PEDIATRICS CH 31: Infant & Family

How should solid foods be introduced?

(4-6 months) One at a time; one food item should be introduced at intervals of 4-7 days to allow for identifications of food allergies

Who are individuals at risk for ALTE?

-Gastroesophageal reflux -Respiratory infections -Seizures -UTIs

What are risk factors for SIDS?

-Maternal smoking during pregnancy -Exposure to tobacco smoke -Co-sleeping -Use of pillow in infant bed -Soft bedding -loose bedding -prone position

What is "organic" failure to thrive?

-Medical condition -GI reflux, cystic fibrosis

What are benefits of pacifier use?

-Non-nutritive sucking: makes them more comfortable -Managing pain: Pacifier in combination with concentrated sucrose

Diagnostic evaluation for plagiocephaly

-Physical examination of the head (view frontal & above)

Nursing Management for SIDS

-Preventable so educate -Allow parents to verbalize; listen & validate feelings

What are common causes of death in infancy?

-SIDS -Suffocation* -MVAs* -Drowning*

What are blood pressure changes seen in infancy? (what happens to systolic & diastolic? why will it fluctuate?)

-Systolic pressure rises during first 2 months as a result of increasing ability of left ventricle to pump blood into the systemic circulation -Diastolic decreases during 1st 3 months then gradually rises to values close to those at birth -Blood pressure will fluctuate with activity & emotions

If infants are exclusively breast fed what are recommendations to follow?

-Take vitamin D & iron supplements (these are already in formula, so why it's used for infants exclusively breastfed)

Infants at risk for SIDS include:

-Those born prematurely (LBW) -Low APGAR scores, recent viral illness -Infant with siblings who have died of SIDS) -Infants of adolescent mothers -Male sex -Infants of Native-American & African-American ethnicity

What are potential causes of colic?

-Too rapid feeding -Overeating -Swallowing excessive air -Poor feeding technique -Infants with cow's milk allergy symptoms have a high rate of colic -maternal smoking -inadequate parent-infant interaction -lactase deficiency -difficult infant temperment -fecal microflora -abnormal GI motility

What are clinical findings of SIDS that are Important to note?

-Typically, the infant is found with blankets over the head and hands clutching the sheets -Frothy, blood tinged fluid fills the infants mouth & nostrils -Infant may be lying in secretions and the diaper filled with urine & stool

Manifestations of FTT:

-Weight below 5th percentile -May be hypotonic & weak -Have issues with sleeping

What are the four goals in nutritional management for FTT

1) Correct nutritional deficit (determine cause) 2) Play catch up with calories (give formula with more calories) 3) Restore body composition (see that they're gaining weight) 4) Education (

What are the stages of separation anxiety? Describe them

1) Protest: Will cry, scream 2) Despair: Might refuse to eat & withdraw 3) Detachment: Interact with strangers, parents have been gone for awhile & now they want to interact with others

When does separation anxiety usually begin?

4-8 months (this is predictable)

Apnea of infancy has been diagnosed in an infant who will soon be discharged with home monitoring. When teaching the parents about the infant's care, what is the most important information the nurse should include in the discharge teaching plan? Cardiopulmonary resuscitation (CPR) Administration of intravenous (IV) fluids Reassurance that the infant cannot be electrocuted during monitoring Advice that the infant not be left with other caretakers such as baby-sitters

A

The mother of a 3-month-old breastfed infant asks about giving her baby water since it is summer and very warm. The nurse should recommend that: fluids in addition to breast milk are not needed. water should be given if the infant seems to nurse longer than usual. water once or twice a day will make up for losses caused by environmental temperature. clear juices would be better than water to promote adequate fluid intake.

A

^ When will you start to be concerned about possible anemia?

3-6 months is when physiological anemia will present because maternal iron stores present for the first 5-6 months gradually diminish which accounts for lower hemoglobin levels by end of 6 months

How sleep patterns differ from breastfed infants and bottle-fed infants?

Breastfed infants usually sleep for shorter periods with more frequent waking, especially during the night compared with bottle-fed infants -Important to establish bed-time routine

At what age would the nurse advise parents to expect their infant to be able to say "mama" and "dada" with meaning? 4 months 6 months 10 months 14 months

C

The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. The nurse should recognize that: this assessment is normal. the child is probably cognitively impaired. developmental/neurologic evaluation is needed. the parent needs to work with the infant to stop head lag.

C A 6-month-old infant should have social interaction beyond smiling and cooing. The child requires evaluation. The head lag should be almost gone by 4 months of age. This child requires evaluation. The child requires evaluation before interventions can be determined.

When can solid foods be introduced?

Around 4-6 months (MUST HAVE VOLUNTARY CONTROL OF THEIR HEAD & TRUNK)

Sara is a formula-fed, 1-month-old infant who weighed 7 lb, 2 oz at birth. She is gaining weight well and appears healthy. Sara's mother looks exhausted and states she is concerned and frustrated and feels like she is not a good mother. Sara's mother discusses that the baby begins to cry early in the evening and continues to cry for hours. The crying started about a week ago. Sara's mother is worried there is something wrong with the baby; nothing she does seems to help. The nurse recognizes this description of paroxysmal abdominal pain. Which of the following is the most appropriate response to the mother's concerns? A. Tell her to ignore the crying for as long as possible before picking the baby up. B. Provide support to the parents. Stress that despite the crying and obvious pain, the infant is doing well. C. Encourage the mother to be more responsive to the child in order to prevent the crying episodes. D. Change the child's formula to a soy-based product.

B

A 4-month-old infant is brought to the clinic by his parents for a well-baby checkup. What should the nurse include at this time concerning injury prevention? "Never shake baby powder directly on your infant because it can be aspirated into his lungs." "Do not permit your child to chew paint from window ledges because he might absorb too much lead." "When your baby learns to roll over, you must supervise him whenever he is on a surface from which he might fall." "Keep doors of appliances closed at all times."

C This is appropriate guidance for a first-month appointment. This information should be included at the 9-month visit when the infant is beginning to crawl and pull to a stand. Rolling over from abdomen to back occurs between 4 and 7 months. This is the appropriate anticipatory guidance for this age. This information should be included at the 9-month visit when the infant is beginning to crawl and pull to a stand.

Mixed

Combination of both

Treatment of ALTE

Depends on underlying condition For apnea: -Continuous home monitoring of cardiorespiratory rhythms -Methylxanthines (respiratory stimulant drugs i.e. caffiene) -General guideline for discontinuing home monitoring when infant has gone 2-3 months without significant number of episodes requiring intervention

What does diagnosis of ALTE entail?

Detailed description of event: -Who witnessed? -Where was the infant? -Was any activities involved? (feeding, riding in a car, other children around)

Because the digestive process is immature at birth infants are vulnerable to _________

Diarrhea

Why is it important that parents should be educated that thumb-sucking is normal & is infant's chief pleasure?

Problems can arise when parents are overly concerned about the sucking of the fingers, thumb or pacifier and attempt to restrain this natural tendency. Before giving advice, nurses should investigate the parents' feelings and base guidance on this info *NO NEED TO RESTRICT THIS -Doing this after 4-6 years of age can cause dental damage

Pacifier use has been associated with increased risk for otitis media

Recommended that parents reduce pacifier usage in second 6 months of life

What is the heart rate rhythm often seen in infants?

Sinus dysrhythmia/arrythmia because of increase in HR with inspiration and decrease with expiration

What kind of play to infants engage in?

Solitary play

The nurse should provide further teaching about sudden infant death syndrome (SIDS) prevention when hearing the mother of an 8-week-old make which statement? Select all that apply. "I only smoke in the kitchen." "I put my baby to sleep on her back." "I have my baby sleep with me instead of alone in the crib." "I make sure my baby wears a flannel sleeper and has two blankets to keep warm in her crib." "I always leave my baby's favorite stuffed bunny rabbit in the crib to keep her from crying at night."

Everything but B Maternal smoking increases the risk of SIDS. Smoking anywhere in the home with an infant present is not recommended. The "Back to Sleep" Campaign is given credit for reducing the rate of SIDS in the United States. Co-sleeping increases the risk of SIDS. D. Overheating increases the risk of SIDS. Leaving a stuffed animal in the crib is a suffocation risk but still needs to be addressed as a safety hazard.

Nutrition: What should be provided for nutrition for first year? When can they have whole milk? *KNOW THIS

First year: Breask milk/iron fortified formula WHOLE MILK OVER 12 months (can lead to iron-deficiency anemia if given before 12 months)

What is fluoride? When should it be introduced?

Fluoride is an essential mineral for building caries-resistant teeth -It is needed beginning at 6 months if water supply does not contain fluoride (6 months to 3 years: take 0.25 mg of fluoride daily; dose has been decreased due to cases of excessive fluoride ingestion) -If using bottle water use low fluoride or fluoride free

When does stranger fear begin?

Follows separation anxiety, they can begin to discriminate between who is familiar and who is not (ex: doctors walk into the room & they immediately scared even before they haven't touched them yet)

Where are large quantities of IGA found?

In colostrum (push for breast milk b/c colostrum helps protect GI tract & helps b/c they are prone to diarrhea)

Management of plagiocephaly

Initially exercise to loosen the tight muscles and switching head position sides during feeding, carrying and sleep

When should shoes be worn?

Only for protection (don't really need them)

What is colic? When does it usually happen?

Paroxysmal abdominal pain manifested by loud crying & drawing the legs up to the abdomen -More common in infants younger than 3 months of age

What are age-appropriate toys for infants?

Pat-a-cake, rattles, nestling toys, reading books, bright-colored toys, blocks (enjoy colors & lights like colorful mobiles)

Positional plagiocephaly

The sutures in the infants head are not closed, the skull is pliable and when placed in supine position for sleep over time the posterior occiput flattens -Don't forget tummy time when awake To fix: REPOSITION frequently -the sternocleidomastoid muscle may tighten

What are effective forms of discipline for this age group?

Time-outs (keep in mind the place for time outs appropriate for age; ex: play yard is better for most infants than a chair) -Although parents may be concerned with instituting discipline during infancy, it is important to stress that the earlier effective disciplinary methods are employed, the easier it is to continue these approaches

TRUE OR FALSE: Auditory acuity is at adult levels during infancy & visual acuity begins to improve

TRUE

Immunologic system: TRUE OR FALSE: They are protected by mom for approximately 3 months

TRUE; maternal IgG for approximately 3 months (why breastfeeding so highly encouraged) (overall immunologic system is immature)

TRUE OR FALSE: Infants are at increased risk for respiratory illness

TRUE; trachea & bronchi close together so they have a smaller respiratory system (think increased risk for respiratory illness just because of their anatomy)

Because renal structures are immature the infant can be predisposed to

dehydration (output less than 0.5 mL/kg/hr after 48 hours of age is considered oliguria)

When evaluating a child for FTT be sure to observe the

parent child interaction (is it a bonding issue?)

The nurse educator instructs a nursing student that according to Erikson, infancy is concerned with acquiring a sense of: trust. industry. initiative. separation.

A

What is an ALTE (apparent life-threatening event)?

A sudden even that frightens the observer in which the infant exhibits a combination of apnea, change in color (pallor, cyanosis, redness), muscle tone changes (usually hypotonia) & choking, gagging or coughing that usually requires significant intervention & even CPR. Note that apnea does not always have to occur (can also be called brue (brief resolved unexpected event) ex: mom will say they were eating & all of a sudden started coughing & turned blue, or they were fine sleeping & just woke up & started coughing

For children who are crawling what would you educate parents on to prevent injury?

Anchor furniture so that they don't fall over onto child

A parent of an 8-month-old infant tells the nurse that the baby cries and screams whenever he or she is left with the grandparents. The nurse's reply should be based on knowledge that: the infant is most likely spoiled. this is a normal reaction for this age. this is an abnormal reaction for this age. grandparents are not responsive to that infant.

B

The parents of a 5-month-old girl complain to the nurse that they are exhausted because she still wakes up as often as every 1 to 2 hours during the night. When she awakens, they change her diaper, and her mother nurses her back to sleep. What should the nurse suggest to help them deal with this problem? Putting her in parents' bed to cuddle Beginning to put her to bed while still awake Letting her cry herself back to sleep Giving her a bottle of formula instead of breastfeeding her so often at night

B The nurse needs to discuss the issue of co-sleeping with parents. Having the infant in bed with them may still interfere with their sleep. Parents need to develop bedtime rituals that involve putting the child in bed when awake. If the child is put in bed awake, she will be able to return to sleep more easily if she awakens at night. Providing formula at night contributes to bottle-mouth caries.

Why are we not as concerned about anemia during first 5 months?

Because fetal hemoglobin is present for first 5 months

When should oral examination begin?

By 6 months of age

How many teeth will they have by end of first year? What are the first teeth to come through? When do they come through?

By end of 1st year: 6-8 teeth 1st teeth: lower central incisors at 6-10 months (average 8 months) (age in months -6 = number of teeth)

Which strategy might be recommended for an infant with failure-to-thrive to increase caloric intake? Using developmental stimulation by a specialist during feedings Avoiding solids until after the bottle is well accepted Being persistent through 10 to 15 minutes of food refusal Varying schedule of routine activities on a daily basis

C Feeding times should have a nonstimulating environment so the focus is on the meal. Solids should be introduced slowly to decrease dependence on the bottle. Calm perseverance is important. Parents often fail to persist through the child's refusals. Daily schedule should be structured to provide consistency for the child.

What happens to respiratory rate?

In infancy the respiratory rate slows somewhat and is relatively stable (newborn 35, 1-11 months 30) *as they grow it slows

What is a major cause of death in infancy, especially 6-12 months?

Injuries

What may be present during teething?

Low-grade fever, biting on things

What is an important thing to remember before you introduce a pacifier to an infant in the hospital?

Sometimes families don't want to introduce or use pacifiers so check with them & make sure it's been introduced before you give it

TRUE OR FALSE: Infants require no additional water

TRUE; giving infants water will decrease their sodium & can lead to seizures

Nursing interventions for diaper dermatitis include

altering three factors that produce dermatitis: wetness, pH and fecal irritants

What is the most immature GI organ?

The liver -ability to conjugate bilirubin & secrete bile is achieved after first couple weeks of life -Why you can see bilirubin levels increasing when they're younger

In infancy does the heart slow as they age?

Yes (just like respiratory)

Because of the back to sleep movement to prevent SIDS, _______ is now occurring more

plagiocephaly

What is failure to thrive? When are most children diagnosed?

Chronic potentially life-threatening condition characterized by failure to maintain weight and height above the 5th percentile on growth charts. -Before the age of 2

Management of Colic

-Change the formula -Mylicon (Simethicone) aka gas drops

What is "nonorganic" failure to thrive?

-Caused by many factors: -Don't bond well with mother -Poverty (they only have select amount of formula to give them) -Lack of support

Dental: What should be avoided to prevent the formation of dental caries?

-Avoid propping the bottle, giving milk bottle in bed, or giving fruit juices in a bottle (baby bottle tooth decay/early childhood caries)

Thermoregulation in infancy

-Becomes more efficient & the ability of the skin to contract and of muscles to shiver in response to cold increases (vasocontriction occurs conserving core body temp) -Increased adipose tissue during 1st 6 months insulates the body against heat loss (most heat lost through head= put hat on & swaddle them)

A mother is bringing her 4-month-old infant into the clinic for a routine well-baby check. The mother is exclusively breastfeeding. There are no other liquids given to the infant. What vitamin does the nurse anticipate the provider will prescribe for this infant? Vitamin B Vitamin D Vitamin C Vitamin K

ANSWER: B The American Academy of Pediatrics recommends that infants who are exclusively breastfed receive 200 IU of vitamin D daily by age 2 months to decrease vitamin D deficiency. Vitamin B is not needed. Vitamin C is not needed. Vitamin K is not needed.

The exhausted parents of a 2-month-old infant with colic ask the nurse what is the best method to promote comfort and sleep for the infant. The nurse's initial action is to: advise the mother to follow a milk-free diet for 3 to 5 days. take a thorough, detailed history of usual daily events. administer simethicone drops to provide relief from gas pains. explain that the parents need to stay calm so the infant will remain calm.

ANSWER: B The initial step in managing colic is to take a thorough, detailed history of the usual daily events including: diet, time of day when child cries, presence of family members, type of cry, etc. Before suggesting formula changes or medications to relieve symptoms, a detailed history is needed. It is important that the nurse convey an empathetic and compassionate attitude and reassure the parents that they are not doing anything wrong.

Infants most at risk for sudden infant death syndrome (SIDS) are those: Select all that apply. who sleep supine who sleep prone who were premature with prenatal drug exposure with a cousin that died of SIDS

ANSWER: B, C, D Infants at increased risk for SIDS are low birth weight, have low Apgar scores, sleep prone, cosleep, were premature, and have a mother who smokes. It is recommended that infants sleep supine to reduce the risk of SIDS. A cousin dying of SIDS does not present an increased risk for the infant.

Respiratory movement is ______ in infancy

Abdominal

The nurse is providing education to a parent of a 10-month-old infant receiving iron supplements. What will be included in the teaching? Select all that apply. Administer iron with meals. Place iron toward the back side of the mouth with a dropper. Mix iron with milk for greater absorption. Report black, tarry stools to health care provider. Apply barrier ointment if needed to buttocks.

B, D Administration of Iron Supplements includes:Ideally iron supplements should be administered between meals for greater absorption.Liquid iron supplements may stain the teeth, therefore administer with a dropper. toward the back of the mouth (side). In older children, administer liquid iron. supplements through a straw or rinse mouth thoroughly after ingestion.Avoid administration of liquid iron supplements with whole cow's milk or milk. products as these bind free iron and prevent absorption.Educate parents that iron supplements will turn stools black or tarry green.Iron supplements may cause transient constipation. Caution parents not to switch to a low-iron containing formula or whole milk, which are poor sources of iron and may lead to iron deficiency anemia (see Iron Deficiency Anemia, Chapter 43).In older children, follow liquid iron supplement with a citrus fruit or juice drink (no more than 3 to 4 oz).Avoid administration of iron supplements with food or drinks that bind iron and prevent absorption.

A 3-month-old bottle-fed infant is allergic to cow's milk. The nurse's BEST option for a substitute is: goat's milk. soy-based formula. skim milk diluted with water. casein hydrolysate milk formula.

D

A 9-month-old infant is seen in the emergency department after developing a urticaric rash with cough and wheezing. When collecting the history of events before the sudden onset of the rash with cough and wheezing, the mother states they were "feeding the baby new foods." Which food is the possible cause of this type of reaction in the infant? Potatoes Green beans Spinach Peanut butter

D

A nurse is caring for a 2-month-old exclusively breastfed infant with an admitting diagnosis of colic. Based on the nurse's knowledge of breastfed infants, what type of stool is expected? Dark brown and small hard pebbles Loose with green mucus streaks Formed and with white mucus Semiformed, seedy, yellow

D

The nurse expects which characteristic of fine motor skills in a 5-month-old infant? Strong grasp reflex Neat pincer grasp Able to build a tower of two cubes Able to grasp object voluntarily

D

The nurse is interviewing the parents of a 4-month-old male infant brought to the hospital emergency department. The infant is dead on arrival, and no attempt at resuscitation is made. The parents state that the baby was found in his crib with a blanket over his head, lying face down in bloody fluid from his nose and mouth. They say he was "just fine" when they put him in his crib already asleep. The nurse should suspect his death was caused by: suffocation. child abuse. infantile apnea. sudden infant death syndrome (SIDS).

D

The parents of a 9-month-old infant tell the nurse that they are worried about their baby's thumb-sucking. What is the nurse's BEST reply? A pacifier should be substituted for the thumb. Thumb-sucking should be discouraged by age 12 months. Thumb-sucking should be discouraged when the teeth begin to erupt. There is no need to restrain nonnutritive sucking during infancy.

D

The parent of a 12-month-old infant says to the nurse, "He pushes the teaspoon right out of my hand when I feed him. I can't let him feed himself; he makes too much of a mess." The nurse's BEST response is: "It's important not to give in to this kind of temper tantrum at this age. Simply ignore the behavior and the mess." "You need to try different types of utensils, bowls, and plates. Some are specifically designed for young children." "It's important to let him make a mess. Just try not to worry about it so much." "Feeding himself will help foster his growth and development. Perhaps we can discuss ways to make the messes more tolerable."

D The child is developmentally ready for self-feeding. Ignoring the behavior and not allowing the child to self-feed is not fostering the child's development. The child is developmentally ready for self-feeding. The parent should not force the use of the spoon but should substitute finger foods. This response minimizes the parent's concerns about the mess created by self-feeding. At 12 months the child should be self-feeding. Since children this age eat primarily finger foods, it is useful to offer the parent suggestions for keeping the mess to a minimum.

Diagnostic FTT

Rule out organic cause FIRST, if no organic cause, nutrition & nurturing is provided in consistent manner

^However, during 1st 6 months pacifier use has been found to reduce the risk of

SIDS