician

4. The thighs and legs are flexed as much as possible to

increase the space between the spines of the vertebrae

for easier entry into the subarachnoid space

5. Small pillow is placed under the patient’s head to maintain

the spine in horizontal position

6. Assist the patient to maintain the position to avoid sudden

movement, which can produce trauma

7. Instruct the patient to breathe normally, because

hyperventilation may lower an elevated pressure

Post procedure Care:

1. Instruct the patient to lie prone 2-3 hours to reduce the

leakage of CSF.

2. Encourage increased fluid intake to reduce the risk of post

procedure headache.

3. Cheek the puncture site for any leakage/bleeding

Examination of the CSF:

CSF should be clear and colorless. Pink blood-tinged or

grossly bloody CSF may indicate a cerebral contusion,

laceration, or subarachnoid hemorrhage. Sometimes with a

difficult lumbar puncture the CSF initially is bloody because of

local trauma but then becomes clearer.

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Usually specimens are obtained for cell count, culture,

glucose and protein. The specimen should be sent to the

laboratory immediately because changes will take place and

alter the result if the specimens are allowed to stand.

10.3 Epilepsy/ Seizure

Epilepsy/ Seizure is the recurrent occurrence of convulsion or

fit.

Causes:

1. Idiopathic:

ƒGenetic defects
ƒDevelopmental defects

2. Acquired:

ƒ-Brain hypoxia

ƒFever (childhood)

ƒHead injury

ƒCNS infection

Clinical Manifestations:

A, Few seconds before convulsion begins the patient has a

warning sign (aura) such as

ƒStrange pain in the abdomen or

ƒStrange movement of the arm or

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ƒHis may be affected Immediately after warning sign

patient become completely unconscious:

ƒFalls to ground suddenly or

ƒFalls into open fire

ƒMuscles are tightly clenched

This is the first part of fit or convulsion and lasts only a

few seconds (Need formatting)

Following this

ƒAll muscles contract and relax quickly

ƒThe tongue may be bitten

ƒUrine and faces may be passed

This is the second part of fit or convulsion and the

convulsion lasts only few minutes.

These jerky movements are called Convulsions and are

diagnostic of major or Grand mal epilepsy.

When convulsions are prolonged or repeated the condition is

known as “Status epilepticus”. Such convulsions are very

exhausting and unless controlled may lead to patient death.

During the third part of the fit or convulsion

ƒPatient lies quietly

ƒMuscles are relaxed

ƒHe is still unconscious

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This part lasts from a few minutes to an hour or more. Then

ƒPatient return to consciousness

ƒHe may have bad headache

ƒRemembers nothing of the fit

ƒOften feels very sleepy

B, Some patients do not show the first or second part of the

fit, and suddenly become unconscious for only a few seconds.

The eye may stare but see nothing and these are the ‘lesser

fit of epilepsy (petit Mal)”.

Medical Management:

1. Phenobarbitone from 30 mg daily to 120 mg three times a

day or

2. Phenytoin sodium from 45 mg daily to 180 mg three times

a day may be given

Nursing Management during seizure:

ƒProvide privacy

ƒProtect head injury by placing pillow under head and neck

ƒLoosen constrictive clothing’s

ƒRemove any furniture from patient side

ƒRemove denture if any

ƒPlace padded tongue blade teethes to prevent tongue bit

ƒDo not attempt to restrain the patient during attack

ƒIf possible place patient on side

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Nursing Management after seizure:

ƒPrevent aspiration by placing on side

ƒAdmister medication as ordered to control the seizure

ƒRemove hard toes from the bed to protect the child from

injury during convulsion

ƒDonot give any thing by mouth during convulsion

ƒPlace the child where he can be watched closely to

observe for recurrent seiures

ƒOn awaking re-orient the patient to the environment. Reassure and calm the patient

10.4 Diseases of genitourinary tract

• Acute Glomerlonephritis:

Glomerlonephritis refers to inflamation of the kidneys caused

by an antigen antibody reaction following an infection in some

part of the body. Acute glomerlonephritis is predominately a

disease of childhood and is the most common type of

nephritis in children.

Etiology:

1. Antigen antibody reaction secondary to an infection

elsewhere in the body.

2. Initial infection of (upper respiratory system or skin) most

frequently a beta hemolytic streptococcus and other

bacteria’s and viruses.

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Pathophysiology:

1. Antibodies produced to fight the invading organism also

react against the glomerular tissue

2. The antigen antibdy combination results in an inflamatory

reaction I the kidney.

3. General vascular disturbances, including loss of capillary

integrity and spasm of arterioles, are secondary to kidney

changes and are responsible for much of the

symptomatolgy of the disease.

Clinical Manifestations:

1. Onset is usually 1-3 weeks after the onset of the initating

infection

2. Sign and symptoms

ƒDecreased urine out put

ƒBlood or brown color urine

ƒEdema result in most patients

ƒHypertension present in 50 % of patients ( in 4-5 days of

illness)

ƒVariable fever and mild headache

ƒGI disturbances (anorexia and vomiting often with loin

pain).

Diagnostic evaluation:

1. Urinalysis (decreased out put, hematuria, high specific

gravity, protein urea, white cells, casts) may be reported

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2. Blood urea nitrogen and cretinin often elevated

3. Sedimentation rate –elevated

4. Chest x-ray may show pulmonary congestion and cardiac

enlargement

Complications:

1. Hypertensive-encephalopathy (restlessness, stupor,

convulsions, vomiting severe headache, visual

disturbances) occur frequently.

2. Congestive heart failure- may occur due to persistent

hypertension, hypervolaemia and perirenal

vasoconstriction

3. uremia-manifested by drowsiness, coma, stupor,

muscular twitching and convulsion may occur.

4. Anemia- usually caused by hypervolaemia rather than red

blood cells in the urine may occur.

Nursing Care:

1. Maintain bed rest during the acute phase of the illness

2. Protect the child from infection

3. Provide adequate diet recommended

4. Maintain a complete record of the child’s intake and

output

5. Weigh the child daily

6. Record B/P at regular interval

7. Observe for signs of complication (edema, vomiting..)

8. Record appearance of urine

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10.5 Nephritic Syndrome:

Nephrotic syndrome refers to a common complex

characterized by edema, marked proteinuria

hypercholesterolaemia, and hypoalbuminaemia. Although

there are many types of the diseases lipid nephrosis is the

most common in children.

Etiology: The exact cause is not known, but the symptom

complex results from large loss of protein in the urine, too

great to the body to replenish by albumin synthesis.

Pathophysiology:

1. Protein, especially albumine, leaks through the membrane

and is lost in the urine

2. Plasma protein decreases as protein uria increases

3. Over production of aldestrone causes retention of sodium

and results in accumulation of fluid in the inertial spaces

4. Decreased gamaglobine results in increased susceptibility

for infection

5. Generalized edema is responsible for (respiratory

distress, GI symptoms, loss of body tissue, malnutrition.)

Clinical Manifestations:

1. Insidious onset of edema

2. GI symptoms (vomiting, anorexia,)

3. Severe recurrent infection

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4. Marked edema

5. Profound weight gain

6. Decreased urine out put during the edematous phase

7. Nephrotic crisis (albuminuria, fever, Erysipeloid skin

eruption may be possible)

Nursing Care:

1. Administer steroids as prescribed by the pediatrician

2. Administer immunosuppressive as prescribed by the

pediatrician

3. Administer diuretics as prescribed by the pediatrician

4. Maintain the child at bed rest during periods of severe

edema

5. Administer diet low in sodium and high in potassium

6. Restrict fluid as requested by the pediatrician

7. Provide meticulous skin care to the edematous area of

the body

8. Provide a high protein, high calorie diet and offer in small

amounts in frequent interval.

9. Observe the child’s entire body at frequent intervals for

edema

10. Observe for side effects of all medications.

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10.6 Urinary Tract Infection:

Urinary tract infection refer to an infection within urinary

system. The lower urinary tract (urtetha,bladder,or the lower

portion of the ureters0 or the upper urinary tract ( upper

portion of the ureters, or kidney) or both may be involved.

Etiologic agents:

1. GI flora Organisms responssible for 75 % of all cases.

ƒE.Coli ( most common causative agent)

ƒProteus

ƒAerobacter

ƒEntrobacter

ƒkelbsella

ƒPsudomonus
2. Streptococci and staphylococci causes most other cases.

3. Contributing causes

ƒobstruction

ƒinfection elsewhere in the body

ƒpoor perineal hygiene

ƒShort female urethra

ƒCatheteriztion

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Path physiology:

Inflammatory changes occur in the affected portion of the

urinary tract

Inflammation results in urine retention and stats is of urine in

the bladder

There are inflammatory changes in the renal pelvis and

throughout the kidney when this organ is involved:

The kidney may become large and swollen

Eventually, the kidney become small, tissue is destroyed, and

renal function fails.

Incidence:

1. Most common renal disease in children

2. More common in females than in males, ratio 6:1 except

in the neonatal period, when both sexes are equally

affected.

Clinical Manifestations:
1. Fever may be accompanied by chills or convulsion

2. Anorexia and general malaise

3. Urinary frequency, urgency, dysuria

4. Dull or sharp pain in the kidney area

5. Vomiting

6. Failure to thrive in infancy

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Diagnostic Evaluation:

1. Urinalysis

2. Urine culture

3. Renal concentrating ability decreases

4. Urological and radiological studies

Nursing Care:

1. Obtain mid-stream urine specimen whenever possible

and send to Lab. Immediately for examination

2. Administer antibiotics as prescribed by the pediatrician

3. Maintain bed rest, administer analgesics and antipyretic

drugs as prescribed, encourage fluid to reduce fever and

dilute the concentration of urine during the febrile period

4. Monitor and record vital signs to observe the progress of

disease

10.7 Tuberculosis

Tuberculosis in children almost always results from primary

infection with Mycobacterium tuberculosis rather than

reactivation of latent disease as found in adults. Tuberculosis

in a child indicates exposure to an adult with contagious

disease and should prompt identification and treatment of the

source case.

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Most children infected with M. tuberculosis are asymptomatic

and are only identified a positive tuberculin skin reaction.

Tuberculin skin testing consists of the intradermal injection of

5 tuberculin units of purified protein derivatives

Definition of a positive Mantoux skin test in children:

A reaction greater than or equal to 5mm is POSITIVE in:

ƒChildren in close contact with person who have known or

ƒSuspected infectious tuberculosis

ƒChildren suspected to have tuberculosis disease including

those

ƒWith clinical evidence or a consistent chest radiography or

ƒChildren who are immuno suppressed or who have HIV

infection

A reaction greater than or equal to 10 mm is POSITIVE in:

ƒChildren younger than 4 years of age

ƒChildren at risk of disseminated tuberculosis including

those with chronic diseases like malnutrition, diabetes

mellitus, chronic renal failure

ƒChildren born in areas where tuberculosis highly prevalent

ƒChildren exposed to adults at risk of tuberculosis,

including adults who are HIV infected, or live in poor living

condition etc.

A reaction greater than or equal to 15 mm is POSITIVE in:

Children over 4 years of age with no risk factors .Previous

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immunization with BCG does not alter these definitions. The

presence of clinical manifestations distinguishes tuberculosis

disease from tubercle infection. A chest radiography usually

service to distinguish children with the disease from those with

the infection. Because the sputum of children with pulmonary

tuberculosis is usually negative for mycobacterium, either by

acid-fast stain or culture, these children are non infectious.

Extrapulmonary tuberculosis: including cervical amenities,

tuberculosis meningitis, and milary tuberculosis occurs in app.

One quarter of cases of children with tuberculosis disease.

Infants and young children who immunocompromised or

malnourished are at risk of the serious and often fatal form of

miliary or tuberculosis meningitis. Children with tuberculosis

infection (without evidence of disease) should receive

isoniazid prophylaxis for 9 months. Children with pulmonary

tuberculosis are usually treated with a 6-month regimen

consisting of isoniazid, rifampin, and pyrazinamide for the first

2 months and isoniazid and rifampin the remaining 4 months.

In areas where isoniazid and refampin resistance is prevalent,

a fourth drug should be added to the regimen (usually

ethambutol, or streptomycin).

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10.8 Disease of the Skin

Burns: Burns are a frequent form of childhood injury. A

second degree burn of 10 % or more of the body surface in a

child younger than 5 year or a second degree burn of 15 % or

more of the body surface in a child over 1 year is considered a

very serious injury. The effects of burn are not limited to the

burn area.

Causes of Burn in Children:

1. Burns from hot water

2. Burns from open faire

3. Electrical burns

4. Acid or alkali burns of mouth and esophagus

5. Chemical burns of the skin

6. Burns inflicted upon the child as a result of child abuse

Clinical Manifestations:

The characteristics of burn wounds are classified as follows

A . First degree burns involves superficial epidermis; the skin

is red or pink in appearance,and is painful to touch.

B. Second degree burn involve the entire epidermis; the skin

is red, blistered, moist with exudate, and painful to touch.

C. Third degree burn involve the dermis or underlying fat,

muscle or bone, the skin appears white,dry and is

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painless to touch1.Symptoms of shock (rapid pulse,

subnormal temprature,pallor, prostration, low BP) appear

soon after the burn.

2. Symptoms of toxemia (Prostration, fever, rapid pulse,

cyanosis, vomiting, edema) may develop within 1-2 days after

initial burn. These symptoms may progress to coma or death.

3.Burns of the upper respiratory tract result in symptoms of

upper respiratory tract obstruction resulting from edema and

inflammation of the glottis, vocal cords, and upper trachea.

Treatment:

The objective of treatment are to:

• replace fluid loss from burn surface

• maintain circulation

• prevent renal failure

• prevent or treat infection

• aim toward early repair of the burn wound

• restore the child to the best possible state of physical and

psychological functioning

Complications:

Acute:

• Infection
• wound sepsis

• pneumonia

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• urinary tract infection

• Renal failure

• Respirator failure

• Post-burn seizure

• Anemia and malnutrition etc

Long-term:

• Malnutrition

• Scaring

• Contracture

• Psychological trauma

Nursing Care:

1. Monitor vital signs as ordered

2. Monitor the administration of IV fluid

3. Maintain an accurate record of intake and output

4. Provide adequate oxygenation

5. Provide sedation to relieve pain

6. Determine the for tetanus inoculation

7. Observe for symptoms of respiratory distress and take

measures to alleviate if any.

8. Position the child and turn him frequently

9. Administer antibiotics as prescribed

10. Provide high protein, calorie diet in order to provide

nutrition necessary for healing and for the growth and

development need of the child.

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10.9 Other problems

A. Pediatrics HIV infection and AIDS:

In children older than 15 months; HIV infection is defined by

detection of anti-HIV antibody alone. The WHO case definition

for AIDS surveillance in children where HIV testing is not

available is fulfilled in the presence of at least 2 major signs

and 2 minor signs (if no other known cause of

immunosuppresion).

Major Signs:

• Weight loss or abnormally slow growth

• Chronic diarrhea (> 1 month)

• Prolonged fever (> 1 month)

Minor Signs:

• Generalized lymph node enlargement

• Oropharyngeal candidiasis

• Recurrent common infections, e.g. ear infections,

pharyngitis

• Persistent cough

• Generalized rash

The WHO case definition for AIDS surveillance in children

where HIV testing is available is complex and depends on

advanced clinical and laboratory diagnostic facilities.

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B. Neonatal HIV Infection:

• Infants of HIV seropositive mothers have:

• Increased anti- HIV IgG levels in most of them

• Anti HIV IgM is present in about 50 %

• HIV infection may be present in 60-70 %; of the 50 %

develop AIDS

• Infants may present with AIDS or ARC

• most infants with AIDS present within 6 months of age

Maternal HIV antibody:

• Mean age at loss of maternal antibody is 10 months; 75 %

loss maternal IgG by 12 months

• Loss of maternal IgG does not exclude infection. Some

infants with HIV infection may be negative for antibody.

• -Infants may acquire infection in utero or perinataly

• In the first 2 years of life definite diagnosis of HIV infection

is by viral culture

• from peripheral blood vessels

• loss of HIV anti-body is reported in some children infected

with HIV

Presentation of pediatric AIDS:

Commonly with

• Severe recurrent bacterial infection and

• failure to thrive

• Chronic lymphoid interstitial pneumonitis

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• Generalized lyphadenopathy, hepatosplanomegaly

• Oral candidiasis, recurrent diarrhea, otitis media.

• Neurological deficits-encephalopathy

• Cardiac involvement with myocardial dysfunction.

Prevention of HIV Infection:

The public should be accurately and well informed

ƒAvoiding sexual transmission of HIV

ƒUse of HIV free Blood or blood products

ƒIV drug users should not share syringes and needles

ƒDisinfecting of the equipment appropriately

ƒProtection from accidental inoculation with HIV

ƒProtection from infected secretions

10.10 Ophthalmic neonatrum

Ophthalmic neonatorum is an eye caused by the Neisseria

gonorrhea; chalmydia from genital tract during delivery, or

from the infected hands of personnel. The newborn acquires

the infection during birth process by direct contact with

infected material from vagina of the mother.

Clinical Manifestations:
The onset is usually within two or three days after birth, but

symptoms may appear earlier. There is redness and swelling

of the lids and a profuse, purulent discharge.

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Complications:

The common complication is corneal ulceration with resulting

opacity and partial or complete loss of vision. The extent of

the handicap depends on the duration and severity of

untreated condition.

Treatment:

The treatments of Opthalmia neonatorum include: prompt

antibiotic injections and antibiotic eye ointments or drops to

prevent eye damage and isolation of the infant.

Responsibility of the nurse:

The must be sure that:

1. The drops are instilled within the lids during the treatment

2. Prevent the infant from rubbing the infected eye

3. The purulent discharge must irrigate and removed

frequently by directing the flow of fluid from the inner

cantus outward.

4. Extreme care must be taken that no drops of the return

flow splash into the nurse’s eyes.

5. Antibiotic eye ointments are administered to all newborns

immediately after birth as prophylaxis.

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10.11 Congenital Syphilis

Congenital syphilis is a Transplacental infection of the fetus

before the fourth month of pregnancy by the spirochete

Treponema pallidum. It may result in miscarriage, still-birth, or

manifest itself in early infancy.

Clinical features:

• Rhinitis with purulent or even bloody discharge

• Lesions on the (large blisters on palms and soles) and

mucocutaneous junctions (mouth, nostrils anogenital)

• Signs of systemic involvement: hepatosplenomegaly,

prolonged jaundice, and anemia.

• Painful swelling of long bones with characteristic x-ray

changes

• Positive serological test for syphilis in mother and child

Management

1. PPF 100,000u/kg/day im for 10 days

2. Check the whole family for syphilis

Prevention:

All measures which decrease the incidence of acquired

syphilis in adults

serological tests for syphilis in all pregnant women is

desirable.

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CHAPTER ELEVEN

VACCINE PREVENTABLE

DISEASES

Learning Objectives:

After studying the material in this unit the students will be able

to:-

- Identify vaccine preventable childhood diseases

- Recognize different forms of antigens used to protect

against vaccine preventable diseases

- Recognize contraindications and adverse effects of

immunization

- Immunize children at appropriate age

- Teach parents and care givers to immunize their children

against vaccine preventable diseases

11.1 Justifications for immunization:

Of every 1000 children born in the world, about:

• grow up crippled by poliomyelitis

• die of neonatal tetanus

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• 20 die of whooping cough

• 30 or more die of measles and its complication

Yet effective vaccinations against the disease exist.

The purpose of immunization is to protect against infectious

diseases before they attack any individual. Immunization is

the cost-effective method of infectious disease control. Once

an immunization program has been established, it must

continue or the disease will return to affect large numbers of

unprotected individuals. The aims is to immunize in the first

year of life against those infections that cause severe disease

in infants and children; and to follow up it up with reinforcing

(booster) inoculations and additional vaccines according to

age. The most serious diseases of infants are whooping

cough, (Pertusis), diphtheria, tetanus, tuberculosis, measles,

poliomyelitis.

11.2. Immunization Schedules:

Immunization schedules are determined by:

The immunogenicity of the vaccine: good immunogenic

vaccine (measles, BCG) need only one injection to produce

long lasting immunity, weak immunogens (DPT, cholera)

require several injections to establish protective antibody

levels-ensure protection against the disease.

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The epidomiology of the disease-when the disease occurs at

an early age, immunization must be given early tuberculosis

(BCG), polio vaccine, pertusis).

11.3. Hazards of Immunization:

a. Complications of immunization:
• Normal toxicity or reactivity- fever, malaise, local

swelling

• Bacterial contamination-septicemia, abscess,

tuberculosis

• Allergic reaction-anaphylaxis

b. Contraindications to immunizations:

1. Inactivated vaccine

• Major febrile illness

• Major intercurrent infections

• Severe reaction to previous dose

• Specific contraindication to pertusis and DPT

2. Attenuated (live) vaccines

• Major febrile illness

• Major intercurrent infections

• BCG to tuberculin individuals-severe local react

3. BCG Vaccination:0.05 ml of vaccine is injected

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intradermal in the newborn

• 0.1 ml is used in all other ages

• Recommended site- just above the insertion of the

deltoid muscle

• If tuberculin positive individuals are given BCG

• the skin reaction will be more rapid-noticeable in 3

days
• the inflammatory reaction will be more intense and

likely to ulcerate

Complications of BCG vaccinations:

• Local abscess formation and ulceration

• Regional lymphadenitis

• Local granulomatous lesions

• Hypertrophied scars and keloids

4. DPT and DT Vaccines:

DPT is a combination of Diphtheria taxied-killed pertusis

organisms, and Tetanus toxoid. DPt is given by IM or deep

SC injections. It is the pertusis component that causes severe

reaction to DPT.

a. Contraindication to the DT vaccine

• Major febrile illness

• Significant intercurrent infection

• Allergy to vaccine contents

• Severe reaction to previous dose

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b. Contraindications to pertusis immunization (as DPT)

History of severe local or generalized reaction to previous

dose

History of fits or convulsions

Current progressive neurological disease

5. Polio Vaccines:
Oral poliovirus vaccine (OPV).

Provides greater herd immunity-spreads to immunize contact

of the vaccine

Is easier to administer and less expensive

At least three doses are required in primary immunization to

establish protection against the 3 poliomyelitis serotypes

1,2,3. Any of the serotypes can cause paralytic disease.

6. Measles Vaccines:

Natural measles infection is a serious disease with greater

risk of morbidity and mortality than the vaccine.

Measles vaccine:

Early vaccination produces a poor response in some children

because of maternal antibody still in the child’s circulation. By

6-9 months of age seroconvertion rates are satisfactory.

Measles is given at 6-9 months in measles endemic areas;

and after 12 months elsewhere. Children immunized before

12 months need a second dose after 14 months of age to

ensure individual protection

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Indication for measles vaccination:

• All children in measles endemic area

• To interrupt a measles outbreak

• the incubation period for the vaccine is shorter than that of

the natural disease

• measles vaccine given within days of contact stops the

spread of the disease

Contraindication to measles vaccine:

• Sensitivity to vaccine content (e.g. chicken egg)

• Personal and family history of convulsions

• Immunodeficiency diseases

• Acute tuberculosis

Adverse reaction to measles vaccine:

ƒ10-20 % of children get a mild illness 7-14 days after the

vaccine (fever, cough, and occasionally a rash)

ƒConvulsion in association with fever

ƒEncephalitis and encephalopathy ( rare after vaccine)

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Study Questions

1. What are the common vaccine preventable diseases?

2. What are the adverse effects of vaccinations and

measures to be taken?

3. List the most common contraindications for vaccination?

4. Discuss the importance of vaccines.

5. List the types of vaccines commonly used in developing

countries?

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CHAPTER TWELVE
EXPANDED PROGRAM ON

IMMUNIZATION (EPI)

Learning Objectives:

After studying the material in this chapter, the student will be

able to:

- Recognize the six vaccine preventable diseases and their

annual incidence rate in Ethiopia.

- State the objectives of EPI and its target groups

- Identify vaccine schedule for each target diseases and

provide vaccinations as scheduled.

- Realize the dangers of unsterile vaccination equipment

and use appropriate sterilization methods before using it.

Communicable diseases are among the major causes of child

mortality in Ethiopia. The estimated annual incidence rates

per 100,000 live births for six EPI target diseases are as

follows:

• Measles 400

• Pertusis 400

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• Poliomyelistis 12

• Tuberculosis 77

• Diphtheria 17

• Neonatal tetanus 840

Mortality by these diseases is highly aggravated by:

• Ignorance

• Undernutrition and

• Poor environmental hygiene. The six vaccine preventable

diseases are estimated to account for at least one-third of

infant and child disability and mortality.

The objective of EPI is making immunization available to all

infants and women of childbearing age (15-49).

12.1 Strategies of EPI Service Delivery:

ƒPermanent health units (static)

ƒScheduled sessions at out-reach sites and

• By mobile vaccine teams to control/epidemics such as

measles and meningitis.

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Table 11. Child immunization scheme

Contact Age of child Vaccine

1. At birth BCG and OPV Zero

2. 6 Weeks DPT1 and OPV1

3. 10 Weeks DPT2 and OPV2

4. 14 Weeks DPT3 and OPV3

5. 9 Months Measles

The immunization schedules for the six “EPI” antigens are

given in the tables above. These tables reflect the ideal

situation for immunization. Often mothers bring their children

at less frequent intervals than those suggested here. If the

child is first seen at a later stage than indicated in the

immunization scheme, the immunization is started with

vaccines 1,2,3 and 4, given with four weeks interval. If the

child is 9 months or older, the 5th injection, measles is given

four weeks after DPT3. The vaccination scheme should be

started on all children under 2. BCG and measles should be

given to all under 5. BCG and measles may then be given at

the same time. Tetanus Vaccination: some women have

certificate that they had DPTs. They need only one injection

at each of their two first pregnancies.

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Table 12. Type of Immunization, dosage and route for

administration.

Vaccine Route of administration Dose

BCG Intradermal injection 0.05 ml

0.1 ml after 1 year

of age

Polio (OPV) By mouth 2 drops each time

DPT Intramuscularly

injection into the thigh

0.5 ml each time

Measles Subcutaneous injection

left upper arm

0.5 ml
12.2. Contraindications:

There are only three contraindications to immunizations.

1. Give no BCG vaccine to a child with clinical AIDS

2. Do not give DPT2 and DPT3 to a child who has had

convulsions or shock within three days of the previous

dose

3. Do not vaccinate in the presence of severe illness.

Vaccinate at later occasion when the child has recovered.

Children with diarrhea should be given OPV. This dose

should not be counted.

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12.3. Sterilization:

Contaminated needles and syringes can transmit AIDs virus

and the Hepatitis virus. Applying the following rules can

prevent the spread of these viruses.

1. Reusable needles and syringes should be sterilized

correctly (steam sterilization or boiling for 20 minutes)

2. If possible used syringes and needles should be

destroyed after each use

3. A single sterile needle and syringe should be used for

each injection

12.4 Principles of the immunization program

The aim of the EPI program is to improve management of

immunization activities at all levels. To achieve this EPI uses

the following principles:

• integration in MCH program

• health education

• disease surveillance

• monitoring and evaluation

• operational research

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Study Questions

1. What are the strategies used to achieve the objectives of

EPI in Ethiopia?

2. What are the dangers of using contaminated syringes and

needles during vaccination and what are the steps to be

used to prevent it?

3. The vaccine preventable diseases estimated to account

for one third of infant and child disability and mortality in

Ethiopia. What factors do you think contributed to this?

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CHAPTER THIRTEEN

COMMON GENETIC PROBLEMS OF

CHILDREN

Learning Objectives:

After studying the material in this unit, the student will be able

to:-
- Identify the most common genetic problems of children

- Manage children with different genetic problems

- Support parents of children with genetic problems

- Help children with mental retardation to be trained basic

skills

13.1. Mental Retardation:

If a child is significantly retarded in his psychomotor

development (milestones)

we suspect subnormal intelligence and speak of mental

retardation. Several degree of mental retardation is seen.

Severe, moderate, mild. In very mild case there may be only

minimal brain damage giving rise to slight delay only and less

than optimal intelligence may only become obvious in school.

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Minimal brain damage, hardly recognized, but probably much

more frequent than severe damage may will be a much bigger

burden to the society. A child is considered mentally retarded

if (without other obvious reasons):

a. He can not sit without support at age 9 months, can not

stand at at age 15 months, can not walk at age 18 months

b. He can not lough loudly at age 6 months, speak three

words at age 2 years, and follow a few simple directions

at age 3 years

c. He can not grasp actively at age 6 months, and take small

objects with thumb and finger at age 1 year.

Causes:

a. Inherited abnormalities or subnormalities of the brain like

in microcephalus, hydrocephalus.

b. An abnormality of chromosomes the carrier of inheritance

in the cellular nucleus the feature of mongolism (Down’s

syndrome) characteristic faces with slanting eyes, a small

flat nose a protruding tongue, low set ears and small

head.

c. Perinatal problems (prematurity, asphyxia) , or disease

acquired after the neonatal period (meningitis,

encephalitis, cerebral malaria) may damage the brain

d. Hypothyroidism (cretinism)

e. Environmental factors (pronounced parental neglect)

f. Deafness can mimic mental retardation

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Management:

Since there is no treatment of the cause

1. In moderate retardation habit training – eating, walking,

and putting on cloths

2. In mild retardation special attention in schools or ideally

special school can of value

3. For any degree of mental retardation parents should be

supported
13.2. Cerebral Palsy

Cerebral palsy is a syndrom- a combination of symptoms. It is

a term used for all permanent, no-progressive, generalized

brain damage in children irrespective of the cause. Usually

some degree of spasticity symptoms are combined with

mental retardation, but sometimes the mental retardation is

minimal or even abscent.

Causes:

a. Prenatal: acquired disease such as congenital infection

Perinatal: (shortly before or after delivery) : asphyxia,

cerebral hemorrhage,

b. prematurity and severe jaundice are the most common

causes of cerebral palsy

c. After the first week of life: meningitis, encephalitis,

cerebral malaria can also cause cerebral palsy

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Clinical Features:

1. Spastic paralysis if the lesion unilateral or spastic

paraplegia if the lesion bilateral

2. Mental retardation may or may not be present

3. Ataxia is prominent

4. Deafness and blindness can occur as well

5. Squint is common

Management:
1. Regular exercise under the guidance of physiotherapist

help in preventing deformity and contracture

2. Simple home training must be initiated

3. Parents of such children support and reassurance

Prevention:

• Proper antenatal and perinatal care,

• early recognition of meningitis etc

13.3. Down’s Syndrome:

Down’s syndrome is a chromosomal abnormality involving an

extra chromosome (number 21) characterized by a typical

physical appearance and mental handicap.

Etiology:

1. An error in cell division

2. Associated with advanced maternal age

3. Abnormal attachment of chrosomes inherited from

parents

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Clinical Manifestations:

1. Eyes slant upward and outward

2. Excess skin on back of neck

3. Flatened nasal bridge and flat facial profile

4. Small ears often incompletely developed

5. Short broad feet

6. small male genitalia

7. Absence of moro reflex

Complications:

1. Recurrent infection of upper respiratory tract

2. Skin infection

3. Serious behavioral problems

Nursing Responsibility:

1. Establishing and maintaining adequate nutrition

2. Recording and reporting any sign of physical complaints

3. Providing a safe environment for the infant

4. Providing appropriate stimulation according to child’s age

5. Encouraging parental participation in caring for and

handling the infant

6. Working effectively with parents

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13.4 Cretinism/ hypothyroidism:

Defects or complete absence of the thyroid gland with

insufficient production thyroid hormone causes severe

retardation of physical and mental development of the child,

sometimes known as cretinism. Earl detection and proper

treatment can provide a normal life.

Clinical Features:

1. Delayed growth and development

2. Signs of slow metabolism (hair and skin dry, thick and

coarse)
3. Goiter may be present or thyroid gland may be absent

Management:

1. Thyroid hormone treatment should be continued for life

2. If diagnosed within the first month of life and substitution

with thyroid hormone continued regularly the child will

have a normal life

3. With late diagnosis and inadequate treatment the child will

be severely retarded and handicapped

13.5 Juvenile Diabetes Mellitus:

The characteristics of juvenile diabetes millitus differ from

those when the onset is latter in life.

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Symptoms:

The onset can be insidious with loss of appetite, weight loss,

abdominal cramps, vomiting, emotional disturbance and

lassitude. Polyuria, and polydipsia in young children are

symptoms to make you think of diabetes mellitus which is not

uncommon and is often overlooked

Findings of sugar in urine, and an increased blood sugar

prove the diagnosis.

Treatment:

1. Insulin injection must be given for life

2. Lengthy hospital admission is often necessary

3. If a child is comatose and the test for sugar in the urine is

strongly positive

• set IV drip with normal saline

• give 1u/kg crystalline insulin im

• refer the child urgently to hospital

Prognosis:

The prognosis is poor because the management is difficult

and complications like hypoglycemia and vascular changes

occur frequently.

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Study Question

1. Discuss the differences between severe, moderate, and

mild mental retardation.

2. What are the criteria’s to consider a child as mentally

retarded?

3. What are the possible causes of mental retardation?

4. What are the common causes of Cerebral palsy?

5. What are the possible causes of Down’s syndrome?

6. List the clinical features of Down’s syndrome.

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growing child, Little, Brown and Company.

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care of the child bearing and child rearing family, J.B.

Lippincott Company.

3. Adele Pilliter child health nursing, care of the growing

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4. AMRF (1975), Child Health, a manual for Medical

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5. AMRF (1984) Child Health Manual for Medical assistant

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6. AMRF, (1984), Manual for rural health workers, Nairobi

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7. Behrman Kliegman. Essentials of paediatrics, 2nd

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8. Child Health Manual for Medical assistant and other

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9. Dickinson Silver man, maternal and infant nursing care.

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Chelmstord, Kampala

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190

12. EPI models

13. EPI National strategy ( If you can get access from MOH)
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countries, 2nd edition.

15. Katharyn May, Laura Mahlmeister (1990), Comprehensive

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16. Lillian S. brunner and Doris S.Suddarth (1988), Manual of

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17. Manual on maternal and child care, MOH, Addis Ababa,

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23. Patricia Wiel and Cadewing, essentials of maternal and

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