Newborn Growth Development

Pediatric Nursing

Mary Lourdes Nacel G. Celeste, R.N., M.D.

Nursing Care of a Newborn and Family

Newborn or neonate – a baby in the neonatal period (the first 28 days of life) MLNG CELESTE, RN, MD

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Nursing Diagnoses Ineffective airway clearance related to mucus in airway Ineffective thermoregulation related to heat loss from exposure in birthing room Imbalanced nutrition, less than body requirements, related to poor sucking reflex Readiness for enhanced family coping related to birth of planned MLNG CELESTE, RN, MD 4 infant

The Average Newborn

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X

Profile of a Newborn

“All newborns look alike.” –

 Every child is unique. -

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NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE 1. Initiation & maintenance of respirations 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Adequate nourishment 5. Waste elimination 6. Prevention of infection 7. Infant-parent relationship 8. Developmental care MLNG CELESTE, RN, MD

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Immediate Care of the Newborn I. Care of the Newborn at the D.R.

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A. Establish and Maintain Respiration 1.   Suctioning - Turn head to one side - Suction gently and quickly - Suction the MOUTH first before the nose - Test patency of the airway - Proper position a. Ensure an open airway. b. Do not hyperextend head - place neonate supine - head slightly extended MLNG CELESTE, RN, MD

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B. Maintain Appropriate Body Temperature *Blot dry/ Rub dry the infant. 1.  Wrap the newborn immediately 2.     Wrap him warmly 3.     Put himMLNG under aMDdroplight CELESTE, RN,

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Warmth • At birth, the newborn must begin thermoregulation (maintenance of body temperature). 3 Factors : • Heat production • Heat retention • Heat loss MLNG CELESTE, RN, MD

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1. Heat Production Thermogenesis – through • general metabolism • muscular activity • nonshivering thermogenesis (unique to the newborn)

Newborns rarely shiver as adults do to increase heat production. Shivering in newborns indicates that the metabolic rate has already doubled. MLNG CELESTE, RN, MD

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Infant in a cool environment requires more heat metabolic rate increases producing more heat – Newborn may cry and have muscular activity when cold, but there is no voluntary control of muscular activity. – if the newborn’s temperature is not adequately raised through increased metabolism, MLNG nonshivering RN, MD thermogenesis :CELESTE, the metabolism of

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Non Shivering Thermogenesis - the metabolism of brown

fat Brown fat - special tissue/ fat found only in newborns - highly vascularized giving it a brown color - oxidized to produce or conserve heat - increasing metabolism - located at the of MLNG back CELESTE, RN, MD the neck, 17

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• Once the brown fat has been metabolized, the infant no longer has this method of heat production available.

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2. Heat Retention Newborns retain heat by staying in a flexed position. - reduces the area of skin exposed to the environmental temperature, thus decreasing heat loss - peripheral vasoconstriction retains heat MLNG CELESTE, RN, MD

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Conservation of Heat 1.Brown fat 2. kangaroo care – placing the newborn against the mother’s skin and then covering the newborn helps to transfer heat from the mother to the newborn, thus, conserving heat loss MLNG CELESTE, RN, MD 21

3. Heat Loss Newborn - thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss Cold Stress - excessive heat loss MLNG CELESTE, RN, MD

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increased metabolism significant increase in need for oxygen newborn may experience hypoxia There may not be enough oxygen for the metabolic rate to increase, and the newborn will not be able to maintain body temperature. MLNG CELESTE, RN, MD 23

Effects of Cold Stress (temp<36.5) 1. Metabolic Acidosis - increased BMR, anaerobic glycolysis, increased acid production, metabolic acidosis 2. Hypoglycemia - increased energy requirement to produce heat - glucose necessary for increased metabolism is made available when glycogen stores are converted to glucose MLNG CELESTE, RN, MD 24 - if the glycogen is depleted,

4 MECHANISMS OF HEAT LOSS 1. Convection - flow of heat from the newborn’s body surface to cooler surrounding air 2. Radiation - transfer of body heat to cooler solid object not in contact with the baby 3. Conduction - transfer of body heat to cooler solid object in contact with MLNG CELESTE, RN, MD 25 the baby

4 MECHANISMS OF HEAT LOSS A. Convection B. Radiation C. Conduction D. Evaporation MLNG CELESTE, RN, MD

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Other Causes of Heat Loss 1. insulation in newborn is not effective (little subcutaneous fat ) 2. shivering is not present

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Immediate Assessment of the Newborn

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Assessment for Well-being

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APGAR SCORE 0

1

2

Appearance

Blue/Pale

Acrocyanosis

Pink; Ruddy

Pulse

Absent

< 100

> 100

Grimace

None

Weak cry

Good cry

Activity

Flaccid

Respiration

Absent

Some flexion Well flexed Flex/ext <30 >60

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A ppearance (color) – least important P ulse rate - most important G rimace (reflex activity); irritability A ctivity (muscle tone) R espiration

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Apgar Scoring System 1st minute: general condition (NEURO/RESPI/CIRCULATORY CHECK)

5th minute: adjustment to extrauterine life

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System

Apgar Scoring

Score: 9 – highest score; 10 – perfect score   0-3: poor, serious, severely depressed, needs CPR 4-6: fair, guarded, moderately depressed, needs suction   7-10: good, healthy MLNG CELESTE, RN, MD

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Silvermann Anderson Scoring (Respiratory Distress)

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Feature observed

Grading of Neonatal Respiratory Distress (Silvermann Anderson) 0

1

2

synchronized

lag

seesaw

2.Intercostal retractions

None

just visible

marked

3.Xiphoid retraction

none

just visible

marked

4.Nares dilatation

none

minimal

marked

5.Expiratory grunt

none

audible by stethoscope

audible by Unaided ear

1.Chest movement

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Grading of Neonatal Respiratory Distress (Silvermann Anderson)  

0: No respiratory distress 1 -3: slight distress 4-6: moderate distress   7-10: seriously distressed !!!

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Congenital Anomalies 1. Choanal Atresia - a complete blockage or severe narrowing of the nasal airway at the posterior nares 2. Tracheobronchial fistula - there is a fistula between the trachea and the distal portion of the esophagus 3. Cleft lip and cleft palate Substances 1. drugs 2. smoking 3. alcohol MLNG CELESTE, RN, MD

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Dubowitz (Maturity Testing Tool) – 1st 24 hrs Full Term - 38-42 weeks AOG Preterm - < 38 weeks Postterm - > 42 weeks MLNG CELESTE, RN, MD

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AGA – 10th – 90th percentile SGA <10th percentile LGA > 90th percentile Low birthweight <2500 gm Very Low Birthweight <1500 gm Extremely Low Birthweight <1000 gm IUGR - Rate of growth does not meet MLNGpattern CELESTE, RN, MD 39 expected - growth

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Gestational Assessment (Dubowitz) Finding Sole creases

Breast nodule diameter (mm) Scalp hair Ear lobe

Testes and scrotum

0-36

37-38

39 and over

Anterior transverse crease

Occasional creases in ant 2/3

Sole covered w/ creases

2

4

7

Fine and fuzzy

Fine and fuzzy

Coarse and silky

Pliable, no cartilage

Some cartilage

Scrotum empty, few rugae

Testes descended. rugae

Stiffened by thick cartilage pendulous, full scrotum, ext rugae 41

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Prematurity < 37 weeks AOG Risk Factors: 1. Fetal 2. Placental 3. Maternal 4. Infection

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Problems: 1. 2. 3. 4. 5.

Respiratory adaptation Susceptibility to infection Hyperbilirubinemia Cold stress Hypoglycemia

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Hypoglycemia - <40 mg/100 ml - dependent on maternal supply - Birth, continue to produce insulin S/sx: limpness, jitteriness, apnea, twitching and hi pitched cry CX: mental retardation Tx: early feeding D10W Nsg: monitor blood glucose level MLNG CELESTE, RN, MD

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PE

1. Skin and subcutaneous tissue -thin transparent 2. Increased lanugo 3. Decreased plantar creases 4. Breast bud scarcely felt 5. Pinna flat and shapeless 6. Scrotum not pigmented 7. Testes not descended MLNG CELESTE, RN, MD 8. Labia majora widely separated52

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Management 1. 2. 3. 4. 5. 6.

Maintain patent airway Incubator care VS monitoring Oxygen therapy Feeding Infection precautions

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Nursing Intervention 1. 2. 3. 4.

Meet physiologic needs Meet psychological needs Foster healthy family relationships Provide education

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C. Proper Identification – done in D.R. before being brought to the Nursery a.      Footprints – most reliable  b.     ID bands – ankle, wrist c.

Birthmarks MLNG CELESTE, RN, MD

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Post-term (>42 weeks) • SIGN: dry,cracked almost leather like skin,absence of vernix caseosa, fingernails grown well beyond the end of fingertips • Complication: 1. may develop polycythemia ( oxygenation) 2. hypoglycemia MLNG CELESTE, RN, MD

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Immediate Care of the Newborn in the Nursery

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* Note that ID bands of mother and baby are matched.

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Special Care 1. Initial Bath – temp stabilizes 36.5ºC 6-8 hrs after birth • vernix caseosa - use oil •

warm water during the 1st week

•

Don’t use soap

•

without hexachlorophene base MLNG CELESTE, RN, MD

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2. Taking the Temperature * Maintain temperature to prevent cold stress * Use Rectal route * Meconium - 24-48 hrs MLNG CELESTE, RN, MD

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3. Initial Cord Dressing * Inspect for A .V. A. * aseptic technique * Povidone (Betadine); 70% Isoprophyl alcohol - prevent Tetanus Neonatorum and Omphalitis (streptococcal and MLNG CELESTE, RN, MDstaphylococcal) 67

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Signs of Omphalitis: 1. Reddening of the area 2. Fever 3. Discharge or foul smell     * Application of sterile cord clamp prevent bleeding within 1st 24 hours (Omphalangia) MLNG CELESTE, RN, MD 69

4. Crede’s Prophylaxis  

* Legal requirement for all NB (US) * Infection - acquired during delivery from a mother with untreated gonorrhea

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Medications:

c. Opthalmic drops – Silver Nitrate o AgNO3 1% 1-2 drops

- lower conjunctival sac - wash with sterile NSS after minute to prevent chemical conjunctivitis MLNG CELESTE, RN, MD

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b. Ointment Terramycin Gentamycin Chloramphenicol Erythromycin

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Erythromycin -

pull eyelids downward 0.5-1 cm Inner to outer canthus Wipe excess away

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5. Vitamin K Injection - sterile GIT - facilitates production of clotting factor - 1 mg. Aquamephyton - IM - lateralMLNG anterior thigh (Vastus CELESTE, RN, MD lateralis)

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6. Take Anthropometric Measurements (Vital Statistics)  BW: 2.5 – 3.4 kgs (5.5 – 7.5 lbs) * 1 K = 2.2 lbs BL: 47.5 – 53.75 cm (19 – 21MLNG ½CELESTE, in) RN, MD

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HC: 33 – 35 cm CC:

31 – 33 cm

AC: 31 – 33 cm

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Anthropometric Measurement

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• Length : mature female neonate-53 cm(20.9 in) mature male- 54cm(21.3in) • Head circumference: mature newborn34-35 cm (13.5 to 14 in) ( measure with the tape measure drawn across the center of the forehead and around the most prominent portion of the posterior head) MLNG CELESTE, RN, MD 79

Physiologic weight loss - 5-10 % in 10 days Causes 1. No longer under influence of maternal hormones 2. Voids and passes out stools 3. relatively low nutritional intake 4. beginning difficulty establishing sucking MLNG CELESTE, RN, MD

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Initial Feeding 1-6 hours after birth 1 oz of sterile water Subsequent feeding – by demand

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Breastfed infant recaptures birth weight within 10 days Formula fed infant recaptures weight gain with in 7 days Then continues to gain weight of 2lb/month( 6-8oz/ wk) for the 1st 6 months of life MLNG CELESTE, RN, MD

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Breastfeeding 1. bonding 2. uterine contraction 3. colostrum 4. Contraceptive 5. Cheap 6. Right temperature 7. Antibacterial – Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes, MLNG CELESTE, RN, MD

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Differences Between Human and Cows Milk NUTRIENTS

HUMAN MILK

COW’S MILK

CHON Fats Carbohydrates

8% 50% 42%

20% 50% 30%

Na K Ca Phosphorus Cl

7 mEq/l 14 mEq/l 12 mEq/l 9 mEq/l 12 mEq/l

25 meq/l 36 mEq/l 61 mEq/l 53 mEq/l 34 mEq/l

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Nutrients

Human milk Cows milk

Fe

0.5

0.5

Linoleic acid (+)

(-)

Vit D

22

14

Vit A

1898

1025

Vit C

43

11

Vit K

15

60

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• Contraindications of breastfeeding: 1. an infant with galactosemia ( can’t digest lactose in milk) 2.herpes lesion on a mother’s nipple 3.maternal diet is nutrient restricted, preventing quality milk production 4.maternal medication inappropriate for feeding 5. maternal exposure to MLNG CELESTE, RN, MD 86 radioactive compounds

• Advantages of breastfeeding : to the baby 1. contains secretory immunoglobulins A 2.contain lactoferrin ( iron-binding chon in breast milk that interferes with growth of pathogenic bacteria 3. contains antibodies 4. reduces incidence of diarrhrea ( presence of L.Bifidus interferes with colonization of pathogenic bacteria in the GIT) 5.contains high amount of mineral MLNG CELESTE, RN, MD 87 and electrolytes

Advantages of breastfeeding : to mother 1. serves as protective function in preventing breast cancer 2.release of oxytocin from the post. Pit. Gland aids in uterine involution 3. successful breastfeeding can have an empowering effect, skill only women can master 4.breastfeeding reduces the cost and preparation time 5.provides an excellent opportunity MLNG CELESTE, RN, MD 88 to enhance true

Physical Assessme nt MLNG CELESTE, RN, MD

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1. Vital Signs a. Pulse - 1 full minute; use apical pulse - irregular, rapid >160-180 at birth NORMAL: 120–160 bpm During sleep - 90-110 bpm If crying, up to 180 bpm MLNG CELESTE, RN, MD

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Pulse : heart rate in utero- 120 t0 160bpm after 1 hr newborn settles, heart rate stabilizes to an average of 120 to 140 bpm - remains irregular because of immaturity of cardiac regulatory center in the medulla - crying, rate might increase to 180 bpm, 90 to 110 bpm during sleep - femoral pulses are more appreciated than radial and temporal pulses ( always palpate for the femoral MLNG CELESTE, RN, MD 91 pulses; their absence suggests

b. Respirations - 1 full minute - irregular, shallow, rapid w/ brief apneic spells < 15s 60-80 breaths/min at birth NORMAL: 30–60/minute MLNG CELESTE, RN, MD

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Respiration : average is 30 to 60 breaths per minute - respiratory rate, rhythmn, depth are likely to be irregular and short periods of apnea ( periodic respiration) are normal - coughing and sneezing are present at birth to clear the airway - newborns are obligate nosebreathers MLNG CELESTE, RN, MD

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c. Blood Pressure - not usually measured 80–60/45–40 mm Hg at birth 100/50 mm Hg at day 10

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d. Temperature Normal range: 36.5C–37.5C (axilla) Axillary: 36.4C–37.2C Skin: 36.0 C–36.5C Rectal: 36.6C–37.2C MLNG CELESTE, RN, MD

* Temperature 37.2 at birth

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     Crying - increase body temperature slightly       Radiant warmer - falsely increase axillary temperature

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2. Skin Dark red – prematurity Acrocyanosis – up to 48 hours Central cyanosis – indicates decrease O2 Generalized mottling Gray color - infection Pale color - anemia Yellow color –jaundice Harlequin sign – pale MLNG CELESTE, RN, MDand pink 97

Pallor  * Excessive blood loss when cord is cut * Untimely cutting of the cord * Inadequate iron stores because of poor maternal nutrition   * Blood incompatibility MLNG CELESTE, RN, MD

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    Jaundice

     Types:      1. Physiologic Jaundice / Icteru Neonatorum 2nd day – 7th day - TERM 2nd day – 10th day - PRE-TERM      Causes: a.Hemolys b.Decreased conversion o bilirubin to urobilirubi MLNG CELESTE, RN, MD c.Decreased uptake of 99fre

2. Pathologic Jaundice Normal total serum bilirubin = 15% Direct bilirubin = 1.7 Indirect bilirubin = 13.2  Causes:  a. Infection  b. Hemolytic disorders

 c.Inability of the newborn to conju bilirubin MLNG CELESTE, RN, MD 100

Breastmilk jaundice Pregnanediol Decrease glucoronyl transferase Decrease conversion of indirect to direct bilirubin jaundice

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Management 1. Early feeding 2. Phototherapy ·  Cover eyes with opaque mask to prevent blindness. ·   distance - 18-20 in from source of light. ·    Monitor V/S especially temp ·    Cover genitalia to prevent 102 PRIAPISMMLNG CELESTE, RN, MD

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Common Marks

1. Harlequin Sign 2. Mongolian spots – (-) school age 3. Milia – unopened sebaceous glands tip of nose and chin of the baby. (-) 2weeks        4. Lanugo – fine downy hair o shoulders, upper arms, back; (-) 2 weeks. MLNG CELESTE, RN, MD 105     

Common Marks 5. Desquamation- peeling; at birth, postmaturity 6. Vernix Caseosa 7. Portwine Stain or Nevus Flammeus – birth; red to purple color; do not blanch on pressure nor disappear; face 8. Strawberry Mark or Nevus Vascularis – 2nd most common type of capillary hemangioma. sharply MLNG elevated, CELESTE, RN, MD 106

9. Erythema Toxicum or Erythema Neonatorum – Newborn rash or fleabite dermatitis; transient; papules with vesicles at nape, back and buttocks. (+) 2nd day; disappears without treatment. 10. Cutis Marmorata – transitory mottling when exposed to cold 11. Nevi – stork bites or Telangiectasia Nevi; pink or red flat areas of MLNG CELESTE, RN, upper MD capillary dilatation at eyelids, 107

Nevus flammeus/ Portwine Stain

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Stork’s beak mark

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Strawberry Hemangioma

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Cavernous Hemangioma

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Mongolian Spot

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Milia

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Erythema toxicum

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3. Head – largest part of the human body (1/4 of his total body length); -forehead is large and prominent; -chin is receding when startled or crying. MLNG CELESTE, RN, MD

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Fontanelles 1.  Anterior – diamond shape; - closes 12-18 months; 3-4 cm long/2-3 cm wide      - junction of 2 parietal bones and 2 fused frontal bones - not indented depressed - suture lines - never appear widely separated MLNG CELESTE, RN, MD

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Fontanelles

2. Posterior – triangular in shape - junction of the parietal bones and the occipital bones. - 1 cm - closes by end of 8th-12th week of life

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Sutures  Lambdoid (2) Coronal (2) Frontal (1) Sagittal (1)

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CRANIOSYNOSTOSIS suture lines separated or fontanels prematurely closed; leads to mental retardation Molding –overlapping of sagittal and coronal suture line Craniotabes – localized softening of cranial bones; indented by pressure of a finger. Corrects w/o treatment in weeks or months. Common to first borns because of early lightening MLNG CELESTE, RN, MD 119

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Comparison between Caput Succedaneum and Cephalhematoma Indicators Definition Location Extent of Involvement Cause Period of absorption Treatment

C. Succedaneum

Cephalhematoma

Edema of scalp

blood b/w

Presenting part of the head Both hem; (+) cross suture lines Pressure (as in prolonged labor)

periosteum of skull bone & bone individual bone; (-) cross suture line Pressure (rupture of capillaries)

On or about the 3rd day or 4th days

Takes several weeks - months

None

Support

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Caput and Hematoma

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4. Eyes - Eyelids of equal size - temporarily gray or blue in color (d/t thinness) - Cry tearlessly 1st 3 months      - Cornea round and adult sized      - Pupils round, not keyholed (Coloboma)      - cross-eyed (Strabismus) MLNG CELESTE, 124      - see object atRN,8MD inches; V.A. of

5. Ears -Top of ear should align with inner and outer canthus of the eye  

- sense of Hearing – highly developed in NB

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6. Nose

- Nasal obligates   - Note for marked flaring of alae nasi, indicative of airway obstruction                       Causes of obstruction: 1. Secretions 2. septal deviation - Sense of smell – least developed MLNG CELESTE, RN, MD

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7. Mouth - open evenly when crying. If not, suspect CN VII Paralysis (Bell’s Palsy). -  Palate intact; no breaks on the lip cleft palate; cleft lip - Eptein’s Pearls – small round glistening cysts; palate and gums, due to extra load of maternal Ca - NATAL TEETH MLNG CELESTE, RN, MD -  Oral thrush – white gray patches128

8. Neck -  Thyroid gland not palpable      - soft, palpable and creased with skin folds - Head - rotate freely on the neck and flex forward and back. (+) rigidity of the neck- CONGENITAL TORTICOLLIS (injury to SCM) -NB whose membranes ruptured 24 hours before MLNG birth, nuchal rigidity CELESTE, RN, MD 129 meningitis.

9. Chest - As large as or smaller than the head -  Symmetrical - Breasts may be engorged

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10. Abdomen -  dome shaped; - If scaphoid DIAPHRAGMATIC HERNIA -   Bowel sounds should be present within 1 hour after birth - Liver, spleen and kidneys are palpable at birth. MLNG CELESTE, RN, MD

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11. Extremities - symmetric and of equal length - Fingers and toes equal count Supernumerary = polydactyly; fused or webbed = syndactyly     Simean line       - Asymmetrical movement of upper and lower extremities - ERB – DUCHENE PARALYSIS - congenitalMLNG hip dislocation: CELESTE, RN, MD 132

Simian crease

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Congenital hip dysplasia/dislocation • 0.1% of infants • with a predilection for females to males of 5:1 • infants with a family history (firstdegree relative affected) of CHD, the incidence is 10 times higher • also higher in infants born in the breech position and infants with certain other congenital MLNG CELESTE, RN, MD 134 abnormalities, including torticollis,

A. Ortolani test • In this maneuver, the infant is examined in the supine position. • The examiner holds the infant's pelvis with one hand to stabilize it during manipulation. • The examiner then slowly and gently abducts the infant's opposite hip with the other hand, pulling the femur forward and using the greater trochanter as a fulcrum. • In the infant with an unstable hip, the examiner will feel a sudden shifting sensation and may hear MLNG CELESTE, RN, or MD feel a "clunk" 135 simultaneously as the hip reduces

Ortolani test

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B. Barlow test • In this maneuver, the infant is examined in the supine position. • The examiner holds the infant's pelvis with one hand to stabilize it during manipulation. • With the other hand, the examiner holds the infant's opposite hip in the adducted, flexed position while exerting gentle pressure over the lesser trochanter. MLNG CELESTE, RN, MD 137 • In the infant with an unstable hip, a

Barlow test

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A. Ortolani’s test B. Barlow’s Test * Assessment on the R and L hips may be done simultaneously

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Clubfoot • A birth deformity in which the front portion of the foot is deformed and turned inward. It can be benefited greatly by surgery.

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12. Anogenital Area 3 types of stools passed by NB: 1. Meconium – greenish-blackish viscous; - amniotic fluid, intestinal secretions and cells shed from mucosa - take note of time when meconium first passed

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2. Transitional – passed from 3rd to 10th day 3. Milk stool a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day b. Bottle fed infant stool – formed, pale yellow with a typical odor; MLNG CELESTE, RN, MD 142 usually passed 1-2 times a day

13. Female Genitalia – swollen labia and pass a slightly bloody vaginal discharge -“PSEUDOMENSTRUATION”

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Male Genitalia – Scrotum may be edematous due to maternal hormones. - Testes should be present; if undescended CRYPTORCHIDISM MLNG CELESTE, RN, MD

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Conditions for Cryptorchidism: 1. Agenesis – absence of an organ 2. Ectopic testes – Testes cannot enter the scrotum because opening of the scrotal sac is closed. 3. Vas deferens or artery is too short to allow the testes to descend.

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Circumcision – prior to discharge from nursery, preferably end of 1st week Procedure: 1. Vitamin K injected IM 2. Infant is restrained; penis is cleansed with soap and water 3. clamp is used 4. Petroleum gauze dressing is applied to prevent adherence of MLNG CELESTE, RN, MD circumcised site to the diaper 146

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Nursing Care: - Check hourly for bleeding - Do not attempt to remove exudates which persist for 2-3 days; just wash with warm water. - Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis is tender.

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14. Back - On prone appears flat - Note for mass, hairy nodule and dimple along axis - Spina Bifida. - Cremasteric reflex – test for integrity of spinal nerves (T8 thru T10)

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III. Discharge Instructions Bathing

a.   b. Cord Care c. Nutrition Calories 120 kcal/kg body weight/day CHON 2.2 gms/KBW/day Fluids 160-120 cc/KBW/day Vitamins A,C, D for formula and CELESTE, RN, MD breastfed MLNG babies

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Common Health Problems

1. Constipation 2. Loose stools 3. Colic Causes: Overfeeding Gas distention Too much carbohydrates MLNG CELESTE, RN, MD

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Management Feed by demand Burp infant Feed in upright position May need to change formula MLNG CELESTE, RN, MD

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Diaper Rash Miliaria Seborrheic Dermatitis Occasional “Crossed Eyes” Clothing Sleep Pattern

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SYSTEMIC EVALUATION

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I. Cardiovascular System  Fetal Circulation 2. Oxygen exchange occurs in placenta 3. pressure on the left side of the heart < right side 4. (+) accessory structures  

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Accessory Structures

Foramen ovale Ductus arteriosus Ductus venosus Umbilical vein Umbilical arteries

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1.Cardiovascular system - changes in the cardiovascular system are necessary because the lungs must oxygenate the blood that was formerly oxygenated by the placenta. - as the lung inflates for the 1st time, pressure decreases in the chest, decreased pressure in the pulmonary artery leads to closure of ductus arteriosus, as pressure increases in the left side the MLNG CELESTE, RN, MD of

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umbilical vein, umbilical artery, and ductus venosus – no longer receive blood,these atrophy over the next few weeks (+) acrocyanosis ( cyanosis of infant feet and hands) for the 1st 24hrs due to sluggish peripheral circulation MLNG CELESTE, RN, MD 159

Neonatal/ Adult Circulation

- With 1st breath, oxygenation takes place in lungs - Lung expansion occurs - Increase pressure on left side of heart > right side results in: Closure of accessory structures and obliteration of umbilical vessels MLNG CELESTE, RN, MD

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blood values: blood volume- 80 to 110 ml per kg of body weight or about 300 ml total (+) leukocytosis - about 15,000 to 30,000 cells/mm3 this is response to trauma in birth and is non pathogenic( predominantly of neutrophils) blood coagulation –(+) prolonged coagulation or prothrombin time due to lower vit. K vit. K is needed to synthesize: 1. factor II- prothrombin MLNG CELESTE, RN, MD 2. Factor VII- proconvertin

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II. Respiratory system first breath is initiated by: 1. combination of cold receptors 2. lowered partial pressure of oxygen(PO2) 3. increased partial carbon dioxide pressure (PCO2) - after the 1st breath ,breathing becomes much easier for a baby requiring only 6 MLNG CELESTE, RN, MD 162 to 8cm h20 pressure

III. Neuromuscular system Reflexes: blink reflex Rooting reflex – (-) 6 wks old Sucking reflex –(-) 6 mos Extrusion Reflex – (-) 4 mos Swallowing reflex Tonic neck Reflex – (-)2-3 mos Babinski reflex – (-) 3 mos                   MLNG CELESTE, RN, MD

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Landau reflex Palmar/Grasp (-) 3-4 mos   Plantar reflex – (-) 8 mos    Stepping reflex (-) 1 mo    Moro reflex- (-) 4-5 mos    Trunk Incurvation reflex – (-) 2-3 mos

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III. Neuromuscular system 1. blink reflexes - to protect the eyes from any object coming near it by rapid eyelid closure 2. rooting reflexes- cheek is brushed or stroked near the corner of the mouth, a newborn infant turn the head on that direction, disappear about six weeks of life 3. sucking reflexes - when newborn lips is touched the baby makes sucking motion, diminish with in 6 months of life - if disappearMLNG immediately - if never CELESTE, RN, MD 165 stimulated tracheoesophageal fistula

Rooting Reflex

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Sucking Reflex

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REFLEXES 4. Swallowing reflexes - food that reaches the posterior portion of the tongue is automatically swallowed 5. Extrusion reflexes - substance that is placed on the anterior portion of the tongue is extruded, prevent the swallowing of inedible substance, disappear with in 4 months of age 6. Palmar grasp reflex - newborn grasp an object placed in their palm, disappears about 6 wks to 3 months MLNG CELESTE, RN, MD

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Palmar grasp reflex

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REFLEXES 7. Step-in-place reflex - newborn who is held in a vertical position with their feet touching a hard surface will take few alternating step -disappears by 3 months of age 8. Placing reflex - same as step in place reflex except that it is elicited by touching the anterior surface of newborn legs against hard surface, newborn makes a quick lifting motion

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Step-in/ Stepping Reflex

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Placing Reflex

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REFLEXES 9. plantar grasp reflex - when an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the finger do; disappears about 8 to 9 months 10. tonic neck reflex - when the newborn lies on his back, the head usually turns to one side , arm and leg on that side extend and the opposite arm and leg contract, disappears 2nd or 3rd month of life MLNG CELESTE, RN, MD

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Plantar Reflex

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Tonic-neck Reflex

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REFLEXES 11. Moro reflex - can be stimulated by startling the newborn with loud noise or by jarring the bassinet, fades on 4th or 5th month of life 12. Babinski reflex – when the side of the sole of the foot is stroked, fanning of the toes (+) will result 13. Magnet reflex - if pressure is applied to the sole of the foot while the newborn is lying in supine position, he pushes back against the pressure; test for spinal cord integrity MLNG CELESTE, RN, MD

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Moro Reflex

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Babinski Reflex

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REFLEXES 14. Crossed extension reflex - if one leg of the newborn lying supine is extended and the sole of that foot is irritated by being rubbed, infant raises the other leg and extends it as if trying to push away the hand irritating the first leg 15. Trunk incurvation reflex - newborn lies on prone position and is touched along the paravertebral area by probing finger, newborn flexes his trunk and swings the pelvis toward the touch MLNG CELESTE, RN, MD

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REFLEXES 16. Deep tendon reflexes - patellar reflex can be elicited in newborn by tapping the patellar tendon with the tip of the finger, test for spinal nerve L2-L4 - bicep reflex - place the thumb of your left hand on the tendon of bicep muscles,test for C5 and C6

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TrunK Incurvation Reflex

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IV. Gastrointestinal System

Meconium – mucus, vernix, lanugo, hormones - if not pass stool within 24 to 48 hrs there is possibility of meconium ileus, imperforate anus or bowel obstruction

Transitional stools – 2-10 days of life Breastfed babies stools FormulaMLNG fed babies stools CELESTE, RN, MD 182

a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day b. Bottle fed infant stool – formed, pale yellow with a typical odor; usually passed 1-2 times a day

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Gastrointestinal system - git of newborn is sterile at birth - newborn stomach hold 60 to 90 ml in 1 week of life

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newborn under phototherapy- has bright green stool due to increase excretion of bilirubin newborn with bile duct obstruction- has clay-colored stool blood flecked stool- newborn with anal fissure MLNG CELESTE, RN, MD

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V. Urinary System Females – strong urine stream Males – projected arc

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- newborn should void within 24hrs, amounting 15 ml - specific gravity from 1.008 to 1.010 - daily urine output for the 1st to 2nd day is about 30 to 60 ml, by week 1,total volume rises to 300ml - first voiding maybe pink or dusky ,small amount of protein maybe present( immature glomeruli) MLNG CELESTE, RN, MD

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VI. Autoimmune System Passive natural immunity – mother to child (+) Ab from the mother against Polio, DPT, Rubella and Measles * immunization starts usually at 2 mos MLNG CELESTE, RN, MD

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Expanded Program on Immunization

Vaccine

Age at 1st dose

Dose

Number of Doses

Min Interval

Possible Reaction

BCG

At birth

0.05 ml ID

1

 

DPT

6 wks

0.5 ml IM

3

4 wks

OPV

6 wks

2 drops

3

4 wks

Keloid, suppurative adenitis Fever, restlessness, irritability Paralytic polio rare

Hepa B

6 wks

0.5 ml IM

3

4 wks

Measles

9 mos

0.5 ml SC

1

 

MMR

12-15 mos

0.5 ml SC

1

 

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Arthralgia Neuro reactions rare Fever and rash 5-10 days after dose Fever, rash,arthralgia, lymphadenopathy ,rare – febrile seizures, nerve deafness, encephalitis 189

VII. Senses 1. 2. 3. 4. 5.

Sight – at birth (9 inches) Hearing-at birth Taste – at birth Smell-at birth Touch-at birth (well developed)

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Newborn Screening Act of 2004 REPUBLIC ACT NO. 9288 “…ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening and thus be spared from heritable conditions that can lead to mental retardation and death if undetected and untreated.” MLNG CELESTE, RN, MD

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1. CONGENITAL HYPOTHYROIDISM

• Thyroid hypofunction or enzyme defect • reduced T3, T4 • Females

S/sx: excessive sleeping, enlarged tongue, noisy respiration, poor suck, cold extremities, slow pulse and respiratory rate, lethargy and fatigue, short and thick neck, dull expression, open mouthed, slow DTR, obesity, brittle hair, delayed MLNG CELESTE, RN, MD 192 dentition, dry, scaly skin

1. CONGENITAL HYPOTHYROIDISM

Dx: low T3 T4, inc TSH

Mx: synthetic thyroid hormone Nsg Care: Assist parents administer drugs

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2. CONGENITAL ADRENAL HYPERPLASIA   -inability to synthesize cortisol inc ACTH stimulate adrenal glands to enlarge inc androgen S/sx: masculinization, sexual precocity Mx: Steroids to decrease stimulation of ACTH MLNG CELESTE, RN, MD

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3. G6PD DEFICIENCY - reduction in the levels of the enzyme G6PD in RBC leads to hemolysis of the cell upon exposure to oxidative stress Dx: blood smear – heinz bodies rapid enzyme screening test, electrophoresis MLNG CELESTE, RN, MD Mx: avoid drugs ie ASA, sulfonamides,195

4. GALACTOSEMIA (-) enzyme that converts galactose to glucose S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract Dx: Beutler test Tx: dec lactose – soy based formula regulate diet MLNG CELESTE, RN, MD

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5. PHENYLKETONURIA (PKU) - dec phenylalanine hydroxylase w/c converts phenylalanine to tyrosine S/sx: mental retardation, musty odor, blond hair, blue eyes Dx: Guthrie bld test Tx: dec phenylalanine (Lofenalac) regulate dietMLNG CELESTE, RN, MD

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Common Illnesses of the Newborn

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Respiratory distress syndrome - HMD ( hyaline membrane disease)

Common: 1. preterm infant 2.infant of diabetic mother 3.meconium aspiration

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• Pathologic feature: hyaline-like membrane formed lines the terminal bronchioles, alveolar duct,and alveoli prevents exchange of O2 and CO2 at alveolar-capillary membrane respiratory acidosis MLNG CELESTE, RN, MD

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• S/Sx: initial

late

1.low body temperature 2.nasal flaring 3.sternal and subcostal retraction 4.tachypnea 5. cyanotic mucuos membrane 1. seesaw respiration 2. heart failure 3. pale gray skin 4. period of apnea 5. bradycardia 6. pneumothorax MLNG CELESTE, RN, MD

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diagnosis: - clinical sign of grunting, cyanosis in room air, nasal flaring, retraction and shock - chest X-ray reveals diffuse pattern of radioopaque areas management 1. surfactant replacement 2. oxygen administration- in very immature infant is retinopathy of prematurity 3.ventilation-( normally I/E ratio is 1:2,there is difficulty in supplying O2 MLNG to stiff lung, CELESTE, RN, MD so in child it is reverse

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prevention: -usually happens on preterm infant ; ( steroids-quicken the formation of lecithin)

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Transient Tachypnea of Newborn -results from slow absorption of lungs fluid , reflects slight decrease in production of mature surfactant -limits the amount of alveolar surface area available for oxygenation MD -infant tends MLNG to CELESTE, haveRN, increased RR and204

- peaks in intensity at approx. 36hrs of life, and by 72hrs of life spontaneously fades as lung fluid is absorbed Common: 1.infant born via CS 2.infants whose mother received extensive fluid administration during labor 3. preterm infants Management: 1. close observation MLNG CELESTE, RN, MD 205

Meconium Aspiration - infant may aspirate meconium either in utero or in first breath after birth. cause severe respiratory distress in 3 ways: 1. causes inflammation of bronchioles because it’s a foreign substance 2. blocks small bronchioles by mechanical plugging MLNG CELESTE, RN, MD 206 3. causes a decrease in surfactant

sign and symptoms: 1. tachypnea 2. retraction 3. barrel chest 4. blood gas shows decrease PO2 and increase PCO2 5. chest x-ray shows a peculiar honeycomb effect MLNG CELESTE, RN, MD

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Management: 1. suctioning with bulb syringe or catheter while at the perineum 2. severe aspiration- infant might be intubated 3. don’t administer O2 under pressure 4. antibiotic therapy 5. chest physiotherapy and chest clapping MLNG CELESTE, RN, MD

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Apnea : • pause in respiration longer than 20 secs. with accompanying bradycardia commonly seen in: 1.preterm infant 2.infection 3.hyperbilirubinemia 4.hypoglycemia MLNG CELESTE, RN, MD

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MANAGEMENT: 1. gently shaking an infant or flicking the sole of the feet 2. always suction the secretion gently to minimize naso pharyngeal irritation 3. never take rectal temperature in infant prone to apnea - may cause vagal stimulation which results to bradycardia MLNG CELESTE, RN, MD 210

SIDS Sudden Infant Death Syndrome - sudden unexplained death in infancy - cause is unknown who are at risk: 1. infant of adolescent mother 2.infant of closely spaced pregnancies 3.underweight infant 4. preterm infant MLNG CELESTE, RN, MD

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Contributory factors: 1. viral respiratory infection 2. botulism infection 3. brain stem abnormalities 4.neurotransmitter defeciency 5. heart rate abnormality 6.decrease arousal responses 7. possible lack of surfactant in alveoli 8. sleeping prone MLNG CELESTE, RN, MD

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Hemolytic disease of the newborn • ABO incompatibility: set up is mother’s type is O baby’s type is A, B, AB Sign and symptom- primarily jaundice Txt: 1. phototherapy 2.if with severe jaundice can do exchange transfusion 3.initiation of early feeding MLNG CELESTE, RN, MD

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• RH incompatibility: mother is RH(-) ( has D antigen) baby is RH (+) Sign and symptoms: kernicterus hydrops fetalis (edema) ( lethal state)

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Isoimmunization (Rh Incompatibility)  Rh: major blood group antigen of importance during pregnancy  Rh (-) negative mother is carrying a fetus with Rh (+) positive blood  Incompatibility between the mother’s Rh (-) and fetus’ Rh (+) can lead to Hemolytic disease of the newborn

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Rh- mother carries Rh+ fetus • Rh Sensitization and Prevention Rh+ fetal blood may mix with Rh- maternal blood Mother’s immune system produces Rh antibodies in response to Rh+ fetal blood cells Antibodies remain in maternal blood following pregnancy Maternal antibodies attack Rh+ fetus in the next pregnancy, resulting in hemolysis Mother receives Rhogam to prevent her immune system from producing Rh antibodies so in a subsequent pregnancy, Rh+ fetal MLNG CELESTE, RN, MDblood cells are NOT

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• If a tear in the placenta occurs and there was no treatment, the next Rh+ positive fetus will have RBCs destroyed by the maternal Rh antibodies. • This causes hemolysis of fetal RBCs and then -anemia which in turn causes fetal edema – Hydrops fetalis or Erythroblastosis fetalis (a syndrome with a hyperdynamic state, heart failure, diffuse edema, ascites and pericardial effusion) MLNG CELESTE, RN, MD

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RhoGAM • Rh immune globulin given to gravidas who are Rh(-) if there is suspicion of feto-maternal bleeding (amniocentesis, miscarriage, vaginal bleeding and delivery), during any trimester, after delivery and prophylactically at 28 weeks MLNG CELESTE, RN, MD

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MATERNAL ANTIBODY FORMATION AGAINST THE RH ANTIGEN

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ABO INCOMPATIBILITY • The problem occurs when the maternal blood enters fetal circulation. • Most common: mother is Type O and the fetus is either Type A, B, or AB • The mother’s plasma naturally contains antiA and anti B antibodies • With weaker hemolytic effect than Rh antibodies and only affect mature RBC’s • Number of antibodies is limited to the amount of maternal blood that entered circulation • May affect fetus of the 1st pregnancy • Affected newborn will become jaundiced in the first 3 days of life MLNG CELESTE, RN, MD

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• Possible combinations for ABO INCOMPATIBILITY MOTHER A B O

FETUS B A A, B, AB

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Hemorrhagic disease of newborn - due to deficiency of vitamin K - bleeding occurs on 2nd to 5th day of

life Sign and symptoms: 1. petecchiae 2.vomit fresh blood or pass black tarry stool

Management:-IM administration of 1mg of vit K CELESTE, RN, MD 222 -if withMLNG severe bleeding

Retinopathy of prematurity - acquired ocular disease that leads to partial or total blindness in children - due to vasoconstriction of immature retinal blood vessels Who are at risk: 1. preterm infant 2. severely ill infant Cause: high O2 concentration MLNG CELESTE, RN, MD Txt : cryosurgery /laser therapy

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Growth and development

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Growth • growth and development can be used interchangeably, but they are different • Growth - is generally used to denote an increase in physical size or quantitative change • growth in weight is measured in kgs. or pounds • while growth in height is measured in inches or cm. MLNG CELESTE, RN, MD 225

Development • development (synonymous with maturation) - used to indicate an increase in skills or the ability to function (qualitative change)

• can be measured by the ff: – observing child’s ability to perform specific task – by recording the parent’s description of child’s progress MLNG CELESTE, RN, MDtest such as 226 – by using standardized

• Denver II TEST- (Denver developmental screening test II) 125 easily administered developmental test items, with age norm, presented in a convenient one-page format. • Types of development – – – –

psychosexual development psychosocial development moral development cognitive development MLNG CELESTE, RN, MD

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1.Psychosexual developmentspecific type of development that refers to developing instinct or sensual pleasure 2.Psychosocial development- refers to stages of personality development (Erikson) 3.Moral development- is the ability to know right from wrong and to apply this to real life situation (Kohlberg) MLNG CELESTE, RN, MD

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4.Cognitive development- refers to the ability to learn or understand from experience, to acquire and retain knowledge, to respond to new situation ,to solve problem.

– measured by intelligence tests, and by observing a child’s ability to function effectively in his/her environment MLNG CELESTE, RN, MD

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Principles of growth and development – – – – –

growth and development are continuous process from conception until death growth and development proceed in an orderly sequence different children pass through the predictable stages at different rates all body systems do not develop at the same rate development is cephalocaudal MLNG CELESTE, RN, MD

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– development proceeds from proximal to distal body parts – development proceeds from gross to refined skills – there is an optimum time for initiation of experiences or learning – neonatal reflexes must be lost before development can proceed – a great deal of skill and behavior is learned by practice MLNG CELESTE, RN, MD

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PHYSIOLOGIC AND STRUCTURAL CHANGES: • Respiratory rate and pulse rate decrease sharply during the first 2 years and then more gradually throughout childhood, blood pressure rises steadily beginning at approximately 6 yrs of age

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• Development of the paranasal sinuses continues throughout childhood, the ethmoid, maxillary, and sphenoid sinuses are present from birth. • the ethmoid reaches its maximum size relatively early in childhood (7-14 yrs of age), others reach their maximum size after puberty

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•Lymphoid tissues develop rapidly, reaching adult size by 6 years of age and continue to hypertrophy throughout childhood and early adolescence before receding to adult size •The metabolism of medication and child’s response to them change rapidly in the first month of life and again under the hormonal influences in MLNG CELESTE, RN, MD 234

•Nutritional needs as well as a wide variety of biochemical and hematologic values undergo marked developmental changes.

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THEORIES OF GROWTH AND DEVELOPMENT

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1. PSYCHOSEXUAL THEORY

• Psychosexual theory- Freudian theory , the idea of bodycentered drives Infancy(0-1yr)- oral ( sucking of the first year of life) Toddlerhood(2-3 yr)-anal (holding on and letting go during MLNG CELESTE, RN, MD the Toddler years)

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Continuation….. Preschool (3-6 yr)-oedipal drives (possessiveness toward a parent In the preschool years) School age (6-12 yr)-Latency Adolescence (12-20)-adolescence MLNG CELESTE, RN, MD

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Oral – infant • oral stimulation for nutrition, enjoyment and release of tension • NI: provide oral stimulation – pacifiers, breastfeeding, thumbsucking Anal - toddler • elimination is a way of discovery and exerting independence • NI: help achieve bowel and bladder control even if hospitalized Phallic – preschool • increased knowledge of 2 sexes • NI: accept sexual interest MLNG CELESTE, RN, MDand answer 239 questions about birth or sexual difference

Latent - school age • libido diverted to school • NI: help achieve positive experiences to promote self esteem Genital - Adolescent • establish sexual aims and finding new love objects • - NI: provide opportunities to relate with opposite sex and allow verbalizationMLNG CELESTE, about new feelings RN, MD

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2.Psychosocial theory > recast Freud’s stages in term of the emerging personality Infancy (0-1) – basic trust vs mistrust Toddler hood (2-3)- autonomy vs. shame and doubt Preschool (3-6) –initiative vs. guilt School age (6-12) – industry vs. MLNG CELESTE, RN, inferiority MD 241

• Trust vs Mistrust – infant T: appreciate environment as safe and people as dependable M: suspicious, fearful, shun emotional involvement NI: provide primary caregiver and visual stimulation • Autonomy vs Shame and Doubt – toddler A: build on new motor and mental abilities, take pride in accomplishments S: doubt and stop trying NI: provide opportunities for decision making and give raises MLNG CELESTE, RN, MD

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• Initiative vs Guilt – preschool I: how to do things G: limited brainstorming and problem-solving skills NI: provide opportunities for exploration, answer questions and do not inhibit fantasy • Industry vs Inferiority - school age Ind: how to do things well Inf: always worried about poor or incorrect performance NI: provide opportunities for completing short projects, give praise and rewards

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• Identity vs Role Confusion – adolescent I: integrate image into a whole R: unsure of who they are or who they can become, may rebel NI: provide opportunities to discuss feelings and support and praise for decision-making MLNG CELESTE, RN, MD

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3.Cognitive theory( piaget theory) described how children actively construct knowledge for themselves through the linked processes of assimilation( seeking experiences) and accommodation (adapting their implicit ideas about the world to take new information into account) MLNG CELESTE, RN, MD

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1. Sensorimotor ( stages 1-VI)practical intelligence, because word And symbols for thinking and problem solving are Not yet available at this early age. – Neonatal reflex-1 mo. (stimuli are assimilated into beginning mental images – Secondary circular reaction- 1-4 mo., hand-mouth and ear-eye coordination develop- beginning CELESTE, RN, MD intention MLNG of behavior is present 246

– Coordination of secondary reaction- 8-12 mo., infant can plan activities to attain specific goalsperceives that others can cause activities and that activities of own body are separate from activity of objects. – Tertiary circular reaction-12-18 mo. Capable of space perception as well as permanence. – Invention of new means through mental coordinations- 18-24 mo.transitional phase, uses memory MLNG CELESTE, RN, MD 247 and imitation to act. good toy are

2. Preoperational thought- 2-7 yr. ( preschool) – – – –

Thought becomes more symbolic Comprehends simple abstraction Child is egocentric Display static thinking( inability to remember what he or she started to talk about so that the end of the sentence the child is talking about another topic) – Concept of time is now and concept of distance is only as far as he or she can see – No awareness of reversibility is present – Unable to state cause-effect relationships, categories and abstraction, good toys are MLNG CELESTE, RN, MD 248 items that require imagination like

3. Concrete operation- 7-12 yr.( school age ) – Includes systemic reasoning – Uses memory to learn broad concepts and subgroups of concept – Child is aware of reversibility – Understand conservation, sees constant despite transformation – Collecting and classifying natural objects-good activity for this period.

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4.Formal operational-12 yr. (adolescence) – Can solve hypothetical problems with scientific reasoning – Understand causality – Can deal with the past, present, and future – Adult or mature thought – Talk-time- good activity for this MLNG CELESTE, RN, MD 250 period

Piaget’s Theory of Cognitive development Sensorimotor – 1 mo-24 mo Preoperational Thought – 2-7 y/o Concrete Operational Thought – 7-12 y/o Formal Operational Thought – 12 y/o

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Sensorimotor - relate through senses, separate from environment, practical intelligence

Preoperational toddler: symbolic thought, simple abstractions, literal thinking, poor concept of time and distance pre-schooler: centering, egocentric, no reversibility, no cause and effect, MLNG CELESTE, RN, MD assimilation, role fantasy

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Concrete Operational - systematic reasoning - memory to learn broad concepts and subgroups - seriation and classification - reversibility - inductive reasoning (specific to general) - conservation (7 y/o – numbers; 7-8 y/o quantity; 9 y/o – weight; 11 y/o – volume) MLNG CELESTE, RN, MD

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Formal Operational Thought    solve hypothetical problems, causality, time - talk time to sort attitudes and opinions

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4.Kohlberg’s theory of moral development developed a theory on the way children gain knowledge of right and wrong or moral reasoning. 1. Preconventional ( level I) 2-3 yr – punishment/ obedience orientation( heteronomous morality), child does right because a parent tells him or her to and avoid punishment. - 4-7 yr- individualism, carries out actions to satisfy own needs rather than societyMLNG CELESTE, RN, MD

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2. Conventional ( level II ) 7-10 yrorientation to interpersonal relation of mutuality ( child follows rules because of a need to be a “good” in own eyes and in eyes of others) - 10-12 yr – maintenance of social order, fixed rules and authority( child finds following rules satisfying) MLNG CELESTE, RN, MD

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3.Postconventional ( level III) older > 12yrs - social contract, utilitarian , law making perspective (follows standards of society for the good of all people) - universal ethical principle orientation (follows internalized standards of conduct) MLNG CELESTE, RN, MD

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Kohlberg’s Theory of Moral Development Preconventional (Level I) Stage 1 - 2-3 yo “mother or father says so” punishment obedience orientation Stage 2 - 4-7 yo “mother says it’s wrong” individualism/egocentrism MLNG CELESTE, RN, MD

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Kohlberg’s Theory of Moral Development Conventional (Level II) Stage 3 – 7-10 yo “nice girl, nice boy” Stage 4 – 10-12 yo following rules is satisfying “Law and Order” MLNG CELESTE, RN, MD

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Kohlberg’s Theory of Moral Development Postconventional (level III) Stage 5 & 6 - >12 following standards for everyone’s good “Social Contract” “Principled conscience” MLNG CELESTE, RN, MD

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Harry Sullivan 3. Prototaxic mode – infancy – need for bodily contact and love; anxiety due to unmet needs 4. Parataxic mode – 2-5 y/o - parents viewed as source of praise and acceptance  5. Syntaxic mode – 5-8 y/o - logical, rational and most mature type of cognitive functioning; need for peers MD 261 and howMLNG to CELESTE, deal RN, with them

DEVELOPMENTAL STAGES

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IMPORTANCE OF KNOWLEDGE OF GROWTH AND DEVELOPMENT

1. health promotion and Illness prevention 2. health restoration and maintenance

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STAGES OF GROWTH and DEVELOPMENT A. 1st Prenatal – conception – birth B. 2nd Neonate - birth - 28 days Infant - 1 month - 1 y/o MLNG CELESTE, RN, MD

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STAGES OF GROWTH and DEVELOPMENT C. 3rd Toddler - 1 - 3 y/o Preschool - 3 - 6 y/o D. 4th School age - 6 - 12 y/o Adolescence - 13 - 18 y/o MLNG CELESTE, RN, MD

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FACTORS THAT AFFECT GROWTH and DEVELOPMENT I. Heredity a. Gender b. Health c. Intelligence d. Temperament e. Genes MLNG CELESTE, RN, MD

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FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT II. Environment a. Socioeconomic level b. Parent-Child Relationship c. Ordinal position in the family d. Health MLNG CELESTE, RN, MD

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FACTORS THAT AFFECT GROWTH and DEVELOPMENT

I. Genetics a. Gender – girls generally lighter in weight at birth; boys taller and heavier at puberty b. Health – inherited illnesses c. Intelligence – advance faster in skills d. Temperament Reaction Patterns – response to situations Nursing implications: 1. talk to parents about reactivity patterns 2. notice temperamental characteristics when hospitalized MLNG CELESTE, RN, MD

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II. Environment a. Socioeconomic level – lack supervision, health care or nutrition b. Parent-Child Relationship – thrive better if loved c. Ordinal position in the family – size and position in family d. Health – debilitating diseases MLNG CELESTE, RN, MD

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DEVELOPMENTAL AGE PERIODS

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INFANCY – 0-1 yo

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INFANCY • 4-6 mos -2x birthweight 1ST 6 mos – 2 lb/mo; 2nd 6 mos – 1 lb/mo • 1 y/o - 3x birthweight - HC=CC 6-12 mos - 50% inc in height; • 1st 6 mos – trunk; 2nd 6 mos - legsMLNG CELESTE, RN, MD - 2/3 brain growth

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·        12-18 mos - Ant fontanel ·        2 mos - Post fontanel - Immune system ·        4 mos - Liquids to solids ·        6 mos - Shivering - Tooth eruption ·        ECF 35%, ICF 40% • Health visits – 2 weeks, 2 mos, 4 mos, 6 mos, 12 mos MLNG CELESTE, RN, MD

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GROWTH AND DEVELOPMENTAL MILESTONES Gross motor • 2 mos - 45 degree head control • 3 mos - 90 degree head control • 4 mos - lifts head & chest on prone - rolls over • 5 mos - 6 mos - good head control - sits with support MLNG CELESTE, RN, MD

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GROSS MOTOR • 8 mos - sits without support • 9 mos - pulls self to stand - creeps • 10-11 mos – cruises MLNG CELESTE, RN, MD • 12 mos – stands

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FINE MOTOR • 1 mo - eyes to midline • 3 mos – eyes past midline • 4 mos –bring hands together • 5 mos – grasps/reaches object MLNG CELESTE, RN, MD

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FINE MOTOR • 7 mos - hand to hand transfer • 9-10 mos - pincer grasp - points at object • 11 mos - bangs objects together • 12 mos - throws toys MLNG CELESTE, RN, MD - attempts 2 tower

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LANGUAGE • 1 mo - throaty gurgling sound • 2 mos - differentiate a cry • 3 mos - squeals • 4 mos - coos and gurgles - moves head to sound • 5 mos - simple vowel sounds MLNG CELESTE, RN, MD

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LANGUAGE • 7 mos - “ma” when crying • 9 mos - mama, dada • 10 mos - understands gestures - responds to name • 12 mos - obeys commands - one word other than mama, dada MLNG CELESTE, RN, MD 281

PERSONAL SOCIAL • 2 mos - social smile • 4 mos - plays with rattle • 7 mos - feeds self with crackers - recognizes familiar faces • 8 mos - peek-a-boo - stranger anxiety MLNG CELESTE, RN, MD

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PERSONAL SOCIAL • 9 mos – waves bye bye • 10 mos – nursery games • 11 mos – holds arm or foot out in dressing MLNG CELESTE, RN, MD

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• 12 mos – attempts to

PLAY – solitary play: self is the interest of activities; alone but enjoys presence of others

• • • •

Balloon mobiles • Mirror play • Peek-a-boo Being held • Rocking Block play • Singing games Feet & toes games • Squeaky toys • Fingers & hand • Pat-a-cake games • Listening to stories • Making faces MLNG CELESTE, RN, MD

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NUTRITION Lipase – dec until 1 yr Amylase – dec until 3 mos Immature liver – inefficient storage and formation of nutrients Extrusion reflex – until 4 mos MLNG CELESTE, RN, MD

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Calories: 100-115 kcal/kg/day 0-3 mos - breastmilk 4-6 mos - semi-solid food Introduce one at a time Start with small quantities Cereals, strained vegetables, meat 7-9 mos - Finger food, fluids 10-12 mos - 3meals w/ snacks MLNG CELESTE, RN, MD

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DAILY CARE -

bathing diaper care care of teeth dressing sleep – 10-12 hrs/day; 1 or more naps - exercise MLNG CELESTE, RN, MD

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Concerns - Constipation - Teething – cleanliness - thumb sucking – until school age - pacifiers – wean after 3 mos - head banging – begin 2nd half of infancy to preschool, naptime, under 15 min - sleep problems – breastfed infants wake up sooner MLNG CELESTE, RN, MD 290 - spitting up

- diaper dermatitis - miliaria/prickly heat – papular, erythematous on neck, ear, face, trunk - baby bottle syndrome - Loose stools – breastfed - Colic – paroxysmal abdominal pain, < 3 mos, inc in formula fed - Obesity – 32 oz formula daily, add fiber and water to diet CELESTE, RN, MD - Stranger MLNG anxiety

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REACTION TO ILLNESS • Discomfort and pain • Lack of stimulation

NURSING CARE • Soothing stimulation • Toys from home • Human contact

• Separation • Provide/Anticipate 292 anxiety MLNG CELESTE, RN, MD needs

TODDLER – 1 –3 yo

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TODDLER • Slowed growth • Wt gain 5-6 lbs (2.5 kg) • 5 in (12 cm) • Baby fat disappears • brain 90 % adult size • Baby fat disappears MLNG CELESTE, RN, MD • CC > HC; inc by

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TODDLER • Protruberant abdomen • Stomach capacity increases • Control of urinary and anal sphincters • IgG and IgM • 20 deciduous teeth MLNG CELESTE, RN, MD

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GROWTH AND DEVELOPMENTAL MILESTONES Gross • 15 mos – walks alone well • 18 mos – run and jump in place - walk up & down stairs holding on to railing - seat self in chair • 24 mos – walks up & down stairs w/ both feet same step, same time • 2 ½ yo – tiptoes • 3 yo - throws balls, rides tricycles MLNG CELESTE, MD - stands on 1RN,foot momentarily 296

LANGUAGE • 15 mos - vocalizes wants - 3 words other than dada, mama • 18 mos - uses phrases • 2 y/o - short sentences; 2-3 words - points to one body part • 3 y/o - speaks fluently using longer sentences - tells stories - plurals MLNG CELESTE, RN, MD

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PERSONAL/SOCIAL • 15 mos - pats pictures - imitates housework • 18 mos - turns page 2-3 at a time - uses spoon • 2 yo - removes garments - toilet trained by day (2-3 yrs old) • 3 yo - dry by night (3-4 yrs old) - washes and dries hands MLNG CELESTE, RN, MD

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NUTRITION • • • • •

Decrease in appetite Picky eaters 1, 300 kcal/day Allow self feeding Allow choice between 2 types of food • Offer finger food • Risk of aspiration MLNG CELESTE, RN, MD

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PLAY – parallel play: plays alongside, but not with another; has not learned sharing yet

• Babbling and talking • Ball games • Clay • Listening to music • Listening to stories

• Making music and noise • Push and Pull toys • Puppet play • Scribbling • Stack-and-dump toys

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DAILY CARE - dressing – can put on socks, underpants, undershirt - sleep – 8 hours sleep w/ 1 nap - bathing - care of teeth   MLNG CELESTE, RN, MD

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CONCERNS • Toilet Training bowel control – 18 mos daytime bladder ctrl – 2-3 yo nighttime bladder ctrl – 3-4 yo CONDITIONS: 1.    control of sphincters 2.    cognitive understanding 3.    delay immediate gratification 4. mature nervous system MLNG CELESTE, RN, MD

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• Negativism • Temper Tantrums • Accidents • Rituals • Egocentrism MLNG CELESTE, RN, MD

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• Sibling rivalry • Discipline • Separation anxiety

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REACTION TO ILLNESS and NURSING INTERVENTIONS • fear of separation - Assure of parents return • Regressive behaviors - reassurance • Nutrition – allow finger food • Dressing changes – allow to pull off tape MLNG CELESTE, RN, MD

• Medication – allow choices of

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• Hygiene – allow choice of bathtime toy, allow to put toothpaste • Pain – allow to express pain • Stimulation • Elimination – continue potty training • Rest – allow choice of toy at bedtime MLNG CELESTE, RN, MD

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PRE SCHOOL 3-5 yo

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PRE SCHOOL • Future body build apparent • Increased skeletal growth • Handedness • 5 yo - may have permanent teeth • Tonsils inc in size • IgG and IgA increases MLNG CELESTE, RN, MD

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PRE SCHOOL • HR 85 bpm • BP 100/60 • 4.5 - 5 kg/yr • 2 - 3.5 in/yr • Frequent voiding MLNG CELESTE, RN, MD

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GROWTH AND DEVELOPMENTAL MILESTONES Gross • 3 1/2 yo - stands on 1 foot 5 sec - upstairs on 1 foot/step; down 2 feet /step • 4 – 4 ½ - climbs stairs - hops on 1 foot • 5 yo – heel to toe walk - skips MLNG andCELESTE, runsRN, MD

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FINE MOTOR • 3 yo – copies circle • 4 –4 1/2 - imitates cross - draws man w/ 3 parts - copies square • 5 yo - copies triangle - writes alphabet MLNG CELESTE, RN, MD

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LANGUAGE • 3 ½ yo - gives full name, sex - counts to 3 or more • 4 yo - exaggerates and boasts • 5 yo- talks constantly

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PERSONAL/SOCIAL • 3 ½ yo - dresses w/ supervision - separates more easily from mother • 4 yo – buttons up • 4 ½ - dresses w/o supervision MLNG CELESTE, RN, MD

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NUTRITION • Slow/Steady growth • Decreased appetite • Offer small servings • Healthy snack food

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PLAY – associative play; plays in random without group goal; follows a leader • Dress up clothes • Housekeeping toys • Dolls and other toys for pretending • Bikes and climbing toys • Paper and crayons

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DAILY CARE -         accidents – bicycle safety, seat belts -         dressing – choose own clothes -         sleep – resist taking naps -         exercise – very active -         bathing – can wash and dry hands; need supervision -         care of teeth – independent brushing; 1st dental visit MLNG CELESTE, RN, MD

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CONCERNS - imitation - Oedipus and electra complex - gender roles – need exposure to parents of opposite sex - Socialization – capable of sharing - Discipline – “time out” - Common fears – dark, mutilation, separation - Telling tales - Imaginary friends MLNG CELESTE, RN, MD 319

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- sharing – define limits and teach property rights - Regression –reaction to stress - Sibling rivalry - sex education - pre-school center - broken fluency - swearing - High energy level MLNG CELESTE, RN, MD 321 - Curiosity

REACTIONS/CONCERNS IN ILLNESS AND NURSING INTERVENTIONS

-    fear of the dark – allow dim light and parent to sit beside child -    Fear of body mutilation - Prepare for and explain procedure; reassure -    Fear of injury, pain and the unknown - Encourage expressive play/medical play -    Fear of separation/abandonment – relate time and space to familiar situations MLNG CELESTE, RN, MD

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-

nutrition – food in animal/alphabet shapes -     dressing change – allow to measure, cut tape, see incision site -     medication – allow to choose “chaser” -     hygiene – allow choice of toys, wash hands and face -     pain – allow pain expression, handle syringe, analgesic -     stimulation MLNG CELESTE, RN, MD

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School Age 7 – 11 yo

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SCHOOL AGE

• 3-5 lb/yr • 1-2 in /yr • 10 yo – brain growth complete • Adult vision • Abundant tonsillar and adenoid tissue • “innocent” heart murmurs • HR 70 bpm • BP 112/60 MLNG CELESTE, RN, MD • 32 permanent

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SECONDARY SEX CHARACTERISTICS AGE

BOYS

GIRLS

9-11

Wt gain

Breast bud

11-12

Sparse pubic hair growth of penis & testis Sebaceous gland sec

12-13

Pubic hair inc Penis lengthens Linear growth spurt Breast enlargement

Pubic hair along labia Sebaceous gland sec Growth spurt Pubic hair darker Breasts enlarge Axillary hair menarche

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GROWTH AND DEVELOPMENTAL MILESTONES • 6 yo – skip, jump, tumble, hop, ride bicycle, walk a straight line; first molars • 7 yo – central incisors; sexual differences seen in play; quiet play • 8 yo – improved coordination; playing w/ gang important; eyes fully developed

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GROWTH AND DEVELOPMENTAL MILESTONES • 9 yo – all activities done w/ gang - hero worship • 10 yo – more improved coordination - well mannered w/ adults • 11 yo – active but awkward - mixed sex activities • 12 yo – coordination improves MLNG CELESTE, RN, MD - joins organizations

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PERSONAL/SOCIAL/PLAY Competitive play and recreational activities Hobbies and personal interests • Arts and crafts • Biking • Board games • Clubs • Collecting items • Chess MLNG CELESTE, RN, MD • Comic Books

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NUTRITION • Good appetite • Food w/ high nutritional value - more calories and nutrients - hungry after school – give snacks and make mealtimes enjoyable

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DAILY CARE -         dressing – influenced by peers -         sleep – 8-12 hrs; no naps -         exercise – games, bike riding, walking -         hygiene – 8 yo – capable of bathing alone -         care of teeth – 2x yearly visit to the dentist; brush daily safety – bicycle, school bus safety, prevention of falls and sports injuries MLNG CELESTE, RN, MD

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CONCERNS -         problems w/ articulation – disappears 9 yo -         School anxiety and phobia -         Sex education -         Stealing – 7 yo – importance of money -         Violence/terrorism – education;reassurance -         Bullying -         Recreational drug and alcohol MLNG CELESTE, RN, MD 336 use

REACTION TO ILLNESS AND NURSING INTERVENTIONS  -        Death and disability - Still need comfort -         Unknown events & procedures - Allow to help w/ care & treatment -         Loss of ctrl & independence - Give choices -         Loss of contact w/ peers - Allow visits -         Disruption of school - Talk about MLNG CELESTE, RN, MD 337 interests

- nutrition – allow choices -     dressing – ask opinions on bulk of dressing and where to apply tape -     medicine – teach name and action, allow to choose form if possible -     pain – allow expression of pain, explain source and cause -     stimulation MLNG CELESTE, RN, MD

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ADOLESCENT • Girls taller than boys 2-8 in, 15-55 lbs • Growth stops 16-17 yo • Boys grow 4-12 in and gain 15-65 lbs • Growth stops 18-20 yo • Heart and lung size increase more slowly • HR 70 bpm • RR 20 breaths/min • BP 120/70 MLNG CELESTE, RN, MD

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ADOLESCENT • Androgen inc sebaceous gland activity resulting in acne • Apocrine glands inc activity • 13 yo – 2nd molars • PUBERTY – capable of sexual reproduction • Secondary sexual characteristics • Competitive Play: with win-lose type of rules MLNG CELESTE, RN, MD

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GROWTH AND DEVELOPMENTAL MILESTONES • 13 yo – sports • 15 yo - enjoys privacy - stays in room • 16 yo - part time job - charitable causes

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NUTRITION -         faddish diet -         give responsibility for food planning -         increased calories   DAILY CARE -         dressing and hygiene -         care of teeth -         sleep – need more sleep MLNG CELESTE, RN, MD -         exercise – daily

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CONCERNS

-       Socialization – falling

in love -      Obesity; Diseases – HPN -      Acne -      Body piercing -      Fatigue - emotional fatigue -      Menstrual irregularities -      Sexuality and sexual activity -      Poor posture -      Stalking – educate girls MLNG CELESTE, RN, MD -      Substance abuse

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REACTION TO ILLNESS AND NURSING INTERVENTION Main issue – body image – educate and Allow participation in tx decisions; compassionate understanding   Fears loss of control and independence Respect privacy and confidentiality   Fears injury and pain - Provide opportunities for self expression   Separation from peers and lack of emotional support - Approach w/ caring and understanding, age compatible roommate,345 MLNG CELESTE, RN, MD Phone at bedside

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-         Nutrition – food preferences -         Dressing – final appearance of dressing, and time for changing -         Medicine – choice for injection site, teach name and action -         Rest – time and length of rest periods -         Hygiene – respect modesty, extent of self care -         Pain – allow pain expression, ask for analgesics MLNG CELESTE, RN, MD 347 -         stimulation

Thank You!

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