2 diseases of the newborn

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  • NEC usually occurs within the first 2 weeks of life, usually after milk feeding has begun (at first, feedings are usually given through a tube that goes directly to the baby's stomach). About 10% of babies weighing less than 3 lbs.-5 oz. (1,500 grams) experience NEC. These premature infants have immature bowels, which are sensitive to changes in blood flow and prone to infection. They may have difficulty with blood and oxygen circulation and digestion, which increases their chances of developing NEC.
  • The exact cause of NEC is unknown, but one theory is that the intestinal tissues of premature infants are weakened by too little oxygen or blood flow. So when feedings are started, the added stress of food moving through the intestine allows bacteria normally found in the intestine to invade and damage the wall of the intestinal tissues. The damage may affect only a short segment of the intestine or can progress quickly to involve a much larger portion. The infant is unable to continue feedings and starts to appear ill if bacteria continue to spread through the wall of the intestines and sometimes into the bloodstream. He or she may also develop imbalances in the minerals in the blood. In severe cases of NEC, a hole (perforation) may develop in the intestine, allowing bacteria to leak into the abdomen and cause life-threatening infection (peritonitis). Because the infant's body systems are immature, even with quick treatment for NEC there may be serious complications. Other factors seem to increase the risk of developing NEC. Some experts believe that the makeup of infant formula, the rate of delivery of the formula, or the immaturity of the mucous membranes in the intestines can cause NEC. (Babies who are fed breast milk can also develop NEC, but their risk is lower.)Another theory is that babies born through difficult deliveries with lowered oxygen levels can develop NEC. When there isn't enough oxygen, the body sends the available oxygen and blood to vital organs instead of the gastrointestinal tract, and NEC can result.Babies with an increased number of red blood cells (polycythemia) in circulation also seem to be at higher risk for NEC. Too many red blood cells thicken the blood and hinder the transport of oxygen to the intestines.NEC sometimes seems to occur in "epidemics," affecting several infants in the same nursery. Although this may be due to coincidence, it suggests the possibility that it could in some cases be spread from one baby to another, despite the fact that all nurseries have very strict precautions to prevent the spread of infection.Theories to Support that Explains NECLittle supply of oxygenation -> plus feeding -> stress to the intestinal wall -> allowing bacteria to invade intestinal wall and bloodstream -> necrosis/perforation of the intestinal wall -> decrease absorption of the vitamins and minerals and Leak of bacteria into abdomen causing peritonitis.Difficult deliveries -> deprived oxygenation -> vital organs receives more oxygenIncreased RBC counts – thickens the blood and impaired circulation -> hinder the transport of oxgenation
  • The exact cause of NEC is unknown, but one theory is that the intestinal tissues of premature infants are weakened by too little oxygen or blood flow. So when feedings are started, the added stress of food moving through the intestine allows bacteria normally found in the intestine to invade and damage the wall of the intestinal tissues. The damage may affect only a short segment of the intestine or can progress quickly to involve a much larger portion.The infant is unable to continue feedings and starts to appear ill if bacteria continue to spread through the wall of the intestines and sometimes into the bloodstream. He or she may also develop imbalances in the minerals in the blood.In severe cases of NEC, a hole (perforation) may develop in the intestine, allowing bacteria to leak into the abdomen and cause life-threatening infection (peritonitis). Because the infant's body systems are immature, even with quick treatment for NEC there may be serious complications.Other factors seem to increase the risk of developing NEC. Some experts believe that the makeup of infant formula, the rate of delivery of the formula, or the immaturity of the mucous membranes in the intestines can cause NEC. (Babies who are fed breast milk can also develop NEC, but their risk is lower.)Another theory is that babies born through difficult deliveries with lowered oxygen levels can develop NEC. When there isn't enough oxygen, the body sends the available oxygen and blood to vital organs instead of the gastrointestinal tract, and NEC can result.Babies with an increased number of red blood cells (polycythemia) in circulation also seem to be at higher risk for NEC. Too many red blood cells thicken the blood and hinder the transport of oxygen to the intestines.NEC sometimes seems to occur in "epidemics," affecting several infants in the same nursery. Although this may be due to coincidence, it suggests the possibility that it could in some cases be spread from one baby to another, despite the fact that all nurseries have very strict precautions to prevent the spread of infection.
  • Signs and SymptomsThe symptoms of NEC can resemble those of other digestive conditions, and may vary from infant to infant. Common symptoms include:poor tolerance to feedingsfeedings stay in stomach longer than expecteddecreased bowel soundsabdominal distension (bloating) and tendernessgreenish (bile-colored) vomitredness of the abdomenincrease in stools, or lack of stoolsbloody stoolsMore subtle signs of NEC might include apnea (periodic stoppage of breathing), bradycardia (slowed heart rate), diarrhea, lethargy, and fluctuating body temperature. Advanced cases may show fluid in the peritoneal (abdominal) cavity, peritonitis (infection of the membrane lining the abdomen), or shock.Diagnosis and TreatmentThe diagnosis of NEC is usually confirmed by the presence of an abnormal gas pattern as seen on an X-ray. This is indicated by a "bubbly" appearance of gas in the walls of the intestine, large veins of the liver, or the presence of air outside of the intestines in the abdominal cavity. A surgeon may insert a needle into the abdominal cavity to withdraw fluid to determine whether there is a hole in the intestines.
  • NPO – confirmed NECAdministered thru enteral feedings – decrease incidence of NECMost infants with NEC are treated medically, and symptoms end without the need for surgery. Treatment includes:stopping feedingsnasogastric drainage (inserting a tube through the nasal passages down to the stomach to remove air and fluid from the stomach and intestine)intravenous (IV) fluids for fluid replacement and nutritionantibiotics for infectionfrequent examinations and X-rays of the abdomenThe baby's belly size is measured and watched carefully, and periodic blood samples are taken to look for bacteria. Stools are also checked for blood. If the abdomen is so swollen that it interferes with breathing, extra oxygen or mechanically assisted breathing (a ventilator) is used to help the baby breathe.A baby who responds favorably may be back on regular feedings within 72 hours, although in most cases feedings are withheld and antibiotics are continued for 7 to 10 days. If the bowel perforates (tears) or the condition worsens, surgery may be indicated. Severe cases of NEC may require removal of a segment of intestine. Sometimes after removal of diseased bowel, the healthy areas can be sewn back together. Other times, especially if the baby is very ill or there is spillage of stool in the abdomen, the surgeon will bring an area of the intestine or bowel to an opening on the abdomen (called an ostomy). Most infants who develop NEC recover fully and do not have further feeding problems. In some cases, scarring and narrowing of the bowel may occur and can cause future intestinal obstruction or blockage. Another residual problem may be malabsorption (the inability of the bowel to absorb nutrients normally). This is more common in children who required surgery for NEC and had part of their intestine removed.
  • per rectum – increase danger of perforationPosition – avoid pressure on distended abdomenFacilitate observation
  • Some newborns' breathing during the first hours of life is more rapid and labored than normal because of a lung condition called transient tachypnea of the newborn (TTN).About 1% of all newborns develop TTN, which usually eases after a few days with treatment. Babies born with TTN need special monitoring and treatment while in the hospital, but afterwards most make a full recovery, with no lasting effect on growth and development.About TTNBefore birth, a fetus' lungs are filled with fluid. While inside the mother, a fetus does not use the lungs to breathe — all oxygen comes from the blood vessels of the placenta.As the due date nears, the baby's lungs begin to clear the fluid in response to hormonal changes. Some fluid may also be squeezed out during the birth, as a baby passes through the birth canal. After the birth, as a newborn takes those first breaths, the lungs fill with air and more fluid is pushed out of the lungs. Any remaining fluid is then coughed out or gradually absorbed into the body through the bloodstream and lymphatic system.In infants with TTN, however, extra fluid in the lungs remains or the fluid is cleared too slowly. So it is more difficult for the baby to inhale oxygen properly, and the baby breathes faster and harder to get enough oxygen into the lungs.Causes of TTNTTN, also called "wet lungs" or type II respiratory distress syndrome, usually can be diagnosed in the hours after birth. It's not possible to detect before the birth whether a child will have it.TTN can occur in both preemies (because their lungs are not yet fully developed) and full-term babies.Newborns at higher risk for TTN include those who are:delivered by cesarean section (C-section)born to mothers with diabetesborn to mothers with asthmasmall for gestational age (small at birth)During vaginal births, especially with full-term babies, the pressure of passing through the birth canal squeezes some of the fluid out of the lungs. Hormonal changes during labor may also lead to absorption of some of the fluid.Babies who are small or premature or who are delivered via rapid vaginal deliveries or C-section don't undergo the usual squeezing and hormone changes of a vaginal birth. So they tend to have more fluid than normal in their lungs when they take their first breaths.
  • A respiratory problem seen in the newborn shortly after deliveryIt is likely due to retained lung fluid, and common in 35+ week gestation babies who are delivered by caesarian section without laborUsually, this condition resolves over 24-48 hours.Pulmonary immaturity has also been proposed as a causative factor.Mild surfactant deficiency has also been suggested as a causative factor.
  • (higher than the normal range of 40-60 times per minute)
  • Antigens –foreign body capable of producing immune response if recognized by the body as foreignIn Rh system, the person must be exposed to the Rh antigen before significant antibody formation takes place and causes sensitivity response called isoimmunizationHydropsand hemolysis causes hypoxia, cardiac failure (fetus) generalized edema (anasarca) and pleural effusionMay be delivered still born or in severe respiratory distressRh positive – present Rh factorPh negative - absence
  • Jaundice –first 24 hours increase bili liver’s inability to conjugate excess biliAnemia – hemolysisHypogly – pancreatic hyperplasia
  • RhIg (RhoGAM) – must be administered to unsensitized mothers within 72 hours after the first deliveryAdmin of RhIg at 26 to 28 weeks of gestation further reduces risk of isoimmunization
  • RhIg (RhoGAM) – must be administered to unsensitized mothers within 72 hours after the first deliveryAdmin of RhIg at 26 to 28 weeks of gestation further reduces risk of isoimmunization
  • Amount exchanged and infused
  • 3 representatives of chromosome 21 are present instead of the usual 2
  • Extra chromosome 21  trisomy 21-greater risk for older women - > 35 years of agePaternal age factor, 55 years of age or older
  • Epicanthal – extra fold at the inner canthusIris may have white specks(bradycephaly) Head size is usually smaller that 10th – 20th percentileRag-doll appearance – poor muscle toneSimian line – a single horinzontal palm crease rather than the usual crease
  • PN testing – amniocentesis chorionic villus sampling
  • Lack shivering response  produces heat through increased metabolic process 
  • Warm items first – reduce heat loss
  • Head covering to prevent heat loss
  • Essential public strategy that enables the early detection and management of several congenital metabolic disorders, which if left untreated , may lead to mental retardation and even deathFor early detection and management of congenital metabolic disorders
  • A simple procedure to find out if the infant has medical condition that can result to mental retardation or even death if not treated.Air dry in 4-6 hoursSent to the lab within 24 hours
  • Samples taken less than 24 hours from birth require repeat screening at 2 weeks of ageSample collection done before the ideal time may result in:Falsely elevated thyroid stimulating hormone (TSH) = false (+) screen for CHFalsely elevated 17 hydroxyprogesterone (17-OH-P) = false (+) screeen for CHFalsely low galactose and phenylalalnine = false (-) screen for GAL and PKU
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.
  • Thyroid hormone - which is essential to growth of the brain and the bodyNeonates who are born without the ability to synthesize adequate amounts of thyroid hormoneDelayed development of the nervous system
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.*ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walking and talking)*TreatmentLifetime oral doses of thyroid hormone. L-Thyroxine, to promote normal development and mixed with food or formula. Instruct parents to avoid Soy-based formulas and iron supplements. Avoid adjusting medications without MD’s order to prevent under medication or over medication. Excessive medication can cause D-I-T-S Diarrhea, Inability to sleep, Tachycardia, Shakiness in the child
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.*ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walking and talking)*TreatmentLifetime oral doses of thyroid hormone. L-Thyroxine, to promote normal development and mixed with food or formula. Instruct parents to avoid Soy-based formulas and iron supplements. Avoid adjusting medications without MD’s order to prevent under medication or over medication. Excessive medication can cause D-I-T-S Diarrhea, Inability to sleep, Tachycardia, Shakiness in the child
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.*ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walking and talking)*TreatmentLifetime oral doses of thyroid hormone. L-Thyroxine, to promote normal development and mixed with food or formula. Instruct parents to avoid Soy-based formulas and iron supplements. Avoid adjusting medications without MD’s order to prevent under medication or over medication. Excessive medication can cause D-I-T-S Diarrhea, Inability to sleep, Tachycardia, Shakiness in the child
  • Congenital Hypothyroidism*this is a congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development.*this disorder can be used by congenital absence of underdevelopment of the fetal thyroid glands, hereditary conditions, maternal iodine deficiency and maternal intake of anti thyroid drugs during pregancy (H-U-Mi-D)*NB with this d/o do not exhibit symptoms because of the presence of maternal thyroid hormones in their body. After 2 to 3 weeks, MTH are depleted and the infant must rely on its own TG to produce the hormones.*ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walking and talking)*TreatmentLifetime oral doses of thyroid hormone. L-Thyroxine, to promote normal development and mixed with food or formula. Instruct parents to avoid Soy-based formulas and iron supplements. Avoid adjusting medications without MD’s order to prevent under medication or over medication. Excessive medication can cause D-I-T-S Diarrhea, Inability to sleep, Tachycardia, Shakiness in the childRegular monitoring of the child’s weight, overall health and thyroid hormones level
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice*TreatmentLifetime administration of the deficient or missing hormones HYDROCORTISONES lessens the amount of androgens (prevents early puberty and allows for more typical growth and development) *Monitor child’s growth, BP and hormone levels throughout childhood to prevent under or over medication. Over medication can results to Cushing’s syndrome (Stretch marks, rounded face, weight gain, hypertension and bone loss). Under medication can occur during periods of stress and illness when higher doses of the drug are required by the bodyCorrective surgery for enlarged clitoris (can be done as early as one to three years of age. To separate labia and to create a normal vagina
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • Muscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acne
  • Muscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acne
  • Muscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acne
  • Untreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • Untreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • Untreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice*TreatmentLifetime administration of the deficient or missing hormones HYDROCORTISONES lessens the amount of androgens (prevents early puberty and allows for more typical growth and development) *Monitor child’s growth, BP and hormone levels throughout childhood to prevent under or over medication. Over medication can results to Cushing’s syndrome (Stretch marks, rounded face, weight gain, hypertension and bone loss). Under medication can occur during periods of stress and illness when higher doses of the drug are required by the bodyCorrective surgery for enlarged clitoris (can be done as early as one to three years of age. To separate labia and to create a normal vagina
  • CAH is caused by a deficiency of adrenal gland hormones. This disorder develops when a particular enzyme called 21 hydroxylase is missing or not working correctly.21-OH is responsible for the production of hormones in cortisol and aldosterone in the adrenal glands. CORTISOL is involved in glucose metabolism and in normal inflammation and immune response. ALDOSTERONE is responsible for blood pressure and sodium retention. Excessive androgens, since it is produced by the adrenal glands.*ManifestationsPoor feedingListlessness and drowsinessVomitingDiarrheaWeight lossHypotensionHyponatremiaMetabolic acidosisUntreated boys may have some of the following traits: M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair during childhoodSmaller than normal testiclesSevere acneUntreated girls may develop male like traits and behaviors, called VIRILIZATION. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hair in airmpits and pubic areaLack of menstrual periods or scanty or irregular periodsExcess hair on the face and bodyDeep, husky voice*TreatmentLifetime administration of the deficient or missing hormones HYDROCORTISONES lessens the amount of androgens (prevents early puberty and allows for more typical growth and development) *Monitor child’s growth, BP and hormone levels throughout childhood to prevent under or over medication. Over medication can results to Cushing’s syndrome (Stretch marks, rounded face, weight gain, hypertension and bone loss). Under medication can occur during periods of stress and illness when higher doses of the drug are required by the bodyCorrective surgery for enlarged clitoris (can be done as early as one to three years of age. To separate labia and to create a normal vagina
  • This hereditary disorder is characterized by the lack of the enzyme Galactose-1-Phosphate uridylTransferase (GALT) that converts galactose to glucose, the form of sugar that can be used by body cells.Build up of galatactose in the body resutls in blindness, severe mental retardation, growth deficiency and deathInfants with galactosemia usually have diarrhea and vomiting within a few days of drinking ilk or formula containing lactose, initial symptoms also include (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suckWithout treatment, the infant may exhibit hypoglycemia, seizures, hepatomegaly, jaundice, bleeding, serious infections and cataractsTreatment: Giving the child a special lactose free formula and exclusion of lactose and galactose foods such as milk (including breast milk) and other dairy products from the diet through out life.Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medications
  • This hereditary disorder is characterized by the lack of the enzyme Galactose-1-Phosphate uridylTransferase (GALT) that converts galactose to glucose, the form of sugar that can be used by body cells.Build up of galatactose in the body resutls in blindness, severe mental retardation, growth deficiency and deathInfants with galactosemia usually have diarrhea and vomiting within a few days of drinking ilk or formula containing lactose, initial symptoms also include (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suckWithout treatment, the infant may exhibit hypoglycemia, seizures, hepatomegaly, jaundice, bleeding, serious infections and cataractsTreatment: Giving the child a special lactose free formula and exclusion of lactose and galactose foods such as milk (including breast milk) and other dairy products from the diet through out life.Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medications
  • This hereditary disorder is characterized by the lack of the enzyme Galactose-1-Phosphate uridylTransferase (GALT) that converts galactose to glucose, the form of sugar that can be used by body cells.Build up of galatactose in the body resutls in blindness, severe mental retardation, growth deficiency and deathInfants with galactosemia usually have diarrhea and vomiting within a few days of drinking ilk or formula containing lactose, initial symptoms also include (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suckWithout treatment, the infant may exhibit hypoglycemia, seizures, hepatomegaly, jaundice, bleeding, serious infections and cataractsTreatment: Giving the child a special lactose free formula and exclusion of lactose and galactose foods such as milk (including breast milk) and other dairy products from the diet through out life.Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medications
  • This hereditary disorder is characterized by the lack of the enzyme Galactose-1-Phosphate uridylTransferase (GALT) that converts galactose to glucose, the form of sugar that can be used by body cells.Build up of galatactose in the body resutls in blindness, severe mental retardation, growth deficiency and deathInfants with galactosemia usually have diarrhea and vomiting within a few days of drinking ilk or formula containing lactose, initial symptoms also include (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suckWithout treatment, the infant may exhibit hypoglycemia, seizures, hepatomegaly, jaundice, bleeding, serious infections and cataractsTreatment: Giving the child a special lactose free formula and exclusion of lactose and galactose foods such as milk (including breast milk) and other dairy products from the diet through out life.Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medicationsAny foods or drugs which contain the ingredients Lactulose, Casein, Caseinate, Lactalbumin, Curds, Whey or Whey solidsCalcium and Vitamin D deficiency is likely to develop in a child on a lactose free. Therefor, the child is given supplements to prevent deficiences
  • This hereditary disorder is characterized by the lack of the enzyme Galactose-1-Phosphate uridylTransferase (GALT) that converts galactose to glucose, the form of sugar that can be used by body cells.Build up of galatactose in the body resutls in blindness, severe mental retardation, growth deficiency and deathInfants with galactosemia usually have diarrhea and vomiting within a few days of drinking ilk or formula containing lactose, initial symptoms also include (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suckWithout treatment, the infant may exhibit hypoglycemia, seizures, hepatomegaly, jaundice, bleeding, serious infections and cataractsTreatment: Giving the child a special lactose free formula and exclusion of lactose and galactose foods such as milk (including breast milk) and other dairy products from the diet through out life.Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medicationsAny foods or drugs which contain the ingredients Lactulose, Casein, Caseinate, Lactalbumin, Curds, Whey or Whey solidsCalcium and Vitamin D deficiency is likely to develop in a child on a lactose free. Therefor, the child is given supplements to prevent deficiencies
  • A metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanineGuthrie testLow protein dietBreastmilk – low in phenylalanineA metabolic disorder characterized by lack of enzyme Phenylalanine hydroxylase (PAH) needed to process the amino acid phenylalanine, a proteiin that is found in almost every food, except pure fat and sugar. The resultant build up of the said protein in the body leads to mental retardation
  • It is a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.G6PD deficiency is an inherited condition in which the body doesn't have enough of the enzyme glucose-6-phosphate dehydrogenase, or G6PD, which helps red blood cells (RBCs) function normally. This deficiency can cause hemolyticanemia, usually after exposure to certain medications, foods, or even infections. Most people with G6PD deficiency don't have any symptoms, while others develop symptoms of anemia only after RBCs have been destroyed, a condition called hemolysis. In these cases, the symptoms disappear once the cause, or trigger, is removed. In rare cases, G6PD deficiency leads to chronic anemia. With the right precautions, a child with G6PD deficiency can lead a healthy and active life.About G6PD DeficiencyG6PD is one of many enzymes that help the body process carbohydrates and turn them into energy. G6PD also protects red blood cells from potentially harmful by products that can accumulate when a person takes certain medications or when the body is fighting an infection.In people with G6PD deficiency, either the RBCs do not make enough G6PD or what is produced cannot properly function. Without enough G6PD to protect them, RBCs can be damaged or destroyed. Hemolyticanemia occurs when the bone marrow (the soft, spongy part of the bone that produces new blood cells) cannot compensate for this destruction by increasing its production of RBCs.
  • Children are particularly vulnerable to the crises of illness and hospitalization because:Stress represents a change from the usual state of health and environmental routineChildren have limited number of coping mechanisms to resolve stressorsReactions depend on their developmental age
  • Children are particularly vulnerable to the crises of illness and hospitalization because:Stress represents a change from the usual state of health and environmental routineChildren have limited number of coping mechanisms to resolve stressorsReactions depend on their developmental age
  • Detachment occurs usually after prolonged separation from parentsPhase of ProtestReact aggressively to separation from parentBehavior is from a few hours to several daysPhase of DespairChild is less activeUninterested in play or foodWithdraws from othersSad, lonely, apatheticStops cryingDepression is evidentPhase of DetachmentAlso called denialAppears to finally adjust to the surroundingsCopes by forming superficial relationships with othersNot a sign of contentment
  • Detachment occurs usually after prolonged separation from parentsPhase of ProtestReact aggressively to separation from parentBehavior is from a few hours to several daysPhase of DespairChild is less activeUninterested in play or foodWithdraws from othersSad, lonely, apatheticStops cryingDepression is evidentPhase of DetachmentAlso called denialAppears to finally adjust to the surroundingsCopes by forming superficial relationships with othersNot a sign of contentment
  • Detachment occurs usually after prolonged separation from parentsPhase of ProtestReact aggressively to separation from parentBehavior is from a few hours to several daysPhase of DespairChild is less activeUninterested in play or foodWithdraws from othersSad, lonely, apatheticStops cryingDepression is evidentPhase of DetachmentAlso called denialAppears to finally adjust to the surroundingsCopes by forming superficial relationships with othersNot a sign of contentment
  • Increases the perception of threatCan affect child's coping skillsGreatly depend on their age:
  • Fear of bodily Injury and Pain-pain in childhood brings trauma during adulthood and tend to avoid medical careNurses must appreciate their concerns about bodily harm and reactions to painToddler – definition of body boundaries is poorly developed
  • Speak in quiet pleasant tonesBend down to meet child on own levelUse words appropriate to age/communication ability; do not use clichés.Do not explain more than necessaryExplain all procedures and the reason for itBe honestDo not make a promise that you cannot keepObserve nonverbal communication for clues to level of understandingDo not threaten; and when necessary, punish the act not the child (I like you but not what you did)Allow child to show feelings, provide therapeutic play, pounding or throwing toys, allow child to cry, encourage drawing and creative drawing
  • Teach parents to anticipate next stage of developmentIf teaching is interrupted, start over from the beginningProvide independenceDo not compare child’s progress to that of anyone elseProvide praise at every opportunityInstead of asking what something is, ask child to give it a name or tell you about itAllow choices where possible
  • Q-U-E-S-TQUESTION the child’s parents and child too, if he is old enough to respondUSE appropriate pain assessmentEVALUATE the child’s behaviourSECURE the parent’s active participation in treatmentTAKE the cause of the pain into consideration
  • – pictorial tool often used for preschool and young school-age childrenThe child looks at several pictures of faces ranging from happy to sad (0 to 5 scale) and then chooses whichever face reflects his or her pain
  • Oucher Scale – pictorial pain assessment tool for 3-7 year old children 
  • FLACC (Face, Legs, Activity, Cry and Consolability) – for infants and very young childrenBehavior is observed to assess painMeasures each of the five identified categories on a 0 to 2 scaleThe higher the total score, the more pain
  • FLACC (Face, Legs, Activity, Cry and Consolability) – for infants and very young childrenBehavior is observed to assess painMeasures each of the five identified categories on a 0 to 2 scaleThe higher the total score, the more pain
  • CRIES Neonatal Postoperative Pain Measurement ScaleCryingREQUIRES oxygen to maintain saturation about 95%Increased heart rate and blood pressureExpressionSleeplessnessNeonatal Infant Pain ScaleFacial ExpressionCryingBreathing patternsState of arousal Movement of arms and legsPremature Infant pain ProfileGestational ageHeart rateOxygen saturationBehavioral stateBrow bulgeEye squeezeNasolabialfurroq
  • CRIES Neonatal Postoperative Pain Measurement ScaleCryingREQUIRES oxygen to maintain saturation about 95%Increased heart rate and blood pressureExpressionSleeplessnessNeonatal Infant Pain ScaleFacial ExpressionCryingBreathing patternsState of arousal Movement of arms and legsPremature Infant pain ProfileGestational ageHeart rateOxygen saturationBehavioral stateBrow bulgeEye squeezeNasolabial furrow
  • CRIES Neonatal Postoperative Pain Measurement ScaleCryingREQUIRES oxygen to maintain saturation about 95%Increased heart rate and blood pressureExpressionSleeplessnessNeonatal Infant Pain ScaleFacial ExpressionCryingBreathing patternsState of arousal Movement of arms and legsPremature Infant pain ProfileGestational ageHeart rateOxygen saturationBehavioral stateBrow bulgeEye squeezeNasolabial furrow
  • 1. INFANT: Facial expression is the most common and consistent behavioural response to all stimuli, painful or pleasurable and may be the single best indicator of pain for the provider and the parents. According to studies, it is more reliable than crying, HR or body position of movement. Mouth stretched openEyes tightly shutBrows and forehead knittedCheeks raised high enough2. Younger ChildrenNarrowing of the eyesGrimace or fearful appearanceFrequent and longer lasting bouts of crying with a tone that is higher and louder than normalLess receptiveness to comforting by parents or other caregivers Holding or protecting the painful areas
  • PAIN Management:Pharmacologic interventionsAnticipate and prevent or minimize pain related to hospitalization, procedure and treatmentIdentify and relieve existing painNon pharmacologic interventions to reduce stress, increase comfort and enhance healing
  • Pharmacologic Intervention – mainstay of pain management and it depends on the specific needs of the patientOpioid analgesics-Highly effective pain relievers and constitute the core of most pharmacologic interventions to manage acute pain in infants and children-Oral, sublingual, rectal, nasal, subcutaneous, transdermal, IV and intraspinal*Morphine (MS contin)*Fetanyl (Duragesic)
  • Pharmacologic Intervention – mainstay of pain management and it depends on the specific needs of the patientOpioid analgesics-Highly effective pain relievers and constitute the core of most pharmacologic interventions to manage acute pain in infants and children-Oral, sublingual, rectal, nasal, subcutaneous, transdermal, IV and intraspinal*Morphine (MS contin)*Fetanyl (Duragesic)Non Opioid Analgesics-are prescribed to manage mild to moderate pain.-infants and children metabolize non opioid analgesics in the same manner and at the same rate as adult.*NSAIDS -relieve for mild to moderate pain and anti inflammatory effects -Ibuprofen (advil); Naproxen (Naprosyn); Tolmetin (Tolectin); Indomethacin (Indocin) & Ketorolac (Toradol) are approved for use in children -S.E: Inhibition of platelet aggregation and GI irritation*Acetaminophen -Is the DOC for treating mild pain. Available in suppository, liquid and table form. -it has the added benefit of helping reduce fever and is very safe, even for neonates. -long term can cause risk of liver damage
  • Pharmacologic Intervention – mainstay of pain management and it depends on the specific needs of the patientOpioid analgesics-Highly effective pain relievers and constitute the core of most pharmacologic interventions to manage acute pain in infants and children-Oral, sublingual, rectal, nasal, subcutaneous, transdermal, IV and intraspinal*Morphine (MS contin)*Fetanyl (Duragesic)Non Opioid Analgesics-are prescribed to manage mild to moderate pain.-infants and children metabolize non opioid analgesics in the same manner and at the same rate as adult.*NSAIDS -relieve for mild to moderate pain and anti inflammatory effects -Ibuprofen (advil); Naproxen (Naprosyn); Tolmetin (Tolectin); Indomethacin (Indocin) & Ketorolac (Toradol) are approved for use in children -S.E: Inhibition of platelet aggregation and GI irritation*Acetaminophen -Is the DOC for treating mild pain. Available in suppository, liquid and table form. -it has the added benefit of helping reduce fever and is very safe, even for neonates. -long term can cause risk of liver damage
  • Pharmacologic Intervention – mainstay of pain management and it depends on the specific needs of the patientOpioid analgesics-Highly effective pain relievers and constitute the core of most pharmacologic interventions to manage acute pain in infants and children-Oral, sublingual, rectal, nasal, subcutaneous, transdermal, IV and intraspinal*Morphine (MS contin)*Fetanyl (Duragesic)Non Opioid Analgesics-are prescribed to manage mild to moderate pain.-infants and children metabolize non opioid analgesics in the same manner and at the same rate as adult.*NSAIDS -relieve for mild to moderate pain and anti inflammatory effects -Ibuprofen (advil); Naproxen (Naprosyn); Tolmetin (Tolectin); Indomethacin (Indocin) & Ketorolac (Toradol) are approved for use in children -S.E: Inhibition of platelet aggregation and GI irritation*Acetaminophen -Is the DOC for treating mild pain. Available in suppository, liquid and table form. -it has the added benefit of helping reduce fever and is very safe, even for neonates. -long term can cause risk of liver damagePharmacologic InterventionsNonopioids and NSAIDs – mild to moderate pain; antipyretic effectsAcetaminophen and ibuprofenOpioids – sedation, mental confusion, constipation, pruritus, nausea, vomitingMorphine and FentanylMonitor vital signs after administering any analgesicsEMLA (Eutetic mixture of local anesthetics) – topical analgesicCombinationChildren (except infants younger than 3-6 months) – metabolize drugs more rapidly than adultsYounger children may require higher doses of opioids to achieve the same effect
  • EMLA Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact skin under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the skin and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.  Lidocaine and prilocaine are amide-type local anesthetic agents.  Both lidocaine and prilocaine stabilize neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action.
  • Complementary and alternative medicine (CAM)Complementary Pain MedicineMusic TherapyHypnosis – child’s concentration is focused, narrowed or absorbedTENS (transcutaneous electric nerve stimulation) unit – electric stimulation to relieve painAcupunctureNon-Pharmacologic CareComfort, positioning and non-nutritive suckingDistraction – method used to divert attention from the main portion of experience. Ex. Blowing bubblesRelaxation – tense and relax different muscle groupsGuided Imagery – use of pleasant mental images of events, feelings or sensations. Ex. Favorite vacation spotBiofeedback – training designed to help an individual control his or her autonomic nervous systemBehavioral Contracting
  • Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Infancy. Concept of death – NONENursing considerations: Be aware that the older infant will experience separation anxietyHelp the family cope with death so they can be available to the infantEarly childhood. Knows the words “DEAD” and “DEATH”. Reactions are influenced by the attitude of the parents.Nursing considerations:Help the family members including siblings cope with their feelingsAllow the child to express his own feelings in an open and honest manner.Middle childhood. Understands universality and irreversibility of death. May have a fear of parents dying.Nursing considerationsUse play to facilitate the child’s understanding of deathAllow siblings to express their feelings.Late childhood. Beings to incorporate family and cultural beliefs about death. Explores views of an afterlife and faces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize his fearsHelp the child discuss his concerns with the familyAdolescence. Adult perception of death, but still focused on the HERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion and anxietySupport and maintain self esteem
  • Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Infancy. Concept of death – NONENursing considerations: Be aware that the older infant will experience separation anxietyHelp the family cope with death so they can be available to the infantEarly childhood. Knows the words “DEAD” and “DEATH”. Reactions are influenced by the attitude of the parents.Nursing considerations:Help the family members including siblings cope with their feelingsAllow the child to express his own feelings in an open and honest manner.Middle childhood. Understands universality and irreversibility of death. May have a fear of parents dying.Nursing considerationsUse play to facilitate the child’s understanding of deathAllow siblings to express their feelings.Late childhood. Beings to incorporate family and cultural beliefs about death. Explores views of an afterlife and faces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize his fearsHelp the child discuss his concerns with the familyAdolescence. Adult perception of death, but still focused on the HERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion and anxietySupport and maintain self esteem
  • Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Infancy. Concept of death – NONENursing considerations: Be aware that the older infant will experience separation anxietyHelp the family cope with death so they can be available to the infantEarly childhood. Knows the words “DEAD” and “DEATH”. Reactions are influenced by the attitude of the parents.Nursing considerations:Help the family members including siblings cope with their feelingsAllow the child to express his own feelings in an open and honest manner.Middle childhood. Understands universality and irreversibility of death. May have a fear of parents dying.Nursing considerationsUse play to facilitate the child’s understanding of deathAllow siblings to express their feelings.Late childhood. Beings to incorporate family and cultural beliefs about death. Explores views of an afterlife and faces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize his fearsHelp the child discuss his concerns with the familyAdolescence. Adult perception of death, but still focused on the HERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion and anxietySupport and maintain self esteem
  • Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Infancy. Concept of death – NONENursing considerations: Be aware that the older infant will experience separation anxietyHelp the family cope with death so they can be available to the infantEarly childhood. Knows the words “DEAD” and “DEATH”. Reactions are influenced by the attitude of the parents.Nursing considerations:Help the family members including siblings cope with their feelingsAllow the child to express his own feelings in an open and honest manner.Middle childhood. Understands universality and irreversibility of death. May have a fear of parents dying.Nursing considerationsUse play to facilitate the child’s understanding of deathAllow siblings to express their feelings.Late childhood. Beings to incorporate family and cultural beliefs about death. Explores views of an afterlife and faces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize his fearsHelp the child discuss his concerns with the familyAdolescence. Adult perception of death, but still focused on the HERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion and anxietySupport and maintain self esteem
  • Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Infancy. Concept of death – NONENursing considerations: Be aware that the older infant will experience separation anxietyHelp the family cope with death so they can be available to the infantEarly childhood. Knows the words “DEAD” and “DEATH”. Reactions are influenced by the attitude of the parents.Nursing considerations:Help the family members including siblings cope with their feelingsAllow the child to express his own feelings in an open and honest manner.Middle childhood. Understands universality and irreversibility of death. May have a fear of parents dying.Nursing considerationsUse play to facilitate the child’s understanding of deathAllow siblings to express their feelings.Late childhood. Beings to incorporate family and cultural beliefs about death. Explores views of an afterlife and faces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize his fearsHelp the child discuss his concerns with the familyAdolescence. Adult perception of death, but still focused on the HERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion and anxietySupport and maintain self esteem
  • Helping parents to talk with their child about dying if he is ready to do soEncouraging all family members to express their feelings, even though they might be difficult to hearAllowing families to spend as much time as possible with the dying childAllowing and encouraging parents to continue to take an active role in their child’s careReminding parents that they don’t always have to be strong and ask for help
  • Helping parents to talk with their child about dying if he is ready to do soEncouraging all family members to express their feelings, even though they might be difficult to hearAllowing families to spend as much time as possible with the dying childAllowing and encouraging parents to continue to take an active role in their child’s careReminding parents that they don’t always have to be strong and ask for help
  • Thank you for Listening!
  • 2 diseases of the newborn

    1. 1. Di s e a s e s o f t h e Ne wb o r n Pr e p a r e d b y : Ha n s Ch r i s t i a n f . Vi t u g RN, MA N c F a c u l t y /C l i n i c a l I n s t r u c t o r /R e v i e w e r
    2. 2. "Necrotizing"means the deathof tissue, "entero"refers to thesmall intestine,"colo" to the largeintestine, and"itis" meansinflammation.
    3. 3. An acuteinflammatorydisease of the bowelwith increasedincidence inpreterm and highrisk infants
    4. 4. Theories to Support that Explains NEC1.Little supply of oxygenation -> plus feeding -> stress to the intestinal wall -> allowing bacteria to invade intestinal wall and bloodstream -> necrosis/perforation of the intestinal wall -> decrease absorption of the vitamins and minerals and Leak of bacteria into abdomen causing peritonitis.2.Difficult deliveries -> deprived oxygenation -> vital organs receives more oxygen3.Increased RBC counts – thickens the blood and impaired circulation -> hinder the transport of oxgenation
    5. 5. How does it happen?• Prematurity remains the most prominent risk factor• Great damage to mucosal lining  diminished blood supply  stop secreting protective lubricating mucus  unprotected bowel attacked by proteolytic enzymes  unable to synthesize IgM  Gas-forming bacteria invades damaged area  produce intestinal pneumatosis (presence of air in the submucosal or subserosal surfaces of the bowel)
    6. 6. Signs and Symptoms• Infant may “not look well”• Poor feeding• Apnea• Vomiting (often bile stained)• Decreased U/O• Hypothermia• Distended abdomen• Gastric residuals• Blood in the stools
    7. 7. Diagnostic EvaluationRadiographySausage-shapeddilation of theintestines“Soap suds” orbubbly appearance of thickened bowelwall
    8. 8. Diagnostic EvaluationLaboratoryexaminations – Anemia – Leukopenia – Leukocytosis – Metabolic acidosis – Electrolyte imbalance
    9. 9. Therapeutic Management• Oral feedings withheld for at least 24 to 48 hours• Breast feeding is preferred• Antibiotics• Probiotics – Lactobacillus acidophilus – Bifidobacterium infantis
    10. 10. Nursing Management• Observation and assessment• Infants left undiapered• Position infant supine or on the side• Vital signs including blood pressure –Avoid rectal temperature
    11. 11. TRANSIENT TACHYPNEA OF THE NEWBORN
    12. 12. Some newborns breathing duringthe first hours of life is more rapidand labored than normal becauseof a lung condition called transienttachypnea of the newborn (TTN).
    13. 13. Definition• A respiratory problem seen in the newborn shortly after delivery• It is likely due to retained lung fluid• Common in 35+ week gestation babies who are delivered by caesarian section without labor• Resolves over 24-48 hours• Causative Factors – Pulmonary immaturity – Mild surfactant deficiency
    14. 14. Causes of TTNTTN, also called "wet lungs" or type IIrespiratory distress syndrome, usuallycan be diagnosed in the hours afterbirth.TTN can occur in both preemies(because their lungs are not yet fullydeveloped) and full-term babies.
    15. 15. New borns at higher risk for TTNinclude those who are:delivered by cesarean section(C-section)born to mothers with diabetesborn to mothers with asthmasmall for gestational age (smallat birth)
    16. 16. Pathophysiology• Lower levels of circulating catecholamines after a caesarean section which are necessary to alter the function of channels that absorb excess fluid from the lungs• Delayed absorption of fetal lung fluid from the pulmonary lymphatic system increased fluid in the lungs  increased airway resistance and reduced lung compliance
    17. 17. Clinical Manifestations• Period of rapid breathing• Tachypnea• Intracostal and subcostal retractions• Grunting• Nasal flaring• Possible cyanosis
    18. 18. Diagnostic Evaluation and Therapeutic Management• Diagnostic evaluation – Chest X-ray – Levels of PG were found to be negative in certain newborns• Management – Supplemental oxygen – Antibiotics
    19. 19. ERYTHROBLASTOSIS FETALIS/HEMOLYTIC DISEASE OF THE NEWBORNAbnormal, rapiddestruction of RBCHyperbilirubinemiain the first 24hours of life ismost often theresult
    20. 20. Hemolytic disease of the newborn (HDN)Major causes of RBC destruction – Rh Incompatibility (Isoimmunization) • Mother is Rh negative, and infant is Rh positive • May not occur in first pregnancy • Increased risk of fetal blood being transferred to maternal circulation  subsequent pregnancy with Rh (+) fetus maternal antibodies formed will attach and destroy fetal erythrocytes • Progressive hemolysis in utero  fetus compensates, accelerates rate of erythropoesis  immature RBCs appear  erythroblastosis fetalis (hydrops fetalis)
    21. 21. Hemolytic disease of the newborn (HDN)Major causes of RBC destruction – ABO Incompatibility • Between a mother with type O and an infant with A or B blood groups. • Anti-A and Anti-B already present in the maternal circulation cross the placenta and attach to fetal RBCs  hemolysis • Less severe hemolytic reaction the Rh incompatibility • May occur in first pregnancy
    22. 22. Signs and SymptomsJaundice –Most not jaundice at birthAnemiaHypovolemicshock may developHypoglycemia
    23. 23. Diagnostic Evaluation• Maternal antibody titer (Indirect Coomb’s test)• Amniocentesis• Ultrasound
    24. 24. Therapeutic ManagementPrevention of Rh Isoimmunization –Administration of RhIg –RhIg (RhoGAM) – must be administered to unsensitized mothers within 72 hours after the first delivery –Admin of RhIg at 26 to 28 weeks of gestation further reduces risk of isoimmunization
    25. 25. Therapeutic Management• Exchange Transfusion –Infants blood is removed in small amounts (5 to 10 ml at a time) and replaced with compatible blood –For severe hydrops• ABO incompatibility –Early detection and phototherapy
    26. 26. Nursing Management• Recognizing jaundice – initial nursing responsibility• Prepares family incase of transfusion and assist practitioner – Infant remains NPO during procedures – Maintain documentation of blood volume exchange, time, cumulative record of the total blood exchanged – Vital signs – Signs of transfusion reactions
    27. 27. DOWN SYNDROME
    28. 28. Down Syndrome• The genetic disorder most frequently seen as causing moderate to severe mental retardation• Etiology is unknown – Genetic predisposition – Exposure to radiation before conception – Immunologic problems – Infection
    29. 29. Clinical Manifestations• Bradycephaly• Back of the head is flat• Epicanthal folds• Palpebral fissure slanting laterally upward• Tongue may protrude• Narrow palate• Low-set ears• Short broad hands• Transpalmar crease (simian line)• Short stature• Rag-doll appearance• IQ of 50-70
    30. 30. Diagnostic Evaluation• Evident at birth• Prenatal testing• Chromosomal analysis
    31. 31. Therapeutic Management• Surgery to correct cardiac abnormalities, GI malformations and craniofacial deviations• Neck radiography before the child participates in any sports
    32. 32. Nursing Management• Options for fluid and calorie intake – Breastfeeding may not be possible, immature sucking reflex – Special bottles and utensils• Routine – Changes causes frustration and decreased coping abilities• Encourage self-care• Advise X-rays before participating in sports
    33. 33. TEMPERATURE CONTROL
    34. 34. Cold Stress• Infants lack shivering response• Norepinephrine (SNS) stimulates fat metabolism to produce internal heat  blood  surface tissues• Increased in metabolism  increased oxygen consumption• Norepinephrine  vasoconstriction  decrease oxygen decreased glucose metabolism• Results: Hypoxia, Metabolic acidosis, Hypoglycemia
    35. 35. Three primary methods for maintaining a neutral thermal environment• Incubator• Radiant warming panel• Open bassinet with cotton blankets
    36. 36. Temperature control• Warm items first• Plastic wrap• Careful drying• Kangaroo care
    37. 37. Incubator Care• Double walled incubators –improve infants ability to maintain a desirable temp reduces energy expenditure r/t heat regulation• Pre-warm incubator first• Head covering when outside of the incubator
    38. 38. Essential public strategy that enablesthe early detection and management ofseveral congenital metabolic disorders,which if left untreated , may lead tomental retardation and even deathFor early detection and management ofcongenital metabolic disordersTHE NEWBORN SCREENING PROGRAM
    39. 39. Newborn Screening Program (NBS)• Mandated through RA 9288 (The Newborn Screening Act of 2004)• Done between 24-72 hours after birth
    40. 40. Collection of NBS Samples• Through heel prick method: 4 drops of blood is drawn from heel puncture blotted onto a filter paper• Air dry 4-6 hours• Sent to laboratory within 24 hours• BEST - 48th to 72nd hours of life• ACCEPTABLE - anytime after 24 hours from birth until 2 weeks of age
    41. 41. Sample collection donebefore the ideal time mayresult in: Falsely elevated thyroid stimulating hormone (TSH) = false (+) screen for CH Falsely elevated 17 hydroxyprogesterone (17-OH-P) = false (+) screeen for CH Falsely low galactose and phenylalalnine = false (-) screen for GAL and PKU
    42. 42. Disorders tested for newborn screening• Congenital Hypothyroidism (CH)• Congenital Adrenal Hyperplasia (CAH)• Galactosemia (GAL)• Phenylketonuria (PKU)• Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)
    43. 43. Congenital Hypothyroidism (CH)
    44. 44. Congenital Hypothyroidism (CH)• aka Cretinism• Lack or absence of thyroid hormone
    45. 45. (H-U-Mi-D)Hereditary conditionsUnderdevelopment of the fetalthyroid glandsMaternal Intake of anti thyroid drugsduring pregancyDeficiency, Maternal Iodine
    46. 46. *ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walkingand talking)
    47. 47. *TreatmentLifetime oral doses of thyroid hormone. L-ThyroxineNursing Considerations:Instruct parents to avoid Soy-basedformulas and iron supplements.Avoid adjusting medications withoutMD’s order to prevent undermedication or over medication.
    48. 48. Excessive medication cancause : D-I-T-SDiarrheaInability to sleepTachycardiaShakiness in the child
    49. 49. *TreatmentRegularmonitoring ofthe child’sweight, overallhealth andthyroidhormones level
    50. 50. Congenital Adrenal Hyperplasia (CAH)
    51. 51. Congenital Adrenal Hyperplasia (CAH)• Excessive or deficient production of sex steroids• Severe salt loss, dehydration and abnormally high levels of male sex hormones in both boys and girls• If not detected and treated early, infants may die within 7-14 days
    52. 52. Congenital Adrenal Hyperplasia (CAH)CAH is caused by adeficiency of adrenalgland hormones.21 hydroxylaseis missing or notworking correctly.
    53. 53. Congenital Adrenal Hyperplasia (CAH)21-OH is responsible for the productionof hormones :CORTISOL is involved in glucosemetabolism and in normal inflammationand immune response.ALDOSTERONE is responsible for bloodpressure and sodium retention.
    54. 54. Congenital Adrenal Hyperplasia (CAH)*Manifestations• Poor feeding• Listlessness and drowsiness• Vomiting• Diarrhea• Weight loss• Hypotension• Hyponatremia• Metabolic acidosis
    55. 55. Muscle growth at an early ageEnlargement of penis during childhood
    56. 56. Early deepening of thevoiceEarly beard
    57. 57. Pubic hair and underarm hair duringchildhood Severe acne
    58. 58. M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair duringchildhoodSmaller than normal testicles
    59. 59. Severe acneMale pattern baldness
    60. 60. Early puberty changes such as hair inairmpits and pubic areaLack of menstrual periods or scanty orirregular periods
    61. 61. Excess hair on the face and bodyDeep, husky voice
    62. 62. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hairin airmpits and pubic areaLack of menstrual periods or scantyor irregular periodsExcess hair on the face and bodyDeep, husky voice
    63. 63. *TreatmentLifetime administration of thedeficient or missing hormonesHYDROCORTISONESlessens the amount ofandrogens (prevents earlypuberty and allows for moretypical growth and
    64. 64. Over medication can results toCushing’s syndrome (Stretchmarks, rounded face, weightgain, hypertension and boneloss).Under medication can occurduring periods of stress andillness when higher doses of the
    65. 65. Correctivesurgery forenlarged clitoris(can be done asearly as one tothree years ofage. To separatelabia and to
    66. 66. Galactosemia (GAL)
    67. 67. Galactosemia (GAL)This hereditary disorder ischaracterized by the lack of theenzyme Galactose-1-Phosphateuridyl Transferase (GALT) thatconverts galactose to glucose, theform of sugar that can be used bybody cells.
    68. 68. Galactosemia (GAL)Initial symptoms also include: (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suck
    69. 69. Galactosemia (GAL)Treatment: Giving the child a speciallactose free formula and exclusion oflactose and galactose foods such asmilk (including breast milk) and otherdairy products from the diet throughout life.
    70. 70. Galactosemia (GAL)Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medicationsAny foods or drugs which contain the ingredientsLactulose, Casein, Caseinate, Lactalbumin, Curds,Whey or Whey solids
    71. 71. Galactosemia (GAL)Calcium and Vitamin Ddeficiency is likely to developin a child on a lactose free.Therefor, the child is givensupplements to preventdeficiencies
    72. 72. Phenylketonuria (PKU)
    73. 73. Phenylketonuria (PKU)A metabolic disorder characterized bylack of enzyme Phenylalaninehydroxylase (PAH) needed to processthe amino acid phenylalanineThe resultant build up of the saidprotein in the body leads to mentalretardation
    74. 74. Phenylketonuria (PKU)• Excessive accumulation of phenylalanine = brain damage• Dx – Guthrie test• Mx - Low protein diet; breastmilk
    75. 75. Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)
    76. 76. G6PD is one ofmany enzymesthat help thebody processcarbohydratesand turn theminto energy.
    77. 77. Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)• A condition where the body lacks the enzyme called G6PD a metabolic enzyme especially important in RBC metabolism• Hemolytic anemia resulting from exposure to certain drug, food and chemical
    78. 78. Child during Hospitalization
    79. 79. STRESSORS AND THE CHILD’S REACTIONIllness and Hospitalization:
    80. 80. Children are particularly vulnerableto the crises of illness andhospitalization because:1.Stress represents a change from the usual state of health and environmental routine1.Children have limited number of coping mechanisms to resolve stressors
    81. 81. SEPARATION ANXIETY• Also known as Anaclitic depression• Major stress especially for children ages 16 to 30 months• Three Phases: –Phase of Protest –Phase of Despair –Phase of Detachment
    82. 82. SEPARATION ANXIETY Three Phases:Phase of Protest • React aggressively to separation from parent • Behavior is from a few hours to several days
    83. 83. SEPARATION ANXIETY Three Phases:Phase ofDespair •Child is less active •Withdraws from others
    84. 84. SEPARATION ANXIETY Three Phases:Phase ofDetachment • Also called denial • Appears detached and uninterested in parents’ visits • Appears to finally adjust to the surroundings
    85. 85. Loss of Control INFANTS – Trust – Inconsistent care and deviations from daily routine• TODDLERS – Autonomy – Egocentric pleasures – Rely on the consistency and familiarity of daily rituals – Altered routine and rituals – Regression• PRESCHOOLERS – Egocentrism and magical thinking – Physical restriction, altered routines and enforced dependency
    86. 86. Bodily Injury and Pain• INFANTS – Infants younger than 6 months • no obvious memory of previous pain – Facial expression of discomfort – React with physical resistance – Distraction and anticipatory preparation does little to lessen immediate reaction to pain• TODDLERS – Intrusive experience produce anxiety – React with intense emotional upset and physical resistance – Communicate about their pain
    87. 87. Bodily Injury and Pain• PRESCHOOLERS – Cause of illness is seen as concrete action the child does or the child fails to do  self-blame – Contagion – proximity of two object or persons causes the illness – Injection - fear that the puncture will not close• SCHOOL-AGE CHILDREN – May be less concerned with pain than disability – Major concern is their fear of being told that something is wrong with them – Aware of the significance of different illnesses
    88. 88. Bodily Injury and Pain• SCHOOL-AGE CHILDREN – Passive acceptance of pain – Nondirective request for support – When someone identifies unspoken messages and offers support, they readily accept it• ADOLESCENTS – The nature of bodily injury may be more important based on the adolescents’ perception rather than the actual degree of severity of the illness – Changes in body image is their concern – Privacy – Reluctance to disclose pain
    89. 89. NURSING CARE OF THE CHILD WHO ISHOSPITALIZED
    90. 90. Communication• Speak in quiet pleasant tones• Bend down• Do not use clichés.• Explain all procedures• Be honest• Be careful in making promises• Observe nonverbal communication for clues to level of understanding• Do not threaten• Allow child to show feelings• Provide time to talk
    91. 91. Communication• Teach parents to anticipate next stage of development• If teaching is interrupted, start over from the beginning• Provide independence• Do not compare child’s progress to that of anyone else• Provide praise• Instead of asking what something is, ask child to give it a name or tell you about it• Allow choices where possible• Involve parents in child’s care
    92. 92. Communication• Keep routines• If parents cannot stay with child, encourage them to bring in a favorite toy, pictures of family members or to make tape to played for the child
    93. 93. Play
    94. 94. • Toddler – Enjoys repetition – Solitary play – Parallel play• Preschooler – Role play, make believe, associative play• School-age – Group, organized activities – Group goals with interaction
    95. 95. Play• Play is a very important part of development for your growing child.• Not only is play time entertaining for your child, but it also provides stimulation, increases skills and coordination, provides an outlet for your childs energy, and helps to encourage exploration by your child.
    96. 96. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play is an excellentstress reducer andtension reliever. Itallows the childfreedom ofexpression to act outhis fears, concernsand anxieties
    97. 97. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play provides asource ofdiversionalactivity,alleviatingseparationanxiety
    98. 98. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play provides thechild with a sense ofsafety and securitybecause while he isengaging in play, heknows that nopainful procedureswill occur.
    99. 99. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Developmentallyappropriate play fostersthe child’s normalgrowth anddevelopment, especiallyfor children who arerepeatedly hospitalizedfor chronic conditions
    100. 100. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)• Play puts the child in the driver’s seat, allowing him to make choices and giving him a sense of control
    101. 101. Play – Way to solve problems – Express creativity – Decrease stress – Prepare for procedures – Enhance fine and motor skills• Make play appropriate for mental age and physical/disease state• Multisensory stimulation• Safe toys for mental age• Offer play specific to age group
    102. 102. NURSING CARE OF THE CHILD IN PAIN
    103. 103. Concept of PainPreoperational Thought (2-7 yrs)Relates to pain primarily as physical concrete experienceMagical disappearance of painPain as punishmentHold someone accountable for own painConcrete Operational Thought (7-10 yrs)Relates to pain physicallyPerceive psychologic painFears bodily harm & annihilationPain as punishmentFormal Operational Thought (13 yrs and older)Give reason for painPerceives several types of psychologic painFears losing control during painful experience
    104. 104. Q-U-E-S-T (PAIN ASSESSMENT)QUESTION the child’s parents and childtoo, if he is old enough to respondUSE appropriate pain assessmentEVALUATE the child’s behaviourSECURE the parent’s active participationin treatmentTAKE the cause of the pain intoconsideration
    105. 105. ASSESSMENT• Wong-Baker FACES Pain Rating Scale
    106. 106. ASSESSMENT• FLACC (Face, Legs, Activity, Cry and Consolability) – for infants and very young children• Behavior is observed to assess painMeasures each of the five identifiedcategories on a 0 to 2 scale• The higher the total score, the more pain
    107. 107. CRIES Neonatal Postoperative Pain Measurement ScaleCryingRequires oxygen to maintain saturationabout 95%Increased heart rate and bloodpressureExpressionSleeplessness
    108. 108. Neonatal Infant Pain ScaleFacial ExpressionCryingBreathingpatternsState of arousalMovement ofarms and legs
    109. 109. Premature Infant pain ProfileGestational ageHeart rateOxygen saturationBehavioral stateBrow bulgeEye squeezeNasolabial furrow
    110. 110. INFANT Mouth stretched open Eyes tightly shutFacial expression Brows and forehead knitted Cheeks raised high enough
    111. 111. Younger Children Narrowing of the eyes Grimace or fearful appearance Frequent and longer lasting bouts of crying with a tone that is higher and louder than normal Less receptiveness to comforting by parents or other caregivers Holding or protecting the painful areas
    112. 112. P-A-I-N ManagementPharmacologic interventionsAnticipate and prevent or minimize painrelated to hospitalization, procedure andtreatmentIdentify and relieve existing painNon pharmacologic interventions to reducestress, increase comfort and enhance
    113. 113. Pharmacologic Intervention – mainstay of painmanagement and it depends on the specificneeds of the patientOpioid analgesics-Highly effective pain relievers andconstitute the core of most pharmacologicinterventions to manage acute pain ininfants and children-Oral, sublingual, rectal, nasal,subcutaneous, transdermal, IV andintraspinal*Morphine (MS contin)*Fetanyl (Duragesic)
    114. 114. Non Opioid Analgesics-are prescribed to managemild to moderate pain.-infants and childrenmetabolize non opioidanalgesics in the same mannerand at the same rate as adult.
    115. 115. NSAIDS-relieve for mild to moderate pain andanti inflammatory effects-Ibuprofen (advil); Naproxen(Naprosyn); Tolmetin (Tolectin);Indomethacin (Indocin) & Ketorolac(Toradol) are approved for use inchildren-S.E: Inhibition of platelet aggregationand GI irritation
    116. 116. Acetaminophen-Is the DOC for treating mild pain.Available in suppository, liquid and tableform.-it has the added benefit of helpingreduce fever and is very safe, even forneonates.-long term can cause risk of liverdamage
    117. 117. EMLA Cream (lidocaine 2.5% and prilocaine 2.5%),applied to intact skinunder occlusivedressing, providesdermal analgesia bythe release oflidocaine andprilocaine from thecream into theepidermal and dermallayers of the skin
    118. 118. • Complementary and alternative medicine (CAM) – Complementary Pain Medicine • Music Therapy • Hypnosis • TENS (transcutaneous electric nerve stimulation) unit • Acupuncture – Non-Pharmacologic Care • Comfort, positioning and non-nutritive sucking • Distraction • Relaxation • Guided Imagery • Biofeedback • Behavioral Contracting
    119. 119. Pediatric Surgery
    120. 120. Pediatric Surgery• Preoperative classes – Younger – simple and as close to the time of the procedure as possible• Allow to play with equipment• Teach and provide time to practice• Show pictures• Describe sensations• Detect misconceptions or fantasies• Parents can often be helpful in preparing
    121. 121. PEDIATRIC SURGERY• Preoperative class• Listen to child for clarifying misunderstandings• Give simple information about the system that will be affected• Use of anatomically correct dolls• Preschool boys: allow to look at penis after surgery• Post surgery: helping child master a threatening situation and minimizing physical and psychological complications
    122. 122. CHRONICALLY ILL PEDIATRIC CLIENTS:CONCEPTS OF DEATH DYING AND GRIEVING
    123. 123. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)InfancyConcept of death – NONENursing considerations:Be aware that the older infantwill experience separationanxietyHelp the family cope with deathso they can be available to theinfant
    124. 124. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Early childhoodKnows the words “DEAD” and“DEATH”. Reactions are influencedby the attitude of the parents.Nursing considerations:Help the family members includingsiblings cope with their feelingsAllow the child to express his ownfeelings in an open and honestmanner.
    125. 125. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Middle childhood.Understands universality andirreversibility of death. May havea fear of parents dying.Nursing considerationsUse play to facilitate the child’sunderstanding of deathAllow siblings to express theirfeelings.
    126. 126. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Late childhoodBeings to incorporate family and cultural beliefsabout death. Explores views of an afterlife andfaces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize hisfearsHelp the child discuss his concerns with the family
    127. 127. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)AdolescenceAdult perception of death, but still focused on theHERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion andanxietySupport and maintain self esteem
    128. 128. Helping Families to Cope• Accept and support participants• Be available and express your availability• Encourage parents to assist in the care of their child• Encourage involvement of siblings• Religious associations as source of strength and support
    129. 129. Helping parents to talk with their child about dyingif he is ready to do soEncouraging all family members to express theirfeelings, even though they might be difficult tohearAllowing families to spend as much time aspossible with the dying childAllowing and encouraging parents to continue totake an active role in their child’s careReminding parents that they don’t always have tobe strong and ask for help
    130. 130. Thank you for Listening!

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