NCM 101Pediatric Nursing

Prepared By:Adahlia T. Basco, RN,MAN

Growth & Development

Growth and DevelopmentGrowth:• Is physical change and increase in

size.• It can be measured quantitatively.• Indicators of growth includes height,

weight, bone size, and dentition.• Growth rates vary during different

stages of growth and development.• The growth rate is rapid during the

prenatal, neonatal, infancy and adolescent stages and slows during childhood.

• Physical growth is minimal during adulthood

Development:

• Is an increase in the complexity of function and skill progression.

• It is the capacity and skill of a person to adapt to the environment.

• Development is the behavioral aspect of growth

DEVELOPMENTAL MILESTONEIs a standard of reference by which to compare a child’s behavior at specific ages

Sigmund FreudAge Name Pleasure Source Conflict

0-2 years old Oral Mouth: sucking, biting, swallowing

Weaning away from mother’s breast

-4 years old Anal Anus: defecating or retaining feces

Toilet training

4-5 years old Phallic Genitals Oedipus (boys), Electra (girls)

puberty Latency Sexual urges sublimated into sports and hobbies. Same-sex friends also help avoid sexual feelings

puberty onwards Genital Physical sexual changes reawaken repressed needs.Direct sexual feelings towards others lead to sexual gratification.

Social Rules

Erick EriksonSTAGE AGE CENTRAL TASK (+) RESOLUTION (-) RESOLUTION

1. Infancy Birth-18 mos Trust vs Mistrust

Learn to trust others

Mistrust, withdrawal, estrangement

2. Early childhood

1½ to 3 y/o Autonomy vs Shame & doubt

Self control w/o loss of self esteemAbility of cooperate & express oneself

Compulsive, self-restraint or compliance.Willfulness & defiance.

3. Late childhood

3 to 5 y/o Initiative vs guilt

Learns to become assertiveAbility to evaluate one’s own behavior

Lack of self-confidence.Pessimism, fear of wrongdoing.Over-control & over-restriction.

Erick Erikson`s4.School Age 6 to 12 y/o Industry vs

InferiorityLearns to create, develop & manipulate.Develop sense of competence & perseverance.

Loss of hope, sense of being mediocre.Withdrawal from school & peers.

. School Age

5. Adolescence

12–20 y/o Identity vs role confusion

Coherent sense of self.Plans to actualize one’s abilities

Feelings of confusion, indecisiveness, & possible anti-social behavior.

5. Adolescence

Erick Erikson`s6. Young Adulthood

18-25 y/o Intimacy vs isolation

Intimate relationship with another person.Commitment to work and relationships.

Impersonal relationships.Avoidance of relationship, career or lifestyle commitments.

7. Adulthood 25-65 y/o Generativity vs stagnation

Creativity, productivity, concern for others.

Self-indulgence, self-concern, lack of interests & commitments.

8. Maturity 65 y/o to death Integrity vs despair

Acceptance of worth & uniqueness of one’s own life.Acceptance of death.

Sense of loss, contempt for others.

INFANCY

Birth to 1 yearErickson: Trust vs MistrustFreud: Oral Solitary playConsistent primary caregiver

SMILES: After two months of sleepless nights and round-the-clock soothing, you've seen plenty of your baby's tears. Maybe you've spotted a fleeting smile, but then again, it could have been gas. Now it's time for the real reward. By around 2 months of age, your baby will smile in response to you! The sound of your voice or the sight of your face is often all it takes to trigger baby's irresistible grin.

LAUGHS: If the frequent sound of baby's crying has you on edge, take heart. By 4 months, you can look forward to another sound, possibly the sweetest you'll ever hear - your baby's laughter. The best part is how easily a baby laughs. Silly faces, tickling, and peek-a-boo are usually more than enough to set off lots of squeals and giggles.

SLEEP: Like no other baby milestone, a full night of sleep becomes the Holy Grail for new parents. While it is unrealistic and unhealthy to expect a newborn to sleep all night, parents can rest assured that relief will come soon. By 4-6 months, most babies are capable of sleeping through the night.

SITS UP: How different the world looks when you're not stuck on your belly! Around 5 or 6 months, most babies can sit up with support - either by resting on their hands in front of them or by leaning on pillows or furniture. Babies can usually sit alone steadily by 7-9 months.

CRAWLS: If you have an 8-month-old, you may want to put your gym membership on hold. You're about to get plenty of exercise chasing your suddenly mobile baby around the house. By 9 months, most babies crawl using both hands and feet, though some babies never crawl, preferring to creep or wriggle instead. Crawling is not an essential baby milestone, and infants who choose to scoot or creep still tend to reach other milestones on schedule.

Waving "bye-bye" is not just a cute trick - it is an actual expression of language. By 9 months most babies begin to make the link between sounds, gestures, and meaning. They understand that waving is connected to the phrase "bye-bye."

Just when spoon-feeding begins to lose its luster, babies are ready to feed themselves. Between 9-12 months, babies develop better control over their hands and fingers, making it easier to grab small objects - like finger foods! Unfortunately, babies this age love to explore taste and texture, so food is not the only thing they'll try to pop into their mouths. Environmental safety should, therefore, become a big parental concern at this age.

By 12 months, most babies begin to stand briefly without support. They also take small steps while holding onto furniture or other objects, an activity called "cruising." In the weeks or months before they walk independently, babies may spend hours cruising to practice for the real thing.

You might call it the crown jewel of baby milestones. No other moment is met with more anticipation (or camera clicks) than baby's first step on his or her own. But not all babies walk by their first birthday. The normal range is anywhere from 9 to 17 months, with most babies taking at least a few steps by about 13 months.

Says a Word"Mama! Dada!" There's nothing like hearing your baby call your name, and it usually happens right around the one-year mark. By this time, most babies can say at least one real word and actively try to imitate others. It won't be long before you finally get to hear what's on your little one's mind.

INFANCY

Physiological:BW x 2 in 6 monthsBW x 3 in 1 yearPosterior fontanel closes in 2-3 monthsAnterior fontanel remains open until 18 mosHeight increase by 50% in 1 yearHC > chest circumference until 1 yearHC is measured until 2 y/oTooth eruption begins in 4 – 6 mos

Weaning – is the transition from the bottle or breastfeeding to a cup, typically begun at 8 – 9 mos.

Most infants can bang 2 cubes held in their hands by the time they are...9 months

TODDLER

1 – 3 yearsErickson: Autonomy vs Shame & Doubt IndependenceFreud: Anal – child gratifies by controlling body excretionToilet trainingParallel play

TODDLERPhysiological: BW x 4 in 3 yearsAnterior fontanel closes Sphincter control begins around age 2All deciduous teeth by 2 ½ yearsPot belly appearanceHC = CCBow legs are normal around 2 – 3 yearsAppetite decreases

PRESCHOOL

3 – 6 yearsErickson: Initiative vs GuiltFreud: Genital or PhallicAssociative PlaySense of self esteemLoves school

PRESCHOOL

Physiological:Growth of extremitiescan get dressed by themselves, without any help by 41/2 yearsWeight increases by 4-6 lbs/yearHandedness establishedBody systems matureDay time toilet training completeAll deciduous teeth complete, see dentist.Mental:Can name 1 color by 3 years

SCHOOL AGE

6 – 12 yearsErickson: Industry vs InferiorityFreud: LatencyCompetitive playPrivacy is importantGroup playSame sex friends

SCHOOL AGEPhysiological:

Increased physical strength & capabilitiesSlower physical growthPermanent teeth starts to replace deciduous teethBoys and girls remain close in size

ADOLESCENCE

13 – 18 yearsErickson: Identity vs Role ConfusionFreud: GenitalIndependence from familyPeer groupIntense relationship

Prematurity

Babies that are born before 37

weeks arecalled premature or preterm. They are affectionately

known as “preemies.”

Prematurity

Prematurity• low birth weight (LBW), which means they weigh less

than 2,500 grams (about 5 pounds, 8 ounces).• Very low birth weight (VLBW) describes an infant that

weighs less than 1,500 grams (about 3 pounds, 5 ounces).

• Problems of babies that are born prematurely: low birth weightrespiratory and breathing difficulties and underdeveloped organs and organ systems.death for newborns major cause of both intellectual and physical disabilities

Intellectual and Physical Disabilities

mental retardation or learning difficulties

Cerebral palsy Breathing and respiratory problems,

such as chronic lung disease Vision and hearing loss, and Feeding and digestive problems.

Risk FactorsCarrying more than one baby (twins, triplets,

quadruplets or more).Having a previous preterm birth.Problems with the uterus or cervix. Chronic health problems in the mother, such as

high blood pressure, diabetes, andclotting disorders. Certain infections during pregnancy. Cigarette smoking, alcohol use, or illicit drug use

during pregnancy

COMMON HEALTH PROBLEMS ASSOCIATED WITH PREMATURITY

• Hypothermia. Babies who are born too small and too soon often have trouble controlling their body temperature because they don’t have enough body fat to prevent the loss of heat. This is known as low body temperature or hypothermia.

• Babies in the NICU are placed in an incubator or warmer right after birth to help control their temperature.

• A tiny thermometer taped to the baby’s stomach senses her body temperature and regulates the heat in the incubator. Maintaining a normal body temperature will help the baby grow faster.

COMMON HEALTH PROBLEMS

• Respiratory distress syndrome (RDS): A serious breathing problem that affects mainly

babies born before 34 weeks of pregnancy. type of medication known as corticosteroids is given to these infants to help the lungs mature more quickly.

If a woman is at risk of delivering her baby before 34 weeks, corticosteroids may be given to her to try to prevent the baby from developing RDS. RDS can result from several situations. The first is that the baby’s lungs aren’t fully developed. Sometimes a

COMMON HEALTH PROBLEMS• Apnea. Premature babies sometimes stop

breathing for 20 seconds or more. This• Interruption in breathing is called apnea, and

it may be accompanied by a slow heart rate. Premature babies are constantly monitored for apnea. If the baby stops breathing, a nurse will stimulate the baby to start breathing by patting him or

• touching the soles of his feet

COMMON HEALTH PROBLEMS• Bleeding in the brain (IVH): • Most common in babies born before 32 weeks of• pregnancy. • Bleeding in the brain is called intraventricular hemorrhage (IVH). can cause pressure in the brain and brain damage. The bleeds usually

occur in• the first three days of life and generally are diagnosed with an

ultrasound examination. • Most brain bleeds are mild and resolve themselves with no or few

lasting problems. More severe bleeds can cause the fluid-filled structures

• (ventricles) in the brain to expand rapidly, causing pressure on the brain that can

• lead to brain damage (such as cerebral palsy and learning and behavioral

problems). • In such cases, surgeons may insert a tube into the brain to drain the

fluid and reduce the risk of brain damage. In milder cases, drugs sometimes can reduce fluid buildup. IVH also is associated with a risk for developing cerebral palsy.

COMMON HEALTH PROBLEMS• Patent ductus arteriosus (PDA): • A heart problem that is common in premature babies. • Untreated, it can lead to heart failure. Before birth, a large artery called

the• ductus arteriosus lets the blood bypass the lungs because the fetus gets

its oxygen• through the placenta. The ductus normally closes soon after birth so

that blood can travel to the lungs and pick up oxygen. When the ductus does not close properly, it can lead to heart failure. PDA can be diagnosed with a specialized

• form of ultrasound (echocardiography) or other imaging tests. Babies with PDA

• are treated with a drug that helps close the ductus, although surgery may be

• necessary if the drug does not work.

COMMON HEALTH PROBLEMS

Necrotizing enterocolitis (NEC): • Some premature babies develop this potentially

dangerous intestinal problem usually two to three weeks after birth.

• It can lead to feeding difficulties, abdominal swelling and other complications.

• NEC can be diagnosed with imaging tests, such as X-rays, and blood tests.

• Affected babies are treated with antibiotics and fed intravenously (through a vein) while the bowel heals. In some cases, surgery is necessary to remove damaged sections ofthe intestine.

COMMON HEALTH PROBLEMS

• Retinopathy of prematurity (ROP): An eye problem that occurs mainly in babies born before 31 weeks of pregnancy.

• In severe cases, treatment is needed to help prevent vision loss.

• The smaller a baby is at birth, the more likely that baby is to develop ROP.

• most common causes of visual loss in childhood and can lead to lifelong vision impairment and blindness.

COMMON HEALTH PROBLEMS

• Jaundice. Premature babies are more likely than full-term babies to develop jaundice because their livers are too immature to remove a waste product called bilirubin from the blood

• premature infants may be more sensitive to the ill effects of excess bilirubin.

• Babies with jaundice have a yellowish color to their skin and eyes. Jaundice often is mild and usually is not harmful; however, if the bilirubin level gets too high, it can cause brain damage.

• This generally can be prevented because blood tests show when bilirubin levels are too high, so the baby can be treated with special lights (phototherapy) that help the body eliminate bilirubin. Occasionally, a baby may need a blood transfusion.

COMMON HEALTH PROBLEMS

• Anemia. Premature infants often are anemic, which means they do not have enough red blood cells. Normally, the baby stores iron during the later months of pregnancy and uses it late in pregnancy and after birth to make red blood cells.

• Infants born too soon may not have had enough time to store iron. Babies with anemia tend to develop feeding problems and grow more slowly; anemia also can worsen any heart or breathing problems.

• May be treated with dietary iron supplements, drugs that increase red blood cell production or, in severe cases, blood transfusion

COMMON HEALTH PROBLEMS

• Chronic lung disease (also called bronchopulmonary dysplasia or BPD).

• Chronic lung disease most commonly affects premature infants who require ongoing treatment with supplemental oxygen. The risk of BPD is increased in babies who still need oxygen when they reach 36 weeks after conception (weeksof pregnancy plus weeks after birth adding up to 36 or more weeks). These babies develop fluid in the lungs, scarring and lung damage, which can be seen on an Xray.

• Affected babies are treated with medications that make breathing easier and

• are slowly weaned from the ventilator. Their lungs usually improve over the first

• two years of life. However, many children develop chronic lung disease• resembling asthma.

COMMON HEALTH PROBLEMS

Infections. Premature babies have immature immune systems that are inefficient:

• at fighting off bacteria, viruses and other organisms that can cause infection.

• Serious infections that are commonly seen in premature babies include pneumonia

• (lung infection), sepsis (blood infection) and meningitis (infection of the

• membranes surrounding the brain and spinal cord). Babies can contract these

• infections at birth from their mother, or they may become infected after birth.

• Infections are treated with antibiotics or antiviral drugs.

TREATMENTAntibiotics or antiviral drugs to help treat

infections Blood transfusions to treat anemia or

jaundiceSurfactant and oxygen treatments to help

prevent lung damage Equipment such as monitors and incubators

to help warming and breathing

Non-medical Treatment Physical therapy Occupational therapyRespiratory therapy Speech and language therapy Vision and hearing aids

Postmaturity

• the condition of an infant after a prolonged gestation period.

• A condition in which a pregnancy persists for longer than 42 weeks; the average length of a normal pregnancy is 40 weeks.

• Postmaturity may be associated with a family tendency to prolonged pregnancy, or it may be a sign that the baby is unable to descend properly

Causes unknownComplications

Placenta`s ability to transmit oxygen and nutrients to the fetus may begin to decline.

at birth the baby commonly has a characteristic postterm appearance: wrinkled, cracking, peeling skin; long nails; abundant hair; and little fat tissue beneath the skin.

meconium into the amniotic fluid before delivery-(pneumonia)

Treatment

periodically check the fetal heartbeat until labor starts.

Labor is induced by administering the drug oxytocin (Pitocin).

Fetal monitor is generally used to detect any abnormalities of the fetal heartbeat.

Small for Gestational Age• Small for gestational age

(SGA) is a term used to describe a baby who is smaller than the usual amount for the number of weeks of pregnancy.

• SGA babies usually have birthweights below the 10th percentile for babies of the same gestational age.

Small for Gestational Age

• SGA babies may appear physically and neurologically mature but are smaller than other babies of the same gestational age.

• SGA babies may be proportionately small (equally small all over) or they may be of normal length and size but have lower weight and body mass.

• SGA babies may be premature (born before 37 weeks of pregnancy), full term (37 to 41 weeks), or post term (after 42 weeks of pregnancy).

What causes small for gestational age (SGA)?

• genetics (their parents are small), most SGA babies are small because of fetal growth problems that occur during pregnancy.

• Babies with SGA have a condition called intrauterine growth restriction (IUGR). IUGR occurs when the fetus does not receive the necessary

nutrients and oxygen needed for proper growth and development of organs and tissues.

IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal

abnormalities, maternal disease, or severe problems with the placenta.

Late-onset growth restriction (after 32 weeks) is usually related to other problems.

Factors that may contribute to SGA and/or IUGR

• Maternal factors:high blood pressurechronic kidney diseaseadvanced diabetesheart or respiratory diseasemalnutrition, anemiaInfectionsubstance use (alcohol, drugs)cigarette smoking

Factors involving the uterus and placenta:

• decreased blood flow in the uterus and placenta

• placental abruption (placenta detaches from the uterus)

• placenta previa (placenta attaches low in the uterus)

• infection in the tissues around the fetus

Factors related to the developing baby (fetus):

• multiple gestation (twins, triplets, etc.)

• infection• birth defects• chromosomal

abnormality

Babies with SGA and/or IUGR may have problems at birth:

• decreased oxygen levels

• low Apgar scores (an assessment that helps identify babies with difficulty adapting after delivery)

• meconium aspiration (inhalation of the first stools passed in utero) which can lead to difficulty breathing

• hypoglycemia (low blood sugar)

• difficulty maintaining normal body temperature

• polycythemia (too many red blood cells)

How is small for gestational age (SGA) diagnosed?

• height of the fundus (the top of a mother's uterus) can be measured from the pubic bone.

• SGA babies, especially those with IUGR, appear thin, pale, and with loose, dry skin.

• The umbilical cord is often thin, and dull-looking rather than shiny and fat.

• They sometimes have a wide-eyed look.

Other Diagnostic Procedures

• ultrasoundUltrasound (a test using sound waves to create a picture of internal structures) is a more accurate method of estimating fetal size. Measurements can be taken of the fetus' head and abdomen and compared with a growth chart to estimate fetal weight. The fetal abdominal circumference is a helpful indicator of fetal nutrition.

Other Diagnostic Procedures

• Doppler flowAnother way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound waves to measure blood flow. The sound of moving blood produces wave-forms that reflect the speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow studies.

Other Diagnostic Procedures

• mother's weight gainA mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may correspond with a small baby

• gestational assessmentBabies are weighed within the first few hours after birth. The weight is compared with the baby's gestational age and recorded in the medical record. The birthweight must be compared to the gestational age.

Treatment of babies who are small for gestational age (SGA):

• temperature controlled beds or incubators• tube feedings (if the baby does not have a

strong suck)• checking for hypoglycemia (low blood sugar)

through blood tests• monitoring of oxygen levels• Babies who are SGA and are also premature

may have additional needs including oxygen and mechanical help to breathe.

Specific treatment for SGA will be determined by your baby's physician based on:

• our baby's gestational age, overall health, and medical history

• extent of the condition• baby's tolerance for specific medications,

procedures, or therapies• expectations for the course of the condition• your opinion or preference

Prevention of small for gestational age (SGA):

• Prenatal care is important in all pregnancies, and especially to identify problems with fetal growth.

• Stopping smoking and use of substances such as drugs and alcohol are essential to a healthy pregnancy.

• Eating a healthy diet in pregnancy may also help.

Large for Gestational Age

• Infants are considered large for gestational age (LGA) if their birth weight is greater than the 90th percentile for gestational age.

• Some restrict the definition to greater than the 97th percentile (2 standard deviations above the mean).

• At 40 weeks gestation, LGA infants weigh more than 3800 or 4400 g (90th or 97th percentile, respectively)

SGA&LGA

Causes• Newborns may be large because the parents are

large or because the mother has diabetes.• Large newborns born to mothers with diabetes are

likely to be overweight as adults.• Women who are obese or who have previously had

a large infant are also at risk of having large-for-gestational-age newborns.

• Genetic factors, such as having rare syndromes (for example, Beckwith-Wiedemann syndrome or Sotos' syndrome).

• Cesarean delivery is sometimes necessary.

Sotos syndrome

• is characterized by the cardinal features of typical facial appearance, overgrowth (height and/or head circumference ≥2 SD above the mean), and learning disability ranging from mild (children attend mainstream schools and are likely to be independent as adults) to severe (lifelong care and support are required).

• Sotos syndrome is associated with the major features of behavioral problems, congenital cardiac anomalies, neonatal jaundice, renal anomalies, scoliosis, and seizures.

SOTO`S Syndrome (Cerebral Gigantism)

Symptoms and Complications• Excess amount of red blood cells

(polycythemia: Large-for-gestational-age newborns may have a ruddy complexion because too many red blood cells are produced. As the excess red blood cells are broken down, bilirubin is formed, which, along with poor feeding, results in jaundice.

Symptoms and Complications

• Low blood sugar levels (hypoglycemia): In newborns of mothers with diabetes, the oversupply of glucose from the placenta stops abruptly at delivery when the umbilical cord is cut and the continuing rapid production of insulin by the newborn's pancreas leads to low levels of sugar in the blood (hypoglycemia).

• Often hypoglycemia causes no symptoms.• Sometimes, newborns are listless, limp, or jittery.

Despite their large size, newborns of mothers with diabetes often do not feed well for the first few days.

Symptoms and Complications

• Lung problems: Lung development is delayed in newborns whose mothers have diabetes. When these newborns are delivered by cesarean, they are at risk of developing lung problems.

• Newborns born prematurely are more likely to have immature lungs and to develop respiratory distress syndrome (even when born only a few weeks before full term).

• Increased risk of birth injuries: Newborns who are large for gestational age are at increased risk of birth injuries such as;– stretching of the nerves in the shoulder (brachial plexus

injuries) and collarbone (clavicle) fractures. • Vaginal delivery, especially breech deliveries, may be

difficult when the fetus's head is large in comparison with the mother's pelvic measurements, which increases the risk of birth injury. – Therefore, such a fetus may have to be delivered by

caesarean.

Symptoms and Complications

• Infants whose mother has diabetes also have a higher rate of birth defects than other newborns.

• Large-for-gestational-age newborns born to mothers with diabetes are likely to be significantly overweight later in childhood and as adults, which, along with their genetic predisposition, puts them at risk of developing type 2 diabetes

Treatment• Treat hypoglycemia in newborns, glucose given

by vein (intravenously) or frequent feedings by mouth or by tube into the stomach are often needed.

• Treatment of respiratory distress syndrome may require supplemental oxygen through a tube placed in the nose or intense intervention, such as respiratory support with a ventilator.

• Other complications may also require treatment, such as phototherapy for jaundice.

Respiratory Distress Syndrome

Infant respiratory distress syndrome (IRDS), also called neonatal respiratory distress syndrome or respiratory distress syndrome of newborn, previously called hyaline membrane disease,

a syndrome in premature infants caused by developmental insufficiency of surfactant production and structural immaturity in the lungs.

Respiratory Distress Syndrome

Causes

• Neonatal RDS occurs in infants whose lungs have not yet fully developed.

• The disease is mainly caused by a lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps the air sacs from collapsing.

• Neonatal RDS can also be the result of genetic problems with lung development.

• The earlier a baby is born, the less developed the lungs are and the higher the chance of neonatal RDS.

• Most cases are seen in babies born before 28 weeks. It is very uncommon in infants born full-term (at 40 weeks).

Predisposing Factors

• A brother or sister who had RDS• Diabetes in the mother• Ceasarean delivery• Delivery complications that reduce blood flow to the

baby• Multiple pregnancy (twins or more)• Rapid labor– risk of neonatal RDS may be decreased if the pregnant

mother has chronic, pregnancy-related high blood pressure or prolonged rupture of membranes, because the stress of these situations can cause the infant's lungs to mature sooner.

Symptoms

• Bluish color of the skin and mucus membranes (cyanosis)• Brief stop in breathing (apnea)• Decreased urine output• Grunting• Nasal flaring• Rapid breathing• Shallow breathing• Shortness of breath and grunting sounds while breathing• Unusual breathing movement -- drawing back of the

chest muscles with breathing

Exams and Tests

• blood gas analysis shows low oxygen and excess acid in the body fluids.

• chest x-ray shows the lungs have a characteristic "ground glass" appearance, which often develops 6 to 12 hours after birth.

• Lab tests are done to rule out infection and sepsis as a cause of the respiratory distress.

Treatment

• High-risk and premature infants require prompt attention by a neonatal resuscitation team.

• Delivering artificial surfactant directly to the infant's lungs can be enormously important, but how much should be given and who should receive it and when is still under investigation.

• Infants will be given warm, moist oxygen. This is critically important, but needs to be given carefully to reduce the side effects associated with too much oxygen.

Treatment

• A breathing machine can be lifesaving to the follwing:– High levels of carbon dioxide in the arteries– Low blood oxygen in the arteries– Low blood pH (acidity)– infants with repeated breathing pauses.

• Treatment called continuous positive airway pressure (CPAP) that delivers slightly pressurized air through the nose can help keep the airways open and may prevent the need for a breathing machine for many babies. Even with CPAP, oxygen and pressure will be reduced as soon as possible to prevent side effects associated with excessive oxygen or pressure.

Other treatment• Extracorporeal membrane oxygenation (ECMO) to

directly put oxygen in the blood if a breathing machine can't be used

• Inhaled nitric oxide to improve oxygen levels• careful fluid management and close attention to

other situations, such as infections, if they develop.

• excellent supportive care– Few disturbances– Gentle handling– Maintaining ideal body temperature

Outlook (Prognosis)

• The condition often worsens for 2 to 4 days after birth with slow improvement thereafter. Some infants with severe respiratory distress syndrome will die, although this is rare on the first day of life. If it occurs, it usually happens between days 2 and 7.

• Long-term complications may develop as a result of too much oxygen, high pressures delivered to the lungs, the severity of the condition itself, or periods when the brain or other organs did not receive enough oxygen.

Possible Complications

• Air or gas may build up in:– The space surrounding

the lungs (pneumothorax)– The space in the chest

between two lungs (pneumomediastinum)

– The area between the heart and the thin sac that surrounds the heart (pneumopericardium)

Other complications

• Bleeding into the brain (intraventricular hemorrhage of the newborn)

• Bleeding into the lung (sometimes associated with surfactant use)

• Blood clots due to an umbilical arterial catheter• Bronchopulmonary dysplasia• Delayed mental development and mental

retardation associated with brain damage or bleeding

• Retinopathy of prematurity and blindness

Prevention

• Prenatal Check up• Avoiding unnecessary or poorly timed cesarean

sections can also reduce the risk of RDS.• If a mother does go into labor early, a lab test will be

done to determine the maturity of the infant's lungs. When possible, labor is usually halted until the test shows that the baby's lungs have matured. This decreases the chances of developing RDS.

• corticosteroids may be given to help speed up lung maturity to avoid other complications like

intraventricular hemorrhage, patent ductus arteriosus and necrotizing enterocolitis.

Miconium Aspiration Syndrome• Meconium pneumonitis

(inflammation of the lungs)

• Meconium aspiration syndrome is a serious condition in which a newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery.

Causes

• Stress of not getting enough blood• Decreased oxygen to the infant while in the

uterus• Diabetes in the pregnant mother• Difficult delivery or long labor• High blood pressure in the pregnant mother• Passing the due date

Symptoms

• bluish skin color (cyanosis) in the infant

• Breathing problems– Difficulty breathing (the

infant needs to work hard to breathe)

– No breathing– Rapid breathing

• Limpness in infant at birth

Exams and Tests

fetal monitor may show a slow heart rate.During delivery or at birth meconium can be

seen in the amniotic fluid and on the infant.lowApgar score.abnormal breath sounds, especially coarse,

crackly sounds. blood gas analysis will show low blood pH

(acidic), decreased oxygen, and increased carbon dioxide.

chest x-ray may show patchy or streaky areas in the infant's lungs.

Treatment

suction the newborn's mouth as soon as the head emerges during delivery. if there have been no signs of fetal distress during

pregnancy and the baby is an active full-term newborn, experts do not recommend deep suctioning of the windpipe, because it carries a risk of causing a certain type of pneumonia.

If the baby is not active and crying tube is placed in the infant's trachea and suction is applied as the endotracheal tube is withdrawn.

infant may be placed in the special care nursery or newborn intensive care unit for close observation.

Other Treatment• Antibiotics to treat

infection• Breathing machine

(ventilator) to keep the lungs inflated

• Oxygen to keep blood levels normal

• Radiant warmer to maintain body temperature

Outlook (Prognosis)

• Meconium aspiration syndrome is a leading cause of severe illness and death in newborns.

• In some cases outlook is excellent and there are no long-term health effects.

• in more severe cases, breathing problems may occur. They generally go away in 2 - 4 days. However, rapid breathing may continue for days.

• infant with severe aspiration who needs a breathing machine may have a more guarded outcome, it may lead to brain damage

Possible Complications

• Aspiration pneumonia• Brain damage due to lack of oxygen• Breathing difficulty that lasts for several days• Collapsed lung (pneumothorax)• Persistent pulmonary hypertension of the

newborn (inability to get enough blood into the lungs to take oxygen to the rest of the body)

Prevention

• Risk factors should be identified as early as possible. If the mother's water broke at home, she should tell the health care provider whether the fluid was clear or stained with a greenish or brown substance.

• Fetal monitoring so that any signs of fetal distress can be recognized early.

• Immediate intervention in the delivery room can sometimes help prevent this condition. Health care providers who are trained in newborn resuscitation should be present.

Sepsis (sepsis neonatorum) infection that spreads throughout the baby’s

body. Sepsis occurs in less than 1 percent of newborns (1 out of every 100), but accounts for up to 30 percent of deaths in the first few weeks of life.

Infection is 5-10 times more common in premature newborns and in babies weighing less than 5½ pounds than in normal-weight, full-term newborns.

Causes• Complications

experienced during birth,– such as premature

or prolonged rupture of the membranes

– infection in the mother,

Typical symptoms of a newborn with sepsis

• listlessness (a very sleepy baby)• feeding problems• a high OR low temperature• difficulty breathing, rapid breathing, or apnea

(when the baby stops breathing)• Other symptoms– seizures– excessive jitteriness– repeated vomiting or diarrhea– a swollen abdomen

Diagnosis• White Blood Cell Count and Differential: When an infant is

fighting an infection, their white blood cell count may either go up, as the infant’s body produces more infection-fighting cells, or it might also go down if the infant has used up all of their white blood cells fighting the infection and can no longer keep up with their production of white cells.

• Another change that is seen when an infant is fighting an infection is an increase in the percentage of immature white cells. This is due to the increased production rate of white blood cells, such that more immature white blood cells are being released into the blood stream. This higher percentage of immature white cells is sometimes referred to as a “left-shift,” and is one of the things that can tell the doctors that the infant has an infection.

Diagnosis• C-Reactive Protein (CRP): This is a laboratory

test that measures a protein that is a non-specific marker for inflammation and therefore infection. If the infant has two normal CRP levels measured 24 hours apart, then there is a 99% chance that the infant does not have an infection. Therefore, this test is most useful in ruling out an infection.

Diagnosis• Lumbar Puncture: If the doctor suspects

meningitis, which is more common if something has grown in the baby’s blood culture, a spinal tap, or lumbar puncture will be performed. Lumbar punctures allow the doctor to obtain a small amount of cerebrospinal fluid (CSF), which is the protective fluid that surrounds the brain and the spinal cord. The CSF can then be cultured to determine if the bacteria has spread to the nervous system.

Lumbar Puncture:

Prognosis and Treatment• antibiotics given intravenously. • doctor may then switch to a different antibiotic that is more

specific to the baby’s infection once the results of laboratory tests are back.

• The length of antibiotic treatment varies depending on the infant’s clinical status, laboratory test results, and kind of infection.

• If blood cultures and other laboratory tests are all negative, antibiotics may be stopped after 48 hours of treatment.

• If the infant’s cultures are positive, or if the laboratory tests and clinical status are suggestive of infection, the infant will be treated with antibiotics, usually anywhere from 7-14 days.

• appropriately treated with antibiotics and cared for in the intensive care unit, the great majority of newborns with sepsis live without any long-term problems.

Hyperbilirubinemia• is a yellowing of the skin and other tissues of a

newborn infant. A bilirubin level of more than 85 umol/l (5 mg/dL) manifests clinical jaundice in neonates whereas in adults a level of 34 umol/l (2 mg/dL) would look icteric.

• In newborns jaundice is detected by blanching the skin with digital pressure so that it reveals underlying skin and subcutaneous tissue.

• Jaundice newborns have an apparent icteric sclera, and yellowing of the face, extending down onto the chest.

Signs and Symptoms• Yellowing of the skin• Yellowing of the eyes• An easy way to test for infant jaundice in

a baby of any race is to gently press your finger on the baby`s forehead or nose.

Hyperbilirubinemia

It can be physiologic (appears on 2nd day or 3rd day of life) or pathologic ( resulting from underlying disease.Also called as infant jaundice.

Physiological jaundice

• Infants develop visible jaundice due to elevation of unconjugated bilirubin concentration during their first week.

• Phase one– Term infants - jaundice lasts for about 10 days with a rapid rise

of serum bilirubin up to 204 umol/l (12 mg/dL).– Preterm infants - jaundice lasts for about two weeks, with a

rapid rise of serum bilirubin up to 255 umol/l (15 mg/dL).• Phase two - bilirubin levels decline to about 34 umol/l

(2 mg/dL) for two weeks, eventually mimicking adult values.– Preterm infants - phase two can last more than one month.– Exclusively breastfed infants - phase two can last more than

one month.

Causes

1. Increase bilirubin load on liver cells:– Increased red blood cell (RBC) volume– Increased labeled bilirubin– Increased circulation of bilirubin in the liver– Decreased RBC survival

2. Defective hepatic uptake of bilirubin from blood plasma:– Decreased ligadin (Y protein)– Increased binding of Y proteins by other anions– Decreased liver uptake especially in phase two

Causes

3. Defective billirubin conjugation:– Decreased UDPG

activity

4. Defective bilirubin excretion

Conjugated• Hepatic causes

Infections• Sepsis• Hepatitis B• TORCH infections

Metabolic• Galactosemia• Alpha-1-antitrypsin deficiency• Cystic fibrosis

Hepatic causes

DrugsTotal parenteral nutritionIdiopathic• Post-hepaticBiliary atresia or Bile duct obstructionAlagille syndrome-genetic

disorder that affects the liver, heart, kidney, and other systems of the body.

Pathological Jaundice of Neonates

(Unconjugated Pathological Hyperbilirubinemia)• Clinical jaundice appearing in the first 24

hours.• Increases in the level of total bilirubin by more

than 8.5 umol/l (0.5 mg/dL) per hour or (85 umol/l) 5 mg/dL per 24 hours.

• Total bilirubin more than 331.5 umol/l (19.5 mg/dL) (hyperbilirubinemia).

• Direct bilirubin more than 34 umol/l (2.0 mg/dL).

Hemolytic

• Intrinsic causes of hemolysis Membrane conditions

– Spherocytosis– Hereditary ellipsoidosis

Systemic conditions– Sepsis– Arteriovenous malformation

Enzyme conditions– Glucose-6-phosphate dehydrogenase deficiency (also called

G6PD deficiency)– Pyruvate kinase deficiency

Globin synthesis defect– sickle cell disease– Alpha-thalassemia

Extrinsic causes of hemolysis

• Alloimmunity (The neonatal or cord blood gives a positive direct Coombs test and the maternal blood gives a positive indirect Coombs test)– Hemolytic disease of the newborn (ABO)– Rh disease– Hemolytic disease of the newborn (anti-Kell)– Hemolytic disease of the newborn (anti-Rhc)– Other blood type mismatches causing hemolytic

disease of the newborn– Breast milk feeding.

Non-hemolytic causes

• Cephalohematoma• Polycythemia• Sepsis• Hypothyroidism• Gilbert's syndrome• Crigler-Najjar syndrome

CAUSES• If present at birth or appears in 24 hours– Severe bruising– An infection in the baby`s blood (sepsis)– Rh IncompatibilityIf develops in or last past the second week of life– Liver malfunction– Severe infection– Enzyme deficiency– Abnormality in baby`s RBC

Screening and Diagnosis

• Risk assessment• Follow up visit with the baby`s doctor 3-5 days

after your baby is born• Measure the bilirubin level

Signs and Symptoms(severe jaundice)

• Deep yellow or orange skin tone• Extreme sleepiness• High pitched cry• Poor sucking• Weakness or limpness

COMPLICATIONS

• Kernicterus ( hyperbilirubinemia)–Damage to newborn`s brain–Deafness–Severe developmental disabilities–Unusual form of cerebral palsy

TREATMENT

• Phototherapy• IV Immunoglobulin

(IVIg)• Exchange blood

transfusion

Phototherapy

SIDS

Sudden infant death syndrome (SIDS)

• Unexpected death of an apparently healthy infant under 1 year of age for which a thorough autopsy fails to demostrate an adequate cause of death

• Cause is unknown

Risk Factor• Maternal risk factor– Smoking– Substance abuse– Younger mother

• Birth risk factor– Prematurity– Low birth weight– Multiple birth– Infant with CNS problems

SIDS Risk Factor

• Time of year-most frequently winter months• Age- occurs most frequently from 2-4

months of life• Sex and race– Higher in male– Higher in native americans and blacks

• Sleep risk habit– Prone position– Use of soft bedding– Overheating– Possibly sleeping with an adult

prevention• Healthy infants should be placed in the

supine position for sleep• Infant with GERD or other airway anomalies

that predispose to airway obstruction may be placed in a prone sleeping position

• Soft moldable mattress and bedding such as pillows or quilts should not be used under the infant for bedding

• Stuff animals should be removed from the crib while the infant is sleeping

TRISOMY 13• also called Patau syndrome, is a chromosomal

condition associated with severe intellectual disability and physical abnormalities in many parts of the body.

• Most cases of Patau's syndrome result from Trisomy 13, which means each cell in the body has three copies of chromosome 13 instead of the usual two copies.

• cases occur when only some of the body's cells have an extra copy, resulting in a mixed population of cells with a differing number of chromosomes; such cases are called mosaic Patau.

Individuals with trisomy 13 often have

– heart defects, brain or spinal cord abnormalities,– very small or poorly developed eyes

(microphthalmia), extra fingers and/or toes, an opening in the lip (a cleft lip) with or without an opening in the roof of the mouth (a cleft palate)

– weak muscle tone (hypotonia). – Due to the presence of several life-threatening

medical problems, many infants with trisomy 13 die within their first days or weeks of life. Only five percent to 10 percent of children with this condition live past their first year.

Causes

• part of chromosome 13 becomes attached to another chromosome (translocated) before or at conception.Affected people have two copies of chromosome

13, plus extra material from chromosome 13 attached to another chromosome. With a translocation, the person has a partial trisomy for chromosome 13 and often the physical signs of the syndrome differ from the typical Patau syndrome.

causes• Most cases of Patau syndrome are not

inherited, but occur as random events during the formation of reproductive cells (eggs and sperm).An error in cell division called non-disjunction can

result in reproductive cells with an abnormal number of chromosomes.

an eggor sperm cell may gain an extra copy of the chromosome. If one of these atypical reproductive cells contributes to the genetic makeup of a child, the child will have an extra chromosome 13 in each of the body's cells.

Manifestations and physical findings

• Nervous system– Mental and motor challenged– Microcephaly– Holoprosencephaly (failure of the forebrain to divide

properly).– Structural eye defects,

including microphthalmia, Peters anomaly (a type of eye abnormality), cataract, iris and/or fundus (coloboma, retinal dysplasia or retinal detachment sensory nystagmus, cortical visual loss, and optic nerve hypoplasia

– Meningomyelocele(a spinal defect)

Manifestations and physical findings• Musculoskeletal and cutaneous– Polydactyly(extra digits)– Low-set ears– Prominent heel– Deformed feet known as rocker-bottom feet– Omphalocele(abdominal defect)– Abnormal palm pattern– Overlapping of fingers over thumb– Cutis aplasia (missing portion of the skin/hair)– Cleft palate

Manifestations and physical findings• Urogenital– Abnormal genitalia– Kidney defects

• Other– Heart

defects (ventricular septal defect)

– Single umbilical artery

TRISOMY 18• (also known as Trisomy E or Edwards

syndrome) is a genetic disorder caused by the presence of all or part of an extra 18th chromosome. It is named after John H. Edwards, who first described the syndrome in 1960.

• It is the second most common autosomal trisomy, after Down Syndrome, that carries to term.

TRISOMY 18

CAUSES• Trisomy 18 is caused by the presence of three – as

opposed to two – copies of chromosome 18 in a fetus' or infant's cells.

• Edwards' syndrome occurs in around one in 6,000 live births and around 80 per cent of those affected are female.

• The majority of fetuses with the syndrome die before birth.

• The incidence increases as the mother's age increases. • The syndrome has a very low rate of survival, resulting

from heart abnormalities, kidney malformations, and other internal organ disorders.

CHARACTERISTICS• kidney malformations, structural heart defects

at birth (i.e., ventricular septal defect, atrial septal defect, patent ductus arteriosus)

• intestines protruding outside the body (omphalocele),esophageal atresia

• mental retardation, developmental delays, growth deficiency,

• feeding difficulties, breathing difficulties, and arthrogryposis (a muscle disorder that causes multiple joint contractures at birth).

Signs and symptoms

• small head (microcephaly) accompanied by a prominent back portion of the head (occiput); low-set, malformed ears

• abnormally small jaw (micrognathia); cleft lip/cleft palate; • upturned nose; narrow eyelid folds (palpebral fissures);

widely spaced eyes (ocular hypertelorism); drooping of the upper eyelids (ptosis);

• a short breast bone; clenched hands; choroid plexus cysts; underdeveloped thumbs and or nails, absent radius, webbing of the second and third toes; clubfoot or Rocker bottom feet; and in males, undescended testicles.

CRI DU CHAT SYNDROME• Cri du chat syndrome, also known as chromosome

5p deletion syndrome, 5p minus syndrome or Lejeune’s syndrome, is a rare genetic disorder due to a missing part ofchromosome 5.

• Its name is a French term (cat-cry or call of the cat) referring to the characteristic cat-like cry of affected children.

• It was first described by Jérôme Lejeune in 1963. The condition affects an estimated 1 in 50,000 live births, strikes all ethnicities, and is more common in females by a 4:3 ratio

CRI DU CHAT SYNDROME

Signs and symptoms

• feeding problems because of difficulty swallowing and sucking.

• low birth weight and poor growth.• severe cognitive, speech, and motor delays.• behavioral problems such as hyperactivity,

aggression, tantrums, and repetitive movements.• unusual facial features which may change over

time.• excessive drooling.• constipation.

DIAGNOSIS AND TREATMENT• Diagnosis is based on the

distinctive cry and accompanying physical problems. Genetic counseling and genetic testing

• Can be detected from amniotic fluid or chorionic villi samples with BACs-on-Beads technology

• speech, sound, and occupational therapists. Cardiac abnormalities often require surgical correction.

TURNER`S SYNDROME• Turner syndrome or Ullrich-Turner syndrome (also known

as "Gonadal dysgenesis") encompasses several conditions in human females, of which monosomy X (absence of an entire sex chromosome, the Barr body) is most common.

• It is a chromosomal abnormality in which all or part of one of the sex chromosomes is absent (unaffected humans have 46 chromosomes, of which two are sex chromosomes).

• Normal females have two X chromosomes, but in Turner syndrome, one of those sex chromosomes is missing or has other abnormalities.

• In some cases, the chromosome is missing in some cells but not others, a condition referred to asmosaicism or 'Turner mosaicism

Signs and symptoms

• Short stature• Lymphedema (swelling) of the hands and feet• Broad chest (shield chest) and widely spaced nipples• Low hairline• Low-set ears• Reproductive sterility• Rudimentary ovaries gonadal streak (underdeveloped gonadal

structures that later become fibrosed)• Amenorrhoea, or the absence of a menstrual period• Increased weight, obesity• Shield shaped thorax of heart• Shortened metacarpal IV• Small fingernails

Signs and symptoms

• Characteristic facial features• Webbed neck from cystic hygroma in infancy• Coarctation of the aorta• Bicuspid aortic valve• Poor breast development• Horseshoe kidney• Visual impairments sclera, cornea, glaucoma, etc.• Ear infections and hearing loss• High waist-to-hip ratio (the hips are not much

bigger than the waist)

Signs and symptoms

• Attention Deficit/Hyperactivity Disorder or ADHD (problems with concentration, memory, attention with hyperactivity seen mostly in childhood and adolescense)

• Nonverbal Learning Disability (problems with math, social skills and spatial relations)

• Small lower jaw (micrognathia), cubitus valgus (turned-in elbows),

• soft upturned nails, palmar crease, and drooping eyelids. Less common are pigmented moles, hearing loss, and a high-arch palate (narrow maxilla).

CAUSES• Risk factors for Turner syndrome are not well known. • Genetic mosaicism (46XX/45XO) is most often implicated,

alongside nondisjunction(45XO) and partial monosomy (46XX).

• Nondisjunctions increase with maternal age, such as for Down syndrome, but that effect is not clear for Turner syndrome.

• It is also unknown if there is a genetic predisposition present that causes the abnormality, though most researchers and doctors treating Turners women agree that this is highly unlikely.

• In 75% of cases inactivated X chromosome is paternal origin. There is currently no known cause for Turner syndrome,

TURNER`S SYNDROME

KLINEFELTER`S SYNDROME

• Klinefelter syndrome, 46/47, XXY, or XXY syndrome is a condition in which human males have an extra X chromosome. While females have an XX chromosomal makeup, and males an XY, affected individuals have at least two X chromosomes and at least one Y chromosome.

• Because of the extra chromosome, individuals with the condition are usually referred to as "XXY Males", or "47, XXY Males".[2]

Klinefelter syndrome

• is the most common sex chromosome disorder in males and the second most common condition caused by the presence of extra chromosomes.

• The condition exists in roughly 1 out of every 500-650 males but many of these people may not show symptoms.

• Other mammals also have the XXY syndrome, including mice

Klinefelter syndrome• Principal effects

include:– hypogonadism and

reduced fertility. – A variety of other

physical and behavioural differences and problems are common,

– severity varies and many boys and men with the condition have few detectable symptoms.

FRAGILE X SYNDROME• Fragile X syndrome (FXS), Martin–Bell

syndrome, or Escalante's syndrome (more commonly used in South American countries), is a genetic syndrome that is the most commonly known single-gene cause of autism and the most common inherited cause of intellectual disability.

• It results in a spectrum of characteristic physical and intellectual limitations and emotional and behavioral features which range from severe to mild in manifestation.

Signs and symptoms

• Intellectual disability, • prominent characteristics of the syndrome include an

elongated face, large or protruding ears, flat feet, larger testes (macroorchidism), and low muscle tone.

• Speech may include cluttered speech or nervous speech.

• Behavioral characteristics may include stereotypic movements (e.g., hand-flapping) and atypical social development, particularly shyness, limited eye contact, memory problems, and difficulty with face encoding.

FRAGILE X SYNDROME• Individuals with the fragile

X syndrome also meet the diagnostic criteria for autism.

• Most females who have the syndrome experience symptoms to a lesser degree because of their second X-chromosome; however, they can develop symptoms just as severe as their male counterparts

Mental Retardation• Sub-average general intellectual functioning

along with deficit in adaptation in behavior with onset before the age of 18.

• Down syndrome is a congenital condition that results in a moderate to severe retardation and it has been linked to an extra group G chromosomes, chromosome 21 ( trisomy 21).

Assessment

• Deficit in cognitive skills and level of adaptive functioning.

• Delays in fine and gross motor skills• Speech delays• Decrease spontaneous activity• Nonresponsive• Irritability• Poor eye contact during feeding

TRISOMY 21• Mental retardation

• Mental retardation

Management

• Medical strategies are focused at correcting structural deformities and treating associated behaviors.

• Implement community and educational services using a multidisciplinary approach.

• Promote care skills as much as possible• Assist with communication and socialization skills• Facilitate appropriate playtime

TRISOMY 21

• Initiate safety precautions as necessary.

• Assist the family with decisions regarding care.

• Provide information regarding support services and community agencies.