NURSING CARE OF AT

RISK/ HIGH RISK/ SICK

CLIENT
Group 3
Ferrer, Maria Angelica Allam, Jeremiah
Salum, Christian Achim Pinera, Alyssa
Jara, Hanesly Hope TO, Emmanuel
Ligas, Roselyn Constantino, Yousuff
 Introduction:

Children change rapidly as they grow. Many of these changes are

physical. Other changes is cognitive, which means the changes
affect the way children think and learn. Child development often
occurs in stages, with the majority of children hitting specific
developmental landmarks by the time they reach a certain age.

As we go on with our topic, we are going to discuss about the health

risks and the care given on each level of Child development.
NEWBOR
N
 ■ Newborn development at 0-1 month: what’s happening

■ Cuddling, sleeping, feeding. That’s what it’s all about in the first few
months.

■ Your baby is also learning a lot as you spend time together every day. Her
brain is growing and developing as she sees, hears and touches the world
around her.

■ Your baby might be able to follow your face with his eyes. Around this age

Newborn
faces are the most interesting thing to your baby. He’ll also like looking at
toys with contrasting colours like red, black and white. Your baby will
enjoy toys with faces or patterns like swirls or checks.

■ Your one-month-old can hear you and knows your voice, but she might
sometimes startle when she hears you or another sound.

■ Although eye contact is one way your baby tells you he wants your
attention, your baby communicates with you mostly through crying. For
example, he’ll cry or make throaty noises if he needs you.

■ Your baby might lift her head briefly when she’s lying on her tummy or
turn it to the side when she’s lying on her back. This helps her see where
you are and what’s around her.

■ Sometimes your baby will hold your finger, but most of the time he’ll keep
his hands in a tight fist.
 Newborns, especially those who are premature, have problems that develop
or are discovered after birth. Disorders may affect various organ systems in
the body.

Disorders that affect the lungs and breathing includes:

Health Risks Apnea of prematurity

for Newborns Apnea (not breathing) of prematurity is a pause in breathing that lasts for 20
seconds or more in an infant born before 37 weeks of gestation who is not
known to have any underlying disorder that causes apnea.

Apnea episodes may occur in premature newborns if the part of their brain
that controls breathing (respiratory center) has not matured fully.

Apnea may lower the amount of oxygen in the blood, resulting in a slow
heart rate and bluish lips and/or skin.
 Apnea of prematurity commonly occurs in about 25% of
infants who are born prematurely (delivered before 37
weeks of gestation). Apnea of prematurity is often more
frequent and more severe the more premature a baby is. This
disorder usually begins 2 to 3 days after birth and only
rarely on the first day.

Three types of apnea:

• Central
• Obstructive
• Mixed
Central apnea 
- occurs when the part of the brain that controls
breathing (respiratory center) is not functioning
properly because it has not matured fully. 
Obstructive apnea 
- is caused by temporary blockage of the throat
(pharynx) due to low muscle tone or a bending
forward of the neck.
Mixed apnea is a combination of central apnea and
obstructive apnea
Signs and Symptoms
- Bluish discoloration of the skin and/or lips (cyanosis) or pale skin
(pallor).

Treatment
• Gentle prodding or touching
• Treatment of cause
• Stimulants (caffeine)
• Measures to support breathing

When apnea is noticed, either by observation or monitor alarm, newborns are

touched or prodded gently to stimulate breathing, which may be all that is required.
Further treatment of apnea depends on the cause. Doctors treat known causes such
as infections.
If episodes of apnea become frequent, and especially if newborns have
cyanosis, they remain in the neonatal intensive care unit (NICU). They may
be treated with a drug that stimulates the respiratory center, such as caffeine.
If this treatment does not prevent frequent and severe episodes of apnea,
newborns may need treatment with continuous positive airway pressure
 (CPAP). This technique allows newborns to breathe on their own while
receiving slightly pressurized oxygen or air given through prongs placed in
the nostrils. Newborns who have apnea spells that are difficult to treat may
need a ventilator (a machine that helps air get in and out of the lungs) to help
them breathe.
 Assess the frequency and pattern of breathing; Observe
Assess presence of apnea and changes in the heart rate.

Assess skin, nail beds, skin, mucous membranes for pallor or

Assess cyanosis.

Avoid prolonged suctioning; Discourage taking rectal

Nursing Avoid temperatures and tube feedings.

intervention Provide Provide tactile stimulation by applying gentle rub in the soles
of feet or chest wall

Administer methylxanthines (e.g., (theophylline, caffeine) as

Administer prescribed

Use Use of Nasal Continuous positive airway pressure (CPAP).

 Meconium Aspiration Syndrome
- Meconium aspiration syndrome is trouble breathing
(respiratory distress) in a newborn who has breathed
(aspirated) a dark green, sterile fecal material called meconium
into the lungs before or around the time of birth.
- Meconium aspiration syndrome occurs when stress (such as
infection or low oxygen levels) causes the fetus to take
forceful gasps, so that the amniotic fluid containing meconium
is breathed (aspirated) in and deposited into the lungs. After
delivery, the aspirated meconium may block the newborn's
airways and cause regions of the lungs to collapse. 
 Symptoms:
■  Their skin and/or lips may be bluish (a
condition called cyanosis) if the blood levels
of oxygen are reduced. They may also
develop low blood pressure. The newborn's
umbilical cord, nail beds, or skin may be
covered in meconium, giving them a greenish
yellow color.
Treatment:

■ Sometimes suctioning of the airways

■ Measures to support breathing
■ Sometimes surfactant and antibiotics
■ Treatment of any underlying disorder
Newborns who have trouble breathing after delivery may need to have a breathing tube placed in their
windpipe and be placed on a ventilator (a machine that helps air get in and out of the lungs), or they
may be put on continuous positive airway pressure  (CPAP). 
Newborns may be treated with antibiotics given by vein if a bacterial infection is thought to be what
caused the fetus distress before birth.
 Reduce Reduce body temperature.

Improve Improve fluid volume level. 

Nursing Increase Increase tissue perfusion.

intervention
Improve Improve frequency of breastfeeding.

Improve Improve newborn-parent relationship.

Disorders that affect the blood:

 Anemia in newborn
- Anemia is a disorder in which there are too few red blood cells in the
blood.
- Anemia can occur when red blood cells are broken down too rapidly,
too much blood is lost, or the bone marrow does not produce enough
red blood cells.
- If red blood cells are broken down too rapidly, anemia may develop
and levels of bilirubin (a yellow pigment produced during the normal
breakdown of red blood cells) increase, and the newborn’s skin and the
whites of the eyes can appear yellow (a condition called jaundice).
Very premature newborns have a greater drop in red blood cell count. This
condition is called anemia of prematurity. Anemia of prematurity most
commonly affects infants whose gestational age (length of time spent in the
uterus after the egg is fertilized) is less than 32 weeks and infants who have
spent many days in the hospital.

More severe anemia can occur when

 Red blood cells are broken down too rapidly (a process called
hemolysis).
 A lot of blood is taken from premature newborns for blood tests.
 Too much blood is lost during labor or delivery.
 The bone marrow does not produce enough new red blood cells.
Symptoms:
■ Newborns who have suddenly lost a large amount of blood during labor or delivery
may be in shock and appear pale and have a rapid heart rate and low blood pressure,
along with rapid, shallow breathing.
■ When the anemia is a result of rapid breakdown of red blood cells, there is also an
increased production of bilirubin, and the newborn’s skin and whites of the eyes may
appear yellow (jaundice).
 For anemia caused by rapid blood
loss, fluids by vein and a blood
transfusion

For anemia caused by hemolytic

Treatment: disease, treatment varies

Sometimes iron supplements

 Assist the client in planning and prioritizing
Assist activities of daily living (ADL).

Instruct Instruct the client about medications that may

stimulate RBC production in the bone marrow.
Nursing
interventions:
Provide Provide
needed.
supplemental oxygen therapy, as

Refer the client and family to an occupational

Refer therapist.
 • Hemolytic disease of the newborn is a
condition in which red blood cells are broken
down or destroyed by the mother's antibodies.

 Hemolytic
Hemolysis is the breakdown of red blood cells.
• This disorder may occur if a mother's blood is
incompatible (not a match) with her fetus's

diseases of •
blood.
Hemolytic disease of the newborn may result

the in high levels of bilirubin in the blood (

hyperbilirubinemia), a low red blood cell
count (anemia), and, very rarely, in the most

newborn: severe forms, death. Bilirubin is a yellow

pigment produced during the normal
breakdown of red blood cells.
 Signs and
Symptoms:
■ After delivery, newborns who have hemolytic
disease may be swollen, pale, or yellow (a
condition called jaundice) or may have a large
liver or spleen, anemia, or accumulations of
fluid in their body.
 Treatment:
■ Before delivery, sometimes blood transfusions for the fetus
■ After delivery, sometimes more transfusions
■ Treatment of jaundice if present

Nursing Interventions:
  AdministerRhoGAm to the unsensitized Rh-negative client as appropriate
 Provide management for the sensitized Rh-negative mother and Rh-positive fetus.
 Provide management for ABO incompatibility.
 ■ Polycythemia is an abnormally high
concentration of red blood cells.
■  A newborn who is born postterm or whose 
mother has diabetes, has severe 
high blood pressure, smokes, or lives at a high

Polycythemia ■
altitude is more likely to have polycythemia.
Polycythemia may also result if the newborn

in the receives too much blood from the placenta

(the organ that connects the fetus to the uterus
and provides nourishment to the fetus) at birth,

Newborn which may occur if the newborn is held below

the level of the placenta for too long before the
umbilical cord is clamped.
 Symptoms:

■ A newborn with severe polycythemia has a

very ruddy or dusky color, is lethargic, feeds
poorly, and may have seizures.
 Fluids by vein

Treatment:
Sometimes partial exchange
transfusion
 Disorders ■ Hyperthyroidism in the newborn

that affect - Hyperthyroidism is increased production of

thyroid hormone.

hormones: - Hyperthyroidism in the newborn is usually

caused by Graves disease in the mother.
- Hyperthyroidism, or Graves disease in the
newborn (neonatal Graves disease), is rare in
newborns but is potentially fatal if not
recognized and treated by a medical doctor
who specializes in disorders of the endocrine
glands in children (pediatric endocrinologist)
Symptoms:
■ An affected newborn has increased bodily
functions, such as a rapid heart rate and
breathing, irritability, and excessive appetite with
poor weight gain. Other symptoms include 
failure to thrive, vomiting, and diarrhea. The
newborn, like the mother, may have bulging eyes
 (exophthalmos). If the newborn has an enlarged
thyroid gland (congenital goiter), the gland may
press against the windpipe and interfere with
breathing at birth. A very rapid heart rate can lead
to heart failure. Untreated hyperthyroidism may
result in early closing of the bones of the skull (
craniosynostosis), intellectual disability, growth
failure, short stature, and hyperactivity later in
childhood.
 Treatment:
■ Antithyroid drugs
■ Beta-blockers
■ Sometimes iodine or hydrocortisone

Nursing Interventions:
■ Maintain a stable weight. Educate the client and family regarding body weight changes in
hypothyroidism; collaborate with a dietician to determine client’s caloric needs; encourage
the intake of foods rich in fiber; encourage a low-cholesterol, low-calorie, low-saturated-fat
diet.
■ Learn more about the disease. Provide information about hypothyroidism; educate the
client and family regarding thyroid hormones; emphasize the importance of rest periods.
■ Reduce fatigue. Note daily energy patterns; plan care to allow individually adequate rest
periods; schedule activities for periods when the client has the most energy; promote an
environment conducive to relieve fatigue.
 ■ Hypothyroidism is decreased production of
thyroid hormone.
■ Hypothyroidism in the newborn may occur if
there is a structural problem with the thyroid
gland.

Hypothyroidism ■ Symptoms may include delayed growth and

development over time.
In the Newborn ■ The most common cause of hypothyroidism
in the newborn is: Complete absence of the
thyroid gland, underdevelopment of the
thyroid gland, or development in the wrong
place
Symptoms:

■ Initially, the newborn may have no symptoms of hypothyroidism. Later, if the

underlying cause of hypothyroidism is not identified and hypothyroidism remains
undiagnosed or untreated, development of the central nervous system is slowed.
The newborn may become sluggish (lethargic) and have a poor appetite,
yellowing of the skin (jaundice), low muscle tone, constipation, large fontanelles,
a hoarse cry, low heart rate, and a bulging of the abdominal contents at the
bellybutton (called an umbilical hernia). If the newborn has an enlarged thyroid
gland (congenital goiter), the gland may press against the windpipe and interfere
with breathing at birth. A delay in the diagnosis and treatment of severe
hypothyroidism causes intellectual disability and short stature. Eventually, the
infant may develop dry, cool, mottled skin, coarse facial features (such as a flat,
broad nasal bridge and a puffy face), and a slightly open mouth with an enlarged
tongue.
Treatment:
■ Thyroid hormone replacemen

Nursing interventions:
■ Assess the client’s weight.
■ Assess the client’s appetite.
■ Provide a food diary to the client.
■ Educate the client and family regarding body weight changes in hypothyroidism.
 Disorder that  Cholestasis in the Newborn

affect the - Cholestasis is a reduction of bile formation or

bile flow. As a result, bilirubin backs up into

gastrointestinal the bloodstream (hyperbilirubinemia), leading

to a yellow to yellow-green discoloration of

tract and liver

the whites of the eyes and skin called jaundice.
Cholestasis Biliary atresia (blockage of the bile ducts)
in the
newborn Biliary cysts
can be
caused by Infection
An immune disorder
Metabolic disorders
Genetic defects
Toxic causes
Symptoms:
■ Jaundice
■ Dark urine
■ Light-colored stool
■ Enlarged liver
Nursing intervention:
 Discuss home management of mild or moderate physiological jaundice, including
increased feedings, diffused exposure to sunlight (checking infant frequently), and
follow-up serum testing program.

 Provide information about maintaining milk supply through use of breast pump and
about reinstating breastfeeding when jaundice necessitates interruption of
breastfeeding.
 Discuss possible long-term effects of hyperbilirubinemia and the need for
continued assessment and early intervention.
 Assess family situation and support systems. Provide parents with appropriate
written explanation of home phototherapy, listing technique and potential problems,
and safety precautions. Discuss appropriate monitoring of home therapy, e.g.,
periodic recording of infant’s weight, feedings, intake/output, stools, temperature,
and proper reporting of infant status.
 ■ Jaundice is a yellow color to the skin and/or
eyes caused by an increase in bilirubin in the
bloodstream. Bilirubin is a yellow substance
formed when hemoglobin (the part of red
blood cells that carries oxygen) is broken
down as part of the normal process of
recycling old or damaged red blood cells.
Bilirubin is carried in the bloodstream to the

 Jaundice liver and processed so that it can be excreted

out of the liver as part of bile (the digestive
fluid produced by the liver). Bilirubin
processing in the liver involves attaching it to
another chemical substance in a process called
conjugation.
 ■ Kernicterus is brain damage due to accumulation of

Complication bilirubin in the brain. The risk of this disorder is

higher for newborns who are premature, who are

of Jaundice seriously ill, or who are given certain drugs. If

untreated, kernicterus may lead to significant brain
injury resulting in developmental delay, cerebral palsy
, hearing loss, seizures, and even death. Although now
rare, kernicterus still occurs, but it can nearly always
be prevented by early diagnosis and treatment of
hyperbilirubinemia. Once brain injury has occurred,
there is no treatment to reverse it.
Common The most common causes of jaundice in the newborn are
■ Physiologic jaundice (most common)
causes of ■ Breastfeeding:

Jaundice ■ Breastfeeding can cause jaundice in two ways, which

are called
- Breastfeeding jaundice (more common)
- Breast milk jaundice
■ Excessive breakdown of red blood cells (hemolysis)
Less common Less common causes of jaundice include:

causes of ■ Severe infections

Jaundice ■ An underactive thyroid gland (hypothyroidism)

■ An underactive pituitary gland (hypopituitarism)
■ Certain hereditary disorders
■ Obstruction of bile flow from the liver
Treatment:

■ Physiologic jaundice usually does not require treatment and resolves

within 1 week. For newborns being fed formula, frequent feedings
can help prevent jaundice or reduce its severity.

■ Breastfeeding jaundice may also be prevented or reduced by

increasing the frequency of feedings.

■ breast milk jaundice, mothers may be advised to stop breastfeeding

for only 1 or 2 days and give their newborn formula
 High
unconjugated
bilirubin
levels may be
treated with

Exposure to light Exchange

(phototherapy) transfusion
Infant- Young infant
Infancy is designated as the period of time from 1 month to 1 year of age.

An infant undergoes such rapid development that parents sometimes believe

their baby looks different and demonstrates new abilities every day.

An infant triples birth weight and increases length by 50%. Infant’s reflexes
develop and senses sharpen and, with the process of attachment to primary
caregivers, they form a first social relationship.
IN PHILIPPINES
In 2018, the infant mortality
rate in the Philippines was at
about 22.5 deaths per 1,000 live
births.
High Risk Infant
Identification of some High-risk infants:

The previous conditions often will result in Premature birth, Low birth
weight infants, or infants suffering from: Hypothermia, Hyperthermia,
Hypoglycemia, Infant of Diabetic Mother (IDM), Neonatal Sepsis,
Hyperbilirubinemia, and Respiratory Distress Syndrome (RDS).
Some Definitions:

Low Birth Weight Infant:

● Is any live born baby weighing less than 2500 gm at birth. (VLBW: <1500
gm, ELBW:<1000 gm).

Preterm:

● When the infant is born before term.

● before 38 weeks of gestation.

Premature:

When the infant is born before 37 weeks of gestation.

Full term:

● When the infant is born between 38 – 42 weeks of gestation.

Post term:

When the infant is born after 42 weeks of gestation.

HYPOTHERMIA
-It is a condition characterized by lowering of body temperature than 36°C. A low
body temperature in babies can be dangerous, and, though rare, may lead to
death.

-Significant problems in neonates at birth and beyond (15%)

-Mortality rate twice in hypothermic babies

A body temperature lower than 97.7°F (36.5°C) puts a baby at increased risk for:

● Infections
● respiratory problems
● blood clotting disorders
● death
Types of Hypothermia:

Could be classified according to: Causes and according to Severity.

IAccording to Causes:

1-Primary Hypothermia: (immediately associated with delivery)

In which the normal term infant delivered into a warm environment may drop its
rectal temperature by 1 – 2°C shortly after birth and may not achieve a normal
stable body temperature until the age of 4 – 8 hours.
In low birth weight infants, the decrease of body temperature may be much
greater and more rapid unless special precautions are taken immediately
after birth. (loss at least 0.25 °C/ min.) (careful dryness).

2- Secondary Hypothermia:

This occurs due to factors other than those immediately associated with
delivery.

Important contributory factors are:

e.g: Accute infection especially Septicemia.

II) According to Severity:

(1) Mild Hypothermia:

When the infant’s body temperature is less than 36°C.

(2) Moderate Hypothermia:

When the infant’s body temperature is less than 35.5°C.

(3) Severe Hypothermia:

When the infant’s body temperature is less than 35°C.

Causes
Situation causing excessive heat loss Poor metabolic heat production
● cold environment ● deficiency of brown fat
● cold linen ● CNS damage
● wet or naked baby ● Hypoxia
● during transport , and ● hypoglycaemia
● procedure of bath, blood sampling, infusion

Poor ability to conserved

● LBW (low birth weight)

● IUGR (intrauterine growth restriction)
Clinical Picture:

1-Decrease in body temperature measurement.

2-Cold skin on trunk and extremities.

3-Poor feeding in the form of poor suckling.

4-Shallow respiration.

5-Cyanosis.

6-Decrease activity,

e.g.: Weak crying.

The Four modalities by which the infant lost his/ her body temperature:

1-Evaporation:

Heat loss that resulted from expenditure of internal thermal energy to convert liquid on an exposed surface to gases.

e.g.: amniotic fluid, sweat.

Prevention:

Carefully dry the infant after delivery or after bathing.

2- Conduction:

Heat loss occurred from direct contact between body surface and cooler solid object.

Prevention:

Warm all objects before the infant comes into contact with them.
3- Convection:

Heat loss is resulted from exposure of an infant to direct source of air draft.

Prevention:

· Keep infant out of drafts.

· Close one end of heat shield in incubator to reduce velocity of air.

4- Radiation:

It occurred from body surface to relatively distant objects that are cooler than skin temperature.
General management:

1- Infant should be warmed quickly by wrapping in a warm towel.

2- Uses extra clothes or blankets to keep the baby warm.

3- If the infant is in incubator, increase the incubator’s temperature.

4- Use hot water bottle (its temperature 50 °C).

5- Food given or even intravenous solution should be warm.

6- Avoid exposure to direct source of air drafts.

7- Check body temperature frequently.

8- Give antibiotic if infection is present.

HYPERTHERMIA
It is a condition characterized by an elevation in body temperature more than
37.5°C. Hyperthermia is frequently a result of environmental factors that cause
overheating. It is less likely to be a sign of sepsis in the newborn.

.
Causes of hyperthermia:

● Overheating from incubators, radiant warmers, or ambient

environmental temperature
● Maternal fever
● Maternal epidural anesthesia
● Phototherapy lights, sunlight
● Excessive bundling or swaddling
● Infection
● CNS disorders (i.e. asphyxia)
● Dehydration
Signs and symptoms of hyperthermia:
● Tachycardia, tachypnea, apnea
● Warm extremities, flushing, perspiration (term newborns)
● Dehydration
● Lethargic, hypotonia, poor feeding
● Irritability
● Weak cry
Management :

1)The infant should be moved away from the source of heat.

2) Undressed the infant partially or fully, if necessary.

3) If the newborn is in an incubator, the air temperature should be lowered.

4)Breastfed frequently to replace fluids

 HYPOGLYCEMIA
(Untreated hypoglycemia can result in permanent neurological damage or death.

-Neonatal hypoglycemia is usually defined as a serum glucose value of < 40-45 mg/dl. For the
preterm infant a value

< 30 mg/dl is considered abnormal (hypoglycemia). Hypoglycemia is when the level of sugar
(glucose) in the blood is too low. Glucose is the main source of fuel for the brain and the body.
In a newborn baby, low blood sugar can happen for many reasons. It can cause problems such
as shakiness, blue tint to the skin, and breathing and feeding problems.
New Born: The normal plasma glucose concentration in the
neonate is approximately 60 to 80 percent of the maternal
venous glucose level, or nearly between 70 – 80 mg/dl in
neonates of normoglycemic mothers. A steady-state level
occurs by approximately three hours after birth.
Neonates at risk for developing hypoglycemia:

1- The main cause may become maternal malnutrition during pregnancy which leads to fetal malnutrition and of
course a low birth weight.

2- Those infants whom are Small for gestational age infants (SGA), that manifested by decrease in their birth weight
and subcutaneous fat and hepatic glycogen.

3- Those infants’ of diabetic mothers (IDM) or those named as large for gestational age (LGA).

4- Those whom placentas were abnormal,

e. g.: placenta previa.

5- Those whom their mothers had toxemia during pregnancy,

e. g.: eclampsia or preeclampsia induction of labor preterm infant.

6- Those very ill or stressed neonates whom their metabolic needs were increased due to hypothermia, infection,
respiratory distress syndrome, or cardiac
Clinical manifestations:
8- Irregular respiratory pattern
1- Hypotonia.
(Apnea).
2- Feeding poorly after feeding well.
9- Irritability.
3- Tremors (rhythmic shaking that typically take place in the
10- High pitched cry followed by weak
arms, feet, hands, head or legs.
cry.
4- Cyanotic spells.
11- poor reflexes, especially sucking
5- Lethargy (may be a sign of infection or conditions such as reflex.
low blood sugar.)

6- Seizures.

7- Hypothermia.
Management of the Neonate at Risk:

Prevention:

first of all, providing a warm environment.

Early enteral feeding is the single most important preventive measure. If enteral feeding is to be started,
breast or artificial milk should be used if the infant is able to tolerate nipple or nasogastric tube feeding.

These infants should have glucose values monitored until they are taking full feedings and have three
normal pre-feeding readings above 40-45 mg/dl. Care must be taken to ensure that breastfeeding mothers are
providing an adequate intake.

If the infant at risk for hypoglycemia is unable to tolerate nipple or tube feeding, maintenance IV therapy
with 10% glucose should be initiated and glucose levels monitored.
Management of the Neonate with Hypoglycemia:

Infants who develop hypoglycemia should immediately be given 2cc/kg of 10% dextrose over 5 minutes,
repeated as needed.

A continuous infusion of 10% glucose at a rate of 8-10 mg/kg/min should be started to keep glucose values
normal (NOTE: 10 mg/kg/min of 10%dextrose = 144cc/kg/day). Frequent bedside glucose monitoring is
necessary.

When feedings are tolerated and frequent bedside glucose monitoring values are normal, the infusion can be
tapered gradually.
Infant of Diabetic Mother
A fetus (baby) of a mother with diabetes may be exposed
to high blood sugar (glucose) levels, and high levels of other
nutrients, throughout the pregnancy.
There are two types of diabetes that occur in pregnancy:

Gestational diabetes. This term refers to a mother who does not have diabetes before
becoming pregnant but develops a resistance to insulin because of the hormones of
pregnancy.

Pregestational diabetes. This term describes women who already have insulin-
dependent diabetes and become pregnant.

With both types of diabetes, there can be complications for the baby. It is very
important to keep tight control of blood sugar during pregnancy.
Specific Disorders frequently encountered in Infants of Diabetic
Mothers (IDM):

● Hypoglycemia.
● Hypocalcemia.
● Hypomagnesemia.
● Cardio-respiratory disorders.
● Hyperbilirubinemia (Unconjugated)
● Birth injuries
● Congenital malformations
Management:
I) For the mother:

Through good antenatal care for proper control of maternal diabetes.

II) For an infant:

All IDMs should receive continuous observation and intensive care. Serum
glucose levels should be checked at birth and at half an hour, 1, 2, 4, 8, 12,
24, 36 and 48 hours of age:
 If clinically well and normoglycemic; oral or gavage feeding should
be started and continued within 2 hours intervals.

If hypoglycemic; give 2 – 4 ml/kg of 10% dextrose over 5 minutes,

repeated as needed. A continuous infusion of 10% glucose at a rate of 8-10
mg/kg/min. Start enteral feeding as soon as possible. Give Corticosteroids
in persistent hypoglycemia.

Treatment of other complications should also start; oxygen therapy for

RDS, calcium gluconate 10% for hypocalcemia, phototherapy for
hyperbilirubinemia etc.
Neonatal Sepsis
The newborn infant is uniquely susceptible to acquire infection, whether bacterial,
viral or fungal. Bacterial sepsis and meningitis continue to be major causes of
morbidity and mortality in the newborn. The mortality rate due to sepsis ranges from
20% to as high as 80% among neonates. Surviving infants can have significant
neurologic squeal because of CNS involvement.

Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days
old. Early-onset sepsis is seen in the first week of life. Late onset sepsis occurs after 1
week through 3 months of age.
Risk Factors:

I) Maternal risk factors:

- e.g.: Premature rupture of membrane.

II) Neonatal risk factors:

- e.g.: Prematurity (less immunologic ability to resist

infection + more liable to penetrate their defensive barriers).
 Bacteria can reach the fetus or newborn and cause infection in one of the following ways:
✘Bacteria can pass through the maternal blood through placenta as rubella, toxoplasma, and syphilis.
✘Bacteria from the vagina or cervix can enter the uterus, as groups B streptococci.
✘The newborn may become contract with bacteria as it passes through the birth canal as gram negative
organisms.
✘The newborn may come in contact with bacteria in its environment after birth (Coagulate positive or negative
staphylococci.)
✘When a susceptible host acquires the pathogenic organism, and the organism proliferates and overcomes
the host defense, infection results.
Classification of neonatal sepsis:

Neonatal sepsis may be categorized as early or late onset.

--Newborns with early-onset infection present within 24 hours till 72 hours. Early-onset sepsis
is associated with acquisition of microorganisms from the mother during pregnancy
(transplacental infection), or during labor (an ascending infection from the cervix).

--Late-onset sepsis; occurs beyond the first 72 hours of life (most common after the 3 rd day till
the 7th day after birth) and is acquired from the care giving environment (Nosocomial infection).
Clinical presentation of neonatal sepsis:

Physical findings may be nonspecific and are often subtle.

e.g.: apnea , Jaundice , Hypothermia , Bulging or full fontanel , Seizures ,

hypotonia

Laboratory indicators of sepsis include:

- Total leukocytic count (WBC count)

- C – reactive Protein (CRP)

- Erythrocyte Sedimentation Rate (ESR)

Management of Sepsis:
- Prevention: through proper application to infection
control practices.
- Early onset sepsis; give intrapartum antimicrobial
prophylaxis (IAP) to the mother.
- Neonates with clinically suspected sepsis:

*) Culture should be obtained first.

*) The recommended antibiotics are ampicilin and gentamicin.

*) Third generation cephalosporins (Cefotaxime) may replace gentamicin if meningitis is

clinically suspected or if gram-negative rods are dominant in the unit.

- Late onset neonatal sepsis:

Vancomycin in combination with either gentamicin or cephalosporins should be considered in

penicillin resistant cases.

Note: Administer all medications IV.

Nursing consideration
*Prevention
*Curative
Prevention:

1- Demonstrate the effect of hand washing upon the prevention of the noscomical infections.

2 -Standard precautions should be applied in the nursery for infection prevention.

3- Instillation of antibiotics into newborn’s eye 1-2 hours after birth is done to prevent the infection.

4- Skin care should be done using worm water and may use mild soup for removal of blood or meconium and avoid the
removal of vernix caseosa.

5- Cord care should be cared out regularly using alcohol or an antimicrobial agent.
Curative:

Encourage breast feeding from the mother.

*Adequate fluid and caloric intake should be administered by gavage feeding or

intravenous fluid as ordered.

*Extra-measure for hypothermia or hyperthermia that may take place to the

newborn.

*Administering medications as doctor order.

*Follow the isolation precautions.

*Monitoring intravenous infusion rate and antibiotics are the nurse responsibility.
 *Administer the medication in the prescribed dose, route, and time within
hour after it is prepared to avoid the loss of drug stability.

*Care must be taken in suctioning secretions from the newborn as it may be

infected.

*Isolation procedures are implemented according to the isolation protocols of the

hospital.

*Observe for the complication e.g. meningitis and septic shock.

*Encourage in-service programs and continuing education of nurses regarding

the infection control precautions.
Important Notes about Hypoxic Ischemic Encephalopathy (HIE)

Perinatal asphyxia, more appropriately known as hypoxic-

ischemic encephalopathy (HIE), is characterized by clinical and
laboratory evidence of acute or subacute brain injury due to
asphyxia. The primary causes of this condition are systemic
hypoxemia and/or reduced cerebral blood flow (CBF) (see the
image below). Birth asphyxia causes 840,000 or 23% of all
neonatal deaths worldwide.
The following health problems and negligent actions can lead to HIE:

Management of High-risk pregnancy: Women with conditions such as preeclampsia and gestational
diabetes require more extensive monitoring and treatment.

Umbilical cord complications: The umbilical cord is like a lifeline between mother and baby,
supplying oxygen and nutrients and removing fetal waste. Anything that compresses the cord or
reduces its function puts the baby at risk of HIE.

Placental or uterine complications: The placenta and uterus also play very important roles in
providing oxygenated blood to the baby. Examples of placental and uterine issues that may cause HIE
include:

● Placental abruption
● Placenta previa
● Placental insufficience
● Uterine rupture
Infections: Infections in the mother can spread to the baby during labor and
delivery, especially if the medical team do not take adequate precautions
(such as doing indicated infection screening and prescribing antibiotics when
needed).

Improper fetal heart monitoring: If a baby shows signs of fetal distress on

the fetal heart monitor, doctors and nurses can often intervene so that their
oxygen supply is restored. If necessary, this may involve an emergency C-
section. However, if monitoring is sporadic or does not occur, important signs
of danger may be missed.
Failure to prevent a premature birth: Premature babies are at higher risk for HIE and other birth injuries because their
lungs are so underdeveloped. Therefore, it is very important that doctors do what they can to prevent premature birth,
such as performing a cervical cerclage (a stitch placed in the cervix to stop it from opening too early) or providing
progesterone treatment.

Allowing prolonged labor to continue: Labor is stressful for babies because uterine contractions compress the placenta
and umbilical cord that supply their oxygen. If something is preventing labor from progressing, and physicians do not
offer intervention (such as an emergency C-section), this is negligence. Prolonged labor is more likely to occur when a
baby is larger than normal, or the mother’s pelvis is smaller than normal.
Medication problems: Sometimes physicians prescribe medications such
as Pitocin and Cytotec in order to induce or enhance labor. Unfortunately,
these medications can also cause uterine contractions to become so strong
and frequent that the baby is dangerously deprived of oxygen.

Mismanagement of a neonatal condition: Hypoxic-ischemic injury can

be caused by complications during the neonatal period, i.e. a baby’s first
month of life. Problems such as respiratory distress, jaundice, and
neonatal hypoglycemia can all contribute to an HIE diagnosis, especially
if mismanaged.
Babies with HIE may exhibit any of the following signs (among others):

-Breathing problems

-Feeding problems

-Missing reflexes (for example, the baby does not respond to loud noises)

-Seizures

-Low APGAR score

-Low or high muscle tone

-Altered level of consciousness (e.g. not alert)

Medical care of Hypoxic Ischemic Encephalopathy:

Therapeutic hypothermia is indicated for infants with moderate-to-severe hypoxic-ischemic

encephalopathy (HIE). Supportive management is also critical to prevent additional injury from
seizure activity, poor perfusion, electrolyte imbalance, and abnormal glycemic control.

Following initial resuscitation and stabilization, treatment of HIE includes hypothermia

therapy for moderate to severe encephalopathy as well as supportive measures focusing on
adequate oxygenation, ventilation and perfusion, careful fluid management, avoidance of
hypoglycemia and hyperglycemia, and treatment of seizures. Intervention strategies aim to
avoid any further brain injury in these infants
Hyperbilirubinemia
Hyperbilirubinemia is an elevation in the neonatal serum bilirubin ≥ 12.9 mg/dl
in Full-term, Formula feed infant OR ≥ 15 mg/dl in Preterm, Breast feed infant;
characterized by JAUNDICE, which is defined as “yellowish discoloration of
skin and mucous membranes”. In the neonate clinical jaundice is diagnosed if the
total serum bilirubin is ≥ 7 mg/dl.
N.B.:
The normal adult range of Total
Serum Bilirubin is 0.2 – 1 mg/dl
(Direct: 0 – 0.2 mg/dl and Indirect: 0.2
– 0.8 mg/dl).
The following are possible causes of hyperbilirubinemia in the newly born
infants:

1. Over production of bilirubin.

2. Under excretion of bilirubin.

3. Combined over production and under excretion.

4. Physiological jaundice.

5. Breast milk associated jaundice.

Complication:
The most common complication of hyperbilirubinemia is
Kernicterus (Bilirubin Encephalopathy), which usually occurs
when the unconjugated serum bilirubin level exceeds than 20
mg/dl. In small, sick preterm infants, even a bilirubin level in a low
range may cause Kernicterus.
Intravenous immunoglobulin (IVIg)

Jaundice may be related to blood type differences between mother and baby. This condition
results in the baby carrying antibodies from the mother that contribute to the rapid breakdown
of the baby's red blood cells. Intravenous transfusion of an immunoglobulin — a blood protein
that can reduce levels of antibodies — may decrease jaundice and lessen the need for an
exchange transfusion, although results are not conclusive.

Exchange transfusion

Rarely, when severe jaundice doesn't respond to other treatments, a baby may need an
exchange transfusion of blood. This involves repeatedly withdrawing small amounts of blood
and replacing it with donor blood, thereby diluting the bilirubin and maternal antibodies — a
procedure that's performed in a newborn intensive care unit.
Neonatal Respiratory
Disorders
Common Neonatal Respiratory disorders:

· Respiratory distress syndrome (RDS) = Hyaline membrane

disease (HMD).

· Transient tachypnea of the newborn (TTN).

· Meconium aspiration syndrome (MAS).

· Apnea.
A) Respiratory distress syndrome (RDS) = Hyaline membrane disease (HMD).

Definition:

Respiratory distress syndrome is A low level or absence of surfactant system

Risk factors (High risk group):

e.g: Prematurity and low birth weight.

Clinical Presentation:

Grade I: (Mild distress): Rapid respiratory rate (tachypnea >60 breaths

per minute) + nasal flaring (alae nasai).

Grade II: (Moderate distress): GI + intercostals and substernal

retractions.

Grade III: (Severe distress): GI + GII + expiratory grunting.

Grade IV: (Advanced distress): GI + GII + GIII + central cyanosis and

disturbed consciousness.
Management of RDS:

A) General:

* Basic support including thermal regulation and parentral nutrition and

medications (antibiotics).

* Oxygen administration, preferably heated and humidified

B) Specific:

Surfactant replacement therapy through ET tube.

B) Transient Tachypnea of the Newborn (TTN).

Definition:

TTN is a benign disease of near-term or term infants who display

respiratory distress shortly after delivery. It occurs when the infant fails to
clear the airway of lung fluid or mucus or has excess fluid in the lungs,
this limit the amount of alveolar surface available for gas exchange,
leading to respiratory rate and depth to better use of the surface available.
Risk factors:
· Secondary to hypothermia.
· Infant born by Cesarean section, in which the thoracic
cavity is not squeezed by the force of vaginal pressure, so
that less lung fluid is expelled than normally happen.
Clinical presentation:

* The infant is usually near-term or term.

* Exhibits tachypnea (> 80 breaths/min) shortly after delivery.

* The infant may also display mild grunting, nasal flaring, intercostals retraction,
and cyanosis.

* Spontaneous improvement of the neonate, which considered as the most

important marker of TTN.
Management of TTN:
- Oxygenation.
- Fluid restriction.
- Start feeding as tachypnea improves.
C) Meconium Aspiration Syndrome (MAS).

Definition:

This respiratory disorder is caused by meconium aspiration by the fetus in utero

or by the newborn during labor and delivery. MAS is often a sign that the neonate
has suffered asphyxia before or during birth. The mortality rate can be as high as
50% and survivors may suffer long-term sequelae related to neurological damage.
Management of MAS:

*) Suctioning of the oropharynx by obstetricians before delivery of the shoulders.

*) Immediate insertion of an ET tube and tracheal suctioning before ambu bagging

(Maintain a neutral thermal environment).

*) Gastric lavage, and emptying of the stomach contents to avoid further aspiration.
*) Postural drainage and chest vibration followed by frequent suctioning.

*) Pulmonary toilet to remove residual meconuim if intubated.

*) Antibiotic coverage (Ampicillin & Gentamicin).

*) Oxygenation ( maintain a high saturation > 95%)

*) Mechanical ventilation to avoid hypercapnia & respiratory acidosis.

D) Apnea.

Definition:

Apnea is the cessation of respiration accompanied by bradycardia and/or cyanosis for more than 20
second.

Types:

1- Pathological apnea:

Apnea within 24 hours of delivery is usually pathological in origin.

2- Physiological apnea:

Apnea developing after the first three days of life and not associated with other pathologies,
may be classified as apnea of prematurity.
Management of apnea:

· Monitor at-risk neonates of less than 32 weeks of

gestation.
Begin with tactile stimulation; gentle shaking or
prick the sole of the foot often stimulate the infant to
breath again.
· If no response to tactile stimulation, bag and mask ventilation should be used
during the spell.

· Provide CPAP or ventilatory support in recurrent and prolonged apnea.

· Pharmacological therapy:

- Theophylline.

Treat the cause, if identified, e.g., Sepsis, Hypoglycemia, Anemia etc.

PARENTAL CONCERNS AND PROBLEMS
RELATED TO INFANT DEVELOPMENT
TEETHING

● Most infants have little difficulty with teething, but some appear very
distressed the gums are sore and tender before a new tooth breaks the
surface. As soon as the tooth is through, the tenderness passes.
SIGNS AND SYMPTOMS
● High fever, seizures
● vomiting or diarrhea
● earache are never normal signs of teething
MANAGEMENT

● Rub your baby's gums. Use a clean finger or wet gauze to rub your
baby's gums. The pressure can ease your baby's discomfort.
● Keep it cool. A cold spoon or chilled — not frozen — teething ring can be
soothing on a baby's gums. To avoid cavities, don't dip these items in
sugary substances.
● Try an over-the-counter remedy. If your baby is especially cranky,
consider giving him or her infants' or children's over-the-counter pain
medications such as acetaminophen (Tylenol, others) or ibuprofen (Advil,
Motrin, others).
To keep your baby safe, avoid using:
● Over-the-counter remedies, including homeopathic teething tablets.
The benefits of topical gels and teething tablets haven't been demonstrated.
In recent years, lab analysis of some homeopathic remedies found greater
amounts than labeled of the ingredient belladonna, which can cause
seizures and difficulty breathing.
● Teething medications containing benzocaine or lidocaine. These pain
relievers can be harmful — even fatal — to your baby.
● Teething necklaces, bracelets or anklets. These items pose a risk of
choking, strangulation, mouth injury and infection.
THUMB- SUCKING

● Sucking is a surprisingly strong need: prenatal ultrasounds even demonstrate

fetal thumb-sucking in utero.
● The sucking reflex peaks at 6 to 9 months, whereas thumb- sucking peaks at
about 18 months
● Parents can be assured that thumb-sucking is normal and does not deform the
jaw line as long as it stops by school age.
HEAD BANGING

● Some infants rhythmically bang their heads against the bars of a crib for a
period of time before falling asleep.
● Children use this measure to relax and fall asleep.
● Advise parents to pad the rails of cribs so infants cannot hurt themselves, and
reassure them this is a normal mechanism for relief of tension in children of
this age.
SLEEP PROBLEMS

● Sleep problems develop in early infancy because of colic or because an

otherwise healthy infant takes longer than usual to adjust to sleeping through
the night. Breastfed babies tend to wake more often than those who are
formula fed because breast milk is more easily digested, so infants become
hungry sooner. In late infancy, the problem of waking at night and remaining
awake for an hour or more becomes common.
Suggestions for eliminating or at least coping with night waking are
a. delay bedtime by 1 hour;
b. shorten an afternoon sleep period;
c. do not respond immediately to infants at night so they can have time to fall
back to sleep on their own; and
d. provide soft toys or music to allow infants to play quietly alone during this
wakeful time.
CONSTIPATION

● Breastfed infants are rarely constipated because their stools tend to be loose.
Constipation may occur in formula-fed infants if their diet is deficient in
fluid. This can be corrected simply with the addition of more fluid.
● Some parents misinterpret the normal pushing movements of a newborn to
be constipation If constipation persists beyond 5 or 6 months of age,
encourage parents to check with the infant’s health care provider
● All infants with a history of constipation for more than 1 week should be
examined for an anal fissure or tight anal sphincter.
● One of the first symptoms of Hirschsprung’s disease (aganglionic
megacolon, or lack of nerve innervation to a portion of the colon) is
constipation. If no stool is present in the rectum of a constipated infant on
rectal examination, this disease is suggested (Sondheimer, 2008). symptoms
of Hirschsprung’s disease: ribbon- like stools, bouts of diarrhea, and a
distended abdomen
● Constipation also may occur in children with congenital hypothyroidism
(decreased functioning of the thyroid gland).
● an infant with constipation also should be carefully observed for
characteristic signs of hy- pothyroidism, such as lethargy, protruding tongue,
and fail- ure to meet developmental milestones
MANAGEMENT
Infant constipation often begins when a baby starts eating solid foods. If your
baby seems constipated, consider simple dietary changes:
● Water or fruit juice. Offer your baby a small amount of water or a daily
serving of 100 percent apple, prune or pear juice in addition to usual
feedings. These juices contain sorbitol, a sweetener that acts like a
laxative. Start with 2 to 4 ounces (about 60 to 120 milliliters), and
experiment to determine whether your baby needs more or less.
● Baby food. If your baby is eating solid foods, try pureed peas or prunes,
which contain more fiber than other fruits and vegetables. Offer whole
wheat, barley or multigrain cereals, which contain more fiber than rice
cereal.
COLIC

● Colic is paroxysmal abdominal pain that generally occurs in infants under 3

months of age and is marked by loud, in- tense crying (Bolte, 2007). An
infant cries loudly and pulls the legs up against the abdomen. The infant’s
face becomes red and flushed, the fists clench, and the abdomen becomes
tense. If offered a bottle, the infant will suck vigorously for a few minutes as
if starved, then stop as another wave of intestinal pain occurs.
● The cause of colic is unclear. It may occur in susceptible infants from
overfeeding or from swallowing too much air while drinking. Formula-fed
babies are more likely to have colic than breastfed babies, possibly because
they swallow more air while drinking or because formula is harder to digest.
NURSING MANAGEMENT
● Ask parents about the duration of the problem and its fre- quency (it usually lasts up to 3 hours a day and occurs
at least 3 days every week). Ask what happens just before the attack (Colic usually occurs at a time removed from
a feeding), and ask the parent to describe the attack itself and associated symptoms.
● For a breastfed baby, a change in ma- ternal diet such as avoiding “gassy” foods like cabbage might be helpful to
reduce or limit colicky periods.
● Some parents try placing a hot water bottle on their in- fant’s stomach for comfort, but this should be discouraged.
A basic rule for any abdominal discomfort is to avoid heat in case appendicitis is developing.
SPITTING UP

● Almost all infants spit up, although formula-fed babies appear to do it more
than breastfed babies.
● A baby who spits up a mouthful of milk (rolling down the chin) two or three
times a day (or sometimes after every meal) is experiencing normal, early-
infancy spitting up. Associated signs such as diarrhea, abdominal cramps,
fever, cough, cold, or loss of activity suggest illness.
● If an infant is spitting up so forcefully that milk is projected 3 or 4 feet away,
it may be beginning pyloric stenosis (an abnormally tight valve between the
stomach and duodenum), which requires surgical intervention
● If the spitting up is a large amount with each feeding, parents may be
describing gastroesophageal reflux, in which a lax cardiac sphincter from the
stomach into the esophagus allows regurgitation of gastric contents into the
esophagus. This also requires medical attention
DIAPER DERMATITIS
● Some infants have such sensitive skin that diaper dermatitis (diaper rash) is
a problem from the first few days of life. It occurs for several reasons.
● When parents do not change a child’s diaper frequently, feces is left in
contact with skin, and irritation may result in the perianal area. Urine that is
left in diapers too long breaks down into ammonia, a chemical that is
extremely irritating to infant skin. Ammonia dermatitis of this type is
generally a problem in the second half of the first year of life, when an infant
is producing a larger quantity of urine than before.
PREVENTION AND MANAGEMENT

The best way to prevent diaper rash is to keep the diaper area clean and dry. A
few simple strategies can help decrease the likelihood of diaper rash developing
on your baby's skin.

● Frequent diaper changing, applying A&D or Desitin ointment, and exposing

the diaper area to air may relieve the problem. Some infants may have to
sleep without diapers at night to control the problem. Changing the brand or
type of diaper or washing solution usually alleviates this problem.
● Change diapers often. Remove wet or dirty diapers promptly. If your
child is in child care, ask staff members to do the same.
● Rinse your baby's bottom with warm water as part of each diaper
change. You can use a sink, tub or water bottle for this purpose. Moist
washcloths, cotton balls and baby wipes can aid in cleaning the skin, but
be gentle. Don't use wipes with alcohol or fragrance. If you wish to use
soap, select a mild, fragrance-free type.
● Gently pat the skin dry with a clean towel or let it air dry. Don't scrub
your baby's bottom. Scrubbing can further irritate the skin.
● Don't over tighten diapers. Tight diapers prevent airflow into the diaper
region, which sets up a moist environment favorable to diaper rashes.
Tight diapers can also cause chafing at the waist or thighs.
● Give your baby's bottom more time without a diaper. When possible, let your baby
go without a diaper. Exposing skin to air is a natural and gentle way to let it dry. To
avoid messy accidents, try laying your baby on a large towel and engage in some
playtime while he or she is bare-bottomed.
● Consider using ointment regularly. If your baby gets rashes often, apply a barrier
ointment during each diaper change to prevent skin irritation. Petroleum jelly and zinc
oxide are the time-proven ingredients in many diaper ointments.
● After changing diapers, wash your hands well. Hand-washing can prevent the
spread of bacteria or yeast to other parts of your baby's body, to you or to other
children.
MALARIA

● Miliaria, or prickly heat rash, occurs most often in warm weather or when babies are
overdressed or sleep in over -heated rooms.
● Clusters of pinpoint, reddened papules with occasional vesicles and pustules surrounded
by erythema usually appear on the neck first and may spread upward to around the ears
and onto the face or down onto the trunk.
● Bathing an infant twice a day during hot weather, particularly if a small amount of baking
soda is added to the bath water, may improve the rash. Eliminating sweating by reducing
the amount of clothing on an infant or lowering the room temperature should bring almost
immediate improvement and prevent further eruptions.
SIGNS AND SYMPTOMS

Early symptoms of malaria can include

● irritability and drowsiness

● poor appetite
● trouble sleeping
● Chills
● fever with fast breathing.
● The fever may either gradually rise over 1 to 2 days or spike very suddenly
to 105°F (40.6°C) or higher.
MANAGEMENT

Infants with suspected malaria should have prompt parasitological confirmation of the
diagnosis before treatment begins.

● Artemisinin-based combination therapy (ACT) is the recommended treatment for

uncomplicated malaria in infants. Artemisinin derivatives are safe and well tolerated by
young children, so the choice of ACT will be determined largely by the safety and
tolerability of the partner drug. For infants weighing less than 5 kg with uncomplicated
P. falciparum,
● WHO recommends treatment with an ACT at the same mg/kg body weight dose as for
children weighing 5 kg.
INFANT CARIES (BABY-BOTTLE SYNDROME)

● Putting an infant to bed with a bottle of formula, breast milk, orange juice, or
glucose water can result in aspiration. It also can lead to decay of all the
upper teeth and the lower posterior teeth. Decay occur because while an
infant sleeps, liquid from the propped bottle continuously soaks the upper
front teeth and lower back teeth (the lower front teeth are protected by the
tongue). The problem, called baby-bottle syndrome, occurs because the
carbohydrate in solutions such as formula or glucose water ferments to
organic acids that demineralize the tooth enamel until it decays.
● To prevent this problem, advise parents never to put their baby to bed with a
bottle. If parents insist a bottle is necessary to allow a baby to fall asleep,
encourage them to fill it with water and use a nipple with a smaller hole to
prevent the baby from receiving a large amount of fluid. If the baby refuses
to drink anything but milk, the parents might dilute the milk with water more
and more each night until the bottle is down to water only.
OBESITY ON INFANTS

● Obesity in infants is defined as a weight greater than the 90th to 95th

percentile on a standardized height/weight chart. Obesity occurs when there
is an increase in the number of fat cells because of excessive calorie intake.
Preventing obesity in infants is important because the extra fat cells formed
at this time are likely to remain throughout childhood and even into
adulthood. If a child becomes obese because of overingestion of milk, iron-
deficiency anemia may also be present because of the low iron content of
both breast and commercial milk. Once infant obesity begins, it is difficult to
reverse, so prevention is the key.
MANAGEMENT

● an infant should take no more than 32 oz of formula daily. When solid food
is introduced, a bottle of water can be substituted for formula at one feeding.
Nonfat milk should not be given because it contains so little fat that essential
fatty acid requirements may not be sufficient to en- sure cell growth
● Another way to help prevent obesity is to add a source of fiber, such as
whole-grain cereal and raw fruit, to an infant’s diet. These prolong the
stomach-emptying time, so they can help reduce food intake. Caution parents
about giving obese infants foods with high amounts of refined sugars, such
as pudding, cake, cookies, and candy. Encourage parents to learn more about
balanced nutrition and to provide this for their entire family.
PROMOTING INFANT
SAFETY
● Accidents are a leading cause of death in children from 1 month through 24 years of age.
They are second only to acute infections as a cause of acute morbidity and physician visits
(National Vital Statistics System [NVSS], 2009).
● Accidents are a leading cause of death in children from 1 month through 24 years of age.
They are second only to acute infections as a cause of acute morbidity and physician visits
(National Vital Statistics System [NVSS], 2009)
● Most accidents in infancy occur because parents either underestimate or overestimate a
child’s ability. Nursing interventions that help parents become sensitive to their infant’s
developmental progress not only help establish sound parent–child relationships but also
guard infant safety.
ASPIRATION PREVENTION
● Aspiration is a potential threat to infants throughout the first year.
● Round, cylindrical objects are more dangerous than square or flexible objects
in this regard. A 1 inch (3.2-cm) cylinder, such as a carrot or hot dog, is
particularly dangerous because it can totally obstruct an infant’s airway.
NURSING MANAGEMENT
● Educate parents who feed their infant formula not to prop bottles.

- they are overestimating their infant’s ability to push the bottle away, sit up,
turn the head to the side, cough, and clear the airway if milk should flow too
rapidly into the mouth and an infant begins to aspirate.
● Aspiration occur because parents underestimate their infant’s ability to grasp
and place objects in their mouth. Even a newborn can wiggle to a new
position to reach an attractive object such as a teddy bear with small button
eyes. Newborns’ grasp and sucking reflexes automatically cause them to
grasp and pull the object into their mouth.
● Caution parents to be certain nothing comes within an infant’s reach that
would not be safe to put into the mouth.
FALL PREVENTION
● Falls are a second major cause of infant accidents. As a preventive measure,
no infant, beginning with a newborn, should be left unattended on a raised
surface.
● Teach parents to be prepared for their infant to roll over by 2 months of age.
CAR SAFETY
Teaching car safety for infants (as well as for the whole family) is a vital
preventive health measure. up to 20 lb and 1 year old should be placed in rear-
facing seats in the back seat because an inflating front-seat airbag could suffocate
an infant
SAFETY WITH SIBLINGS
● As infants become more fun to play with at about 3 months, older brothers
and sisters grow more interested in interacting with them.
● Some preschoolers may be so jealous of a new baby they will physically
harm an infant if left alone.
CHILDPROOFING
● When infants begin teething at 5 to 6 months, they chew on any object
within reach to lessen gum-line pain. Remind parents to check for possible
sources of lead paint, such as painted cribs, playpen rails, or windowsill
● Urge parents to move all potentially poisonous substances from bottom
cupboards and store them well out of their infant’s reach.
● When infants begin creeping, remind parents to recheck bottom cupboards
and stairways for safety.
● Do not leave possibly dangerous supplies in an infant’s room.
● By 10 months, achievement of a pincer grasp makes infants able to pick up
very small objects. Remind parents to check play areas or areas such as table
tops for pins or other sharp objects that could be swallowed.
TODDLER
TODDLER
• During the toddler period, the age span from 1 to 3 years, enormous changes take
place in a child and, consequently, in a family.
• The toddler years are a time of great cognitive, emotional and social development.
• During this period, children accomplish a wide array of developmental tasks and
change from largely immobile and preverbal infants who are dependent on
caregivers for the fulfillment of most needs to walking, talking young children with
a growing sense of autonomy (independence).
COMMON DISEASE AND
DISORDER IN TODDLERS
AUTISM SPECTRUM DISORDER (ASD)
•a neurological and developmental disorder that begins early in childhood and lasts
throughout a person's life. It affects how a person acts and interacts with others,
communicates, and learns.
•Although autism can be diagnosed at any age, it is said to be a “developmental disorder”
because symptoms generally appear in the first two years of life.
•ASD begins before the age of 3 and last throughout a person’s life, although symptoms may
improve over time. Some children with ASD show hints of future problems within the first few
months of life. In others, symptoms may not show up until 24 months or later.
•Some children with an ASD seem to develop normally until around 18 to 24 months of age
and then they stop gaining new skills, or they lose the skills they once had.
•Studies have shown that one third to half of parents of children with an ASD noticed a
problem before their child’s first birthday, and nearly 80%–90% saw problems by 24 months
of age.
AUTISM SPECTRUM DISORDER (ASD)
Sign and symptoms:
 Not respond to their name by 12 months of age
 Not point at objects to show interest (point at an airplane flying over) by 14 months
 Not play “pretend” games (pretend to “feed” a doll) by 18 months
 Avoid eye contact and want to be alone
 Have trouble understanding other people’s feelings or talking about their own feelings
 Have delayed speech and language skills
 Repeat words or phrases over and over (echolalia)
 Give unrelated answers to questions
 Get upset by minor changes
 Have obsessive interests
 Flap their hands, rock their body, or spin in circles
 Have unusual reactions to the way things sound, smell, taste, look, or feel
AUTISM SPECTRUM DISORDER (ASD)

Risk factors
• Child's sex
• Family history
• Other disorders
• Extremely preterm babies
• Parents' ages
AUTISM SPECTRUM DISORDER (ASD)

Etiology
•There is no single known cause for ASD, but most researchers believe that genetic
mutations, possibly inherited, are the primary reason for children to develop ASD.
•Infants born extremely preterm (prior to 26 weeks gestation) and those with
disorders such as fragile X syndrome and Rett syndrome are at increased risk of
developing ASD.
•­Children are screened at well visits with their primary provider beginning at 9
months and continue until 2-3 years old.
AUTISM SPECTRUM DISORDER (ASD)

Nursing intervention
 Perform nursing assessment progressively and slowly.
 Obtain information and history from the patient’s parents regarding triggers for anxiety and behaviors,
eating habits, and sleeping patterns.
 Have parents complete evaluation screening questionnaires such as ASQ (Ages & Stages Questionnaires) or M-
CHAT (Modified Checklist for Autism in Toddlers) appropriate for age.
 Provide for safety. Place infants or toddlers in the crib, raise rails on the bed.
 Sit down or position yourself near the patient’s eye level.
 Explain every procedure and demonstrate on self or parent
 Talk with the patient about their  interests
 Provide a calm and inviting atmosphere
 Review diet and eating habits with parents and provide or recommend foods and food presentations
that may make healthy choices more appealing.
 Administer medications appropriately as required
 Provide resource information and education for parents
ROTAVIRUS
- a virus that causes diarrhea and other intestinal symptoms. It’s very
contagious and is the most common cause of diarrhea in infants and
young children.
- It usually affects children between the ages of 6 months and to years.
ROTAVIRUS
The most common symptom of rotavirus is severe diarrhea. Children can also
experience:
 Vomiting
 severe fatigue
 a high fever
 irritability
 dehydration
 abdominal pain
ROTAVIRUS
Risk factors
•Most children get the virus between the ages of 3 months and 35 months.
Infections are more common in the cooler months of the year, starting in the
fall and ending in the spring. Children are more at risk at these times. Any child
who is around a child sick with rotavirus is at risk.
ROTAVIRUS
Etiology
•Rotavirus most often spread through a fecal-oral route. This is often because a child
does not wash his or her hands properly or often enough. It can also be caused by
eating or drinking contaminated food or water.
ROTAVIRUS
Management
- There's no specific treatment for a rotavirus infection. Antibiotics and antivirals won't help
a rotavirus infection.
- Management consists of replacement of fluids (ORS) and restoration of Electrolyte balance
- Oral rehydration therapy is highly effective in reducing morbidity and mortality
- Severe dehydration needs parental administration of fluids
- Vaccine - administered by putting drops in the child's mouth to prevent rotavirus infecton
o There are two brands of the rotavirus vaccine -- RotaTeq (RV5) and Rotarix (RV1). With
RotaTeq, three doses are required. They should be given at ages 2 months, 4 months,
and 6 months. Rotarix only requires two doses -- at 2 months and 4 months.
ROSEOLA
- rarely known as “sixth disease,” is a contagious illness that’s caused by a
virus. It shows up as a fever followed by a signature skin rash.
- It generally occurs in children between 6 months to 3 years, mainly in the
spring and fall, although it can occur any time of the year.
ROSEOLA
Signs and symptoms:
 a sudden high temperature
 cold-like symptoms such as a sore throat, runny nose and a cough
 loss of appetite
 skin rash
 swollen eyelids and swollen glands in their neck
ROSEOLA
Risk factors
•Most children will contract roseola at a young age. They are at greatest risk
between the ages of 6 and 15 months of age when their immune systems have
not yet developed antibodies to fight the virus, as this illness occurs upon virus
exposure.
ROSEOLA
Etiology
•Roseola is caused by a type of herpes virus. The virus can enter the body
through the nose and mouth. It is spread when a child breathes in droplets that
contain the virus after an infected person coughs, sneezes or talks.
ROSEOLA
Management
- Roseola will typically go away on its own. There’s no specific treatment for the
illness.
- Treatment focuses on measures to reduce the discomfort of the rash and fever.
- The doctor gives the child over-the-counter medicines, such as acetaminophen
(Tylenol) or ibuprofen (Advil, Motrin) to help lower fever and reduce pain.
- Make sure that the child drinks plenty of fluids to prevent dehydration
- Dressing the child in lightweight clothing and give sponge bath if necessary, during
the fever
CROUP
- a common infection in children. It causes swelling in the upper part of the
airway in the neck. It causes a barking cough, with or without fever. And it
may cause problems with breathing. The illness is seen more often in the
winter.
CROUP
Signs and symptoms
 cold symptoms like sneezing and runny nose
 Fever
 Barking cough
 heavy breathing
 hoarse voice
 Swelling of the larynx blocking air flow
CROUP
Risk factors
•Most at risk of getting croup are children between 6 months and 3 years of
age. Because children have small airways, they are most susceptible to having
more symptoms with croup.
CROUP
Etiology
Croup is usually caused by a viral infection, most often a parainfluenza virus.
A child may contract a virus by breathing infected respiratory droplets coughed or
sneezed into the air. Virus particles in these droplets may also survive on toys and
other surfaces. If a child touches a contaminated surface and then touches his or her
eyes, nose or mouth, an infection may follow.
CROUP
Therapeutic Management
- One emergency method of relieving croup symptoms is for a parent to run the
shower or hot water tap in a bathroom until the room fills with steam, then keep
the child in this warm, moist environment.
- In emergency room, cool moist air with a corticosteroid such as dexamethasone, or
racemic epinephrine, given by nebulizer, reduces inflammation and produces
effective bronchodilation to open the airway.
- Intravenous therapy may be prescribed to keep the child well hydrated.
- Maintain accurate intake and output records and test urine specific gravity to
ensure that hydration is adequate.
 SHIGELLOSIS
 Shigellosis is a type of food poisoning caused by infection with the shigella bacterium.
Shigella species are a highly contagious cause dysentery (intestinal inflammation) and
humans are the only reservoir. Children ages 2 to 4 are most likely to get the condition.
 Shigellosis is likely to occur among toddlers who are not fully toilet trained. Family
members and playmates of infected children are also at high risk of becoming infected
 Shigellosis is spread when the bacteria in feces or on soiled fingers are ingested. Poor hand-
washing habits and eating contaminated food may cause the condition. Shigellosis is often
found in nursing homes, refugee camps, and other places where conditions are crowded.
 SHIGELLOSIS
Signs and symptoms
 Diarrhea (often bloody)
 Tenesmus (sensation of being unable to empty your bowel after you have already defecated)
 Fever
 Nausea and Vomiting
 Abdominal pain or cramps (starting 1 to 2 days after exposed to the bacteria)
SHIGELLOSIS
Therapeutic Management
 Toddlers who are severely dehydrated need treatment in a hospital emergency
room, where they can receive salts and fluids through a vein (intravenously), rather
than by mouth.
 Antibiotics such as azithromycin may shorten the duration of the illness
 Avoid drugs intended to treat diarrhea such as loperamide or atropine
 SHIGELLOSIS
Prevention
 You can help prevent the spread of shigellosis by washing hands frequently and carefully with
soap, especially if you spend time with children who are not completely toilet trained. When
possible, keep young children with shigellosis who are still in diapers away from uninfected
children.
 If toddler is in diapers and has shigellosis, after diaper changing, put the diapers in a closed-lid
garbage can. Then wash hands with soap and warm water.
 People who have shigellosis should not prepare food or pour water for others. Shigella are
present in the diarrhea of people with shigellosis and for 1 or 2 weeks after symptoms have
stopped.
EAR INFECTION
 Otitis media is an inflammation of the middle ear.
 They are very common, especially in children between 6 months and 3 years of age.
They are usually not serious and aren’t contagious. Most ear infections happen when a
child has already had a cold for a few days
 Viruses or bacteria (germs) cause middle ear infections. The eustachian tube connects
the middle ear with the back of the throat. Germs travel from the back of the throat
when the eustachian tube is swollen from a cold, causing infection in the middle ear.
 These include children already at risk for developmental delays or difficulties
 EAR INFECTION
Signs and Symptoms
 Ear pain
 Loss of appetite
 Irritability
 Poor sleep
 Fever
 Drainage from the ear
 Trouble hearing
 EAR INFECTION
Risk Factors
 Children less than 5 years old, because they have shorter eustachian tubes.
 Toddlers who are exposed to cigarette smoke. Smoke causes inflammation of the
eustachian tube, making ear infections more likely.
 Children who were not breastfed. Breast milk has antibodies that help fight infections.
 Babies who are being bottle fed, especially if they swallow milk while lying too flat. Milk
can enter the eustachian tube and cause inflammation, which increases the risk of an ear
infection. Children should be held upright while drinking a bottle.
EAR INFECTION
Nursing Care
• Positioning. Have the child sit up, raise head on pillows, or lie on unaffected ear.
• Heat application. Apply heating pad or a  warm hot water bottle.
• Diet. Encourage breastfeeding of infants as breastfeeding affords natural immunity to
infectious agents; position bole-fed infants upright when feeding.
• Hygiene. Teach family members to cover mouths and noses when sneezing or coughing
and to wash hands frequently.
• Monitoring hearing loss. Assess hearing ability frequently.
School-Age
School-age

 School-age child development describes the

expected physical, emotional, and mental
abilities of children ages 6 to 12. As children
enter into school age, their skills and understanding
of concepts continue to grow.
Common Health Problems of the
School-age Period
Anxieties of a school-age child
Anxiety causes of a School-age child

 -Bullying in school/Problems in academically

 -Family problem
 -Stressful events
Signs and symptoms

 School Refusal, Poor school performance, Panic

attacks. Also include headaches, dizziness,
sweating, body or muscle aches, nausea and upset
stomach, excessive fatigue, change in diet and
unexplained illness.
Nursing Intervention

 Helpthe child relieve or reduce anxiety by

teaching relaxation exercises, Provide emotional
support to the child. If the child is being bullied or
has school problems the nurse can do a
collaborative intervention by approaching the
guidance counselor for addressing certain school
problem.
 Obesity

 Obesity appearsto significantly increase

through childhood
Causes of Obesity in the School-age Period

 Lifestyle issues is the main contributor to

childhood obesity. Mainly, too little physical
activity and too many calories from food and
drinks. Genetic and hormonal factors might play a
role as well.
Risk Factors of Childhood Obesity

 -Genetic Makeup
 -Lack of physical activity
 -Unhealthy eating behaviors
 -Not enough sleep
 -High amounts of stress
Assessment of Childhood Obesity

 Thebody mass index (BMI), which provides a

guideline of weight in relation to height, is the
accepted measurement for obesity. Formula of
BMI = kg/m2. Obesity is diagnosed when the body
mass index (BMI) is 30 or higher
Prevention to Childhood Obesity

 Limit the child's consumption of sugar-sweetened

beverages or avoid them
 Provide plenty of fruits and vegetables
 Teach the child how to make healthier choices
 Limit the use of television and mobile phones to
the children
 Be sure the child gets enough sleep
Treatments for Obesity in the School-age
Period

 Treatment usually includes changes in the child's

eating habits, sleep pattern and physical activity
level.
Nursing Interventions

 Nurses'actions should take a whole-family

approach because it is challenging for obese
children to alter their dietary or physical habits if
not supported by their families. Nurses can
intervene by providing knowledge about obesity to
the children and their parents. Nurses will promote
healthy eating and exercising habits to the children.
SORE THROAT
Signs and symptoms

•Pain or a scratchy sensation in the throat

•Pain that worsens with swallowing or talking
•Difficulty swallowing
•Sore, swollen glands in your neck or jaw
•Swollen, red tonsils
•White patches or pus on your tonsils
•A hoarse or muffled voice
Causes

 Viral infections
 Bacterial infections
Risk factors

 Chronic or frequent sinus infections

 Close quarters
 Weakened immunity
 Allergies
 Exposure to chemical irritants
Prevention

 Teach the children to wash their hands thoroughly and frequently,

especially after using the toilet, before eating, and after sneezing or
coughing.
 Teach them to avoid drinking glasses or utensils.
 Teach them to avoid close contact with people who are sick.
 Teach them to use alcohol-based hand sanitizers as an alternative to
washing hands when soap and water aren't available.
Treatment

 A sore throat caused by a viral infection

usually lasts five to seven days and doesn't
require medical treatment.
 If
the child's sore throat is caused by a
bacterial infection, your doctor or pediatrician
will prescribe antibiotics.
Nursing Interventions

 Promote Rest. Let the child get plenty of

sleep and instruct the child to rest his/her
voice
 Encourage the child to drink plenty amount
of water  so that the throat will be moist and to
prevent dehydration
 Instructthe parents to avoid irritants like
cigarette smoking
PRESCHOOL AGE
● The preschool period traditionally includes ages 3, 4 and 5.
● This is also an important period of growth for parents. They
may be unsure about how much independence and
responsibility for self-care they should allow their preschooler.
● Most children of this age want to do things for themselves
choose their own clothing and dress by themselves, feed
themselves completely, wash their own hair, and so forth.
BEHAVIORAL AND EMOTIONAL
DISORDERS
A child under 5 years old receive a diagnosis of a serious behavioral
disorder. However, they may begin displaying symptoms of a disorder that
could be diagnosed later in childhood. These may include:
•attention deficit hyperactivity disorder (ADHD)
•oppositional defiant disorder (ODD)
•anxiety disorder
•Depression
•bipolar disorder
•learning disorders
•conduct disorders
ATTENTION DEFICIT
HYPERACTIVITY
•ADHD is the most common neurobehavioral disorder of childhood, among the
most prevelant chronic health conditions affecting preschool age and the most
extensively studied mental disorder of childhood.
•ADHD is characterised by inattention, including increased distractibiity and
difficulty sustaining attention, poor impulse control and decreased self inhibitory
capacity and motor over activity and motor restlessness.
Inattention means a person wanders off task, lacks persistence, has difficulty sustaining focus,
and is disorganized; and these problems are not due to defiance or lack of comprehension.

symptoms of inattention may often:

•Overlook or miss details, make careless mistakes in schoolwork, at work, or during other activities
•Have problems sustaining attention in tasks or play, including conversations, lectures, or lengthy reading
•Not seem to listen when spoken to directly
•Not follow through on instructions and fail to finish schoolwork, chores, or duties in the workplace or start tasks but
quickly lose focus and get easily sidetracked
•Have problems organizing tasks and activities, such as what to do in sequence,
keeping materials and belongings in order, having messy work and poor time
management, and failing to meet deadlines
•Avoid or dislike tasks that require sustained mental effort, such as schoolwork or
homework, or for teens and older adults, preparing reports, completing forms, or
reviewing lengthy papers
•Lose things necessary for tasks or activities, such as school supplies, pencils, books,
tools, wallets, keys, paperwork, eyeglasses, and cell phones
•Be easily distracted by unrelated thoughts or stimuli
•Be forgetful in daily activities, such as chores, errands, returning calls, and keeping
appointments
Hyperactivity means a person seems to move about constantly, including in situations in
which it is not appropriate; or excessively fidgets, taps, or talks. In adults, it may be extreme restlessness or wearing others
out with constant activity.

Impulsivity means a person makes hasty actions that occur in the moment without first thinking
about them and that may have a high potential for harm, or a desire for immediate rewards or inability to delay gratification.
An impulsive person may be socially intrusive and excessively interrupt others or make important decisions without
considering the long-term consequences.
symptoms of hyperactivity-impulsivity may often:

Have trouble waiting for his or her turn

•Interrupt or intrude on others, for example in conversations, games, or activities
Fidget and squirm in their seats
•Leave their seats in situations when staying seated is expected, such as in the classroom or the office
•Run or dash around or climb in situations where it is inappropriate or, in teens and adults, often feel restless
•Be unable to play or engage in hobbies quietly
•Be constantly in motion or “on the go,” or act as if “driven by a motor”
•Talk nonstop
•Blurt out an answer before a question has been completed, finish other people’s sentences, or speak without waiting for a
turn in a conversation
Risk Factors
•Genes
•Cigarette smoking, alcohol use, or drug use during pregnancy
•Exposure to environmental toxins during pregnancy
•Exposure to environmental toxins, such as high levels of lead, at a young age
•Low birth weight
•Brain injuries
ADHD is more common in males than females, and females with ADHD are more likely to have problems primarily with
inattention. Other conditions, such as learning disabilities, anxiety disorder, conduct disorder, depression, and substance
abuse, are common in people with ADHD.
Treatment and Therapies
Treatments include medication, psychotherapy, education or training, or a combination of treatments.
ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn.
Medication also may improve physical coordination.
Stimulants
The most common type of medication used for treating ADHD is called a “stimulant.”
to treat ADHD with a medication that is considered a stimulant, it works by increasing the brain chemicals
dopamine and norepinephrine, which play essential roles in thinking and attention.
Non-stimulants
A few other ADHD medications are non-stimulants. These medications take longer to start working than
stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD.
Psychotherapy and Psychosocial Interventions
Children with ADHD need guidance and understanding from their parents, families, and teachers to reach their
full potential and to succeed.
Behavioral therapy is a type of psychotherapy that aims to help a person change his or her behavior.
•monitor his or her own behavior
•give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting
•Parents, teachers, and family members also can give positive or negative feedback for certain behaviors and
help establish clear rules, chore lists, and other structured routines to help a person control his or her behavior.
•Therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or
respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond
appropriately can also be part of social skills training.
Cognitive behavioral therapy can also teach a person mindfulness
techniques, or meditation. A person learns how to be aware and accepting of one’s
own thoughts and feelings to improve focus and concentration

Stress management techniques can benefit parents of children with

ADHD by increasing their ability to deal with frustration so that they can respond
calmly to their child’s behavior.
OPPOSITIONAL DEFIANT DISORDER (ODD)

Oppositional defiant disorder (ODD) is a type of behavior disorder. It is

mostly diagnosed in childhood. Children with ODD are uncooperative,
defiant, and hostile toward peers, parents, teachers, and other authority
figures. They are more troubling to others than they are to themselves.
SIGNS AND SYMPTOMS
Angry and irritable mood:
•Often and easily loses temper
•Is frequently touchy and easily annoyed by others
•Is often angry and resentful

Argumentative and defiant behavior:

● Often argues with adults or people in authority

● Often actively defies or refuses to comply with adults' requests or rule
● Often deliberately annoys or upsets people
● Often blames others for his or her mistakes or misbehavior
Vindictiveness

● Is often spiteful or vindictive

● Has shown spiteful or vindictive behavior at least twice in the past six months

ODD can vary in severity:

● Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers.
● Moderate. Some symptoms occur in at least two settings.
● Severe. Some symptoms occur in three or more settings.
Causes
There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of
inherited and environmental factors, including:

● Genetics
● Environment
Risk factors
● Temperament
● Parenting issues
● Other family issues
● Environment
ODD may lead to problems such as:

● Poor school and work performance

● Antisocial behavior
● Impulse control problems
● Substance use disorder
● Suicide

Many children and teens with ODD also have other mental health disorders, such as:

● Attention-deficit/hyperactivity disorder (ADHD)

● Conduct disorder
● Depression
● Anxiety
● Learning and communication disorders
Prevention
There's no guaranteed way to prevent oppositional defiant disorder. However,
positive parenting and early treatment can help improve behavior and prevent the
situation from getting worse. The earlier that ODD can be managed, the better.
TREATMENT
The cornerstones of treatment for ODD usually include:

● Parent training
● Individual and family therapy
● Cognitive problem-solving training
● Collaborative problem-solving
● Social skills training
ANXIETY DISORDERS
The term "anxiety disorder" refers to specific psychiatric disorders that involve
extreme fear or worry, and includes generalized anxiety disorder (GAD),
panic disorder and panic attacks, agoraphobia, social anxiety disorder, selective
mutism, separation anxiety, and specific phobias.
Types of Anxiety Disorders
There are several types of anxiety disorders:

● Generalized anxiety disorder . You feel excessive, unrealistic worry and tension with little or no reason.
● Panic disorder . You feel sudden, intense fear that brings on a panic attack. During a panic attack you may break
out in a sweat, have chest pain, and have a pounding heartbeat (palpitations). Sometimes you may feel like you’re
choking or having a heart attack.
● Social anxiety disorder . Also called social phobia, this is when you feel overwhelming worry and self-
consciousness about everyday social situations. You obsessively worry about others judging you or being
embarrassed or ridiculed.
● Specific phobias . You feel intense fear of a specific object or situation, such as heights or flying.
The fear goes beyond what’s appropriate and may cause you to avoid ordinary situations.
● Agoraphobia.You have an intense fear of being in a place where it seems hard to escape or get help
if an emergency occurs. For example, you may panic or feel anxious when on an airplane, public
transportation, or standing in line with a crowd.
● Separation anxiety. Little kids aren’t the only ones who feel scared or anxious when a loved one
leaves. Anyone can get separation anxiety disorder. If you do, you’ll feel very anxious or fearful
when a person you’re close with leaves your sight. You’ll always worry that something bad may
happen to your loved one.
● Selective mutism. This is a type of social anxiety in which young kids who talk normally with their
family don’t speak in public, like at school.
● Medication-induced anxiety disorder. Use of certain medications or illegal drugs, or withdrawal
from certain drugs, can trigger some symptoms of anxiety disorder.
SYMPTOMS
Common symptoms are: ● Dry mouth
● Nausea
● Panic, fear, and uneasiness ● Tense muscles
● Feelings of panic, doom, or danger ● Dizziness
● Sleep problems ● Thinking about a problem over and over again and unable to stop
● Not being able to stay calm and still (rumination)
● Cold, sweaty, numb, or tingling hands or feet ● Inability to concentrate
● Shortness of breath ● Intensely or obsessively avoiding feared objects or places
● Breathing faster and more quickly than normal
(hyperventilation)
● Heart palpitations
TREATMENT
Treatments for anxiety disorder include:

Medication
Several types of drugs are used to treat anxiety disorders. Talk to your doctor or psychiatrist
about the pros and cons of each medicine to decide which one is best for you.
● Antidepressants Examples of SSRIs are escitalopram (Lexapro) and fluoxetine (Prozac
). SNRIs include duloxetine (Cymbalta)and venlafaxine (Effexor).

● Bupropion.
● Benzodiazepines.
● Beta-blockers
● Anticonvulsants.
● Antipsychotics
● Buspirone (BuSpar)
Psychotherapy
This is a type of counseling that helps you learn how your emotions affect your
behaviors.

Cognitive behavioral therapy (CBT)

This common type of psychotherapy teaches you how to turn negative, or
panic-causing, thoughts and behaviors into positive ones.
DEPRESSION
Depression is a condition in which a person feels discouraged, sad, hopeless,
unmotivated, or disinterested in life in general for more than two weeks and when
the feelings interfere with daily activities. Major depression is a treatable illness
that affects the way a person thinks, feels, behaves, and functions. At any point in
time, 3 to 5 percent of people suffer from major depression; the lifetime risk is
about 17 percent.
Signs and symptoms of depression in children
include:

● Irritability or anger ● Difficulty concentrating

● Continuous feelings of sadness and ● Fatigue and low energy
hopelessness ● Physical complaints (such as stomachaches,
● Social withdrawal headaches) that don't respond to treatment
● Increased sensitivity to rejection ● Reduced ability to function during events and
● Changes in appetite -- either increased or activities at home or with friends, in school,
decreased extracurricular activities, and in other hobbies or
● Changes in sleep -- sleeplessness or excessive interests
sleep ● Feelings of worthlessness or guilt
● Vocal outbursts or crying ● Impaired thinking or concentration
● Thoughts of death or suicide
TREATMENT

Treatment options for children with depression are similar to those for adults,
including psychotherapy (counseling) and medication. Your child's doctor may
suggest psychotherapy first, and consider antidepressant medicine as an
additional option if there is no significant improvement. The best studies to date
indicate that a combination of psychotherapy and medication is most effective at
treating depression.
 BIPOLAR DISORDER
Bipolar disorder is a mental disorder that causes people to experience noticeable, sometimes extreme,
changes in mood and behavior. Sometimes children with bipolar disorder feel very happy or “up” and
are much more energetic and active than usual. This is called a manic episode. Sometimes children
with bipolar disorder feel very sad or “down” and are much less active than usual. This is called a
depressive episode.

Bipolar disorder, which used to be called manic-depressive illness or manic depression, is not the
same as the normal ups and downs every child goes through. The mood changes in bipolar disorder
are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the
ability to think clearly. Bipolar symptoms can make it hard for young people to perform well in school
or to get along with friends and family members. Some children and teens with bipolar disorder may
try to hurt themselves or attempt suicide.
Signs and symptoms of bipolar disorder
● attention-deficit/hyperactivity disorder (ADHD)
● conduct problems
● Depression
● anxiety disorders.
Mood episodes in bipolar disorder include
● Intense emotions along with significant changes in sleep habits, activity
levels, thoughts, or behaviors.
● A person with bipolar disorder may have manic episodes, depressive
episodes, or “mixed” episodes.
● A mixed episode has both manic and depressive symptoms. These mood
episodes cause symptoms that often last for several days or weeks. During an
episode, the symptoms last every day for most of the day.
Children and teens having a manic episode may: Children and teens having a depressive episode
may:
● Show intense happiness or silliness for long
periods of time. ● Feel frequent and unprovoked sadness.
● Have a very short temper or seem extremely ● Show increased irritability, anger, or hostility.
● Complain a lot about pain, such as stomachaches
irritable.
and headaches.
● Talk fast about a lot of different things. ● Have a noticeable increase in amount of sleep.
● Have trouble sleeping but not feel tired. ● Have difficulty concentrating.
● Have trouble staying focused, and experience ● Feel hopeless and worthless.
racing thoughts. ● Have difficulty communicating or maintaining
● Seem overly interested or involved in relationships.
● Eat too much or too little.
pleasurable but risky activities.
● Have little energy and no interest in activities they
● Do risky or reckless things that show poor
usually enjoy.
judgment. ● Think about death, or have thoughts of suicide.
 TREATMENT
Treatment options include:

● Medication. Several types of medication can help treat symptoms of bipolar disorder. Children
respond to medications in different ways, so the right type of medication depends on the child. This
means children may need to try different types of medication to see which one works best for them.
Some children may need more than one type of medication because their symptoms are complex.
Children should take the fewest number of medications and the smallest doses possible to help their
symptoms. A good way to remember this is “start low, go slow.” Medications can cause side effects.
Always tell your child’s health care provider about any problems with side effects. Do not stop giving
your child medication without speaking to a healthcare provider. Stopping medication suddenly can be
dangerous and can make bipolar symptoms worse.
● Psychosocial Therapy. Different kinds of psychosocial therapy can help children and their families
manage the symptoms of bipolar disorder. Therapies that are based on scientific research—including
cognitive behavioral approaches and family-focused therapy—can provide support, education, and
guidance to youth and their families. These therapies teach skills that can help people manage bipolar
disorder, including skills for maintaining routines, enhancing emotion regulation, and improving social
interactions.
LEARNING DISORDERS
Common learning disorders affect a child's abilities in reading, written
expression, math or nonverbal skills.
Types of Learning Disabilities

Dyscalculia
● A specific learning disability that affects a person’s ability to understand numbers and learn math facts.
● Learning disorders in reading are usually based on difficulty perceiving a spoken word as a combination of
distinct sounds. This can make it hard to understand how a letter or letters represent a sound and how letter
combinations make a word.
● Problems with working memory — the ability to hold and manipulate information in the moment — also
can play a role.
Even when basic reading skills are mastered, children may have difficulty with the following skills:

● Reading at a typical pace

● Understanding what they read
● Recalling accurately what they read
● Making inferences based on their reading
● Spelling
Dysgraphia
● A specific learning disability that affects a person’s handwriting ability and fine motor skills.
● Writing requires complex visual, motor and information-processing skills. A learning disorder in
written expression may cause the following:

· Slow and labor-intensive handwriting

· Handwriting that's hard to read

· Difficulty putting thoughts into writing

· Written text that's poorly organized or hard to understand

· Trouble with spelling, grammar and punctuation

Dyslexia
● A specific learning disability that affects reading and related language-based processing skills
● A learning disorder in math may cause problems with the following skills:

· Understanding how numbers work and relate to each other

· Calculating math problems

· Memorizing basic calculations

· Using math symbols

· Understanding word problems

· Organizing and recording information while solving a math problem

Non-Verbal Learning Disabilities
● Has trouble interpreting nonverbal cues like facial expressions or body language and may have poor coordination
● A child with a learning disorder in nonverbal skills appears to develop good basic language skills and strong rote
memorization skills early in childhood. Difficulties are present in visual-spatial skills, visual-motor skills, and other skills
necessary in social or academic functioning.
● A child with a learning disorder in nonverbal skills may have trouble with the following skills:

· Interpreting facial expressions and nonverbal cues in social interactions

· Using language appropriately in social situations

· Physical coordination

· Fine motor skills, such as writing

· Attention, planning and organizing

· Higher-level reading comprehension or written expression, usually appearing in later grade school
RISK FACTORS
Factors that might influence the development of learning disorders
include:
● Family history and genetics
● Prenatal and neonatal risks
● Psychological trauma
● Physical trauma
● Environmental exposure
What are the signs of learning disorders?

● ·Doesn't master skills in reading, spelling, writing or math at or near expected age and grade levels
● Has difficulty understanding and following instructions
● Has trouble remembering what someone just told him or her
● Lacks coordination in walking, sports or skills such as holding a pencil
● Easily loses or misplaces homework, school books or other items
● Has difficulty understanding the concept of time
● Resists doing homework or activities that involve reading, writing or math, or consistently can't complete homework assignments

without significant help

● Acts out or shows defiance, hostility or excessive emotional reactions at school or while doing academic activities, such as homework or

reading
TREATMENT
● Learning disabilities are not curable; however, many can be reduced or
controlled with early screening and intervention.
● Once diagnosed with a learning disability, your child’s most beneficial treatment
will be special education services, including a team approach to planning your
child’s Individualized Education Program (IEP), in addition to other therapies, if
these are found helpful. These might include speech therapy or occupational
therapy. One-on-one tutoring with a specialist who understands learning
disabilities can also make a difference in a child’s adaptation and progress.
CONDUCT DISORDER
Conduct disorder" refers to a group of repetitive and persistent
behavioral and emotional problems in youngsters. Children and
adolescents with this disorder have great difficulty following
rules, respecting the rights of others, showing empathy, and
behaving in a socially acceptable way.
What Are the Symptoms of Conduct Disorder?
Symptoms of conduct disorder vary depending on the age of the child and whether the disorder is mild,
moderate, or severe. In general, symptoms of conduct disorder fall into four general categories:

● Aggressive behavior
● Destructive behavior
● Violation of rules
WHAT CAUSES CONDUCT DISORDER?

The exact cause of conduct disorder is not known, but it is believed that a combination of
biological, genetic, environmental, psychological, and social factors play a role.

● Biological: Some studies suggest that defects or injuries to certain areas of the brain can lead
to behavior disorders. Conduct disorder has been linked to particular brain regions involved
in regulating behavior, impulse control, and emotion. Conduct disorder symptoms may
occur if nerve cell circuits along these brain regions do not work properly. Further, many
children and teens with conduct disorder also have other mental illnesses, such as
attention-deficit/hyperactivity disorder (ADHD), learning disorders, depression,
substance abuse, or an anxiety disorder, which may contribute to the symptoms of conduct
disorder.
● Genetics: Many children and teens with conduct disorder have close family members with
mental illnesses, including mood disorders, anxiety disorders, substance use disorders and
personality disorders. This suggests that a vulnerability to conduct disorder may be at least
partially inherited.
● Environmental: Factors such as a dysfunctional family life, childhood abuse, traumatic
experiences, a family history of substance abuse, and inconsistent discipline by parents may
contribute to the development of conduct disorder.
● Psychological: Some experts believe that conduct disorders can reflect problems with moral
awareness (notably, lack of guilt and remorse) and deficits in cognitive processing.
● Social: Low socioeconomic status and not being accepted by their peers appear to be risk
factors for the development of conduct disorder
HOW IS CONDUCT DISORDER CAN BE
TREATED
● Psychotherapy : Psychotherapy (a type of counseling) is aimed at helping the child learn to express
and control anger in more appropriate ways. A type of therapy called cognitive-behavioral therapy
aims to reshape the child's thinking (cognition) to improve problem solving skills, anger management,
moral reasoning skills, and impulse control. Family therapy may be used to help improve family
interactions and communication among family members. A specialized therapy technique called parent
management training (PMT) teaches parents ways to positively alter their child's behavior in the home.
● Medication : Although there is no medication formally approved to treat conduct disorder, various
drugs may be used (off label) to treat some of its distressing symptoms (impulsivity, aggression,
dysregulated mood), as well as any other mental illnesses that may be present, such as ADHD or
major depression