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Chapter 35: Assisting in Pediatrics

Normal Growth and Development    

Growth refers to measurable changes, such as weight and height Development considers qualitative maturation in motor, mental, social, and language skills Pediatricians check for indications of irregularities in growth and development What factors affect growth and development? (Genetics, nutrition, environmental factors, presence of disease, and caregiver interactions all affect growth and development.)

Growth Patterns      

Birth weight triples by age 1 and length increases by 50% By age 3, the child slims down From 3 to 6, weight increases 3 to 5 lb. per year, and height increases about 1.5 to 2.5 inches per year Continued growth, especially in the legs, until age 12, when a growth spurt usually occurs before puberty begins By age 4, the child usually has doubled the birth length. Body mass index (BMI) can be calculated by dividing the child’s weight in kilograms by the height in meters squared.

Denver II Developmental Screening Test 

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Standardized tool used to: o Screen for developmental delays o Investigate concerns about an infant’s development o Monitor high-risk children for potential problems Test should be given at ages 3 to 4 months, 10 months, and 3 years Each child develops individually and attains developmental plateaus differently. Only those trained in the procedure and in interpretation of the results should give it. Focuses on four key developmental areas o Gross motor skills o Language o Fine motor skills o Personal skills The results of the test are analyzed and determined to be normal or suspect, or the child is diagnosed as untestable. Refer to Figures 35-1 and 35-2.

Therapeutic Approaches for Infants        

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Crying is normal; try to distract without overstimulating Keep the baby close to a caregiver Involve the parent as much as possible Place a familiar object near the baby Eight months is when stranger anxiety generally develops Only restrain when it is necessary for safety Encourage the caregiver to cuddle and hug during a procedure Unpleasant procedures are associated with other objects, so do not use play areas for treatment and do not use a favorite toy or object during the procedure; instead, offer it afterward for comfort. General patterns of child development occur rapidly during the first year of life as the infant progresses from reflex activities to learning to manipulate simple objects.

Therapeutic Approaches for Toddlers and Preschoolers           

Ignore tantrums and negative behavior Praise the child Perform unpleasant procedures quickly Allow the child to keep on as much clothing as possible Use familiar words Explain the procedure as the child would experience it and allow him or her to handle equipment Do not demonstrate on the child’s favorite doll or stuffed animal Explain the procedures to the parents away from the child, if possible Why should you avoid demonstrating procedures on a child’s doll? (The child may believe the toy feels pain and get upset.) By age 3, the child is showing increased autonomy. During the preschool stage, the child becomes increasingly independent and initiates activities.

Therapeutic Approaches for School-Aged Children         

Allow choices when possible A parent or caregiver should be present Remove minimal clothing Explain the procedures in concrete terms Give the child time to ask questions Address conversation to the child Provide privacy Use pictures and diagrams when possible while explaining procedures. School-aged children have perfected fine motor skills and can paint, draw, and play an instrument.

Therapeutic Approaches for Adolescents

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Adolescents are self-conscious and influenced by peers Privacy is key Address how the procedure might affect appearance Do not be judgmental when listening Encourage verbalization of concerns or fears Regression may occur when sick Encourage the teen to see the physician without a parent present Teenagers want to be treated as adults; they want to know what is being done and why. In an attempt to establish an adult identity, the teenager proceeds by trial and error.

Developmental Theories 

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Sigmund Freud o Believed motivating stimulus for human behavior is the libido o First therapist to identify five developmental stages Erik Erikson o Psychosocial approach o Theory based on eight stages of development  Each stage focuses on a developmental crisis What are the four major components of the mind, according to Freud? (The unconscious mind, the id, the ego, and the superego) Refer students to Table 35-1 for a summary of the growth and development theories. Jean Piaget o Focuses on intellectual growth o Four stages of cognitive development Lawrence Kohlberg o Focuses on moral reasoning What are the four stages of cognitive development, according to Jean Piaget? (Sensorimotor stage, preoperational stage, concrete operational stage, and formal operational stage) Refer students to Table 35-1 for a summary of the growth and development theories.

Postpartum Depression  

An estimated 10% to 20% of women struggle with major depression before, during, and after delivery of a baby Risk factors include: o History of depression, abuse, or mental illness o Smoking or alcohol use o Anxiety during pregnancy and fears over childcare o Lack of financial resources and secure relationships o Fussy, colicky infant o Lack of social support

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Fewer than half of the 10% to 20% of women who struggle with depression are diagnosed in routine office visits. Postpartum depression (PPD) must be detected as soon as possible so that treatment can begin.

Colic  

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Seen in the newborn period, or in early infancy An infant between 2 weeks and 4 months of age who has crying episodes that occur at least three times a week for longer than 3 hours a day and lasting 3 weeks A child frequently outgrows the condition before the cause can be identified Drugs are not helpful and, in some cases, may be dangerous for the infant. Parents need reassurance that they are not responsible for the child’s discomfort, and they may find counseling and assistance in developing coping techniques helpful.

Diarrhea     

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Diarrhea can be caused by many microorganisms, like bacteria, viruses, and parasites Can be caused by food allergies or certain medications, like antibiotics Diagnosed when child has two or more watery or abnormal stools within 24 hours Prolonged diarrhea can lead to dehydration and electrolyte imbalance What are some signs of dehydration? (Lack of tears when crying, lethargy, fewer wet diapers or decreased urination, dry mouth and lips, and weight loss) Infants and small children should be followed up by telephone in 12 hours, and then daily, until the diarrhea has stopped. If breast-fed, the baby should continue to nurse, and formula feeding also should be continued.

Failure to Thrive 

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An infant or young child whose weight is consistently below the third percentile on standardized growth charts or one who is 20% below ideal body weight for length Physical, mental, and social skills also are delayed Failure to roll over, smile, coo, stand, or walk at age-appropriate developmental levels Caused by physiologic factor or a problem with parent-child relationship Children with failure to thrive need more calories than usual—approximately 150% of their normal calorie load—to catch up to their target weight. Experts believe that infants may experience this problem if they are being neglected; however, low weight gains also are possible with extremely attentive and cautious parents.

Obesity

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Child is considered overweight if BMI-for-age is between the 85th and 94th percentiles Child is identified as obese if BMI is at or greater than the 95th percentile Reasons include family history, inactivity, high-calorie diets, stress, and, rarely, metabolic or endocrine disorders Provide educational materials, encouragement for child and parents, and referral to support programs The psychosocial impact of obesity can be overwhelming for many children because isolation, loneliness, and lack of self-esteem are common. Overweight and obese children are at greater risk of developing serious health conditions, including asthma, diabetes mellitus type 2, sleep apnea, and hypercholesterolemia, which increase the risk of cardiovascular disease and hypertension.

Common Cold (Rhinitis)     

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Has more than 100 causative pathogens and is highly contagious Signs include nasal congestion, low-grade fever, and general malaise Parent may need to be shown how to use a nasal bulb syringe to suction the nose of an infant Secondary infections in the lower respiratory tract or in the middle ear can occur How is the common cold spread? (It is spread through respiratory droplets from rhinitis, sneezing, or coughing, either from direct contact or from touching contaminated items.) Most colds are self-limiting and run their course in about a week.

Common Secondary Infections 

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Strep throat causes a severe sore throat, fever, headache, and lymphadenopathy o If not treated with antibiotics, can lead to scarlet or rheumatic fever Scarlet fever causes a bright red, rough rash over child’s body Rheumatic fever is a serious disease that can damage heart valves Strep is easily spread when an infected person coughs or sneezes contaminated droplets into the air and another person inhales them. A person also can become infected by touching such secretions and then touching the mouth or nose.

Otitis Media  

Figure 35-4 (left) shows serous otitis media, and Figure 35-5 (right) shows suppurative otitis media. Signs include inflammation of the middle ear, with fluid building up behind the tympanic membrane.

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Traditionally, children with indications of a middle ear infection were treated with antibiotics; however, if the infection is caused by a virus, antibiotics do not help. If fluid in the middle ear persists for longer than 3 months and/or if the child experiences hearing loss, the physician may recommend a myringotomy; in this operation, a small incision is made in the tympanic membrane and a tube is inserted to drain the fluid and balance the pressure between the outer and middle ear.

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Over-the-Counter Medicines    

Over-the-counter (OTC) cough and cold products should not be given to children younger than 2 years old Complications may occur, including but not limited to death, convulsions, rapid heart rate, and diminished levels of consciousness Giving a child more than one product that contains the same active ingredient can result in overdose The FDA also is concerned about the use of these products in children ages 2 to 11 years.

Croup    

Viral inflammation of the larynx and trachea that causes an edema and spasm of vocal cords Hoarseness, a harsh barking cough, and stridor during inhalation Infection usually is self-limiting, and the child typically recovers without treatment Use a cool mist humidifier, sit in a steamy bathroom, or take the child into cool air

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If the problem becomes chronic or continues for a period of time, the child may need to be treated with corticosteroids (e.g., prednisone).

Pertussis (Whooping Cough)    

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Very contagious respiratory illness Caused by bacteria that attach to the cilia Can cause violent and rapid coughing Recommended pertussis vaccine for infants and children is DTaP o Complete vaccination requires 5 doses starting at 2 months of age up through 4 to 6 years of age Current recommendations are that pregnant women get a dose of Tdap during each pregnancy, preferably at 27 through 36 weeks’ gestation.

Bronchiolitis     

Viral infection of small bronchi and bronchioles; usually affects children younger than 3 years old Varies in severity and is seen in children with a family history of asthma and exposed to cigarette smoke Inflammation, edema, increased secretions, and bronchospasm in respiratory pathway Treatment includes acetaminophen and a bronchodilator inhaler or nebulizer treatment Most children fully recover in 2 weeks, but as many as 50% have recurrent wheezing and coughing.

Respiratory Syncytial Virus (RSV)     

Infects the lungs and bronchioles Can cause a serious respiratory infection in infants and older adults Most common cause of bronchiolitis and pneumonia in children younger than 1 year of age Symptoms start out similar to common cold Researchers are working to develop a vaccine for RSV.

Asthma     

The most common chronic health problem among children, triggered by many factors Result of two specific reactions: Bronchospasm and inflammation Nonproductive cough, accompanied by an expiratory wheeze and shortness of breath An attack can last minutes to days, and may develop into a medical emergency What happens to airways during an asthma attack? (During an asthma attack, the bronchial tubes begin to spasm, which reduces the amount of air that can pass through them. At the same time, the tissue lining the bronchioles becomes edematous and secretes mucus; therefore, in an asthma attack, the smaller airways are filling up with mucus and secretions.

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Air passing through these secretions causes the classic symptom of asthma— wheezing on expiration.) A child who experiences symptoms two or more times a week should take daily medication to prevent asthma attacks. The child also is prescribed a quick-acting medication, or "rescue inhaler," such as albuterol (Proventil, Ventolin), for acute relief of bronchospasm or exercise-induced asthma. This inhaler should be readily available at all times.

Influenza (Flu)       

Acute, highly contagious viral infection of the respiratory tract Transmitted by direct contact with moist secretions High fevers and susceptibility to pulmonary complications, like pneumonia Bed rest, increased fluids, and a nonaspirin analgesic Flu vaccines are available; the individual must be vaccinated before the onset of infection The CDC recommends annual flu vaccinations for all healthy children from age 6 months up to the 19th birthday and for their caregivers. Influenza strains continually change, so the child must receive an updated version of the vaccine each year.

Conjunctivitis (Pinkeye) 

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Highly contagious and caused by a bacterial or viral infection o Use good hand sanitization practices and hygiene o Do not share towels or anything that touches the face of an infected child o Disinfect any articles that may be contaminated o Treat with an antibiotic for at least 24 hours before returning to school Health teaching for caregivers of infected children includes the listed suggestions.

Tonsillitis    

Most commonly caused by Streptococcus A Causes intense pain within a short time, in addition to fever and general malaise Bed rest, a liquid to soft diet, an analgesic throat spray, and oral antibiotics if the causative organism is a bacterium What is the danger of tonsillitis? (The danger lies in the secondary problems that can occur, which include rheumatic heart disease and kidney disease, if the streptococcal infection is not treated with antibiotics.)

Fifth Disease  

Also called erythema infectiosum, parvovirus infection, or slapped cheek disease Symptoms begin with a mild fever and general malaise, leading to flushed cheeks and rash

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Children with sickle cell anemia, chronic anemia, or an impaired immune system may become seriously ill when infected and require medical care Infected pregnant women have an increased risk of miscarriage and possible severe anemia in fetus When are outbreaks of fifth disease most common? (In the winter and spring) Fifth disease is spread through direct contact or by breathing in respiratory secretions from an infected person.

Hand-Foot-and-Mouth Disease 

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Caused by coxsackievirus, which is ingested and transmitted by direct contact with the nose and throat drainage, saliva, or stool of an infected individual Fever; sore throat; painful red blisters on tongue, mouth, palms, and soles; headache; anorexia; irritability Most common complication is dehydration Rest, fluids, and acetaminophen or ibuprofen for fever or discomfort To prevent the spread of the disease, family members should be instructed to wash their hands thoroughly, especially after diaper changes, and disinfect shared items such as toys frequently. Children with hand-foot-and-mouth disease should be kept out of day care or school until the fever is gone and mouth sores have healed.

Varicella (Chickenpox)         

Caused by a member of herpes virus group, transmitted by direct or indirect droplets from respiratory tract of an infected person Slight fever for up to 3 days before skin eruptions Infection lasts approximately 2 weeks and usually leaves the child with lifetime immunity Varicella virus vaccine, Varivax, is available Newborns and individuals with impaired immune system may get very ill or even die Can cause stillbirths or birth defects in pregnant women The disease is so contagious in its early stages that an exposed person who is not immune to the virus has a 70% to 80% chance of contracting the disease. The CDC recommends that children receive two doses of the vaccine, the first between 12 and 15 months of age and the second between 4 and 6 years. What causes shingles? (After infection, the virus migrates to a dermatome and may cause "shingles" or herpes zoster.)

Meningitis  

Inflammation of membranes that cover the brain and spinal cord, caused by a bacterial, fungal, or viral infection Bacterial meningitis (sometimes called spinal meningitis) is one of the most serious types o Sudden onset of fever, headache, neck pain or stiffness, vomiting, and irritability

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o Treated with immediate hospitalization and IV antibiotic therapy Meningitis caused by H. influenzae serotype b (Hib) can be prevented with Hib vaccine Viral meningitis usually is mild and clears up on its own within 10 to 14 days. Fungal meningitis can be quite serious and typically is seen in immunocompromised individuals, such as those with AIDS. Many states require reporting of bacterial meningitis cases to the health department, which probably will recommend preventive antibiotics for potentially exposed persons.

Hepatitis B     

Can lead to a serious, chronic infection of the liver Can be transmitted across the placenta or during birth process if the mother is infected Can be transmitted sexually, by blood transfusion, or by direct contact A child can carry the virus for years and only later develop liver failure or liver cancer. Many states now include immunization for HBV in the recommended immunization schedule, which usually is begun in the newborn nursery.

Reye’s Syndrome    

Cause unknown; linked to use of aspirin during viral illness Acute and sometimes fatal illness characterized by fatty invasion of the inner organs, especially the liver, and swelling of the brain Most often seen in children from infancy through puberty Prevention is the best treatment; children up to age 14 should never be given aspirin unless prescribed by a physician for a chronic condition.

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