2. Learning Objectives
After studying this unit, the student will be able to:
Identify the difference between growth and development
Describe milestones of normal growth and development
Detect deviation from normal growth and development
Use growth-monitoring chart to assess nutritional status of under 5 children
Recognize needs of the growing child
3. Growth and development from birth to adolescence
Definition:
• Growth means increase in size, Development means increase in function.
• Growth and development go together but at different speeds.
• Harmful environmental factors, such as infections like rubella(German
measles) in the mother, or exposure to certain drugs or X-rays may interfere
with the development of the fetus at this stage.
The fetus: during the first trimester the main body systems are prepared.
4. • This is mainly the stage of development, when the body systems
become more efficient
• During the last 6 months the fetus increases greatly in size. This
is mainly stage of growth.
• Malnutrition or anemia in the mother, or other disease of
placenta like malaria interfering with its blood supply, will stop
the fetus growing properly.
• The baby may thus be born small, not weighing as much as it
should.
5. Growth
• The body can grow only if it gets enough good food. The food must contain enough
calories, protein, and other nutrients.
• If the body does not grow properly it can not resist diseases either.
• The best way to measure growth is by weighing. Other ways are by measuring length
(height) and the arm circumstances.
6.
7. Weight
• Normal birth weight is 3400gms (normal range 2500 –4000gms).
– Double birth weight at 5 –6 months of age.
– Triple birth weight at 1 years of age.
– Quadruple birth weight at 2.5 years of age.
• Newborns lose 10% of body Wt immediately after birth; by 10 –14 days of age.
• Newborns gain 30gms/day during the 1st 5 –6 months. and 2 –3kgs/yearly
after 1st year.
8. To enhance accuracy of Wt measurement:
• Use the same scale at each visit.
• Scales should be zeroed daily.
• Infant scales should be used for children < 20 kg.
• Remove all clothing including diaper.
• Weigh infant supine and older infants sitting.
• Record Wt to the nearest 0.1 kg.
9. Formula to estimate average Wt:
Age Wt (in Kg)
At birth 3.25
3 –12 months Age (in months) + 9
2
1 –6 yrs Age (in yrs) x 2 + 8
7 –12 yrs
Age (in yrs) x 7 –5
2
10. Height/Length
• Growth in structure progress less rapidly than weight.
• Normal newborn length is 51 cm (46 –56cm).
• Increase 25 –30cms in first year of life.
– After first year, gain 6 –8cms yearly.
– Birth length doubles by 3 –4 years.
– Birth length triples by 13 years.
• Eventual adult Ht can be approximated by doubling child’s Ht by 2 years of age
(i.e. Ht at 2 yrs of age half adult Ht).
11. • The required principles to measure the Height or Length include:
• Length
– Measure length of children up to 2 yrs
– Use supine position, which requires 2 people.
• Straight knees and keep ankles in neutral position.
• Record measurement to the nearest 0.5 cm.
12. Height
– Measure Ht for children > 2 yrs old.
– Use a tape meter or a measuring tape plastered on a wall.
– Remove shoes.
– Make sure the legs are close to each other and the heels, the buttock and the
back of the head touches the wall or are in straight line.
– Place a ruler or a hard paper on top of the head to perpendicular to the wall to
take the measurement.
– If there is large hair, press gently.
13. Formula to estimate Ht of children b/n 2 to 12 years
Age Ht (in Cm)
At birth 50cms
At 1 year 75cms
2 –12 years Age (in yrs) x 6 + 77
14. Head Circumference:
• It is an indirect way of measuring brain growth.
• Increases in HC parallel to the rapidly growing CNS.
• Average newborn HC is 35cms ( 32.6 –37.2cms).
• The infant has relatively larger head than the adult.
• At birth the head is quarter of the whole body length but in an adult it is only one
eight.
15. • The head grows 12 cm (about 10 –12cms) in circumference in the first 12 months.
– 6 cm of this is in the first three months.
– 3 more cm During the next three months
– the rest 3cm grow in the rest months.
• During second years, increases only 2cms
• Brain reaches adult size at about 12 years of age.
16. • HC is measured by taking the greatest distance around the mid forehead-above
the ears to the most prominent-occiput(maximal-front- occipital circumference)
• Record measurement to the nearest 0.5 cm.
• The result may
– Below normal range-abnormally small = micro-cephalous
– Above normal range-abnormally large head = usually hydrocephalus
17. Mid Upper Arm Circumference (MUAC):
• The MUAC remains nearly constant from 1-5 years.
• In the first month the arm of the new born is longer than the leg.
• MUAC works for 1 –5 years child.
• Used for screening purpose (not helpful for Dx).
• Measured mid -point b/n the tip of the shoulder and the tip of the elbow.
• The normal value at birth > or = 12 cms.
– < 12cm indicates malnutrition
– < 11cm is severe malnutrition
18. Other indices of Growth:
Body Proportions
• Body proportions follow a predictable sequence of changes with development
• The head and trunk are relatively large at birth, with progressive lengthening
of the limbs throughout development, particularly during puberty.
• The lower body segment is defined as the length from the symphysis pubis to the
floor, and the upper body segment is the height minus the lower body segment.
19. • The ratio of upper body segment divided by lower body segment (U/L ratio)
equals approximately 1.7 at birth, 1.3 at 3 yr of age, and 1.0 after 7 yr of age.
• Higher U/L ratios are characteristic of:
– Short-limb
– Dwarfism
– Bone disorders, such as rickets.
20. Skeletal Maturation:
• Bone age correlates well with stage of pubertal development and can be helpful in
predicting adult height in early- or late-maturing adolescents.
• In endocrinology short stature, and under nutrition, the bone age is low and
comparable to the height age.
• Skeletal maturation is linked more closely to sexual maturity rating than to
chronological age.
• It is more rapid and less variable in girls than in boys.
21. Dental Development/Tooth eruption:
• Children start teething at the age of 6 months.
• A new tooth appears approximately every month.
• This makes the number of teeth roughly equal to the age in months minus six.
– At 3 yr of age for the primary teeth
– At the age of 6 years the permanent teeth start to appear.
– At 25 yr of age for the permanent teeth
22. • The timing of dental development is poorly correlated with other processes of
growth and maturation.
• Delayed eruption is usually considered when there are no teeth by approximately
13 mo of age.
23. Development:
• Refers to a progressive increase in skill & capacity to function.
• The sequence of development is the same in all children, but the rate of
development varies from child to child.
• Functions and skills are gradual change from simple to complex (language,
psychosocial, various motor skills like sitting, walking, etc)
• The direction of development is Cephalo–Caudal, Proximo-Distal and from
Gross to Fine motor.
• Development is associated with (depends on) the maturation of nervous
system.
24. • Skill development proceeds according to two processes:
– From the head to down, and
– From the center of the body to out to the extremities.
• Development that proceeds from the head down ward through the body toward the
feet is called Cephalo-Caudal development.
25. E.g. At birth, an infant’s head is much larger proportionally than the trunk or
extremities.
• Infants learn to hold up their heads before sitting and to sit before standing or
walking Skills .
• Development that proceeds from the center of the body out ward to the extremities
is called Proximo-Distal development.
E.g. Infants are first able to control the trunk, then the arms and later fine motor
movements of the fingers.
26.
27. Developmental milestones
• The development of a child can be accessed from different points of view.
– What he can do in the way of moving around?
(motor development)
– How he talks and makes his wants known?
(language)
– How he fits into his family and community?
(social behavior)
28. • The various skills the baby learns are called Millstones.
• In watching development we notice at what age the child learns to do certain
things, such as smiling at his mother, sitting without support, grasping objects
with his hands, walking and talking.
29. Developmental milestones
age
Movement and
posture
vision Hearing and
speech
Social behavior
6 weeks When pulled
from supine
head lag is not
quite complete
When held prone,
head is held in
line with body
When prone on
couch, lifts chin
off couch
Primitive
responses persist
Looks at toy, held
in midline
Follows a moving
person
Vocalizes with
gurgles
Smiles briefly
when talked to by
mother
30. 4 months Holds head up in
sitting position, and is
steady
Pulls to sitting with
only minimal head lag
(Fig. 16.12)
When prone, with
head and chest off
couch, makes
swimming
movements
Rolls from prone to
supine
Primitive responses
gone
Watches his or
her hands
Pulls at his or
her clothes
Tries to grasp
objects
Turns head to
sound
Vocalizes
apparently
appropriately
Laughs
Recognizes
mother
Becomes
excited by toys
31. 7 months Sits
unsupported
Rolls from
supine to prone
Can support
weight when
held, and
bounces with
pleasure
When prone,
bears weight on
hands
Transfers
objects from
hand to hand
Bangs toys on
table
Watches small
moving objects
Says 'Da', 'Ba',
'Ka'
Tries to feed
him- or herself
Puts objects in
mouth
Plays with
paper
32. age
motor vision Speech &
language
social
10 months Crawls
Gets to sitting
position
without help
Can pull up to
standing
Lifts one foot
when standing
Reaches for
objects with
index finger
Has developed
a finger-thumb
grasp
Will place
objects in the
examiner's
hands, but not
release them
Says one word
with meaning
Plays 'peep-bo'
and 'pat-a-
cake'
Waves 'bye-
bye'
Deliberately
drops objects
so that they
can be picked
up
Puts objects in
and out of
boxes
33. 13 months Walks
unsupported
May shuffle on
buttocks and
hands
Can hold two
cubes in one
hand
Makes marks
with pen
Says two or
three words
with meaning
Understands
simple questions
such as
'Where is your
shoe?'
May kiss on
request
Tends to be shy
15 months Can get into
standing position
without support
Climbs upstairs
Walks with broad-
based gait
Builds a
tower of two
cubes
Takes off
shoes
Will say around
12 words, but
mostly
gobbledegook
Asks for things by
pointing
Kisses pictures of
animals
Can use a cup
34. motor Speech and
language
Social and
cognitive
18 months Climbs stairs
unaided holding
rail
Runs and jumps
Can climb onto
a chair and sit
down
Builds tower of
three cubes
Turns pages of a
book two or
three at a time
Scribbles
Takes off gloves
and socks
Unzips fasteners
Is beginning to
join two words
together
Recognizes
animals and
cars in a book
Points to nose,
ear etc. on
request
Clean and dry
but with
occasional
accidents
Carries out
simple orders
35. Theories of Growth and development
• Many theorists have attempted to organize their observations of behavior in to a
description of principles or a set of stages.
Freud’s Theory of Psychosexual development
• Freud believes that early childhood experiences form the unconscious motivation
for actions in later life.
• He developed a theory that sexual energy is centered in specific parts of the body
at certain ages.
36. The stages
I. Oral Stage (Birth to 1 Yr)
• The infant derives pleasure largely from the mouth, with sucking and eating as
primary desires. Face conflict over weaning.
II. Anal Stage (1–3 Yrs)
• The young child’s pleasure is centered in the anal area. Gain pleasure from
defecation and face conflict over toilet training.
III. Phallic Stage (3–6 Yrs)
• Sexual energy becomes centered in the genitalia. Gain pleasure from genitals and
most resolve Oedipus and Electra complex.
37. • Oedipus complex: a conflict b/n a child’s desire of the parent of opposite sex and
fear of punishment from the same sex parent.
• Electra complex: Oedipus complex in girls. Girls begin to experience penis envy.
Girls' and women's psychological problems stem from a sense of deprivation about
not having a penis.
IV. Latency Stage (6–12 Yrs):
• Sexual energy is at rest in the passage b/n earlier stages and adolescence. There is
development of friendship (little psychosexual development).
38. V. Genital Stage (12 Yrs –Adult hood)
• Mature sexuality is achieved as physical growth is completed and develops an
erotic attachment to others. Gratification is through genital stimulation and the
development of intimate relationships.
39. Growth monitoring
Growth Charts/Curves
• Graph that records changes in the child’s growth with time compared to
normative growth rates.
• Growth parameters should be standardized and compared with age related norms.
40. 2/13/2024 40
Growth: increase in physical size (process).
Measurable parameters: weight, height,
head circumference, etc…
Analysis of growth pattern: continuous
process.
Single measurements: screening purpose.
41. 2/13/2024 41
Rationale:
Growth monitoring can greatly
strengthen preventive health programs.
Growth is the best general index of the
health of an individual child.
Regular measurements of growth permit
the early detection of malnutrition.
42. 2/13/2024 42
Normal growth
• Trend helps to define if growth is with in acceptable
limits (serial /single measurements)
• Most powerful tool in growth assessment is growth
chart
When caloric intake is inadequate, the wt percentile
falls first, then the height and last the head
circumference.
43. 2/13/2024 43
Growth evaluation
• Weight
• height
• head circumference
• BMI
• body proportions
• mid parental height and target height
46. 2/13/2024 46
Measure Lying or Standing?
Length (Lying)
Unable to stand without
assistance
Use Birth - 36 months
growth chart
Stature (Standing)
Able to stand without
assistance
Use 2-20 years growth
chart
47. 2/13/2024 47
1. Weight – for – age
2. Length/height – for – age
3. Weight – for – height
4. Mid – upper arm circumference
5. Head circumference
48. 2/13/2024 48
1. Weight – for – age: weight of the child (in kg) is
compared with that of a healthy child of the
same age from a reference population.
50. 2/13/2024 50
Analysis of Growth Patterns
• Growth is a process rather than a static quality
• An infant at the 5th percentile of weight for age
may be growing normally, may be failing to grow,
or may be recovering from growth failure,
depending on the pattern of the growth curve.
55. 2/13/2024 55
Weight for
Age (Gomez)
With Edema Without
Edema
60-80% kwashiorkor underweight
< 60% marasmic-
kwashiorkor
marasmus
56. 2/13/2024 56
The only tools needed are weighing scales
and charts.
weighing is a fairly easy task for inexperienced
health workers.
Disadvantages:
should be done regularly
child’s age to the nearest month.
cultural unacceptability (some places).
Falsely normal in edema or Ascites.
57. 2/13/2024 57
Compares height/length with the
expected height of a healthy reference
child of the same age.
Used to assess stunting which may be
an index of long-term nutritional
deprivation.
58. 2/13/2024 58
Degree of wasting assessed by comparing
the child’s weight with the weight that
would be expected for a healthy child of
the same height.
A child who is < 70% of the expected
weight for height is classified as severely
wasted.
61. 2/13/2024 61
Identifies the very thin or wasted child
with definite malnutrition who requires
immediate attention.
Good indicator to distinguish children who
are well proportioned from those who are
wasted for their height.
Doesn’t require age data.
62. 2/13/2024 62
Stunted children with reasonable body
proportion are classified as not
malnourished.
two pieces of equipments required.
takes longer time.
measuring length in infants may require two
persons.
more difficult for unskilled health workers.
63. Weight for age:
1 – 11 months
Median weight (kg) = Age (in months) + 9
2
1 – 6 years
Median weight (kg) = Age (yrs) x 2 + 8
6 – 12 years
Median weight (kg) = (Age (yrs) x 7) – 5
2
2/13/2024 63
64. 2/13/2024 64
Median Length at birth = 50cm
Median Height/length at 1 year = 75cm
Median Height 2 – 6 years
= Age (yrs) x 6 + 77 (cm)
65. 2/13/2024 65
Increases in size during the 1st year of life, but little
increment between 1 and 5 years of age.
Average Head circumference (cm) at birth = 35 (33 –
37)
At 6 mo = 44
At 1 yr = 47
At 2 yr = 49
66. 2/13/2024 66
AGE
APPROXIMATE DAILY WEIGHT
GAIN (gm/day)
GROWTH IN HEAD CIRCUMFERENCE
(cm/mo)
0–3 mo 30 2.00
3–6 mo 20 1.00
6–9 mo 15 0.50
9–12 mo 12 0.50
1–3 yr 8 0.25
4–6 yr 6 1 cm/yr
67. 2/13/2024 67
years Normal Height velocity(Cm/yr)
1 yr 25 cm
2 yr 10 cm
3-4 yr 7 cm
5-7 yr 6 cm
7-puberty 5 cm
puberty 10.3 cm
69. 2/13/2024 69
at birth, average MUAC= 10.5cm
by the age of 1 year, MUAC=16.5cm
between 1 and 5 years of life, average increment
is only about 1cm, to reach 17.5cm at 5 years.
between 1 and 5 years of age, MUAC of
<12.5cm, considered malnourished.
low MUAC is more closely associated with
acute malnutrition (wasting) than stunting.
70. 2/13/2024 70
Useful as method of screening large number
of children, during nutritional emergencies.
less useful in long – term growth monitoring.
Advantages:
Indicates severe current malnutrition.
quick to use.
71. 2/13/2024 71
the measuring tape can be color – coded, for use by
illiterate workers or community.
doesn’t require exact age data.
the equipment is portable and cheap.
Disadvantages:
only identifies children with severe malnutrition and is
not a sensitive early predictor of malnutrition.
great variability in measurement.
72. Meeting the need of the normal children through the stages of development
• The new born has continues demand to be fulfilled throughout the life, especially
during growth and development as promoting factors.
Here are some of important aspects of what every child needs.
• Nutrition: Good nutrition is the base for normal growth and development. The first
six months of life are extremely important as the brain may suffer for the rest of life,
if the child is not getting enough food.
73. • Emotional Support: It is very important to realize that a child is a growing and
developing human being and he ought to be treated very carefully with love and
respect by everyone so he can develop in harmony.
• Love: a child who does not feel loved will not develop properly, and will not learn as
quickly as normal children. He/she may sad, lonely and no longer interested in what
goes on around him.
74. Security: a child can only feel safe if his parents show that they love him and take good
care of him.
• He must know that his parents will look after him, feed him when he is hungry, play
with him and keep him happy and comfortable.
• The love and security he/she gets from family helps him to feel friendly to people
outside his family when he grows up.
75. Acceptance as individual: the young child needs to know that his mother and family
love him for what he is.
• They should not compare him with other children and tell him that he is slow to do
this or that, he is not as good as some other child.
Recognition of achievement: the young child needs to know that his parents are happy
and pleased when he has learned to do something new.
76. • Wise and consistent use of authority: children need to know what they can and what
they cannot do. Parents must teach children how they are expected to behave.
• Independence: as the child grows he needs to be allowed to decide more and more
things alone.
• Playing: Encourage playing even if it may be noisy sometimes. It helps physical,
mental and social development and is also good for health.
• Language training: adults should talk and sing with small children and encourage
them to talk about what they are thinking. Do not laugh when children are talking; try
to understand and be happy when they involve you in their world.
78. Nutrition:-
Ethiopia is one of the countries in the sub
Sahara Africa with the highest rates of
malnutrition.(20-50%)
About 90% of the mothers breast feed
up to two years. ( 70% suboptimal)
Exclusive breast-feeding is 49% (0-6
months).
proportion of infants of 6 -9 months
introduced to complementary food &
continuation of breastfeeding 54%
proportion of newborns breastfed within
one hour of birth 69%
Nutrition and feeding practices in
Ethiopia
79. Nutrition and feeding practices in
Ethiopia
Height for age 44%(21% severe stunting)
wasted weight for height 10.5 %
Under weight, low weight for age 16%
In addition to poor feeding practice,
periodic drought,
war and displacement have contributed to
the severe malnutrition status of
Ethiopian children
Malnutrition
80. Breast feeding
Complementary feeding
Nutrition advice and supplementation
Vitamin A supplementation
Measles vaccination and Rota virus
Family planning
Management of severe acute
malnutrition
Zinc
Malnutrition key interventions
81. Babies
Exclusive breastfeeding on demand
provides all the nutrition a baby needs in
the first 6 months. This is not true for any
breast milk substitute except modern
formulae( scientific literatures)
Breast milk contains vitamin A. Babies
Low in vitamin A have poor appetite, eye
problems, and more infections.
BREAST FEEDING(BF)
82. Breast milk is a clean source of food.
Water used to mix formula and to wash
bottles may have germs that can cause
diarrhea. This is a major cause of infant
death.
It acts like the first immunization for
the baby; it makes the immune system
stronger. “First immunization”
It protects babies against allergies.
If a baby is sick, helps a baby get better
fast.
83. Breast milk helps low birth weight
babies, especially those who are
prematures:
It is the easiest food for the baby to
digest.
It provides nutrients ideally suited for
growth and development
It helps the baby’s body and brain
develop and grow.
84. It helps to prevent a serious disease of
the intestines that affects low birth weight
babies (necrotizing enterocolitis).
Breastfeeding helps to stabilize the
baby’s temperature.
Breastfeeding helps the baby’s mouth,
teeth, and jaw develop properly.
Milk from the breast is always in the
perfect temperature for the baby.
85. Breastfeeding helps to facilitate
placental separation.
Helps the uterus return to its normal
size.
Reduces anemia because the
mother starts her menses later.
MOTHERS
86. Exclusive breastfeeding helps to
suppress ovulation, so it can delay
another pregnancy..
Strengthens the relationship between
a mother and her baby. (Bonding and
attachment)
Saves money.( ?maternal
nutrition)
87. Mother’s milk is the only perfect
nutrition for newborns, infants and
children. It has many advantages both
for the mother and infants as mentioned
above.
Therefore, all newborns, infants and
children should be breast fed if
possible.
88. Ten steps of successful breast feeding
1. Have a written breastfeeding policy
2. Train all health care staff in skills necessary to implement this
policy.
3. Inform all pregnant women about the benefits and management
of breastfeeding.
4. Help mothers initiate breastfeeding within half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain
lactation even if they are separated from their infants.
88
89. 6. Give newborn infants no food or drink other than breast
milk, unless medically indicated.
8. Encourage breastfeeding on demand.
9. Give no artificial to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups
and refer mothers to them on discharge from the hospital or
clinic.
89
90. Proper positioning of babies
• Positioning of baby and mother need to
include
– Infants whole body supported
– Infants head, neck and body should be straight
– Infant facing mother
– Infants body close to mother
90
91. Proper attachment of babies
• Attachment of babies to the breast must include all the
following
– Mouth wide open
– Lower lip turned outward
– More areola visible on above than below
– Chin touching the breast
91
92. Clues for adequate breast feeding
– At least 3-5 strong suckling before pausing for
breath or rest
– Dimpling of cheeks may be seen while suckling
– Hearing of swallowing gurgle
– Milk may be seen around the mouth leaking out
when it is excess
92
93. • Well and adequately fed baby will be satisfied and
– Go asleep for 2- 4 hours between each feedings
– Will have frequent wet diapers (at least 6 times)
– Increase weight daily after 7 postnatal days (20 –
30 gm/kg/day).
93
94. Common maternal worries that need to be reassured
– Colostrum produced in the first 1week of delivery
is smaller in quantity= reassure mother that it is
enough to the baby need, don’t discard it because
rich in immunoglobulin
– the amount of breast milk produced is enough for
the baby even in multiple deliveries
94
95. – if mother is on medication advice properly whether the drug is
safe or toxic
– stimulus for milk production is effective, regular suckling of
the breast by the baby
– Empting breast during each feeding, allows milk to refill for
next feed
– Mother should be relaxed, emotionally and psychologically
stable
– Mother must get adequate rest, take more fluids & nutritious
feedings and also take micronutrients for herself 95
96. Cause for exclusive breastfeeding disruption before
4- 6 mo of age in employed women
• Mother and child friendly workplace
- A room for keeping Babies while mother is
working.
- Separate room for breast milk expression
and storage .
- Protect breast feeding rights of women in
the workplace.
96
97. Energy needs from complementary foods for infants with
“average” breast milk intake in developing countries
are approximately:
•
200 kcal per day at 6-8 months
300 kcal per day at 9-11 months
550 kcal per day at 12-23 months
Complementary feeding
98. Energy needs from complementary foods for infants with
“average” breast milk intake in developing countries
are approximately:
•
200 kcal per day at 6-8 months
300 kcal per day at 9-11 months
550 kcal per day at 12-23 months
Complementary feeding
99. Emergency situations
Malnourished children( needs support from
formula milks) risks of malnutrition
Low-birth-weight babies(Gavage feeding)
Infants of HIV-infected mothers(AFASS)
Orphans
Infants requiring tube feeding
Infants/ children with chronic illnesses etc
are conditions where Formula milk is as
important as mother’s breast milk.
Breast milk not adequate after 6months
Exceptionally difficult circumstances
100. •If Mother or newborn
•Has active and drug resistance tuberculosis.[48]
• Is malnourished,
•Is extremely ill
•Has had certain kinds of breast surgery
•Is taking any kind of drug that could harm the
baby,Anticancer drugs
•Drinks unsafe levels of alcohol.
• IUI CMV, HSV
•Babies with birth defects
•Personal preferences, beliefs, and
experiences
•Adoption
•In prison
•Mental health
101. •Social pressures Husband or boyfriend
or from the angles of mother’s health,
decreased energy or attractiveness
•Lack of:-
Wet nursing
Milk bank
102. • Interferes with bonding and attachement
• More diarrhoea and persistent diarrhoea
• More frequent respiratory infections
• Malnutrition; Vitamin A deficiency
• More allergy and milk intolerance
• Increased risk of some chronic diseases
• Obesity
• Lower scores on intelligence tests
• Mother may become pregnant sooner
• Increased risk of anaemia, ovarian cancer, and
breast cancer in mothers
Disadvantages of artificial feeding
103. Leading nutritional authorities, including
WHO and the AAP, and scientific literatures
have identified 5 “at-risk” nutrients
Vitamin A
Iron
Iodine
Zinc
Vitamin D*3
for which older infants and young children
may be consuming less than the
recommended intake
At risk nutrients
104. VALUE OF PLAY AND SELECTION OF PLAY MATERIAL
• Play is defined as behaviour that is freely chosen, personally directed (process of
trial and error) and intrinsically motivated.
• The need for play is recognized as being particularly important in a hospital
environment where the child is exposed to strange sights, sounds and smells and
development.
105. A successful, well-run play program needs to
– Increase the child’s ability to cope with a hospital and managements
– Facilitate appropriate channels of communication
– Reduce developmental regression
– promote confidence, self esteem and independence
– Relieving fear and anxiety.
– Help professionals to assess development
– Provides opportunities to engage in meaningful activities that enhance physical,
language, social, and cognitive development
106. • Play & Skill Development: Play can be an effective way for Children to develop
skills:
– Language - name games, sing songs, rhymes/same sound.
– Thinking - build towers, puzzles, follow directions.
– Small-muscle - string beads, cut with scissors.
– Large-muscle - play ball, race, roller-skate etc.
– Creative - make-up stories, dress-up puppets.
– Social - decisions playing with others e.g. parts of team going to play in etc.
107. Types of Play
• Quiet play - solo activity/sing play.
• Active play - stimulated play with items/ objects.
• Co-operative play - requires more than one person.
• Dramatic play - children try out different kinds of life roles, and occupations.
108. Type of materials:
• There are various resources, which can
be used to prepare a child for different
hospital procedures, including: dolls,
story books, photographs, medical
equipment and role play.
109. Toys for Physical Development:
EXAMPLES :
Wagons to steer and push; brooms and
shovels; balls; planks/flat wood; skipping
ropes; scooters/sliding board and boxes,
ladders, and board games and puzzles.
110. Toys for Sense Development:
(touching, hearing, seeing, smelling, or tasting):
EXAMPLES:
Water toys, bubble pipes, musical instruments,
toy piano, xylophones, sand toys, pegboards/play
board, large wooden beads and string, puzzles.
111. Toys for Creative Work:
EXAMPLE:
Clay or crayons
and paints, coloured paper,
children's safety scissors, paste/glue.
112. Toys for make-believe & Social Development:
EXAMPLE:
Dolls with washable
clothes, adult
"dress-up" clothes,
cars and airplanes,
broom, brush, mop,
dishes, toys.
113. Play in Hospital
• Since the 1950s recommendations have been that play should be provided in the
hospital setting in order to maintain the emotional wellbeing of the child.
• A hospital play specialist, is often employed in a variety of paediatric settings.
Hospital Play Specialists
• They are specifically trained to enable the sick child to understand and absorb the
hospital situation.
114. Importance of Play in Hospital
1. It empowers children to be familiar with the environment
2. Help them to turn a hospital admission into a positive experience.
3. Relieve pain and prepare for management
For example: A three year-old confined to a traction bed will be frustrated by the
sudden loss of mobility. A rolled up newspaper and balloon, releases emotions
and limits the regression of upper body strength (hand/eye coordination).
116. Therapeutic Play
• Preparation for procedures/treatments - offers the child and family to understand,
accept and co-operate with treatment. e.g. blood tests, x-rays, MRI, etc.
• Post procedural play - can be used to identify fears and misconceptions following a
procedure.
– Post procedural play enables them to work through these events and move
towards recovery.
117. • Acceptance of Chronic Illness/Disease -
The unknown can be very frightening. Simple but realistic explanations of what is
going on the child can resolve or highlight fears/anxiety and aide in
acceptance.
118. • Distraction therapy: is a range of techniques, that the child may be frightened
during a procedure and offers a means of coping whilst the procedure is taking
place.
• Successful distraction therapy enables the child to feel positive about their
treatment and empowers them to take control.
• There are various methods including:
– Bubbles, singing, stories, interactive books and guided imagery
119. Work with Siblings
• Siblings, depending on their age, developmental level, and
previous experience of hospital may adapt to the
hospitalisation of a brother or sister without any difficulty.
• They may resent the sick child and sister/brothers spend caring
for him or her.
120. Visualization:
• The child will decide on a subject they want to visualize i.e., a happy occasion, pet dog
etc.
• This technique is useful during a procedure where talking is difficult, i.e., dental
extraction, radiotherapy, CT or MRI scanning etc.
121. Selection of play materials :
• Toys - are they?/do they?
– Safe? Durable?
– Appropriate to the child’s age? Work?
– Capture a child’s interest? Fun?
– Stimulate creative activity?
– Involve interaction with others?
– Kept clean easily?
– Colourful? Age appropriate?
122. • There are many facets to a child’s play and development.
• The choice of play materials is key to motivate the child and prevent from any
damage.
• The best method of material selection is using age appropriate, safe, capture a
child’s interest, and clean materials.
123. Age appropriate Toys:
• Infants (0-2 months):
Items at which the infant can look, listen & feel are ideal
e.g. Mobiles, music, soft-cloth and animals.
124. Age appropriate Toys
• Infants (2-4 months):
Rattles, shakers, teethers to pick up and grasp and shake; activity gyms with
dangling objects which can be hit and kicked while laying on back.
125. Age appropriate Toys:
• Infants (4-6 months):
Soft vinyl or cloth books, rolly-polly toys (round-bottomed figures that can be
pushed over, but bounce back up), large popping beads, ‘push me-pull me' toys.
126. Age appropriate Toys:
Infants (6-8 months):
Older infants can sit up and explore their
worlds, which gives their toys a new
perspective. You may not need to add
many new toys at this stage. Their own
bodies are fascinating enough to them.
127. Age appropriate Toys:
Infants (8-12months):
Board books, large blocks, musical instruments
(drum, shakers, a simple xylophone), cuddly
toys, activity boxes and boards. Children at this
stage like to make things happen - they like to
push a button and hear a song, or have a bird pop
out of the window.
128. Age appropriate Toys:
Toddler (12-18months):
Walking toys, such as shopping carts, dolls-
pram and ride-on-cars, with a handle for
pushing; shape sorters, blocks, music, soft
dolls and stuffed animals, and balls.
129. Age appropriate Toys:
Toddler (18 months - 2 years):
Crayons and large paper, simple puzzles, blocks,
dress-up items - plastic hats, boots or shoes, bags,
and play food, dolls houses and people, cars and
trucks.
130. Age appropriate Toys:
Toddler (2-3 years):
Plastic buildings, blocks, cars,
trucks, and trains (with tracks);
baby dolls and housekeeping
equipment; play food for kitchen
or grocery, interlocking puzzles
(up to 30 pieces), books,
colouring books and crayons.
131. Age appropriate Toys:
Pre-School (3-4 years):
Scissors, glue, and paper, simple craft kits, books,
beginning board games, items for imaginative play.
Play becomes more social and more involved at this age, as
a child creates conversations between his toys, or setting up
a complete town for their animals.
132. Age appropriate Toys:
Pre-School (4-5 years):
Craft kits, card games, board games, simple sports equipment, story
books, music, computer games, building blocks, collections - be sure
to ask what they are collecting. This is the age at which fads begin,
and if they are mad for dinosaurs (probably) nothing else will satisfy
them!
133. Age appropriate Toys:
School Age (5-6 years):
Small blocks, art supplies, sports equipment,
board games, card games, computer games,
activity books and workbooks, beginning
reader books, story books, collections.
134. Age appropriate Toys:
School Age (6-9 years):
Music, books, games, bikes, sports equipment,
models, small building sets and blocks. science and
craft kits, handicrafts, sports and hobbies, books,
puzzles.
Once children reach
school-age, they are more
influenced by their peers.
135. Age appropriate Toys/Activities:
School Age (9-12 years):
Model kits, crafts, bicycles, racket games, ball games, chemistry
and other science kits, frisbees, magic sets, advanced
construction sets and handicraft kits, toy models, jigsaws/puzzles,
cards and board games, books, computers, compasses,
magnifying glasses, microscopes and telescopes, magnets, and
team sports.
136. Accidents - principal causes and prevention among children
• Accident: is an unplanned and unfortunate event that results in damage, injury, or
upset of some kind.
• Accidents kill 830,000 children worldwide each year, a surprisingly large figure
that marks a growing but often ignored problem.
• Africa has the highest rate overall for accidental deaths; there is 10 times higher
than in high-income countries such as Australia, the Netherlands, (WHO &
UNICEF 2008).
137. • Road crashes (leading cause), among children
• Drowning, burns, falls, and unintended poisoning round out the top five list of
accidental death.
• About half of these deaths could be prevented by expanding the use of car seats,
covering wells, using home safety and erecting barriers to keep from road
construction.
• Most of the common accidents are home related accidents.
139. Home safety
• Keep all poisons out of reach, (child proof' cupboard).
• Do not leave a young child alone in the house.
• Access to first aid kits.
• Install smoke alarms at strategic places.
• Cover all unused power points with a child safety cover.
• Unplug electrical appliances when not being used.
• Ensure that all glass doors, shower screens are fitted.
• Ensure that floors have non-slip surfaces.
• Doors that are likely to slam and jam fingers should be fitted with door-closers.
140. • Make sure that cupboard edges in children's areas are rounded.
• In a multi-story housing, ensure that windows are fixed so that children cannot get
out of them, and that all balconies/platform have adequate barriers.
• Keep all matches, lighters and candles out of reach of children.
• Develop a plan for what to do if there is a fire.
141. Choking
• is stop breathing through blockage of throat.
• Young children learn about the world around them by reaching for things and putting
them in their mouths.
• Therefore mealtimes are a common time for accidents of this sort to happen.
• Choking is a very common and dangerous possibility for children under five.
• Partly due to their nature, small size of their airway and anatomy, (conical in shape),
objects tend to lodge in a position where they can cause complete airway
obstruction….. Leading to sudden onset of choking, cyanosis & collapse.
142. Causes
Toys: Although the majority of choking accidents involve food, around 8% of accidents
involve toys.
Coins: Coins can also pose a choking risk. Coins are the main non-food cause of
choking.
Balloons: Un inflated or pieces from burst balloons can also cause choking and should be
kept away from young children.
143. General signs of choking
• Witnessed episode
• Coughing or choking
• Sudden onset
• Recent history of playing with or eating small objects
Ineffective coughing Effective cough
• Unable to vocalise
• Quiet or silent cough
• Unable to breathe
• Cyanosis
• Decreasing level of
consciousness
• Crying or verbal response to
questions
• Loud cough
• Able to take a breath before
coughing
• Fully responsive
144. Paediatric Choking Treatment Algorithm
Assess severity
Ineffective cough Effective cough
Unconscious
Open airway
5 breaths
Start CPR
Conscious
5 back blows
5 thrusts
(chest for infant)
(abdominal for
child > 1 year)
Encourage cough
Continue to check for
deterioration to
ineffective
cough or until
obstruction
relieved
145. Prevention
• Always ensure your children sit down at mealtimes.
• Cut-up children’s food into small pieces and encourage them to eat slowly.
• Always buy age appropriate toys and try to keep toys for older children separate
from small children.
• Ensure coins, buttons and batteries are stored out of reach of children.
• Don’t leave un inflated or pieces of balloons to give or around !
146. Falls
• Falls are the leading cause of unintentional injury for children.
• Children ages 14 or under account for one-third of all fall-related visits to hospital
emergency rooms.
• Falls from climbing frames, down stairs, out of trees, from walls, baby walker setc.
Injuries sustained are: fractures, head-injuries, cuts.
147. Head Injury
Symptoms in children:
Head injury is very common in young children. But concussions can be difficult to recognize in
infants and toddlers because they can't readily communicate how they feel. Nonverbal clues of a
concussion may include:
• Listlessness/uninterested, tiring easily
• Irritability, crankiness/disagree
• Change in eating or sleeping patterns
• Lack of interest in favourite toys
• Loss of balance, unsteady walking
148. Head Injury cont...
• Any head injury that causes confusion or dizziness, even for just a few minutes, is
considered a concussion.
• Concussion A child may have a concussion if, after a head injury, he has a headache,
dizziness, confusion, nausea or vomiting.
• Concussion is a violent jarring that results to disturbance of brain function.
149. There are three different grades of concussions:
• Grade 1 (Mild concussion) - Confusion, dizziness etc last less than 15 minutes.
• Grade 2 (Moderate concussion) -The symptoms last longer than 15 minutes, but there is
no loss of consciousness.
• Grade 3 (Severe concussion) - There is a loss of consciousness, even if it lasts only a few
seconds or minutes.
150. Prevention
• Young children should be protected by lockable gates at the top and bottom of the stairs.
• The proper use of helmets, mouth guards, and other protective equipment whenever
participating in sports, using skateboards or in-line skates.
• Properly padding, instructing children in the proper techniques for safe sports
involvement, and improved athlete conditioning also help.
151. Fractures
• Although the bones of a child are more elastic, it is porous than adults and greater
energy needs to be applied to young bones to cause a fracture.
• Even falls from low heights can cause fractures in young children.
• Forearm fractures account for 40% to 50% of all childhood fractures, (Common wrist-
end of radius).
152. Fractures cont...
The following factors may affect the probability of fracture:
• The child's age.
• The height of the fall.
• The surface onto which the child falls.
• The affected body part.
• The generated impact velocity.
153. Prevention
• They have to run about and explore but some strategies like special coverings on
playgrounds.
• Rounded corners on children’s furniture.
• Supervision at play.
• Advise children of dangers.
154. Accidental Ingestion
• Infants and toddlers will put any interesting object into their mouths and swallow some
of them. Incidence is greatest in children aged 6 months to 4 years.
• Most swallowed foreign bodies pass harmlessly through the gastrointestinal (GI) tract.
• Foreign bodies that can damage the GI tract or have associated toxicity must be
identified and removed.
155. Prevention
• You cannot prevent children from ingesting objects, however, if you suspect they
have something in their mouths they shouldn’t have encourage them to take it out
or spit it out; but do so safely and effectively, or you may in fact lodge it further
156. Accidental Poisoning
• Babies and toddlers learn about the world around them by touching and tasting.
• Suspected poisoning in children results in Emergency Department attendances and
admitted for observation or treatment.
• The majority of poisonings are accidental, especially in the under-5 age group,
although intentional overdoses and substance abuse are seen in older children.
157. Accidental Poisoning cont...
Common drugs ingested:
– Aspirin/Ibuprofen
– Paracetamol
– Prescription drugs e.g. Antidepressants,
Digoxin, etc.
– Vitamins.
– Cough Syrup.
(A single dose of some medications can be lethal to a
young child).
159. Accidental Poisoning cont...
Alcohol
• Alcohol can be very dangerous for young children as intoxication can lead to a
marked hypoglycaemic state in infants and young children.
• Alcohol has a CNS depressant action that can also lead to respiratory depression and
hypoxia.
160. Prevention
• Keep all medicines out of reach of children resistant If possible in a locked
cupboard.
• Lock any dangerous tools or poisonous substances cannot be reached by a
toddler.
• Do not store poisons in food containers. Keep them in the original container
which has warnings and safety precautions on it.
• Keep alcoholic substances well out of reach of children.
161. BURNS
• About 70% out of 90% of burns occur in the developing world are in children.
• Survival of injuries greater than 40% of total body surface area (TBSA) is rare in the
developing world.
• Burns over 8-10% TBSA in children require admission to hospital.
• Six toddlers are admitted to hospital every day because they’ve been badly burned.
162. Percentage of Total Body Surface Area in Children Affected by Burns (A)
Lund-Browder (1944)
163. Burns cont...
• Babies and young children have such delicate and 15 times thinner than an adult skin
that they can be burned far more easily than adults.
• Hot drinks are the number one cause of scalds among under fives – with coffee
being the biggest culprit.
• A hot drink can burn a young child’s skin half an hour after it has been poured!
164. Causes of burn
Burns are injuries of skin or other tissue caused by
– Thermal - hot liquid or heat/flame
– Radiation - sunburn
– Chemical - corrosive substance
– Electrical - electrocution at entry/exit site.
165. Burns cont...
There are three levels of burns:
• First-degree: burns affect only the outer layer of the skin. They cause pain, redness,
and swelling.
• Second-degree: (partial thickness) burns affect both the outer and underlying layer of
skin. They cause pain, redness, swelling, and blistering.
• Third-degree (full thickness) burns extend into deeper tissues. They cause white or
blackened, charred skin that may be numb.
166. Prevention
• Don't have dangling kettle cords - use short cords
• Don't leave saucepan handles overhanging the edge of the stove so a child could
reach them.
• Use a stove/hot plate guard.
• Put hot drinks out of reach of children.
• Do not drink a hot drink with a child in your arms.
• Replace table cloths with place mats as children can be scalded by pulling on the
tablecloth and spilling hot drinks on themselves.
167. • Keep matches and cigarette lighters out of reach of children.
• When running the bath for your child, put the cold water in first.
• To help prevent scalding from hot water, make sure that the water from your
bathroom tub, shower and basin comes out at 50 degrees or less.
• Sun protection e.g. Slip-dress, Slop-lotion, Slap-hat Campaign.
• Ensure all corrosive substances are locked away.
168. Drowning ...
• A baby can drown in as little as 5cm of water. This means that areas where water
can collect may be hazardous for babies and toddlers.
• The longer a child is immersed in water with loss of consciousness and breathing the
more likely a long term consequences will arise.
169. Drowning cont...
• Drowning is the second leading cause of unintentional injury-related death among
children ages one to 14.
• The majority of drowning occur in residential swimming pools and in open water
sites.
170. Prevention:
• Always stay with a baby when they are in the bath.
• Empty paddling pools after use and turn them over so rain water doesn’t collect in
them.
• Fit a strong cover over the garden pond, such as a heavy metal grid.
• Enclose/fence swimming pool areas and lock the gate.
• Stay with toddlers & children next to any body of water e.g. feeding ducks, seaside etc.
171. Road traffic accidents
• Many accidents happen outside of the house on the roads. However, it is often older
children, who can walk and play outside, who are more vulnerable for these types of
accidents.
• Road Traffic Accidents are
the leading cause of injury/death
among children worldwide.
172. PREVENTION
• Teaching children about crossing the Road safely.
• Strict speed limits.
• Traffic ‘calming’ measures in around residential areas/ schools/play areas.
• Road awareness training for children riding Bicycles.
• Wearing cycle helmets.
• Use of seat belts and car seats.
173. Green cross code
1. THINK! Find the safest place to cross, then stop.
2. STOP! Stand on the pavement near the kerb.
3. USE YOUR EYES AND EARS! Look all around for traffic, and listen.
4. WAIT UNTIL IT'S SAFE TO CROSS! If traffic is coming, let it pass.
5. LOOK AND LISTEN! When it's safe, walk straight across the road.
6. ARRIVE ALIVE! Keep looking and listening
174. Intentional overdose cont...
• Overdoses of drugs or chemicals can be either accidental or intentional.
• Drug overdoses occur when a person takes more than the medically recommended
dose.
• Adolescents are more likely to overdose on one or more drugs in order to harm
themselves; may represent a suicide attempt.
• These conditions may not be diagnosed before.
– May be viewed as a ‘cry for help’.
– Presence of potential Risk Factors.
175. Intentional Overdose cont...
Potential Risk Factors:
– Children in Care
– Emotional upset
– Child Abuse or Bullying
– Psychiatric illness
– Suicidal thoughts (usually rare)
– Alcohol
– Other self-harming behaviour
176. Intentional overdose cont...
Alcohol
• The average age when young people try alcohol is 11 years for boys and 13 years for
girls.
• Developmental transitions, such as puberty and increasing independence, have been
associated with alcohol use. Therefore, just being an adolescent may be a key risk
factor not only for starting to drink, but also for drinking dangerously.
177. PREVENTION
• Very difficult to do so!
• LIFE is precious and snap decisions can have a devastating effect on those left
behind.
• Encourage the individual to seek advice/support or HELP before it is too late!!
