Unit-1:Introduction to pediatrics

• Pediatric Nursing
For UPGRADE MIDWIFERY stude Pediatric Nursing
Pediatric Nursing
For UPGRADE for Undergraduate
MIDWIFERY students nts Students

By :Hunduma D (Msc in CLMW)

27-Feb-24 by:Walle Kumlachew 1

 Outlines
• Unit I- Introduction to pediatric nursing
• Unit II- Child growth and development
• Unit III- Care of Newborn
• UNIT-IV: Management of common childhood disease
• Unit V- Management of systemic child hood disorders
• Unit VI. Expanded program of immunization
• Unit VII. Pediatric HIV/AIDS
• UNIT VIII- IMNCI
•
•

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 Objective
• At the end of this session the students will be able
to:
 Recognize history of paediatric Nursing
 Define paediatric nursing
 Describe the modern concepts of pediatric nursing
care

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 Definition

 Pediatrics is:
 Branch of medicine that deals with the care of
children and adolescents.

 Derived from the two Greek words

• – Pedopais: meaning a child
– Iatros : meaning healer

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 Def…
 It is the art and science of giving nursing care to
children from birth through adolescent with
emphasis on
 physical growth,
 mental, emotional development
 psycho-social development.
 The pediatric nurse gives direct bedside care to sick
children, guide families in their care for their children
during health and illness, in hospitals and at homes.

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 Def….
• The good pediatric nurse must be:
• 1- Good observer
• 2- Honest and truthful
• 3- Sympathetic, kind, patient and cheerful
• 4- Love to work with children
• 5- Interested in family care
• 6- Able to provide teaching to children and their
families

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 Role of Pediatric Nurse
• The goals of nursing care of children, based on primary
health care are:
• 1-Promote the healthy maturation of the child as a
physical, intellectual and emotional being within the
context of his family and community (primary level)
• 2-Provide health care for the child who requires
treatment from disease(s) (secondary level)
• 3-Dealing with the Child's disabilities (tertiary level) or
rehabilitation which means maximizing the child's
potential level of his body function.

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 In primary level
•
• Through health education to the child and his
parents and providing child's basic needs and
immunization.
• The nurse can:
• 1-Maintain child's health.
• 2-Help the child to achieve his optimal growth and
development.
• 3. Prevent diseases and their complications.
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 secondary level:
• The nurse has to provide care to sick children and
their families by:
 Assessing their needs.
 Planning for their care .
 Implementing the nursing care plan.
 Evaluating children's condition and the plan of care
 Providing health teaching to children and their
parents

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 In tertiary level

 The nurse should assist children to return to their

maximal level of functioning following illness and
or disabilities.

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 Family centered care approach:
• Family centered care is philosophy of care that
acknowledges the importance of the family as the
fundamental focus of all health care interventions.
• Although the family is the ultimate coordinator of its
own care, the nurse can establish a positive
environment for family members and help them to
accept and utilize the care provided.

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 Family…
• Health team should be flexible and creative in caring
for the child within his family as their intervention
are based on the needs of parent and child and on
their coping resources.
• Recognize each family's uniqueness and explain the
influence of the family in the child's life

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 Parent education
• One of the crucial roles that pediatric nurses should
undertake with the child (according to his age) and
his family members is parent education. The nurse
has many opportunities in providing health
education to parents and for children

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 Cont..
• Growth and development needs
• Child's health promotion and maintenance as
nutritional need and hygienic care.
• Preventive aspects such as (accident
prevention, immunization, periodic examination).
• Child's illness (nature of illness and care needed).
• Plan for child's discharge such as child's medication,
follow up, nutrition…..etc.

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 Philosophy of paediatric nursing care
• Children need access to care that is
Continuous
Comprehensive
Coordinated
 family centered and compassionate
• This care needs to focus on their changing
oPhysical
odevelopmental needs

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 Modern concepts of child care
• Previously the emphasis was on the care of the ill
child as an individual
• Current emphasis:
 Prevention of illnesses and accidents
 Holistic nursing care
 Independent practice
 Interdisciplinary approach
 Family centred

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 Factors influence the health and illness
patterns of a child
• The health problems of children vary widely between and
within populations in the nations of the world
• The factors include
(1) Economic considerations (economic disparities)
(2) Educational, social, and cultural considerations
(3) The prevalence and ecology of infectious agents and their
hosts
(4) Climate and geography

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 child mortality trends in Ethiopia
• The UN Inter Agency Group on its 2013 mortality estimate
reported that Ethiopia’s
 Under five =64
Infant =44
Neonatal mortality rates = 28
• The Proportion of children who were dying before their fifth
birthday has declined to 64 in 2013 from 204 in 1990 among
1000 live births.
• Thus in August 2013 Ethiopia was declared to have achieved
MDG 4.

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 19

Pediatric History taking and Physical

Examination contents
1. Personal identification 7. Immunization Hx
2. Chief complaints 8. Nutritional Hx
3. History of present illness 9. Developmental Hx
4. Past medical Hx 10. Review of systems (ROS)
5. prenatal /natal /post natal

6. Family and social Hx

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 Pediatric History VS Adult History
I. Content Differences
A. Ante /natal /post natal history
B.Developmental history
C.Immunization history
II. Parent as Historian
A.Parent’s interpretation of signs, symptoms
1.Children above the age of 4 may be able to
provide some of their own history
2.Reliability of parents’ observations varies
• - Parents reflect their vision

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 History taking
• Historian
 Mother

 Father

 Any other relative or care taker with description of extent of

relation with the patient.

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 History taking
Chief complaint
 Should hold the main reason to seek medical advice.

 There can be one or more chief complaints.

extract the most pertinent ones &

present it along with the duration of illnesses chronologically.

 Should be written in the words of the patient.

 e.g., yellowish discoloration of the eyes

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 History of present illness
 Elaborates C/C With:

emphasis on the genesis of the illness & associated Sxs.

 The details of the C/C should include:

Mode of onset: insidious/sudden

Chronology of symptoms
Elaboration of symptoms &
Relevant questions about positive negative statements

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 Past medical Hx:
1. Past childhood illnesses (measles, pertussis, mumps)

2. Major chronic illnesses

3. Hospital admissions with clear description of time, reason &

outcome.

4. Surgical procedures and outcome

5. Accidents – time & sequel

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 prenatal, natal, neonatal, infancy, and
childhood
– prenatal Hx

Maternal health

Previous pregnancies & their outcome

Medications

General nutritional status

Radiation exposure

ANC follow up

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 Natal history
Duration of pregnancy

Duration of labor

Time of ROM ( duration of rupture of membrane)

Place of delivery/mode/complications……

• Post natal

APGAR

Hx of jaundice, convulsions, febrile episodes….

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 Family history
• 1. Social history
√ General demographic and socio-economic information (Parental
occupation, marital status, income, education, housing, income,
water supply, family size, waste disposal, etc)
• 2. Medical history
√ Possible familial (diabetes, bronchial asthma) and hereditary
diseases (Hemophilia, thalasemia)
√ Clustering of disease in family (scabies, infectious hepatitis,
cholera, etc)

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 Nutritional Hx:
– Should include from time of birth till present age.

 Time breast feeding initiated

 Total duration of breast feeding

 Hx of bottle feeding

 Frequency of feeding

 Share of the same plate with older siblings

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 Nutritional Hx…
 Time formula feeding started, type, amount, concentration,
frequency…………….

 Weaning age, type of weaning diet

 Present diet – type, amount, frequency……..

 Hx of sun exposure & the way the infant is exposed.

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 Immunization history
Ask:
 When the vaccine was given
 The route of administration
 For the immunization card (when applicable)

What is recommended national immunization

schedule?

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 Development Hx:
 Developmental mile stones are used to assess the
past progress of the child.

 One of the cardinal manifestations of diseases

 Developmental delay or
regression

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 Review of systems (ROS...)
 GENERAL: Fever; weight loss;
 HEAD:-Headache
 EAR: -discharge; pain
 EYES: discharge; redness
 NOSE:-epistaxis; discharge
 MOUTH: ulceration; oral thrush
 THROAT: Sore throat
 RESPIRATORY SYSTEM: Cough; wheezing; chest pain; dyspnea

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 Review of systems (ROS...)
 CVS:-Dyspnea; Cyanosis
 GASTROINTESTINAL SYSTEM: Nausea,
vomiting, diarrhea;
 GUS:-Hematuria; dysuria
 INTEGUMENTARY SYSTEM:-rash….
 MUSCULOSKELETAL SYSTEM: Joint pain,
Joint swelling
 CNS:-Seizure, weakness; speech problems
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 Physical examination
 Aim is the same as that of adults.

 The approaches are different b/c are in the process of growth

& development
 Tell parents what you intend to do.

 Examination of infants under the age of 6 months is much easier

than the older ones

 Beyond 6 months- fear of stranger and separation of parents

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 Physical examination
 All children must be examined fully, so that no important sign is missed
 In contrast to the systematic approach for adults, however,
examination of a child should be organized in a way that does not
upset the child
 The approach to examining children should be flexible
 Ideally, you will perform the most ‘invasive’ part of the examination
(e.g. the head and neck examination) last
 Do not upset the child unnecessarily
 Leave the child in the arms of the mother or carer

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 Physical examination
 A crying infant can be calmed with gentle rocking or feeding

 Develop patience in examination of children.

 Do not discuss with parent while the patient is undressed

 Do not hurry to undress; better done by the mother.

 Put on cloths in sensitive body parts

 Older children may be shy.

 Be opportunistic in examining a child.

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 Assessment of systems
HEENT
LGS
RS
GI
GUS
NS

 Use the cardinal signs (Inspection, palpation,

percussion, Auscultation)

Refer your Health Asse

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 DEFINITIONS OF TERMS
• PERINATAL: The period from the end of the 28 week
of pregnancy to the end of the 7 day of life of the
new born.
• NEONATAL: The period corresponding to the first 28
days of life.
• Post neonatal: The period between the first
month of life and first birthday
• INFANT: the "child" less one year of age

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 DEFINITIONS OF TERMS...
• CHILD The operational definition of child varies. In
epidemiology it usually refers to a one to four year old
• UNDER FIVE A " child" less than 5 years old.
• MORBIDITY is the measure of prevalence of a specific
illness in a population at a particular time.
• MORTALITY is the number of individuals who have died
over a specific period.

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 Chapter – 2:Growth and Development

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 Objective
By the end of this session, the student will be able to:
 Define growth and development.

 Identify the importance of growth and ‘.

 Mention the principles of growth and development.

 List factors affecting growth and development.

 Identify the stages of development.

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 Brainstorming
• What is growth?

• What is development?

• What is the importance of Growth and

Development?

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 Introduction
 Growth & development refers to the process by which
the fertilized ovum becomes an adult person.I

 Growth & Development are

continuous dynamic process occurring from conception
to maturity & takes place in an orderly sequence with
approximately the same for all individuals.I

 Rate of growth is generally more important than actual

size (absolute number).
 The goal of paediatric care is to optimize the growth
and development of each child.

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 Intro..

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 Definition
 Growth - A measure of physical maturation, signifies an increase in
size of the body and its various organs

 It can be measured in terms of centimeters and kilograms-

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 Defn…
 Development- Is a measure of functional or physiological
maturation and myelination of the nervous system

 It is mainly related to the nervous system.

 It means acquiring functions and skills that involves motor,

social, emotional and intellectual abilities of the child

 it refers to a progressive increase in skill and capacity of

function
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 defn…
Development: is a qualitative change in the child’s
functioning.
It can be measured through observation, by asking
the parents
By understanding what to expect during each stage
of development ,parents can easily capture the
teachable moments in everyday life to enhance their
child's language development, intellectual
development, social development and motor skills.

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 STAGES OF GROWTH AND DEVELOPMENT

•Prenatal
- Embryonic (conception- 8 w)
- Fetal stage (8-40 or 42 w)
•Middle Childhood
•Infancy -School age
Neonate : Birth to end of 1 month -6 to 12 years
Infancy: 1 month to end of 1 year
•Late Childhood
•Early Childhood -Adolescent
-13 years to approximately 18 years
-Toddler: 1-3 years
-Preschool: 3-6 years

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 Measurements of physical growth
(anthropometric measurements)
1. Weight
• Normal birth weight: 2.5-4.0kg,
 loss of 5-15% in the 1st week
 Regained at the age of 10th and 14th day
 Increases 25 gm/day in the 1st 3 months and 50gm/day
in the reminder of the 1st year
 Doubles at 5-6 months,
 triples at 1 year and
 quadriples at 2 years of age

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 Anthropometric….
• 2. Height/length
• At birth=50cm
• At 6 months=65cm
• At 1 year=75cm
• At 2 years=85cm
• At 4 years=100cm,
• then increases about 5-6cm/year

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 Anthropometric….
• 3. Head circumference
• At birth=35cm
• At 1 year=45cm
• At 2 years=48cm
• At 5 years=50cm
• 4. Chest circumference
• At birth 2cm less than head circumference
• At 1 year=head circumference, then it grows relatively
faster than the head

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 Principles of Growth & Development
• 1. Continuous process from conception up to death.
• 2. Predictable or orderly Sequence
• 3. Don’t progress at the same rate (↑ periods of GR
during infancy, early childhood and adolescents & ↓
periods of GR in middle childhood)
• 4. All body system do not develop at the same
rate(developmental pace)
• 5. Each stage of G&D is affected by the preceding
types of development
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 Principles of Growth & Development
• 6. G & D proceed in regular related directions :
• - Cephalo-caudal(head down to toes)
• - Proximodistal (center of the body to the peripheral)
• 7. General to specific/ simple to the complex
pattern of growth is in a head-to-toe direction, or
cephalocaudal, and
• Growth Patterns
• 8. Inward to outward pattern called Proximodistal

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 Factors affecting Growth and Development
 Genetic factors
 Environmental factors
 Sex
 Endocrine system (Hormonal influences)
 Nutrition
 Diseases

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 Environmental factors

1. Pre-natal environment
• Factors related to mothers during pregnancy:
• - Nutritional deficiencies
• - Diabetic mother
• - Exposure to radiation
• - Infection
• - Smoking
• - Use of drugs

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 Environmental factors
• 2. Post-Natal Environment
• External environment:
• - socio-economic status of the family
• - child’s nutrition
• - climate and season
• - child’s ordinal position in the family
• - Number of siblings in the family
• - Family structure (single parent or extended family)

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Developmental Milestones ( Domains)

1. Cognitive development

2. Gross motor/Fine motor

3. Language

4. Social development

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 Cognitive development
• Cognitive development refers to the intellectual
maturation of children

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 Gross Motor Skills
• The term “gross motor skills” refers to those that use
the large muscles (e.g., head control, rolling, sitting,
and walking)
• Gross motor skills develop in a cephalocaudal fashion
(from the head to the tail)
• In other words, the baby learns to lift the head
before learning to roll over and sit .

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 Gross Motor Skills...
• At birth, babies have poor head control and need to
have their necks supported when being held
They can lift their heads only slightly while in a prone
position.
Over the next several months the infant’s motor
skills progress at a dramatic rate
 First the infant achieves head control ability to
roll over sit crawl pull to stand walk
independently (usually around 1 year of age)

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 Gross Motor Skills...
• Head Control
• Newborn: barely able to lift head
• 6 months: easily lifts head, can sit alone in the
tripod position

Age 6 months
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 Gross Motor Skills in infancy…
• Ambulation;
• 9 month old: crawl
• 1 year: stand independently from a crawl position
• 13 month old: walk and toddle quickly
• 15 month old: can run

12-months
13 month old
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 Gross Motor Skills...
 Appropriate presence and disappearance of primitive reflexes, as well
as development of protective reflexes, are indicative of a healthy
neurologic system
 Persistence of primitive reflexes beyond the usual age of
disappearance may indicate an abnormality of the neurologic system
and should be investigated
• The acquisition of gross motor skill precedes the
development of fine motor skills
– Head control preceding arm and hand control
– Followed by leg and foot control

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 Fine Motor Skills

• Fine motor development includes the maturation of

hand and finger use
• Fine motor skills develop in a proximodistal fashion
(from the center to the periphery)
• In other words, the infant first bat with the whole
hand, eventually progressing to gross grasping,
before being capable of fine fingertip grasping

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 Fine Motor Skills
The newborn’s hand movements are involuntary in
nature, whereas the 12-month-old is capable of
feeding himself or herself with a cup and spoon.
By 12 months of age the infant should be able to eat
with his or her fingers and assist with dressing (e.g.,
pushing an arm through the sleeve)

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 • Newborn has very little control. Objects will be involuntarily
grasped and dropped without notice.
• 6 month old: palmar grasp – uses entire hand to pick up an
object
• 9 month old: pincer grasp – can grasp small objects using
thumb and forefinger

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 Language Development
• For several months, crying is the only means of
communication for the infant
• The basic reason for crying is unmet needs
• The 1- to 3-month-old baby coos(sign of surprise)
• At 4 to 5 months of age, the infant makes simple
vowel sounds, laughs aloud, vocalizes in response to
voices.
• Between 4 and 7 months the infant begins to
distinguish emotions based on tone of voice.

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 Language Development...
• 7 to 9 months, babbling begins and progresses to
strings (e.g., mamama, dadada) without meaning
• At 9 to 12 months of age the infant begins to attach
meaning to “mama” and “dada” and starts to imitate
other speech sounds
• The average 12-month-old uses two or three
recognizable words with meaning, recognizes objects
by name, and starts to imitate animal sounds

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 Social and Emotional Development
 The newborn spends much of the time sleeping, but by 2
months of age the infant is ready to start socializing.
 The infant exhibits a first real smile at age 2 months
• He or she spends a great deal of time while awake
watching and observing what is going on around him or
her.
 By about 3 months of age the infant will start an
interaction with a caregiver by smiling widely
• This prompts the caregiver to smile back and talk to the
infant
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 Social and Emotional Development...
• The 3- to 4-month-old will also mimic the parent’s
facial movements tongue
• The baby may hesitate at first, but once the other
person responds pleasantly to the infant, the infant
engages and gets into the interaction
• The infant may cry when the pleasant interaction
stops
• At 6 to 8 months of age the infant may enjoy socially
interactive games

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 Examples

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 Developmental delay
 -is a delay in an age-specific ability for important
developmental milestones
 Ilobal developmental delay significantIdelay seen across multiple domains of
function IIadaptation(Usually Two Or More Domains)
 Specific development delay-delay seen in specific domains of function
&adaption(Single Domain)
 Developmental regression -When a child loses anIalreadyI
achivedIskill Ior fails to progress beyond aIprolonged
plateauI devIt. I
after a period of relatively normalI

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 Importance of Growth and Development
 Early detection of deviation in child’s pattern of
developmentI
 surveillance of developmental progressII
 Knowing what to expect of a particular child at any given
age
 provide age-appropriate anticipatory guidance to the parents
 Gaining better understanding of the reasons behind
illnesses. normal G & D is a reflection of overall health ( e.g.
nutritional status)
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 Importance…
 Growth and Developmental concerns should be included as one
of Ihealth topics at each preventive care visit throughout the first
5Irsof lifeI
 Understanding normal growth, development, and behaviour is
used to
 monitor children's progress,
 identify delays or abnormalities in development,
 Give needed services, and counsel parents

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 Developmental stage summery
• 1. Infancy (0-12 months after birth)
 This is a period of rapid growth
 Babies weigh an average of 10kg at 12months
 Length increases by 25cm and head circumference 12cm
 Momentary visual fixation on objects and adult face
 Keeps hands fisted

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 Developmental stage summery ….
• 2. Toddlerhood (1-3years)
 The growth rate slows down compared to infancy
 The wt. ses by 2kgs, height by 12cm and head circumference by 3cm
 Walks up stairs with help first and followed with out
 Anterior fontanelle closes
 Uses phrases, imitates words
 Plays alone, but near others
 Tapertantrum ,negativism

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 Developmental stage summery ….
• 3. Preschool age (4-5years)
 The average wt. grain is 2kg per year and height increases
7cm per year
 By the end of three years all primary teeth have erupted
 Buttons front and side of clothes
 Plays and interacts with other children.
 Shows creativity
 Less negativistic.
 Learns some number concepts
 Begins naming colors
 Uses language aggressively
 Asks many questions etc

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 Developmental stage summery ….
• 4. School age (6-12 years)
 There will be average wt. gain of 3-3.5kg &height gain of 6cm per year
 Head circumference increases by 2-3cm
 Is active and impulsive
 Balance improves
 Uses hands as manipulative tools in cutting, hammering.
 Can draw large letters or figures
 Uses both hands independently
 Become skillful in manual activities b/se of improved eye-hand
coordination
 More reflective and has deeper understanding of meaning
 Loss of primary teeth starts at 6years of age etc

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 Developmental stage summery ….
• 5. Adolescence (13-20 years)
The body size changes rapidly in size, shape,
physiology, psychology and social functioning
Usually uncoordinated; has poor posture
Secondary sexual characteristics start to appear.
The peak of height in this period.
Acne, odor, menarche, spermarche occurs

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 Developmental theory
Freud theory
• (Psycho-sexual development).
Erikson theory
• (psychosocial development).
Piaget theory
• (cognitive development ).

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 Freud's theory
• 5 stages of development
1. Oral stage (birth to 1 ½ years)
2. Anal stage (1 ½ to 3 years)
3. Phallic stage (3 to 6 years)
• Oedipus complex / Electra Complex
• 4. Latency stage (6 years to puberty)
• 5. Genital stage (puberty onward)

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 Oral Stage (Birth to 18 months)
 During the oral stage, the child focused on oral pleasures

(breast feeding or sucking).

 Too much or too little gratification can result in an Oral

Fixation or Oral Personality which is evidenced by a

preoccupation with oral activities.

 This type of personality may have a stronger tendency to

27-Feb-24 smoke, drink alcohol, over

by:Walle eat, or bite his or her nails.
Kumlachew 83
 Anal Stage (18 months to 3 years)
 The child’s focus of pleasure in this stage is on
eliminating and retaining faeces.
 Through society’s pressure, mainly via parents, the child
has to learn to control anal stimulation.
 In terms of personality, after effects of an anal fixation
during this stage can result in an obsession with
cleanliness, perfection, and control (anal retentive).
 On the opposite end of the spectrum, they may become
messy and disorganized (anal expulsive).

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 Phallic Stage (ages three to six)
 The pleasure zone switches to the genitals.
 Freud believed that during this stage boy develop
unconscious sexual desires for their mother.
 Because of this, he becomes rivals with his father
and sees him as competition for the mother’s
affection.

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  During this time, boys also develop a fear that their
father will punish them for these feelings, such as by
castrating them.
 This group of feelings is known as Oedipus Complex

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Latency Stage: 6 Years to Onset of Puberty
 Freud seemed to view this time as the least
complicated in childhood, believing that during these
years, children focus their energies on their schooling
as well as forming friendship bonds with other
children of their own gender.

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 The Genital Stage: From Puberty On
 In this final stage of psychosexual development,
Freud theorised that the onset of puberty
represented the reawakening of sexual urges.
 At this more mature age, however, adolescents focus
not only on their genitals, but also on developing
sexual relationships with members of the opposite
sex and on seeking sexual satisfaction.

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 Erikson’s psychosocial theory
 Erikson said we develop in psychosocial stages, rather
than in psychosexual stages
 For Freud, the primary motivation for human behaviour
was sexual in nature, for Erikson it was social and
reflected a desire to affiliate with other people
 Erikson emphasized developmental change throughout
the human life span, whereas Freud argued that our
basic personality is shaped in the first five years of life.

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 • 8 stages of development
 Each stage consists of a unique developmental task
that confronts individuals with a crisis that must be
resolved
 The crisis is not a catastrophe but a turning point of
increased vulnerability and enhanced potential
 The more successfully an individual resolves the
crisis, the healthier development will be

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 The Eight stages of development

1. Trust Vs mistrust (infancy)

• A sense of trust requires a feeling of physical
comfort and a minimal amount of fear about the
future
• Trust in infancy sets the stage for a lifelong
expectation that the world will be a good and
pleasant place to live

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 • 2. Autonomy Vs shame and doubt (1 to 3 years)
 After gaining trust in their care givers, infants begin
to discover that their behaviour is their own
 They start to assert their sense of independence, or
autonomy
 They realize their will
 If infants are restrained too much or punished
harshly, they are likely to develop a sense of shame
and doubt

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 • 3. Initiative Vs guilt (3 to 5 years)
 As preschool children encounter a widening social
world, they are challenged more than when they
were infants
 Active, purposeful behaviour is needed to cope with
these challenges
 Children are asked to assume responsibility for their
bodies, their behaviour, their toys, and their pets

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  Uncomfortable guilt feelings may arise, though, if
the child is irresponsible and is made to feel too
anxious
 Most guilt is quickly compensated for by a sense of
accomplishment

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 • 4. Industry Vs inferiority (6 years to puberty,
elementary school years)
 Children’s initiative brings them in contact with a
wealth of new experiences
 They direct their energy toward mastering
knowledge and intellectual skills
 The danger in the elementary school years is that the
child can develop a sense of inferiority – feeling
incompetent and unproductive

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 • 5. Identity Vs identity confusion (10 to 20 years)
 Individuals are faced with finding out who they are,
what they are about, and where they are going in life
 Adolescents are confronted with may new roles and
adult statuses – vocational and romantic, for
example
 Parents need to allow adolescents to explore many
different roles and different paths within a particular
role

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  If an identity is pushed on the adolescent by the
parent, if the adolescent does not adequately
explore many roles, and if a positive future path is
not defined, then identity confusion reigns

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 • 6. Intimacy Vs isolation (20s, 30s, early adulthood)
 Individuals face the developmental task of forming
intimate relationships with others
 If the young adult forms healthy friendship with
another individual, intimacy will be achieved; if not,
isolation will result

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 • 7. Generativity Vs stagnation (40s, 50s, middle
adulthood)
 A chief concern is to assist the younger generation in
developing and leading useful lives – generativity.
 The feeling of having done nothing to help the next
generation is stagnation.

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 • 8. Integrity Vs despair (60s onward, late adulthood)
 A person reflects on the past and either pieces together
a positive review or concludes that life has not been
spent well
 Through many routes, the older person may have
developed a positive outlook in most or all of the
previous stages of development.
 If so, the person will fill a sense of satisfaction –
integrity.
 If the older adult resolved many of the earlier stages
negatively – despair

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 Cognitive Development Theory
• Children "construct" their understanding of the world
through their active involvement and interactions
• Two processes are essential for development:
–Assimilation
– Learning to understand events or objects,
based on existing structure.
–Accommodation
– Expanding understanding, based on new information

Assimilation + accommodation lead to equilibrium

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 Piaget’s cognitive developmental stages

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 • Stage-3 Concrete Operational(7-11 yrs)
 At this stage, children are able to see things from
different points of view and to imagine events that
occur outside their own lives. Some organized,
logical thought processes are now evident and they
are able to:
order objects by size, color gradient, etc.
understand that if 3 + 4 = 7 then 7 - 4 = 3

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 l2
 understand that a short wide cup can hold the same
amount of liquid as a tall thin cup
 However, thinking still tends to be tied to concrete
reality

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 • Stage-4. Formal Operational(11+ yrs)
 Around the onset of puberty, children are able to
reason in much more abstract ways and to test
hypotheses using systematic logic.
 There is a much greater focus on possibilities and on
ideological issues.

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27-Feb-24 by:Walle Kumlachew 111
 Chapter- Three

Care of the newborn

(neonatology)

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 Care of normal newborn

 Preparation before delivery

 Immediate care at and after birth
 Essential postnatal care

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 Definition of neonatal period
• A period from birth to 4 weeks postnatal.
 After the initial observation for neonatal condition
requiring immediate intervention, the baby is sent to
the normal newborn nursery or maternity floor for
the purpose of follow up and stabilization.

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 Admission Care
 The role of the nurse is:
- To carry out good interpersonal communication.
- To take complete history about the mother and neonate.
- To be sure that the neonate has identification band.
- To perform complete physical assessment (General
appearance, V.S, Gestational age assessment).
- Prevention of hemorrhage (administer vit K if not given in
the delivery room).
- Documentation.

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 Systematic Physical examination
• Growth measurements
- Vital Signs
- General appearance:
. Posture:
Flexion of head & extremities, taking them
toward chest & abdomen

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  The four basic needs of ALL babies at the time of
birth (and for the first few weeks of life) are
• i. Warmth
• ii. Normal breathing
• iii. Mother's milk
• iv. Prevention of infection

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  These basic needs indicate that a baby's survival is
totally dependent upon her mother and other
caregivers.
 Therefore it is important to provide proper care to
all the neonates immediately after birth.
 All newborns require essential newborn care to
minimize the risk of illness and maximize their
growth and development.

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  This care will also prevent many newborn
emergencies. For example, care to umbilical cord
from sepsis and tetanus infection,
 Exclusive breastfeeding has a significant protective
effect against infections.
 Early breastfeeding and keeping the baby close to
the mother reduce the risk of hypothermia and
hypoglycemia.

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 Essential newborn care
• 1. Deliver the baby onto a warm, clean and dry towel or
cloth and keep on mother's abdomen or chest
(between the breasts).
• 2. Drying and wrapping the newborn baby.
 Drying often provides sufficient stimulation for
breathing to start in mildly depressed newborn babies.
 Do your best not to remove the vernix (the creamy,
white substance which may be on the skin) as it
protects the skin and may help prevent infection.
 Then wrap the baby with another dry cloth and cover
the head.

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 • 3. Assess breathing and colour;
• As you dry the baby, assess its breathing. If a baby is breathing
normally, both sides of the chest will rise and fall equally at
around 30–60 times per minute. Thus, check if the baby is:
 Breathing normally
 Having trouble breathing
 Breathing less than 30 breaths per minute, or
 Not breathing at all.
 Resuscitation of a baby who is not breathing must start within
one minute of birth.

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 • 4. Clamp and cut the umbilical cord after 1 minute
,if baby breathing well.
 Tie the cord two fingers’ length from the baby’s
abdomen and make another tie two fingers from the
first one . Cut the cord between the first and second
tie. If the baby needs resuscitation, cut the cord
immediately. If not, wait for 3-4 minutes before
cutting the cord.

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 • 5. Place the baby in skin-to-skin contact with the mother,
cover with a warm cloth and initiate breastfeeding.
 The newborn loses heat in four ways
 Evaporation: when amniotic fluid evaporates from the skin.
 Conduction: when the baby is placed naked on a cooler
surface, such as the floor, table, weighing scales, cold bed.
 Convection: when the baby is exposed to cool surrounding air
or to a draught from open doors and windows or a fan.
 Radiation: when the baby is near cool objects, walls, tables,
cabinets, without actually being in contact with them.

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 • 1. Put the baby on the mother’s chest, between the breasts, for
skin-to-skin warmth.
• 2. Cover both mother and baby together with a warm cloth or
blanket.
• 3. Cover the baby’s head.
 The first skin-to-skin contact should last uninterrupted for at
least one hour after birth or until after the first breastfeed.
 The baby should not be bathed at birth because a bath can
cool the baby dangerously.
 After 24 hours, the baby can have the first sponge bath, if the
temperature is stabilized.

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 Initiating immediate breastfeeding.
 If everything is normal, the mother should immediately start
breastfeeding.
 For optimal breastfeeding you should do the following:
 Help the mother begin breastfeeding within the first hour of birth
 Help the mother at the first feed. Make sure the baby has a good
position, attachment, and is sucking well.
 Do not limit the length of time the baby feeds; early and unlimited
breastfeeding gives the newborn energy to stay warm, nutrition to
grow, and antibodies to fight infection.

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 Warm chain

The steps to keep the newborn warm are called the warm chain.
1. Warm the delivery room.
2. Immediate drying.
3. Skin-to-skin contact at birth.
4. Breastfeeding.
5. Bathing and weighing postponed.
6. Appropriate clothing/bedding.
7. Mother and baby together.
8. Warm transportation for a baby that needs referral.

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 • 6. Give eye care (while the baby is held by its mother).
 Shortly after breastfeeding and within one hour of being born,
give the newborn eye care with an antimicrobial medication.
 Eye care protects the baby from serious eye infection which
can result in blindness or even death.
• The steps for giving the baby eye care are these:
• 1. wash your hands, and then using tetracycline 1% eye
ointment:

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 • 2. Hold one eye open and apply a rice grain size of
ointment along the inside of the lower eyelid. Make
sure not to let the medicine dropper or tube touch
the baby’s eye or anything else
• 3. Repeat this step to put medication into the other
eye.
• 4. Do not rinse out the eye medication.
• 5. Wash your hands again.

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 • 7. Give the baby vitamin K, 1 mg by intramuscular injection
(IM) on the outside of the upper thigh (while the baby is held
by its mother).
• 8. Weigh the baby.
 Weigh the baby an hour after birth or after the first
breastfeed. If the baby weighs less than 1,500 gm you must
refer the mother and baby urgently.
• *if the baby is not crying or breathing well, resuscitation have
to be carried out after immediate clamping the cord and
taking the baby towarmer

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 Newborn danger signs
 Newborn danger signs; refer baby if any of these is
present:
 Breathing less than or equal to 30 or more than or
equal to 60 breaths per minute, grunting, severe chest
in drawing, blue tongue and lips, or gasping.
 Unable to suck or sucking poorly.
 Feels cold to touch or axillary temperature less than
35°C.
 Feels hot to touch or axillary temperature equal to or
greater than 37.5°C.

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 Danger…
 Red swollen eyelids and pus discharge from the eyes.
 Convulsion/fits/seizures.
 Jaundice/yellow skin (at age less than 24 hours or more
than two weeks) involving soles of the feet and palms of
the hands.
 Pallor.
 Bleeding.
 Repeated vomiting, swollen abdomen, no stool after 24
hours.

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 Care of abnormal newborn
• 1. Perinatal asphyxia
• Hypoxic-Ischemic encephalopathy

 Failure to breath or cry at birth is called Asphyxia

 Hypoxia: decreased oxygenation of organs
 Anoxia: total lack of oxygen to organ systems
 Ischemia: decreased blood flow to organs
 Most asphyxia occur during intra-partum

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 Perinatal asphyxia
• Definition
 Profound metabolic or mixed acidemia with PH <7.2
in umbilical artery blood sample
 APGAR score of <3 for > 5 minutes
 Neonatal neurologic sequelae: seizures, hypotonic,
coma
 Multi-organ dysfunction

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 APGAR score

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 APGAR score

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 Perinatal asphyxia
• Etiology of asphyxia
 A-Decreased oxygenation of the mother and
placenta
 Maternal hypoxia related to anesthesia, cyanotic
congenital heart disease, respiratory failure, carbon
monoxide poisoning, seizure due to pre-eclampsia

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 Perinatal asphyxia
• B-Decreased placental blood flow
 Uterine tetany due to excess oxytocin
 Premature placental separation (abruptio, previa)
 Cord accidents (rupture, knotting, compression)
 Maternal hypovolemia or shock due to bleeding
 Maternal hypertension, aging of placenta etc

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 Perinatal asphyxia
•Patho-physiology
 Lack of blood or oxygen affect vital organs
 Anaerobic metabolism lead to lactic acidosis
 Lactic acidosis, hypoxia leads to cardiac dysfunction and
further leads to ischemia and hypoxia
 Lack of ATP fail to maintain cellular function
 Cellular swelling and death lead to multi-organ
derangement especially the brain and heart

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 Clinical manifestations of asphyxia

• Evidences during birth: failure to cry, failure to breath, hypotonic,

marked cyanosis, and depressed reflexes
• Evidences of multiorgan failure. (Heart, renal, lung etc)
• Grading severity of perinatal asphyxia
• Mild (stage I): Hyper alert, exaggerated reflexes, mydriasis, no seizure,
normal tone and lasts for 24 hrs with good prognosis
• Moderate (stage II): hypotonic, weak reflexes, lethargic, seizure,
meiosis, last 1-14 days
• Severe (Stage III): comatose, decerebrate posturing, absent reflexes and
it will last days to weeks. Most of them die and if survive develop
permanent neurologic deficit

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 Sar nat staging of hypoxic-ischemic
encephalopathy

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 Diagnosis
 Risk factors during ANC (hypertension, post date, maternal
chronic illness like DM, CHD, COPD)
 Abnormal biophysical profile (Low amniotic fluid, decreased
fetal movement, breathing and tone)
 Evidences of fetal distress during labor (Meconium staining,
bradycardia, persistent tachycardia)
 Laboratory evidences of hypoxia and or ischemia
 (Low blood PH<7, hypotension)
 brain injury: low APGAR score, coma, seizure, posturing
 Radiologic imaging: CT, U/S, MRI to show brain injury

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 Management
 Suction meconium and adequate oxygenation
 Early vigorous resuscitation using bag and mask at birth
 Bagging and ventilation reduces mortality by 20%
 Maintenance fluid
 Avoid early feeding
 Correct hypoglycemia, electrolyte imbalance
 Supportive care to affected organs
 Phenobarbitone to control seizure

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 Prevention
 Delivery in health institution by skilled birth attendant
 Strict follow up of pregnant mothers who have risk
factors and proper labor management
 Health workers trained in neonatal resuscitation should
attend high risk deliveries
 Prepare equipments and anticipate asphyxia
 Early vigorous stimulation, oral and nasal clearing and
ventilation is paramount to save the baby
 Unresponsive babies need intubation and ventilation

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 Meconium aspiration syndrome
 MAS : respiratory distress in the new born delivered with
meconium stained amniotic fluid
• Pathophysiology
 Black green, odorless, sticky material Composed of skin
debris, GIT mucus, vernix caseosa, amniotic fluid and other
glycoprotein
 Passed in utero due to acute or chronic fetal stress
 induces gasping breathing and Aspiration of meconium

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 Risk factors
 Prolonged labor
 Uterine tetany,
 Cord accidents (Knotting)
 Placental abruption or previa
 Acute or Chronic maternal illness causing hypoxia
 Post maturity
 Oligohydraminos
 IUGR

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 Clinical manifestation
 Respiratory distress in a meconium stained baby
 Bulged chest
 Tachypnea, grunting, flaring, retraction and cyanosis
 Air entry may be decreased with lung collapse or
crepitation's heard on areas of inflammation
 Depressed level of consciousness due to hypoxia or
associated asphyxia
 Severe MAS lead to pulmonary hypertension with right to
left shunting and unresponsive cyanosis

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 Diagnosis
 History of high risk pregnancy
 Fetal distress during labor
 Evidence of meconium stained amniotic fluid at birth
 Respiratory distress in a meconium stained baby
 Suctioning of meconium from oropharynx at birth
 CXR: showing ground glass appearance, fluffy
shadows and areas of atelectasis

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 Management
 Early vigorous suctioning
 Avoid bagging before adequate suctioning
 Endotracheal intubation for a limp and severely hypoxic baby to
suction meconium down to the trachea
 Admit to NICU
 Start oxygen supply, maintenance fluid
 Hold feeding until baby is stabilized
 Start antibiotics for bacterial pneumonia
 Mechanical ventilation if there is respiratory failure
 Follow for complications and manage accordingly

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 CXR:

Linear
infiltration on
both lung fields.
Coarse granular
pattern due to
MAS.

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 Hyaline Membrane Disease (Respiratory
Distress Syndrome)
 HMD : occurs primarily in premature infants
 It occurs in 60-80% of infants less than 28 wk of
gestational age, in 15-30% of those between 32 and
36 wk, in about 5% beyond 37 wk, and rarely at
term.
 The incidence is highest in preterm male or white
infants.

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 Etiology and Pathophysiology
 Surfactant deficiency is the primary cause of HMD.
 The major constituents of surfactant are (lecithin),
phosphati-dyl glycerol, lipoproteins and cholesterol.
 With advancing gestational age, increasing amounts
of phospholipids are synthesized and stored in type
II alveolar cells.

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 Cont..
 Surfactant is present in high concentrations in fetal
lung homogenates by 20 wk of gestation, but it does
not reach the surface of the lungs until later.
 It appears in amniotic fluid between 28 and 32 wk.
Mature levels of pulmonary surfactant are usually
present after 35 wk.

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 Clinical Manifestations.
 tachypnea, prominent (often audible)
 grunting,
 intercostal and subcostal retractions,
 nasal flaring,
 Cyanosis increases and is often relatively
unresponsive to oxygen administration.
 The natural course of untreated HMD is
characterized by progressive worsening of cyanosis
and dyspnea.
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 Cont..
 If un treated, blood pressure may fall; fatigue, cyanosis, and
pallor increase, and grunting decreases or disappears as the
condition worsens.
 Apnea and irregular respirations occur as infants tire
 Patients may also have a mixed respiratory-metabolic acidosis.
 Respiratory failure may occur
 signs reach a peak within 3 days
 Death is rare on the 1st day of illness, usually occurs between
days 2 and 7.

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 Diagnosis
 The clinical course
 chest x-ray
 Blood gas and acid-base values help establish the
clinical diagnosis.
• Treatment
 Multidose endotracheal instillation of exogenous
surfactant
 Hydrocortisone
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 supportive measures
 Maintain adequate ventilation and oxygenation.
 Maintain acid–base balance.
 Maintain a neutral thermal environment.
 Maintain adequate tissue perfusion and
oxygenation.
 Prevent hypotension.
 Maintain adequate hydration and electrolyte status.

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 Cont…
 Calories and fluids should be provided intravenously.
 For the 1st 24 hr, 10% glucose and water should be
infused through a peripheral vein at a rate of 65-75
mL/kg/24 hr.
 Subsequently, electrolytes should be added and
fluid volume increased gradually.

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 Cont…
 Infants should be placed in radiant warmer and core
temperature maintained between 36.5 and 37°C
 Respiratory acidosis may require short-term or prolonged
assisted ventilation.
 Metabolic acidosis in HMD may be a result of perinatal
asphyxia and hypotension.
 Sodium bicarbonate, 1-2 mEq/kg, may be administered over a 15-
20 min period through a peripheral or umbilical vein, with the
acid-base determination repeated
– within 30 min.

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 Prevention
 Most important is prevention of prematurity,
including avoidance of unnecessary or poorly timed
cesarean section
 Appropriate management of high-risk pregnancy
and labor

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 Neonatal Resuscitation

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 Cont…
 Transition from IU life to EU (Extra uterine)life is the most
important period in neonatology
 Most infants complete the transition to extra uterine life
without difficulty and require only the routine care; but
 5 to 10 % require resuscitation.
 Failure to initiate and maintain effective respiration is the
most common delivery room emergency for neonates.

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 Goals of neonatal resuscitation
 Prevent the morbidity and mortality associated with
hypoxic-ischemic tissue injury.
 Reestablish adequate spontaneous respiration and cardiac
output.
 Improve the likelihood of preventing brain damage.
 In order to achieve this goal High-risk situations should be
anticipated by
 Pregnancy, labor, and delivery history and
 Identification of signs of fetal distress.

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 Elements of resuscitation
• 1. Initial steps: thermal management, clearing the airway,
tactile stimulation
• 2. Establishment of ventilation
• 3. Chest compression
• 4. Medication

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27-Feb-24 by:Walle Kumlachew 166
 initial steps and how are they administered?
A. Provide warmth
– - The baby should be placed under a radiant warmer
B. Position; clear airway (as necessary)
– - Position by slightly extending the neck Dry,
stimulate, reposition

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 Clear airway (as necessary)
 In vigorous babies (a vigorous baby is one who has
strong respiratory efforts, heart rate>100 bpm and a
good muscle tone), no suctioning of oro-pharynx or the
trachea is required.
 In all non-vigorous babies , suctioning of oro-pharynx
needs to be done. If, such babies were also delivered
through meconium stained amniotic fluid, oropharyngeal
suction would need to be followed by tracheal intubation
to clear it of meconium (if skills are available).

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 How do you clear the airway?
 Secretions may be removed from the airway by wiping
the nose and mouth with a towel or by suctioning with a
mucus extractor or suction catheter.
 If the newborn has copious secretions coming from the
mouth, turn the head to the side.
 The mouth is suctioned before the nose to ensure that
there is nothing for the newborn to aspirate if he or she
should gasp when the nose is suctioned.

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 Cont…
• C. Dry, stimulate, reposition
 Often, positioning the baby and suctioning secretions will
provide enough stimulation to initiate breathing.
 Drying will also provide stimulation.
 If 2 people are present, the second person can be
drying the baby while the first person is positioning and
clearing the airway.
 As part of preparation for resuscitation, you should have
several pre-warmed towels available.

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 Other forms of stimulation

 Safe and appropriate methods of providing additional tactile

stimulation include:
 • Slapping or flicking the soles of the feet
 • Gently rubbing the newborn’s back, trunk, or extremities

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 Cont…
• Harmful Actions Consequences
• Slapping the back - Bruising
• Squeezing the rib cage - Fractures,
• pneumothorax,
• death
• Holding upside down - Intraventricular
• and shaking bleeding, brain
• damage.

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 What do you do after the initial steps?
• Evaluate the baby in the following order:
1. Respiration. There should be good chest movements, and the rate
and depth of respirations should increase after a few seconds of
tactile stimulation.
2. Heart rate. The heart rate should be >100 bpm. The easiest and
quickest method to determine the heart rate is to feel for the pulse
at the base of the umbilical cord. Counting the heart rate for 6
seconds and multiply by 10 to calculate the heart rate per minute.
3. Colour. The baby should have pink lips and trunk. There should
be no central cyanosis once the baby has good respiration and
heart beat that indicates hypoxia.

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 What do you do if the baby is breathing, but has
central cyanosis?
 The baby’s skin color is best determined by looking at the
central part of the body.
– Lips, tongue and central trunk
 If the baby is breathing but appears blue, administration
of supplement oxygen is indicated.
– Give free-flow oxygen
 Give a flow of 0.5 L/min with a tubing by cupped hand
or a mask kept closer to the face.

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 Cont…

27-Feb-24 by:Walle Kumlachew 175

 How do you know when to stop giving
oxygen?
 When the newborn no longer has central cyanosis,
gradually withdraw the supplemental oxygen until
the newborn can remain pink while breathing room
air.
 If cyanosis persists despite administration of free-flow
oxygen, the baby may have significant lung disease,
and a trial of positive-pressure ventilation may be
indicated.

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 Observational Care
 Babies improving after initial steps of resuscitation
require observational care.
 This can be provided either with the mother or in a
newborn care unit.
 Assess breathing, heart rate, color and temperature
every 15 minutes during the first hour after birth.
 Continue to provide warmth and initiate breast feeding.
 If baby is unstable, he will require additional
interventions.

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 Positive Pressure Ventilation
 Indications of Positive pressure Ventilation
 Baby is not breathing or is gasping
 Heart rate is less than 100 bpm
 Persistent central cyanosis despite supplemental
oxygène .
 Ventilation of the lungs is the single most important and
most effective step in cardiopulmonary resuscitation of the
compromised newly born baby.

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 Use of Use
SelfofInflating bag bag
Self Inflating to ventilate
to ventilate
newborns
newborns

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 Appropriately sized masks
 A variety of mask sizes, appropriate for babies of
different sizes, should be available at every delivery,
since it may be difficult to determine the appropriate
size before birth.
 The mask should cover the chin, mouth, and nose,
but not the eyes, while still being small enough to
create a tight seal on the face.

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 Cont…
 You should use bags for newborns which have volume of
500ml.
 Term newborns require only 15 to 25mL with each
ventilation (5 to 8mL/Kg).
 Bags larger than 750mL, which are designed for older
children and adults, make it difficult to provide such small
volumes.
 Bags that are too small will not permit long inflation
times.

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 Cont…
 Masks come in a variety of shapes, sizes and
materials.
 Selection of a mask for use with a particular newborn
will depends on how well the mask fits the newborn’s
face. The correct mask will achieve a tight seal
between the mask and the newborn’s face.

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 Cont…
 For the mask to be of the correct size, the rim will cover
the tip of the chin, the mouth, and the nose but not the
eyes.
 Too large-may cause possible eye damage and will not
seal well.
 Too small-will not cover the mouth and nose and may
occlude the nose.
 Be sure to have various-sized masks available.
Effective ventilation of a preterm baby with a term-
infant size mask is impossible.

27-Feb-24 by:Walle Kumlachew 183

 Cont..

27-Feb-24 by:Walle Kumlachew 184

 Preparation for resuscitation
 Assemble equipment
 The positive-pressure ventilation device should be
assembled and connected to oxygen
 Test the equipment
 Check the bag and mask to be sure they function
properly
 Mask that are cracked or deflated must not be used

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 Check before positive-pressure ventilation
 Select the appropriate-sized mask
 Be sure there is a clear airway
 Position the baby’s head
 Position yourself at the bedside

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 How do you position the bag and mask on
the face?
• You may find it helpful to begin by cupping the chin in the
mask and then covering the nose (Figure below).
• The mask usually is held on the face with the thumb, index,
and/or middle finger encircling much of the rim of the mask,
while the ring and fifth bring the chin forward to maintain a
patent airway.

27-Feb-24 by:Walle Kumlachew 187

 How often should you squeeze the bag?
 During the initial stages of neonatal resuscitation, breaths
should be delivered at a rate of 40 to 60 breaths per
minute, or slightly less than once a second.
 To help maintain a rate of 40 to 60 breaths per minute,
try saying to yourself as you ventilate the newborn:
• Breathe….Two…Three…..Breathe………Two……Three
• (squeeze) (release………) (squeeze) (release…………)

27-Feb-24 by:Walle Kumlachew 188

How do you know if the baby is improving and that you can
stop positive pressure ventilation?
• Improvement is indicated by the following 4 signs:
1. Increasing heart rate
2. Improving color
3. Spontaneous breathing
4. Improving muscle tone

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 If no improvement
• It may be due to one or more of the following
reasons.
1. The seal is inadequate
• The most common place for a leak to occur is between the cheek
and bridge of the nose.
2. The airway is blocked
3. Not enough pressure is being given

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 Chest Compression
 What are the indications for beginning chest
compressions?
 Chest compressions should be started whenever the
heart rate remains less than 60 bpm despite 30
seconds of effective positive-pressure
ventilation.(Check HR for 6 seconds)

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 What are chest compressions?
 Chest compressions, sometimes referred to as
external cardiac massage, consist of rhythmic
compressions of the sternum that
 Compress the heart against the spine
 Increase the intrathoracic pressure
 Circulate blood to the vital organs of the body

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  Remember that chest compressions are of little value
unless the lungs are also being ventilated with
oxygen.
 Therefore, 2 people are required to administer
effective chest compressions one to compress the
chest and one to continue ventilation.

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 How do you position your hands on the chest to begin
chest compressions?
 There are two techniques for performing chest compression.
These techniques are
• 1. Thumb technique, where the 2 thumbs are used to depress
the sternum, while the hands encircle the torso and the fingers
support the spine.
• 2. finger technique, where the tips of the middle finger and
either the index finger or ring finger of one hand are used to
compress the sternum, while the other hand is used to support
the baby’s back (unless the baby is on a very firm surface).

27-Feb-24 by:Walle Kumlachew 194

Thumb technique

• Thumb technique
2-finger technique

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 How much pressure do you use to compress the chest?

 Controlling the pressure used in compressing the sternum is

an important part of the procedure.
 One third of the anterior posterior diameter of the chest.
 One compression consists of the downward stroke plus the
release.
 The actual distance compressed will depend on the size of
the baby.

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 Do not lift the thumb or fingers completely off the sternum after each
compression.

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 Are there dangers associated with administering
chest compressions?
• • Chest compressions can cause trauma to the baby.
• • Two vital organs lie within the ribcage-the heart
and lungs. Pressure applied over the xiphoid, can
cause laceration of the liver.
• • Also, the ribs are fragile and can easily be broken.

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How often do you compress the chest and coordinate
compressions with ventilation?
 chest compressions must always be accompanied by
positive-pressure ventilation.
 Avoid giving a compression and ventilation
simultaneously.
 The 2 activities must be coordinated, with one
ventilation interposed after every third compression.
 For a total of 30 breaths and 90 compressions per
minute.

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When do you stop chest compressions?
 After approximately 30 sec of well-coordinated chest
compressions and ventilation, stop compressions long enough
to determine the heart rate again. Feel the pulse at the base
of the cord,
 If the heart rate is >60 bpm, then Discontinue chest
compressions, but continue PPV now at a more rapid rate of
40 to 60 bpm.
 Once the heart rate rises above 100 bpm and the baby begins
to breathe spontaneously, slowly withdraw PPV and move the
baby to the nursery for post-resuscitation care.

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 When to terminate resuscitation?
 After 10 minutes of continuous and adequate efforts
if there are no signs of life (no heart rate and no
respiratory effort), discontinue resuscitative efforts.
 Remember in all so-called ‘stillbirths’ the resuscitation
efforts must be continued for 10 min
 The data suggests that in fresh stillbirths prognosis is
not all that bad.

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If the heart rate is now below 60 bpm, then

 Despite good ventilation of the lungs with positive-

pressure ventilation and improved cardiac output
from chest compressions,
 A small number of newborns (fewer than 2 per
1,000 births) will still have a heart rate below 60
bpm.
 These babies would require epinephrine to
stimulate the heart.

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 Thank you

27-Feb-24 by:Walle Kumlachew 203

Chapter- Four: Management of common childhood
disease
• 1. RESPIRATORY INFECTIONS
Infections of the respiratory tract are described according
to anatomical area of involvement.
The upper respiratory tract consist of:
Pharynx, larynx, and upper part of the trachea.
The lower respiratory tract consist of:
Lower trachea, bronchi, bronchioles, and the alveoli.

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 Respiratory System

27-Feb-24 by:Walle Kumlachew 205

 Anatomy of the Respiratory system

27-Feb-24 by:Walle Kumlachew 206

 Etiology and risk factors
• 1. Infectious agents:
Respiratory syncytial virus (RSV)
Non-polio enteroviruses
Adenoviruses
Parainfluenza virus
Group A beta hemolytic streptococci (GABHS)
Staphylococci
Hemophilus influenzae, chalamydia trochomatis
pneumococcal

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 • 2. Age
Infant younger than age 3 months have lower
infectious rate (protected from maternal antibodies).
The infection rate increases from 3 to 6 months of
age.
The viral infection rate increase during (toddler, and
preschool years)

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 • 3. Size
The diameter of the airway is smaller in young children, the organism may
move rapidly.
• 4. Resistance
The ability to resist depending on several factors:
Deficiency of immune system
Malnutrition
Anemia
Fatigue
Allergies
Asthma
Cardiac anomalies
• 5. Seasonal variations.

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 Upper Respiratory Infections
1. Pharyngitis
 Inflammation of the throat mucosa (pharynx) is referred to as pharyngitis.
 A sore throat may accompany nasal congestion and is often
• viral in nature.
 A bacterial sore throat most often occurs without nasal symptoms.
• Clinical manifestations
 Headache
 Fever
 Abdominal pain
 Swallowing difficult
 Anorexia
 The tonsils and pharynx may be inflamed and covered with exudates.

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Pharyngitis

27-Feb-24 by:Walle Kumlachew 211

Therapeutic Management
 Viral pharyngitis is usually self-limited and does not
require therapy beyond symptomatic relief.
 bacterial(Group A streptococcal pharyngitis) requires
antibiotic therapy.
 penicillin is generally prescribed. Appropriate alternative
antibiotics include amoxicillin and, for those allergic to
penicillin, macrolides and cephalosporins.
 Analgesic

27-Feb-24 by:Walle Kumlachew 212

Nursing Considerations:
 The nurse often obtains a throat swab for culture.
 Instruct the parents about administering penicillin and analgesic
as prescribed.
 Cold or warm compresses to the neck may provide relief.
Pain may interfere with oral intake , and children should not be
forced to eat.
Cool liquids are usually accepted
Completing the course of antibiotic therapy
Children not return to school until they have been taking
antibiotics for a full 24 hour period.

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2. Tonsillitis
Tonsils are masses of lymphoid tissue located in the pharyngeal cavity.
Tonsillitis is inflammation of palatine Tonsils
• Etiology
Tonsillitis often occurs with Pharyngitis.
Viral or bacterial

27-Feb-24 by:Walle Kumlachew 214

Tonsillitis…cont’d
• Clinical manifestations
 Difficulty swallowing and breathing.
 The child breathes through the mouth.
• Therapeutic management
 Viral tonsilitis is usually self-limited and does not require
therapy beyond symptomatic relief.
 bacterial(Group A streptococcal tonsilitis) requires antibiotic
therapy.
 penicillin is generally prescribed. Appropriate alternative
antibiotics include amoxicillin
 Tonsillectomy

27-Feb-24 by:Walle Kumlachew 215

Tonsillitis…cont’d
• Nursing considerations
 Provide comfort and minimizing activities that precipitate bleeding.
 A soft to liquid diet is preferred.
 Warm salt water gargles, analgesic and antipyretic drugs.
• Postoperative nursing care
 Abdomen or side lying position to facilitate drainage of secretions.
 Discourage from coughing, clearing their throat, blowing their nose that may
aggravate the operation site.
 All secretions and vomitus are inspected for evidence of fresh bleeding.

27-Feb-24 by:Walle Kumlachew 216

Tonsillitis…cont’d
• Postoperative….
Analgesics may be given rectally or intravenously to
avoid the oral route.
Food and fluids are restricted until children are fully alert
and there are no signs of bleeding.
Cool water, crushed ice, diluted fruit juice is given.
Soft foods, cooked fruits, mashed potatoes are started on
the first or second postoperative day.
The nurse observe the throat directly for evidence of
bleeding.

27-Feb-24 by:Walle Kumlachew 217

3. Acute Otitis Media (AOM)
 Acute inflammation of the middle ear
 Bacteria (streptococcus pneumonia, haemophilus influenza…)
 Very common in less than 3 years and rare in adults.

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 Clinical manifestation
Fever
Acute ear pain(crying, irritable, sleeplesness)
Pulling or rubbing in the ear.
Bulging yellow or red tympanic membrane.
Rhinitis, cough , diarrhea.
Ear discharge(otorrhoea)

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 Treatment

27-Feb-24 by:Walle Kumlachew 220

 Nursing considerations
• Nursing objectives
Relieving pain
Facilitating drainage.
Preventing complications or recurrence.
Educating the family in care of the child.
Providing emotional support to the child.
Analgesic drugs (ibuprofen).
An ice compress placed over the affected ear may also
provide comfort and reduce edema.
If the ear drainage , the external canal cleaned with sterile
cotton swabs

27-Feb-24 by:Walle Kumlachew 221

 Nursing considerations
• Nursing objectives
Relieving pain
Facilitating drainage.
Preventing complications or recurrence.
Educating the family in care of the child.
Providing emotional support to the child.
Analgesic drugs (ibuprofen).
An ice compress placed over the affected ear may also
provide comfort and reduce edema.
If the ear drainage , the external canal cleaned with sterile
cotton swabs

27-Feb-24 by:Walle Kumlachew 222

 • Prevention of recurrence
Education regarding antibiotic therapy.
Sitting or holding an infant upright during bottle
feeding.
Aware of potential complications as (loss of hearing).

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 Lower respiratory infections

27-Feb-24 by:Walle Kumlachew 224

Pneumonia
Inflammation of the pulmonary parenchyma, is
common in childhood but occurs more frequently in
infancy and early childhood.
Pneumonia may occur either as a primary disease or
as a complication of another illness.

27-Feb-24 by:Walle Kumlachew 225

 Pathophysiology
 Organism entry via respiration or blood stream

 Parenchyma inflammation

 Infiltration of exudate to alveoli (consolidation)

 Alveoli full of cell debris and leukocytes

 While coughing blood sting sputum and purulent material

comes

27-Feb-24 by:Walle Kumlachew 226

 Cont..

 Bacterial pneumonia most often causes lobar

involvement and sometimes consolidation.

 Viral pneumonia usually causes inflammation of the

interstitial space.

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Bacterial Pneumonia
• Causative organism
Streptococcus pneumoniae
Other bacteria that cause pneumonia in children (
staphylococcus aureus, and Haemophilus influenza).

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 General Signs of Pneumonia
Fever
Fast breathing
Malaise
Rapid and shallow respirations
Cough
Chest pain
Anorexia , vomiting, diarrhea
 abdominal pain

27-Feb-24 by:Walle Kumlachew 229

 Cont..

27-Feb-24 by:Walle Kumlachew 230

Therapeutic Measures
Antibiotics therapy
Amoxicillin is the first line
Bed rest
Oral intake of fluid
Antipyretic
IV fluid and oxygen is required if the child is in
respiratory distress.

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Complications
Necrosis
Empyema
Pneumonic (pleural ) effusion
Lung abcess

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Chest X-ray of Pneumococcal Pneumonia

27-Feb-24 by:Walle Kumlachew 233

Nursing Considerations
Isolation
Encourage rest and conservation of energy.
Encourage the child to regular sleep.
To prevent dehydration fluid are frequently administered intravenous
Oral fluids if allowed to decrease cough.
Children may be placed in a mist tent.
Fever controlled by administration of antipyretic drugs as prescribed.
V/S and breath sounds are monitored to assess the progress of disease.
Children with ineffective cough require suctioning to maintain patent airway.

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NURSING CARE PLAN
1. Nursing diagnosis:
 Ineffective breathing pattern related to allergic response in bronchial
tree.
 Nursing intervention:
Instruct and/ or supervise breathing exercise, controlled breathing.
Teach correct use of prescribed medication.
Assist child and family in selecting activities appropriate to child's
capacity and preferences.
Encourage regular exercise.
Encourage good posture.
Encourage physical exercise
Discourage physical inactivity.

27-Feb-24 by:Walle Kumlachew 235

 • Nursing diagnosis:
 Activity intolerance related to imbalance between O2 supply and
demand.
 Nursing intervention:
Encourage activities appropriate child's capabilities.
Provide ample opportunities for – rest and quite activities.

27-Feb-24 by:Walle Kumlachew 236

 • 3)Nursing diagnosis: Altered family process related to having a child
with a chronic illness.
 Nursing Intervention:
Foster positive family relationships.
Be alert to signs of parental rejection or overprotection.
Intervene appropriately of these is evidence of maladaptation.
Use every opportunity to increase parent's and child's understanding
of the disease and its therapies.
Be alert to signs that child us depressed.
Refer family to appropriate support groups and community agencies.

27-Feb-24 by:Walle Kumlachew 237

 GIT Disorders
• 1. DIARRHEA
 Diarrhea is a symptom that results from disorders
involving digestive,absorptive, and secretory functions.
 Diarrhea is caused by abnormal intestinal water and
electrolyte transport.
 Worldwide, there are an estimated 1.3 billion episodes
of diarrhea each year.
 Approximately 24% of all deaths in children living in
developing countries are related to diarrhea and
dehydration.

27-Feb-24 by:Walle Kumlachew 238

 GIT Disorders…
 Acute diarrhea, a leading cause of illness in children younger than
• 5 years of age,
 it is defined as a sudden increase in frequency and a change
• in consistency of stools, often caused by an infectious agent in the GI tract.
 It may be associated with upper respiratory or urinary tract
• infections, antibiotic therapy, or laxative use.
 Acute diarrhea is usually self-limited (<14 days’ duration) and subsides
without specific treatment if dehydration does not occur.
 Acute infectious diarrhea (infectious gastroenteritis) is caused by a variety
of viral, bacterial, and parasitic pathogens

27-Feb-24 by:Walle Kumlachew 239

 Etiology
 Most pathogens that cause diarrhea are spread by the
fecal–oral route
• through contaminated food or water or are spread from
person to person where there is close contact (e.g.,
daycare centers).
 Lack of clean water, crowding, poor hygiene, nutritional
deficiency, and poor sanitation
• are major risk factors, especially for bacterial or parasitic
pathogens.

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 Etiology
 Rotavirus is the most important cause of serious gastroenteritis
• among children and a significant nosocomial (hospital-acquired)
• pathogen, accounting for 55,000 to 70,000 hospitalizations annually
 Rotavirus disease is most severe in children 3 to 24 months of
• age.
 Children younger than 3 months of age have some protection from
• the disease because of maternally acquired antibodies.
 Approximately 25% of severe cases of rotavirus occur in older children.
 Salmonella, and Shigella, organisms are the most
• frequently isolated bacterial pathogens.
 Salmonella has the highest occurrence in infants; Giardia and Shigella have the
highest incidence among toddlers

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 Diagnosis
Clinical manifestations
Laboratory(stool )

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 Therapeutic Management
 The major goals in the management of acute diarrhea include
• 1. assessment of fluid and electrolyte imbalance,
• 2. rehydration,
3. maintenance fluid therapy, and
4. reintroduction of an adequate diet.
 Infants and children with acute diarrhea and dehydration should be treated
first with oral rehydration therapy (ORT) and zinc.
 Antibiotics is only indicated based on laboratory result (bacteria)
 If dysentry(blood in the stool) ciprofloxacin is first line antibiotic

27-Feb-24 by:Walle Kumlachew 243

 ACUTE APPENDICITIS IN CHILDREN
 Acute appendicitis is an inflammation of appendix
caused by purulent microflora.
 Approximately 7 percent of the population will have
appendicitis in their lifetime with the peak incidence
occurring between the ages of 10 and 30 years.
 Despite technologic advances, the diagnosis of
appendicitis is still based primarily on the patient's
history and the physical examination.

27-Feb-24 By: Walle kum.

 • The mortality rate in nonperforated appendicitis is less
than 1 %, but it may be as high as 5 % or more in young
and elderly patients, in whom diagnosis may often be
delayed, thus making perforation more likely.
• Prompt diagnosis and surgical referral may reduce the
risk of perforation and prevent complications.
• The male-to-female ratio is approximately 2:1.

27-Feb-24 By: Walle kum.

 RISK OF DEVELOPING APPENDICITIS
WITH AGE

27-Feb-24 By: Walle kum.

Age
• The mean age in the pediatric population is 6-10
years.
• Appendicitis is rare in the neonate, and the diagnosis
in this age group is typically made after perforation.
• Younger children have a higher rate of perforation,
with reported rates of 50-85%.

27-Feb-24 By: Walle kum.

27-Feb-24 By: Walle kum.
 Etiology and pathogenesis
• Obstruction of the narrow appendiceal lumen initiates the
clinical illness of acute appendicitis.
• Obstruction has multiple causes, including lymphoid
hyperplasia (related to viral illnesses) fecaliths, parasites,
foreign bodies, primary or metastatic cancer and carcinoid
syndrome.
• Lymphoid hyperplasia is more common in children and young
adults, accounting for the increased incidence of appendicitis
in these age groups.

27-Feb-24 By: Walle kum.

 Symptoms of simple appendicitis
1. Pain localized in a right iliac area.
• In 70 % of patients the pain arises in a epigastric area
– it is an epigastric phase of acute appendicitis. In 2-4
hours it migrates to the area of appendix (the
Kocher’s sign).
2. Single nausea and vomiting.
3. Fever to 37.5-380C.
4. Retention of stool or single diarrhea.
5. Muscular tension in a right iliac area.
27-Feb-24 By: Walle kum.
 Rovsing's sign - pain in right lower quadrant during
palpation of left lower quadrant
Sitkovsky’s sign - increase of pain in a right iliac area
when the patient lies on the left side
Bartomier’s sign - increase of pain intensity during
palpation of right iliac area when the patient lies on
the left side.
Dunphy's sign-increased pain with coughing

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 Diagnostics
Objective examination.
General blood and urine analyses.
Rectal examination.

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 History
• The clinician is more likely to make the diagnosis by
maintaining a high degree of suspicion, a broad
differential diagnosis, and looking for the atypical
case rather than the classic appendicitis (1-2 days of
fever, vomiting, RLQ pain, anorexia).
• Vomiting, RLQ pain, tenderness, and guarding are
significantly associated with appendicitis.

27-Feb-24 By: Walle kum.

 History
• The initial symptom is poorly defined periumbilical
pain, often associated with anorexia.
– In appendicitis, nausea and vomiting develop
shortly after onset of pain.
– In most cases of appendicitis, abdominal pain
precedes vomiting.

27-Feb-24 By: Walle kum.

 History
• After a few hours, the pain shifts to the RLQ due to
inflammation of the parietal peritoneum.
– This pain is more intense, continuous, and more
localized than the initial pain.
– This shift of pain rarely occurs in other abdominal
conditions.

27-Feb-24 By: Walle kum.

 History:
• Most children with appendicitis either are afebrile or
have a low-grade fever.
– High fever is not a common presenting feature
unless perforation has occurred.
– Vomiting and fever are more frequent in children
with appendicitis than in children with other
causes of abdominal pain.

27-Feb-24 By: Walle kum.

 Physical:
• Children vary in their ability to cooperate with the
physical examination.
• It is important to tailor the physical examination
with respect to the child's age and developmental
stage.
• It is important to exclude extra-abdominal causes of
abdominal pain.

27-Feb-24 By: Walle kum.

 Physical:
 The psoas sign is determined by placing the child on
the left side and hyper extending the right leg.

27-Feb-24 By: Walle kum.

 Physical:
 The obturator sign is determined by internal rotation
of the flexed right thigh.
 Pain on movement may be caused by an
inflammatory mass overlying the psoas muscle.

27-Feb-24 By: Walle kum.

 Physical:
 The cough sign (sharp pain in the RLQ after a
voluntary cough) is suggestive of peritoneal
irritation.

27-Feb-24 By: Walle kum.

 Physical:
 A rectal examination should be performed last and
may reveal impacted stool, right-sided tenderness, or
a mass.


27-Feb-24 By: Walle kum.

 rectal examination

27-Feb-24 By: Walle kum.

 Antibiotic therapy
• is an important aspect of the treatment of ruptured
appendicitis.
• Antibiotic therapy should be directed against gram-
negative and anaerobic organisms such as E.coli and
Bacteroides species.
• The administration of antibiotics, NGT, IV lines, urethral
catheters, antiemetic medicine, antipyretic medicine,
and analgesia should ideally be part of the Emergency
Drug protocol for managing the preoperative child.

27-Feb-24 By: Walle kum.

 Surgical mgt
• Appendectomy is the definitive treatment for
appendicitis.

27-Feb-24 By: Walle kum.

 Preoperative antibiotics
• are given to children with suspected appendicitis and
stopped after surgery if no perforation exists.
• Patients presenting with perforated appendicitis may
be volume depleted and require aggressive fluid
resuscitation.
• The combination of ampicillin, clindamycin, and
gentamicin is administered to treat infection from
aerobic and anaerobic organism
• Alternative regimens include ampicillin and
sulbactam,
27-Feb-24 By: Walle kum.
 Complications

1. Appendicular infiltrate.
2. Appendicular abscess.
3. Diffuse peritonitis.

27-Feb-24 By: Walle kum.

 •THANK YOU!!!

27-Feb-24 by:Walle Kumlachew 267

 Chapter Five : Systemic Childhood Disease

• 1. CONGENITAL HEAR DEFECT

27-Feb-24 by:Walle Kumlachew 268

 Congenital heart disease
• After the end of this session the students should be able to..
Define CHD
Distinguish the commonest etiologic agents of CHD
Differentiate the types of Congenital heart disease
List the clinical manifestation of CHD in children.
Recognize the Managements of CHD.
Describe nursing intervention & prevention of CHD.

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  Congenital heart defect (CHD) : defined as an anatomic
malformation of the heart or great vessels which occurs during
intrauterine development, irrespective of the age at presentation.
 “Congenital defect”comes from the words congenital, meaning
“existing at birth”and “defect”, meaning a problem.
 The heart is completely formed by the 8th week of pregnancy.
 Congenital heart defects are some times called congenital heart
disease.

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 Intro….
 A congenital heart defect can increase the risk of
developing other conditions, including pulmonary
hypertension, arrhythmias and congestive heart
failure.

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27-Feb-24 by:Walle Kumlachew 272
 Cardiac Embryology
 The embryonic period is considered to be from two
weeks post fertilization to the end of the eighth
week (Larson 1993).
 Between the third and fourth weeks, the heart
starts to beat and blood begins to circulate.

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  The fourth to eighth weeks constitute a very
important period of embryonic development.
 It is the beginnings of all major external and internal
structures appear during these five weeks.

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  By the end of the eighth week, all the main organs
have begun to develop, but the function of most is
limited, the exception being the heart which is fully
formed and functioning (Moore and Persaud 1998).

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 Fetal Circulation
• Main Blood Flow
 Placenta  Umbilical Vein  Liver  Ductus
Venosus  Inferior Vena Cava  Right
Atrium Foramen Ovale Left Atrium  Left
Ventricle  Aorta Body

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27-Feb-24 by:Walle Kumlachew 277
 • Secondary Route:

 Right Atrium  Right Ventricle 

Pulmonary Artery  Ductus Arteriosus .
(so does not go to lungs)

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 • Third route of blood flow
 Right Atrium  Right Ventricle  Pulmonary
Artery  Lungs (needs to perfuse the lungs and upper
body with oxygen) Left Atrium  Left Ventricle

 Aorta  Body

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 Transition from Fetal Circulation to Pulmonary
circulation
 The umbilical arteries and vein and the ductus venosus
become non-functional
 Decreased pulmonary vascular resistance and increased
pulmonary blood flow
 Increase in pressure of the left atrium, decrease
pressure in right atrium, causing closure of foramen
ovale.

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  Pulmonary resistance is less than systematic
resistance so there is left-to-right shunting resulting
in closure of the ductus arteriosus.

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 CAUSES
Mostly unknown
 Multifactorial: Genetic-environmental interaction
• – Genetic/chromosomal
• – Environmental: CMV, maternal
• hypoxia, hyperthermia, DM .
• drugs: like, phenytoin and other
• anticonvulsants, alcohol, thalidomide

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 CLASSIFICATION OF CONGENITAL HEART
DEFECT

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 Congenital heart defect ---

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 1. A Cyanotic heart diseases

• 1. Ventricular septal defect(VSD)

 Is an abnormal opening in the ventricular septum
which allows free communication b/n the right and
left ventricles.

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 1. Oxygenated blood is shunted from left to right side of
the heart via defect
2. A larger volume of blood than normal must be handled
by the right side of the heart hypertrophy
3. Extra blood then passes through the pulmonary artery
into the lungs, causing higher pressure than normal in
the blood vessels in the lungs  congestive heart
failure

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  VSDs are frequently associated with other defects, such as
pulmonary stenosis, transposition of the great vessels, PDA,
atrial defects, and COA.
 Many VSDs (20%–60%) close spontaneously. Spontaneous
closure is most likely to occur during the first year of life in
children having small or moderate defects.
 A left-to-right shunt is caused by the flow of blood from the
higher pressure left ventricle to the lower pressure right
ventricle.

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 Clinical manifestations
Small VSDs are usually accidental findings during routine physical
examination, the characteristic murmur is a loud, harsh, or blowing
holosystolic murmur best heard at the left lower sternal border
This murmur may not be audible in the first few days of life b/c of the higher
right sided pressure.
In large VSDs
Dyspnea, feeding difficulties, poor growth, profuse perspitation and
heart failure in early infancy.
Bulged precordium, displaced apical beat, murmur

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 Treatment
 Surgical repair with a patch inserted

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 Atrial Septal Defect
1. Oxygenated blood is shunted from left to right side of
the heart via defect
2. A larger volume of blood than normal must be handled
by the right side of the heart hypertrophy
3. Extra blood then passes through the pulmonary artery
into the lungs, causing higher pressure than normal in
the blood vessels in the lungs  congestive heart failure

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 Abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow
into the lower pressure right atrium.

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 Clinical manifestations
 Mostly asymptomatic, may have easy fatigability and mild
growth failure
 Bulged precordium, loud 1st heart sound, systolic ejection
murmur best heard at the left middle and upper sternal
border, rumbling mid diastolic murmur heard at the lower
sternal border

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 Treatment
• Device Closure – Amplatzer septal occluder

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 Patent Ductus Arteriosus
 An opening in fetal circulation between the
pulmonary artery (PA) and aorta (Ao).
 In fetal circulation, most of the blood bypasses the
lungs and returns to systemic circulation by way of
the PDA (PA to Ao).
 In transition to pulmonary circulation, the PDA
constricts over 10-15hrs; permanent closure should
occur by 3wks of age, unless saturation remains low.

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  Failure of the fetal ductus arteriosus (artery connecting the aorta
• and pulmonary artery) to close within the first weeks of life.

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 Clinical manifestations
Large PDA will result in heart failure similar to that
encountered in VSD

Wide pulse pressure, bounding arterial pulses, normal or

moderately enlarged heart,

Classic machinery murmur localized to the 2nd left

intercostal space

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 Treatment
Endomethacin, (prostanglandin inhibitor) could be
used in premature infants
Irrespective of age, patients require surgical or
catheter closure of the defect
• Surgery

Ligate ductus arteriosus

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 Pulmonic Stenosis
 Narrowing at the entrance to the pulmonary artery.
 Resistance to blood flow causes right ventricular
hypertrophy and decreased pulmonary blood flow.
 Pulmonary atresia is the extreme form of PS in that
there is total fusion of the commissures and no blood
flows to the lungs.
 The right ventricle may be hypertrophied .

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 • Narrowing of entrance that decreases blood flow

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 Treatment:

– Medications – Prostaglandins to keep the PDA open

– Cardiac Catheterization
• Baloon Valvuloplasty
– Surgery
• Valvotomy

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 Coarctation of the Aorta
 Localized narrowing near the insertion of the ductus
arteriosus.
 Results in increased pressure proximal to the
defect (head and upper extremities) and decreased
pressure distal to the obstruction (body and lower
extremities).

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 Clinical manifestation
 The patient may have high blood pressure and
bounding pulses in the arms, weak or absent femoral
pulses.
 Cool lower extremities with lower blood pressure.
There are signs of HF in infants.
 In Older children may experience dizziness, headaches,
fainting, and epistaxis resulting from hypertension.
 Patients are at risk for hypertension, ruptured aorta,
aortic aneurysm,and stroke.

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 Treatment
 Goals of management are to improve ventricular function and restore
blood flow to the lower body.
 Medical management with Medication
 A continuous intravenous medication, prostaglandin (PGE-1), is
used to open the ductus arteriosus (and maintain it in an open
state) allowing blood flow to areas beyond the coarctation.
• Baloon Valvoplasty

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 2. Cyanotic congenital heart diseases

1. Tetralogy of Fallot
 The most common cyanotic heart disease
 The classic form includes four defects:
• (1) VSD,
• (2) PS,
• (3) overriding aorta, and
• (4) right ventricular hypertrophy.

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 Tetralogy of Fallot…

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 Signs and Symptoms
 Failure to thrive
 Squatting
 Lack of energy
 Infections
 Polycythemia
 Clubbing of fingers
 Cerebral abscess
 Cardiomegaly

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 Treatment
• Surgical interventions
– Blalock – Tausig or Potts procedure – increases blood flow to the
lungs.

– Open heart surgery

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 Transposition of Great Vessels
 Aorta arises from the right ventricle, and the pulmonary
artery arises from the left ventricle - which is not
compatible with survival unless there is a large defect
present in ventricular or atrial septum.

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 Therapeutic management
 The administration of intravenous prostaglandin E1 may be
initiated to keep the ductus arteriosus open for temporarily
increase blood mixing and provide an oxygen saturation of
75% or to maintain cardiac output.
 Mustard procedure involves insertion of an intra-atrial baffle
which redirects systemic and pulmonary venous blood to the
aorta and pulmonary artery respectively and Total repair by
an arterial switch technique is the surgical treatment of choice
for neonates having TGA with intact ventricular septum.

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 Congested Heart Failure
 Heart failure: is the pathophysiological state in which the
heart is unable to pump blood at a rate equal with the
metabolic requirements of tissues.
 Circulatory failure: an abnormality of some component of
the circulation(the heart, blood volume, the concentration of
oxygenated Hgb in the arterial blood, or the vascular bed).

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 Etiology
 Severe anemia (hemolysis, feto-maternal transfusion,
infection)
 Pulmonary venous congestion
 Complete heart block
 Congenital heart defects
 Myocarditis

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 Clinical manifestation
 Depends on degree of cardiac reserve
 Symptomatic at rest
 Symptomatic on mild activity
 Symptomatic on vigorous activity
• In infants, heart failure may be difficult to identify
• An infant with heart failure often takes less volume per
feeding, becomes dyspneic while sucking, and may perspire
profusely.

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 Clinical mani…
 Tachypnea, feeding difficulties, poor weight gain, excessive
perspiration, irritability, Weak cry, and noisy, labored respirations with
intercostal and subcostal retractions, as well as flaring of the nostril .
 Hepatomegaly usually occurs, and cardiomegaly is invariably present.
 Auscultatory signs produced by the underlying cardiac lesion
 In children, the signs and symptoms of heart failure are often similar to
those in adults and include fatigue, effort intolerance, anorexia,
abdominal pain, dyspnea, and cough.

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 Diagnosis
 Clinical examinations
 CXR
 Cardiac enlargement
 Increased pulmonary vascular bed
 ECG
 Chamber hypertrophy
 Rhythm disorders

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 Management of CHF
• Principles of management
1. Treat underlying cause
2. Treat the congestive state
3. Prevent further deteriorations of cardiac lesions

• 1.Treating underlying cause

 Anemia= transfusion
 Massive effusion= pericardio-centesis

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 Management …
• 2.Treat the congestive state
• General measures
 Bed rest
 Oxygen administration
 Semi-upright position
 Restrictions on activities within the context of the specific
diagnosis and the patient's ability.
 Competitive and strenuous sports activities are usually
contraindicated.

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 Management …
– 3.Prevent further deteriorations of cardiac lesions
• Diet
 Increasing daily calories

 Human breast milk is the ideal low sodium nutrition.

 Most older children can be managed with “salt free ” diets

• Specific measures/Pharmacotherapy
 Digoxin
 diuretics/Lasix
 After load reducing agents

27-Feb-24 by:Walle Kumlachew 317

 • Digoxin : 5–10 μg/kg/day, divided q12h.
• Furosemide (Lasix) - IV:1–2 mg/dose Bid.
– -PO:1–4 mg/kg/day, divided qd–qid
• KCL PO: one to one with the lasix(one tablet of lasix to one tablet of
KCL).
• Spironolactone : 2-3mg/kg/24hrs in 2-3 devided doses.
• ACEI: Enalapril : PO 0.08–0.5 mg/kg/dose q12–24hrs

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 Nursing interventions
 Position the child
 Administer intra -nasal oxygen
 Monitor vital sign
 Measure the in put and out put fluid volume
 Nutrition
 Health education to family about feeding, way of activity,
medication taking & important of follow up.

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 Thank you!!!

27-Feb-24 by:Walle Kumlachew 320

 2. Gastro intestinal disorders

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 Gastro Intestinal disorders
Acute appendicitis in children

Intussusceptions “

Pyloric stenos is “

Gastro esophageal reflex “

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 Acute appendicitis in children
• Learning Objectives
 Define acute appendicitis in children
 Describe the appendix and appendicitis along with its patho-
physiology.
 Explain the pathogenesis of acute appendicitis in children.
 Identify the clinical manifestations of appendicitis.
 Recognize the Rx of acute appendicitis in children.
 Describe the medical and nursing managements of a patient
with appendicitis.
 List the complications of acute appendicitis in children.

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 Definition
Appendicitis-Is inflammation of the lumen of the appendix
which becomes quickly obstructed due to edema, necrosis and
pain.
This condition is a common and urgent surgical illness with
variable manifestations and can overlap with other clinical
syndromes,
 significant morbidity which increases with diagnostic delay.

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 Positions of appendix

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 Etiology
 Appendicitis is caused by many factor: Most causes of appendiceal
inflammation, infection, and perforation due to invasion of
apendical wall by bacteria.
 Items such as stool, barium, food, and parasites can block the
lumen.
 Malignant tissue such as carcinoma, leukemia, and lymphoma can
cause tissue swelling and lumen obstruction. Blunt abdominal
trauma has been identified as a cause for appendicitis.

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 Patho-physiology
The appendix becomes inflamed and edematous as a result
of either becoming kinked or occluded by a fecalith (i.e
hardened mass of stool), tumor, or foreign body.
The inflammatory process increases intra-luminal pressure,
initiating a progressively severe, generalized upper
abdominal pain that becomes localized in the right lower
quadrant of the abdomen within a few hours.

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 Clinical Features
Appendicitis is most common in older children, with
peak incidence b/n the age of 12 and 18 yr.
 It is rare in children <5 yr of age (<5% of cases) and
extremely rare (<1% of cases) in children <3 yr of
age.
It affects boys slightly more often than girls and

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whites more often than blacks.
by:Walle Kumlachew 328
 Cont…
 Epigastric/ periumbilical pain at right lower quadrant. Low-grade
fever, nausea sometimes vomiting & loss of appetite.
 Local tenderness -McBurney’s point when pressure is applied.
 Rebound tenderness (i.e, production or intensification of pain
when pressure is released) may be present.
 Rovsing’s sign may be elicited by palpating the left lower
quadrant; this causes pain to be felt in the right lower quadrant.
 If the appendix has ruptured, the pain becomes more diffuse;

27-Feb-24
abdominal distention develops,
by:Walle Kumlachew
and the patient’s condition
329
 Diagnosis
 History A careful family history should be obtained for every
child in whom acute appendicitis is suspected.

 Primary-symptom: abdominal pain, which begins epigastria

or periumbilical area that is vague and hard to localize.
 The associated symptoms: indigestion, discomfort, flatus,
need to defecate, anorexia, nausea, vomiting as the illness
progresses RLQ localization typically occurs.

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 Diagnosis…
P/E- Localized abdominal tenderness is the single most
reliable finding in the diagnosis of acute appendicitis.
Findings depend on duration of illness prior to exam.
Early on patients may not have localized tenderness
With progression there is tenderness to deep palpation
over McBurney’s poin.
Rovsing’s: pain in RLQ with palpation to LLQ

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 Physical Exam
Rectal exam: pain can be most pronounced if the patient
has pelvic appendix.
Psoas sign: place patient in left lateral decubitus and
extend Right leg at the hip. If there is pain with this
movement, then the sign is positive.
Obturator sign: passively flex the Right hip and knee and
internally rotate the hip. If there is increased pain then the
sign is positive.

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 Appendicitis Scores

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 Pediatric Appendicitis score…
 Combines History/ physical and laboratory data to assist in
the diagnosis.
 Scores of ≤2 suggest a very low likelihood of appendicitis.
 Scores ≥8 are highly associated with appendicitis.
 Scores between 3 and 7 warrant further diagnostic
studies.
Nonetheless, No scoring system is perfectly Sensitive or
Specific.

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 Investigation
Laboratory tests-CBC demonstrates an elevated
white blood cell count (> 10,000 cells/mm3). The
neutrophil count may exceed 75%.
 x-ray -Abdominal films, ultrasound studies, and CT
scans may reveal a right lower quadrant density or
localized distention of the bowel.

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 Differential diagnostics

Gastrointestinal Gynecologic
 Gastroenteritis  Ectopic pregnancy
 Endometriosis
 Intestinal obstruction  Pelvicinflammatory disease
 Mesenteric adenitis  Ruptured ovarian cyst
 Tubo-ovarian abscess.
 Cholecystitis
Genitourinary
 Duodenal ulcer  Kidney stone
Systemic  Pyelonephritis
 Diabetic ketoacidosis  Wilms' tumor
 Henoch-Schonlein purpura
Pulmonary
Other
 Pleuritis  Parasitic infection
 Pneumonia (basilar)  Psoas abscess
 Pulmonary infarction  Rectus sheath hematoma

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 Treatment
Appendectomy is the definitive treatment.
Patients with a localized walled-off abscess may be candidates for
initial medical management with antibiotics, followed by an elective
appendectomy.
Before surgery, correction or prevention of fluid and electrolyte
imbalance and dehydration could be through antibiotics and
intravenous fluids.
Analgesics can be administered after the diagnosis is made.

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 Antibiotic therapy
 Is an important aspect of the treatment of ruptured
appendicitis.
 It should be directed against gram-negative and anaerobic
organisms such as Escherichia coli and bacteroides species.
 Pre-operative antibiotics are given to children with
suspected appendicitis and stopped after surgery if no
perforation exists.
 Patients presenting with perforated appendicitis may be
volume depleted and require aggressive fluid resuscitation.

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 Nursing Management
Prepare the patient for surgery, which includes an
intravenous infusion to replace fluid loss and promote
adequate renal function and antibiotic therapy to prevent
infection.
 Post-operatively, Place the patient in a semi-Fowler
position to reduce the tension on the incision and, thus,
reduce pain.
 Administer pain killers .

27-Feb-24 by:Walle Kumlachew 339

 Nursing Management …
Start oral fluids when tolerated and intravenous fluids as
indicated. Initiating of feed after surgery.
Instruct the patient to make an appointment to have the
surgeon remove the sutures between the fifth and seventh
days after surgery.
Teach incision care (dressing) and activity guidelines;
normal activity can usually be resumed within 2 to 4 weeks.

27-Feb-24 by:Walle Kumlachew 340

 Prevention
 Prevention in general, appendicitis can not be
prevented.
 The incidence of appendicitis is lower in cultures where
people eat more daily dietary fiber, which is thought to
decrease
 the viscosity of feces,
 bowel transit time,
 and discourage formation of fecaliths,
• which predispose individuals to obstructions within the
appendix.

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 Complications

 Appendicular infiltrate.

 Appendicular abscess.

 Diffuse peritonitis.

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 Any questions?

27-Feb-24 by:Walle Kumlachew 343

 •Intussusceptions

27-Feb-24 by:Walle Kumlachew 344

 Learning Objectives
• After the end of this session the students should be able to:
Define intussusceptions in children
List the etiology of intussusceptions in children.
Describe the pathogenesis of intussusceptions in children.
Identify the clinical manifestations of intussusceptions.
Describe the medical and nursing care of a patient with
intussusceptions.
Recognize the RX of intussusceptions in children.
List the complications of intussusceptions in children.
27-Feb-24 by:Walle Kumlachew 345
 Definition
 Invagination of intestine into itself.
 Intussusception occurs when a portion of the
alimentary tract is telescoped into an adjacent
segment.

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 Positions of Intussusceptions

27-Feb-24 by:Walle Kumlachew 347

 Etiology
 90% Idiopathic the most leading point are ileo-cecal.
 Rotavirus vaccine
 Respiratory adenovirus (type C)
 Hyperplasia of Peyer patches in terminal ileum.
 Structural-small bowel lymphoma, Meckel diverticulum,
intestinal polyp….

27-Feb-24 by:Walle Kumlachew 348

 Epidemiology
 It is the common cause of intestinal obstruction
between 3 mo and 6 yr of age.
 60% of patients are younger than 1 yr, and 80% of the
cases occur before 24 mo; rare in neonates.
 The incidence varies from 1 to 4/1,000 live births. The
male: female ratio is 4:1.
 The seasonal incidence has peaks in spring and autom.

27-Feb-24 by:Walle Kumlachew 349

 Patho-physiology
• Invagination of the bowel

• Obstruction resulting in compression of the vessels

and venous congestion and bowel wall edema

• Infarction, perforation

• If left untreated, FATAL

27-Feb-24 by:Walle Kumlachew 350

 Pathophysiology…
 The upper portion of bowel / intussusceptum, invaginates
into the lower / intussuscipiens, pulling its mesentery along
with it into the enveloping loop.
 Compression of mesenteric vessels & lymphatics leads to
edema, ischemia, mucosal bleeding leads to a bloody stool,
sometimes containing mucus and perforation leads
peritonitis.
 Most intussusceptions do not strangulate the bowel within
the 1st 24 hr but can eventuate in intestinal gangrene and
shock.

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 Diagnosis
 Vital signs are usually normal in the early stage.

 The benign clinical appearance may lead to an erroneous Dx

(constipation or gastroenteritis)
 A mass might be palpable anywhere in the abdomen
or even visualized.
 On rectal examination, blood-stained mucus or blood
may be encountered
 Prolapse of the intussusceptum through the anus is a grave
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sign by:Walle Kumlachew 352
 Clinical Manifestation
 Sudden onset intermittent crampy abdominal pain associated with “currant
jelly” stools.
 As the obstruction worsens bilious emesis & worsening abdominal distention.
 Pulse becomes weak, respirations become shallow and grunting.
 In the early phase vomiting is more frequent.
 The intu-ssusception is not reduced; the infant becomes progressively weaker
and lethargic. Eventually, a shock like state, with fever, can develop.

27-Feb-24 by:Walle Kumlachew 353

 Clinical Manifestation…

 In the later phase, the vomitus becomes bile stained.

 Stools of normal appearance may be evacuated in the 1st few hours of symptoms.
 After this time, fecal excretions are small or more often do not occur and little or no
flatus is passed.
 60% of infants pass a stool containing red blood and mucus, the currant jelly stool.
 About 30% of patients do not have a palpable mass.
 Abdominal distention and tenderness develop as intestinal obstruction becomes
more acute.

27-Feb-24 by:Walle Kumlachew 354

 Investigations
 The presence of bloody mucus on the finger as it is
withdrawn after rectal examination supports the
diagnosis of intussusception.
 Diagnosis made by clinical presentation and imaging.
 US confirmed Dx (usually is the 1st investigation when
intussusceptions is suspected.)

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27-Feb-24 by:Walle Kumlachew 356
 Investigation…
 Chemistry –electrolyte imbalance
 CBC – infection
 Differential diagnostics
 Gastroenteritis;
 Enterocolitis

27-Feb-24 by:Walle Kumlachew 357

 Treatment
 Reduction of an acute intussusception is an emergency
procedure and performed immediately after diagnosis
in preparation for possible surgery.
 Non operative management:
 NG tube to decompress the stomach
 NPO
 IV fluid resuscitation
 colon enema

27-Feb-24 by:Walle Kumlachew 358

 Nursing Management
 Prepare the patient for surgery, which includes an intravenous
infusion to replace fluid loss and promote adequate renal function
and antibiotic therapy to prevent infection.
 Instruct the patient to make an appointment to have the surgeon
remove the sutures between the fifth and seventh days after
surgery.
 Teach incision care (dressing) and activity guidelines; normal activity can
usually be resumed within 2 to 4 weeks.

27-Feb-24 by:Walle Kumlachew 359

 Prognosis
 Untreated intussusception in infants is usually fatal;
 The chances of recovery are directly related to the duration of
intussusception before reduction.
 Most infants recover if the intu-ssusception is reduced in the 1st 24
hr, but the mortality rate rises rapidly after this time, especially
after the 2nd day.
• Nelson Textbook of Pediatrics, 18th ed

27-Feb-24 by:Walle Kumlachew 360

 Complications
 A few intussusceptions reduce spontaneously, but if left
untreated, most will lead to:
 Mucosal hemorrhage
 Intestinal infarction,
 Perforation,
 Peritonitis, and death

27-Feb-24 by:Walle Kumlachew 361

 Any questions?

27-Feb-24 by:Walle Kumlachew 362

Pyloric stenosis in children
• After the end of this session the students should be able to:
 Define pyloric stenosis in children
 Describe the pyloric stenosis pathophysiology.
 Explain the pathogenesis of pyloric stenosis in children.
 Identify the clinical manifestations of pyloric stenosis.
 Recognize the RX of pyloric stenosis in children.
 Describe the medical and nursing care of a patient with pyloric
stenosis
 List the complications of pyloric stenosis in children.

27-Feb-24 by:Walle Kumlachew 363

 Definition
 Hypertrophy of pylorus – thickening & elongation of pylorus
 Narrowing of the pyloric sphincter.
 Delayed emptying of the stomach.

27-Feb-24 by:Walle Kumlachew 364

 Etiology
 The cause of pyloric stenosis is unknown,
 Pyloric stenosis is usually not present at birth but probably
develops after birth.

 Associations with - due Abnormal muscle innervations

 Erythromycin (macrolide antibiotics)in
neonates .
 Infant hyper gastrinemia
 The incidence is increased in infants with
B and O blood groups
27-Feb-24 by:Walle Kumlachew 365
 Epidemiology
 Males especially first-borns are affected approximately 4 to 6
times as often as females.
 From children of a mother who had pyloric stenosis 20% of
the male and 10% of the female will develop Pyloric stenosis .
• Nelson Textbook of Pediatrics, 18th ed.

27-Feb-24 by:Walle Kumlachew 366

 Pathophysiology
 The pylorus muscle which is at the distal end of
the stomach becomes thickened causing
constriction of the pyloric canal between the
stomach and the duodenum and obstruction of
the gastric outlet of the stomach.

27-Feb-24 by:Walle Kumlachew 367

 Clinical Manifestations
 The initial symptom of pyloric stenosis is non-bilious vomiting and
abdominal pain
 Emesis might follow each feeding, or it may be intermittent.
 The vomiting usually starts after 3 wk of age.
 Hyper bilirubinemia is the most common clinical association of pyloric
stenosis, also known as ictero pyloric syndrome. The child show-
Hungry after feeding
 Weight loss
 Jaundice

27-Feb-24 by:Walle Kumlachew 368

 Examination?
 Abdominal distension
 Olive mass from RUQ when after feeding.
 visible gastric wave from left to right after feeding.

27-Feb-24 by:Walle Kumlachew 369

 Ddx
 Gastroesophageal Reflux,

 Duodenal Stenosis Proximal

 investigations?
 Lab. Tests - blood Chemistry
 x-ray -Plain abdominal x-ray
 -Ultrasound is very accurate

27-Feb-24 by:Walle Kumlachew 370

 Treatment and Nursing Care
 The surgical treatment of pyloric stenosis is curative.
 The preoperative treatment is directed toward
correcting the fluid, acid-base, and electrolyte losses.
 The surgical procedure of choice is pyloro-myotomy.
 Feedings can be initiated within 12-24 hr after surgery
and advanced to maintenance oral feedings within 36-
48 hr after surgery.

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 Treatment and Nursing Care
 Treatment Surgery- Pyloromyotomy

 Post Operative Care:

 I&O
 Feeding.
 Position with head elevated
 Assess surgical site to prevent infection
 Patient Family teaching

27-Feb-24 by:Walle Kumlachew 372

 Complications
 Be careful for acid-base and electrolyte imbalances.
 Hypokalemic, hypochloremic metabolic alkalosis
 Surgical complications
 Wound infection
 Accidental opening of GI tract

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 Any questions?

27-Feb-24 by:Walle Kumlachew 374

 Gastro esophageal reflex disease
 Gastro esophageal reflux is the return of stomach contents into the
esophagus.
 Gastro esophageal reflux disease (GERD) is a common condition when
the physiological barrier of the esophageal sphincter opens during a
transient lower esophageal sphincter relaxation (TLESR)period.
 resulting in complications like mucosal erosion, bleeding, dysphagia or
failure to thrive
 GERD in children can be directly related to late maturation of the
gastro esophageal (GE) sphincter or an impaired hormonal or
neurotransmitter response.

27-Feb-24 by:Walle Kumlachew 375

 Cont..
 high pressure gradient surrounding the GE
sphincter aides in maintaining forward flow of food
and stomach content.
 When either the position of the sphincter or the
thick mucosal lining of the GE sphincter are affected,
GERD is likely to occur.
 Recurrent reflux results in inflammation of the
esophageal epithelium or esophagitis.
•

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 Epidemiology
 Infant reflux shows up in the first few months of life, peaks
at four months and resolves in almost all children by the age
of 2.
 One out of 300 have significant reflux and associated
complications, and it is the most common esophageal
disorder for all pediatric patients.
 Physiologic GER is the regurgitation that occurs without
effort or pain
 pathologic GERD in infants and children have frequent
and/or persistent symptoms that affect their nutritional or
respiratory status.
27-Feb-24 by:Walle Kumlachew 377
 Pathophysiology
 1. The lower esophageal sphincter (LES) is anatomically
supported by the crura of the diaphragm and the gastro
esophageal junction (GEJ).
 This with the valve-like junction stop the return of gastric
contents.
 When the LES is relaxed or when hiatal herniation prevent
the LES from being proportionately pressurized, reflux is
more likely to occur during events of strain.
• .

27-Feb-24 by:Walle Kumlachew 378

 Ptho…
 . The length of a reflux episode is increased when the
swallowing reflex is decreased as in sleep or by any disease
state that results in defective esophageal peristalsis

 GERD is most common in infants and children with

• gastrointestinal malformations.

27-Feb-24 by:Walle Kumlachew 379

 Signs and Symptoms

 Most clinical manifestations of GERD relate to the pathological effects of acid

found outside of the stomach.
 Symptoms of heartburn and regurgitation are the classic findings.
 Sleep has been found to be interrupted with or without obstructive sleep
apnea when they have GER.
 Some older children may have neck contortions or refuse food with GERD. This
is called Sandifer syndrome.
 Respiratory symptoms are also age specific.
 Infants can present with obstructive sleep apnea, stridor or lower airway
disease where reflux has worsened primary airway disease like laryngomalacia
or bronchopulmonary dysplasia
 Older children are more likely to have asthma and laryngitis or sinusitis related
to GERD.

27-Feb-24 by:Walle Kumlachew 380

 Diagnosis
 History and physical examination is the initial tool
for diagnosis of GERD.
 Diagnostic tools used to assist in diagnosing GERD
include endoscopy, pH monitoring with 24 hour
Ddx
 milk and other food allergies,
 eosinophilic esophagitis,
 pyloric stenosis,
 intestinal obstruction or infection.
27-Feb-24 by:Walle Kumlachew 381
 Treatment
• Medications
• § Antacids: most often used non-prescribed medication treatment
for GERD. They are available over the counter and with their acid
neutralization action directly affect the pathophysiology of GERD
• • Histamine-2 receptor antagonists (H2RAs): inhibit histamine
receptors on the gastric parietal cells. They are very safe for the
pediatric population and work well for mild to moderate GERD
• • Proton pump inhibitors (PPIs): block the hydrogen–potassium
adenosine triphosphatase channels of the final common pathway in
gastric acid secretion.
• Children need larger doses on a dose per weight basis than adults.

27-Feb-24 by:Walle Kumlachew 382

 Treatment…
 Prokinetic agents: increase LES pressure and improve gastric
emptying.
 Metoclopramide, when used longer then 3 months, has been linked
to tardive dyskinesia which can be irreversible (Taketomo, 2015).
 A recent systematic review gave conflicting evidence; no
recommendations could be made (Falk & Vivian, 2015).
• Surgery
 Fundoplication, may be necessary when GERD is intractable to
medical management and complications of esophagitis, strictures, or
risk for morbidity from chronic pulmonary disease is significant.
 A gastrostomy may be used in combination for feeding since impaired
nutrition is a common complication.

27-Feb-24 by:Walle Kumlachew 383

 Nursing Implications

 Pediatric feeding complications like GERD can lead to

serious complicated and longstanding issues. Only by
working as an interdisciplinary team the patient best be
treated.
 As in all pediatric patients, nutrition is measured by growth
and development. These markers require many view points
best cared for by an interdisciplinary team with nursing as
the center participant.

27-Feb-24 by:Walle Kumlachew 384

 Any questions?

27-Feb-24 by:Walle Kumlachew 385

 CLEFT LIP AND PALATE
 Clefts of the lip (CL) and palate (CP) are facial
malformations that occur during embryonic
development
 They may appear separately or, more often, together.
 CL results from failure of the maxillary and
median nasal processes to fuse;
 CP is a midline fssure of the palate that results from
failure of the two palatal processes to fuse.

27-Feb-24 by:Walle Kumlachew 386

  Cleft lip can be unilateral or bilateral;
 unilateral Cleft lip on the left side is the most
common presentation.
 Isolated CP occurs when there is primary lack of
fusion of the palatal shelves.

27-Feb-24 by:Walle Kumlachew 387

  Clefts of the lip and palate are distinct entities closely
related embryologically, functionally, and genetically.
 The incidence of cleft lip with or without cleft palate
is about 1 in 750 white births;
 the incidence of cleft palate alone is about 1 in 2,500
white births. Clefts of the lip are more common in
males.

27-Feb-24 by:Walle Kumlachew 388

 Etiology and epidemiology
 Ethnic factors also affect the incidence of cleft lip and palate.
 Clefts are highest among Asians and lowest among blacks.
 The incidence of affected, the likelihood of the next child
having a cleft lip or palate increases to 17%. associated
congenital malformations and of impairment in development is
increased in children with cleft defects, especially in those with
cleft palate alone.
 When one sibling has a cleft lip or palate, the probability of
the next child being affected is 4%.
 When both a parent and child are

27-Feb-24 by:Walle Kumlachew 389

  The etiology of cleft lip and palate remains unknown, but a
multifactorial combination of heredity and environmental
factors seems most plausible.
 Medications —Antiseizure agents, such as phenytoin and
sodium valproate, and methotrexate are examples of
commonly administered drugs associated with orofacial
clefts.
 Folic acid deficiency
 Cigarette smoking
 Alcohol
27-Feb-24 by:Walle Kumlachew 390
 Clinical Manifestations.
 Cleft lip may vary from a small notch to a complete separation
extending into the floor of the nose.

 Clefts may be unilateral (more often on the left side) or

bilateral

 Isolated cleft palate occurs in the midline and may involve

only the uvula or may extend into or through the soft and
hard palates to the incisive foramen.
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  Unilateral Cleft Lip

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  Bilateral Cleft

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  Clefts of secondary palate

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 Sequelae of Cleft Lip and Palate.
 Recurrent otitis media and hearing loss are frequent
with cleft palate.
 Displacement of the maxillary arches and
malposition of the teeth usually require orthodontic
correction.
 Speech defects are often associated with cleft lip and
palate. Such speech is characterized by the emission
of air from the nose and by a hypernasal quality with
certain sounds.

27-Feb-24 by:Walle Kumlachew 395

 TREATMENT
 For those born with a cleft lip or palate, a multidisciplinary
team approach provides the highest level of care.
 Cleft patients require a wide variety of specialists, including a
plastic surgeon, otolaryngologist, pediatric dentist,
orthodontist, oral surgeon, speech therapist, audiologist,
nutritionist, pediatrician, psychologist, and social worker.
 The timing of cleft repair is important, and a general
recommendation is lip repair at 3 months, palate repair by 12
months, and alveolar bone grafting at about 9 years which
coincides with partial eruption of the canine teeth

27-Feb-24 by:Walle Kumlachew 396

• Three-month-old boy with a unilateral • Postoperative photograph,
cleft lip and palate age 5 years

27-Feb-24 By: Walle kum.

 Malaria
 Malaria is a devastating infection that annually affects
1300 million people worldwide, resulting in 13000
pediatric deaths per day.
 malaria is the leading cause of mortality among
children !5 years of age in Africa and is the cause
of∼20% of all-cause mortality in this age group.

27-Feb-24 by:Walle Kumlachew 398

 Etiology
 The 4 Plasmodium species that infect humans
(Plasmodium
• falciparum, vivax, ovale, and malariae) are usually
transmitted
• by anopheline mosquitoes.
• Both P. vivax and P. ovale can become dormant in the
liver, forming hypnozoites that may emerge months to
years after initial infection to cause disease.
 Infection caused by P. falciparum is associated with the
greatest morbidity and mortality.
27-Feb-24 by:Walle Kumlachew 399
 Cont…
 Severe malaria is usually due to Plasmodium falciparum,
 is a life-threatening condition. The illness starts with fever and
often vomiting.
 Children can deteriorate rapidly over 1–2 days, developing
complications, the commonest of which are coma (cerebral
malaria) or less profound altered level of consciousness,
 inability to sit up or drink (prostration), convulsions, severe
anaemia, respiratory distress (due to acidosis) and
hypoglycaemia.


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 CLINICAL PRESENTATION
1. GENERAL PRESENTATION
 High fever
 may be accompanied by chills, rigors, sweats, and
headache.
 Other common findings include generalized weakness,
backache,
 myalgias, vomiting, and pallor.
 hepatosplenomegaly, anemia, and jaundice.
 anorexia

27-Feb-24 by:Walle Kumlachew 401

 Congenital Anomalies
Neural tube defect
• Anencephaly: the most serious NTD, is a congenital
malformation in which both cerebral hemispheres are
absent. The condition is usually incompatible with life.
 For those who survive, no specific treatment is
available.
 The infants have a portion of the brainstem and are able
to maintain vital functions (e.g., temperature regulation
and cardiac and respiratory function) for a few hours to
several weeks but eventually die of respiratory failure.

27-Feb-24 by:Walle Kumlachew 402

 Myelodysplasia: -
 refers to any malformation of the spinal canal
and cord. Midline defects involving failure of
the osseous (bony) spine to close are called
spina bifida (SB), the most common defect of
the central nervous system (CNS).
 SB is categorized into two types, SB occulta
and SB cystica.

27-Feb-24 by:Walle Kumlachew 403

  Spina bifida occulta refers to a defect that is not visible externally.
 It occurs most frequently in the lumbosacral area (L5 and S1)
 SB occulta may not be apparent unless there are associated
• cutaneous manifestations or neuromuscular disturbances.
 Spina bifida cystica refers to a visible defect with an external saclike
• protrusion. The two major forms of SB cystica are meningocele, which
• encases meninges and spinal fluid but no neural elements and
myelomeningocele (or meningomyelocele), which contains
• meninges, spinal fluid, and nerves .
• Meningocele is not associated with neurologic deficit, which occurs in
varying, often serious, degrees in myelomeningocele. Clinically, the term
spina bifida is used to refer to myelomeningocele.

27-Feb-24 by:Walle Kumlachew 404

 Spinal Bifida Cystica s/s

• Sensory disturbances usually parallel to motor

dysfunction
• Below second lumbar vertebra:
• • Flaccid, partial paralysis of lower extremities
• • Varying degrees of sensory deficit
• • Overflow incontinence with constant dribbling of urine
• • Lack of bowel control
• • Rectal prolapse (sometimes)

27-Feb-24 by:Walle Kumlachew 405

 • Below third sacral vertebra:
• • No motor impairment
• • May have saddle anesthesia with bladder and anal
sphincter paralysis
• Joint deformities (sometimes produced in utero):
• • Kyphosis
• • Lumbosacral scoliosis
• • Hip dislocation or subluxation

27-Feb-24 by:Walle Kumlachew 406

 Spina Bifida Occulta s/s

 Frequently no observable manifestations

• May be associated with one or more cutaneous
manifestations:
• • Skin depression or dimple
• • Dark tufts of hair
• • Soft, subcutaneous lipomas
• May have neuromuscular disturbances:
• • Progressive disturbance of gait with foot weakness
• • Bowel and bladder sphincter disturbances

27-Feb-24 by:Walle Kumlachew 407

 Diagnostic Evaluation

• The diagnosis of SB is made on the basis of clinical

manifestations and examination of the meningeal sac.
• Diagnostic measures include
• MRI,
• ultrasonography,
• and CT.
• A neurologic evaluation will determine the extent of
• involvement of bowel and bladder function as well as
lower extremity neuromuscular involvement.

27-Feb-24 by:Walle Kumlachew 408

 Myelomeningocele

Myelomeningocele with
an intact sac Myelomeningocele with a
27-Feb-24 by:Walle Kumlachew 409
ruptured sac
 Therapeutic Management
 Management of the child who has a myelomeningocele
requires a multidisciplinary team approach.
 Many authorities believe that early closure, within the first
24 to 72 hours, offers the most favorable outcome.
 Surgical closure within the first 24 hours is recommended if
the sac is leaking CSF.
 A variety of neurosurgical and plastic surgical procedures
are used for skin closure without disturbing the neural
elements or removing any portion of the sac.

27-Feb-24 by:Walle Kumlachew 410

 Hydrocephalus

27-Feb-24 by:Walle Kumlachew 411

 Definition:
• It is the condition of excess cerebrospinal fluid accumulation in the
head as a result of disturbance of formation, flow or absorption
• Term arises from greek, hydro ( water) and cephalus (head)
• Epidemiology:
– Infantile HCP: 3-4 per 1000 live births
– As a single congenital disorder: 0.9-1.5 per 1000 live
births

27-Feb-24 by:Walle Kumlachew 412

 Types of Hydrocephalus
1. Obstructive or non-communicating (obstruction
within the ventricular system)
2. Non obstructive or communicating (malfunction of
arachnoid villi)
3. Hydrocephalus Ex-Vaceu: Due to an increase in the
CSF production to compensate the brain atrophy.

27-Feb-24 by:Walle Kumlachew 413

 Etiology
• Obstruction to flow – most common
– Congenital
• Neural tube defects
• Chiari II malformation
• Dandy- walker syndrome
– Acquired
• Post haemorrhagic – intraventricular
• Post meningitic
– Tubercular
– Pyogenic
• Overproduction - choroid plexus papilloma
• Defective reabsorption – absence of arachnoid villi

27-Feb-24 by:Walle Kumlachew 414

 Clinical features
In neonatal period and children < 2 yrs
• Disproportionately increased head circumference
• Tense fontanelle, widely separated cranial sutures
• Failure to thrive, irritability and poor feeding
• ICP may be normal
• Sunset sign positive
• Crackpot sign positive
• Transillumination of head positive

27-Feb-24 by:Walle Kumlachew 415

 Investigations
• Serial head circumference measurement
• Skull radiographs
• If anterior fontanelle open – transcranial sonography
• If anterior fontanelle closed – CT scan
• MRI

27-Feb-24 by:Walle Kumlachew 416

 Clinical features
In a child > 2 yrs:
• No disproportionate enlargement of head
• Signs of raised ICP
– Projectile vomiting
– Headache
– Diplopia, papilledema
– Altered consciousness
– Cranial nerve palsies
– Pupillary asymmetry

27-Feb-24 by:Walle Kumlachew 417

 Management
• Medical (limited role in long term) - methods to
reduce CSF production
• -Mannitol 1mg/kg
• -Acetazolamide 25-100mg/kg/day
• -Oral glycerol 0.5-1g/kg(2.5% solution)
• -Furosemide 0.7 mg/kg
• -Dexamethasone 4-8 mg 4-6 hrly

27-Feb-24 by:Walle Kumlachew 418

 • Surgical
– Reduce CSF production - choroid plexus ablation
– Drainage of CSF – ventriculostomy
– Drainage of CSF into an absorptive viscus
Ventriculoperitoneal shunt
Ventriculoatrial shunt
Lumboperitoneal shunt

27-Feb-24 by:Walle Kumlachew 419

 Shunt
• Thin, flexible tube that directs the flow of CSF from
the ventricles to another place in the body where it
can be absorbed
• All parts of the shunt are under the skin
• Relieves the pressure & prevents the condition
• from getting worse
• It does not cure hydrocephalus

27-Feb-24 by:Walle Kumlachew 420

 VENTRICULOPERITONEAL SHUNT

27-Feb-24 by:Walle Kumlachew 421

 Thank you!!!

27-Feb-24 by:Walle Kumlachew 422