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1 Introduction to Nursing Care of Children, 1 16 The Child with a Fluid and Electrolyte
Alteration, 336
17 The Child with an Infectious Disease, 353
18 The Child with an Immunologic Alteration, 384
DEVELOPMENT: THE 19 The Child with a Gastrointestinal Alteration, 407
CHILD AND THE FAMILY 20 The Child with a Genitourinary Alteration, 454
2 Family-Centered Nursing Care, 23 21 The Child with a Respiratory Alteration, 480
3 Communicating with Children and Families, 37 22 The Child with a Cardiovascular Alteration, 531
4 Health Promotion for the Developing Child, 50 23 The Child with a Hematologic Alteration, 571
5 Health Promotion for the Infant, 77 24 The Child with Cancer, 596
6 Health Promotion during Early Childhood, 106 25 The Child with Major Alterations in Tissue
7 Health Promotion for the School-Age Child, 130 Integrity, 625
8 Health Promotion for the Adolescent, 149 26 The Child with a Musculoskeletal Alteration, 661
27 The Child with an Endocrine or Metabolic
Alteration, 700
UNIT III SPECIAL CONSIDERATIONS 28 The Child with a Neurologic Alteration, 733
IN CARING FOR CHILDREN 29 Psychosocial Problems in Children and
Families, 769
9 Physical Assessment of Children, 168
30 The Child with a Developmental Disability, 795
10 Emergency Care of the Child, 202
31 The Child with a Sensory Alteration, 816
11 The Ill Child in the Hospital and Other Care
Settings, 231
Glossary, 831
12 The Child with a Chronic Condition or Terminal
Index, 837
Illness, 250
13 Principles and Procedures for Nursing Care of
Children, 269
14 Medication Administration and Safety for Infants
and Children, 298
15 Pain Management for Children, 317

Evolve Free Resources

• Animations
• Answer Key for Critical Thinking Exercises
• Common Pediatric Laboratory Tests and Normal Values
• Denver Developmental Screening Test II
• Drug Calculations for Pediatrics
• Growth Charts, CDC and WHO Growth Curves for Children Ages 0 to 2 Years
• Audio Glossary
• Expanded Key Concepts
• NCLEX® Review Questions
• Normal Blood Pressure Readings
• Pediatric Skills
• Pediatric Video Clips
• Chest Physiotherapy Procedure
• Resources for Health Care Providers and Families
• Standard Precautions

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Principles & Practice



Curry College Division of Nursing
Milton, Massachusetts


Assistant Professor of Nursing
Tarrant County College
Trinity River East Campus Center for Health Care Professions
Fort Worth, Texas


Assistant Dean, Undergraduate Student Services
College of Nursing
University of Texas at Arlington
Arlington, Texas
3251 Riverport Lane
St. Louis, Missouri 63043


Copyright © 2013, 2007, 2002, 1997 by Saunders, an imprint of Elsevier Inc.

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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).


Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
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contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Nursing care of children : principles & practice.—4th ed. / [edited by] Susan Rowen James, Kristine Ann
Nelson, Jean Weiler Ashwill.
â•…â•…â•… p. ; cm.
â•… Includes bibliographical references and index.
â•… ISBN 978-1-4557-0366-1 (pbk. : alk. paper)
╅ I.╇ James, Susan Rowen, 1946-╅ II.╇ Nelson, Kristine Ann.╅ III.╇ Ashwill, Jean Weiler.
â•… [DNLM: 1.╇ Pediatric Nursing—methods.â•… 2.╇ Adolescent.â•… 3.╇ Child.â•… 4.╇ Infant.â•… 5.╇ Nursing Process. WY
â•… 618.92′00231—dc23 â•… 2011044713
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To my parents Fran and Steve Rowen,
who always encouraged me in the pursuit of my life’s goals.
You are both missed by us all.
Susan Rowen James

To my special daughter Karlee, who teaches me everyday

how to be a better mother, teacher, and pediatric nurse.
And to my husband Randy for his encouragement and for being my anchor
through so many years of life’s joys and challenges.
Kristine Ann Nelson

In love and thanksgiving for my family, especially my husband Vince,

my children Vin, Amy, and Heidi, their spouses,
and our grandchildren who are the joy of my life.
To all past and future nursing students, you are our future!
Jean Weiler Ashwill

Mary Jane Piskor Ashe, RN, MN Patricia Newcomb, RN, PhD, CPNP
Clinical Instructor Director
Smart Hospital; Genomics Translational Research Laboratory
College of Nursing College of Nursing
University of Texas at Arlington University of Texas at Arlington
Arlington, Texas Arlington, Texas

Jamie Bankston, RN, MS Eileen O’Connell, PhD, RN

Director of Clinical Education Associate Professor
Cook Children’s Medical Center Curry College Division of Nursing
Fort Worth, Texas Milton, Massachusetts

Jacqueline Carroll, RN MSN CPNP Fiona E. Paul, RN, DNP, CPNP

Assistant Professor Pediatric Nurse Practitioner
Curry College Division of Nursing Children’s Hospital of Boston;
Milton, Massachusetts Harvard Medical School
Boston, Massachusetts
Joe Don Cavender, RN, MSN, CPNP-PC
Pediatric Nurse Practitioner Meagan Rogers, RN, MSN, CPEN
Director of Advanced Practice Services Clinical Educator
Children’s Medical Center of Dallas Emergency Department
Dallas, Texas Children’s Medical Center at Legacy
Dallas, Texas
Sheryl Cifrino, RN, DNP, MA
Associate Professor Jennifer Roye, RN, MSN, CPNP
Curry College Division of Nursing Clinical Coordinator
Milton, Massachusetts Academic Partnership BSN Program
College of Nursing
Melissa A. Saffarrans LeMoine, RN, MSN, CPNP University of Texas at Arlington
Pediatric Nurse Practitioner Arlington, Texas
Nephrology, Dialysis, and Transplant Services
Cook Children’s Health Care System Ann Smith, PhD, CPNP, CNE
Fort Worth, Texas Coordinator, Nurse Residency
Cook Children’s Medical Center
Renee C.B. Manworren, PhD, APRN, PCNS-BC Fort Worth, Texas
Nurse Scientist
Division of Pain and Palliative Medicine PowerPoint Presentations and Pediatric Skills
Connecticut Children’s Medical Center; Susan Golden, RN, MSN
Assistant Professor of Pediatrics Nursing Program Director
University of Connecticut School of Medicine Department of Nursing
Hartford, Connecticut Eastern New Mexico University, Roswell
Roswell, New Mexico
Gwendolyn T. Martin, RN, MS, CNS, CPST-I
Assistant Professor of Nursing Test Bank
Tarrant County College Mary L. Dowell, PhD, RN, BC
Department of Nursing Assistant Professor
Fort Worth, Texas Nursing Department
San Antonio College;
Lindy Moake, RN, MSN, PCCNP LVN-ADN Program Coordinator
Clinical Manager of Advanced Practice Services Kerrville Distance Site
Heart Center Kerrville, Texas
Children’s Medical Center of Dallas
Dallas, Texas;
Clinical Faculty
University of Texas at Arlington
Arlington, Texas


Corine K. Carlson, RN, MS Jill Pitts, RNC, MSN

Associate Professor Assistant Professor
Luther College Associate Degree Nursing
Decorah, Iowa South Plains College
Levelland, Texas
Hobie Etta Feagai, EdD, MSN, FNP-BC, APRN-Rx
Associate Professor of Nursing Janice Ramirez, MSN, RN BC, CRRN, CNE
Hawai’i Pacific University RN Instructor
College of Nursing & Health Sciences North Idaho College
Kaneohe, Hawai’i Coeur d’Alene, Idaho

Erica Fooshee, RN, MSN, CNE, CPN Cheryl C. Rodgers, PhD, RN, CPNP, CPON
Program Manager, Nursing Pediatric Nurse Practitioner
Western Governors University Texas Children’s Hospital;
Salt Lake City, Utah Clinical Instructor
Baylor College of Medicine
Susan Golden, RN, MSN Houston, Texas
Nursing Program Director
Department of Nursing Chris Shanks
Eastern New Mexico University at Roswell Vancouver Island University
Roswell, New Mexico Department of Nursing
Nanaimo, British Columbia
Cynthia Gordy, RN, MSN Canada
Clinical Nursing Instructor
Indian Hills Community College Jana Wiscaver Thompson, MNSc, RN
Centerville, Iowa Clinical Assistant Professor
Department of Nursing
Vivian Kuawogai, RN, MSN University of Arkansas for Medical Sciences
Associate Professor of Nursing Little Rock, Arkansas
Prince George’s Community College
Largo, Maryland NCLEX Review Questions
Colleen W. Bible, MSN, RN
Renee C.B. Manworren, PhD, APRN, PCNS-BC Nursing Faculty
Nurse Scientist Division of Health Sciences—Nursing
Division of Pain and Palliative Medicine Technical College of the Lowcountry
Connecticut Children’s Medical Center; Beaufort, South Carolina
Assistant Professor of Pediatrics
University of Connecticut School of Medicine TEACH for Nurses
Hartford, Connecticut Betty Hamlisch, RN, BSN, MS
Health Fducation
Claudia Perry, RN, BSN, MBA Professor Emerita
Nursing Instructor Tompkins Cortland Community College
Clovis Community College Dryden, New York
Clovis, New Mexico
Test Bank
Ann Petersen-Smith, PhD, RN, CPNP-AC Nan Riedé, MSN, RN, CPN
Assistant Professor Assistant Professor
PNP Option Coordinator Baptist College of Health Sciences
Division of Women, Children, and Family Health Memphis, Tennessee
University of Colorado
College of Nursing
Anschutz Medical Campus
Aurora, Colorado


Children are precious gifts. Two of the most satisfying nursing roles a comprehensive glossary for ready access as the student studies.
are being a resource to children and families as they develop their own Teaching guidelines in the form of Patient-Centered Teaching boxes
unique identities and comforting them in times of illness and stress. and other material are written in language that will assist students to
Holding a child, talking softly, or entering into imaginary play—all are teach parents and children about home care, self-care, preventive care,
parts of nursing children. Hugging or sitting quietly with a parent, and follow-up care.
explaining a procedure or a disease, or providing reassurance through In keeping with the focus of incorporating Evidence-Based Practice
quiet, competent care can literally change the way a parent views the as a thread throughout most nursing curricula, this edition includes
child’s experience of illness. Evidence-Based Practice boxes, which facilitate critical thinking about
High-quality nursing care of children combines compassion with how evidence could be used by nurses to make clinical practice
the most up-to-date clinical knowledge grounded in basic theoretical decisions.
principles of nursing care. This fourth edition of Nursing Care of Chil-
dren: Principles & Practice emphasizes using evidence as the basis for
the care nurses provide daily to pediatric patients and their families.
This scientific base is demonstrated in the narrative and features in Several conceptual threads are interwoven throughout the text.
which the nursing process is applied. Physiologic and pathophysiologic
processes are presented in a format that assists the student to under- Family
stand why health problems occur and how to derive appropriate The nurse must care for the child within the context of the family. In
nursing care. Current references provide students with the latest infor- this text, emphasis is placed on the importance of focusing on the
mation that applies to the clinical area. National standards and guide- family when caring for children of all ages and in many different set-
lines, such as those from the American Nurses Association and the tings. Changing family structure and diversity in types of families are
Society of Pediatric Nurses, have been incorporated where applicable. considered. Special sections are devoted to the needs of siblings.
There is an enhanced focus on quality and safety to assist students with
achievement of the Quality and Safety Education for Nurses (QSEN) Growth and Development Within the Concept
competencies. of Health Promotion
This text addresses contemporary changes in health care, recogniz- Concepts of health promotion and anticipatory guidance are orga-
ing that health care costs have led to shorter hospital stays and a shift nized around a developmental framework. A chapter on general health
to health care provided in the community and the home. The fourth promotion for developing children describes the various developmen-
edition of Nursing Care of Children includes a strong focus on the tal assessment areas: parameters of growth, factors influencing growth
growing and changing roles of nurses caring for children in varied and development, developmental milestones, play; nutrition; immuni-
settings. To expand and enhance its community emphasis, the text zations; and safety. Each of the subsequent growth and development
incorporates the recently released Healthy People 2020 national objec- chapters discusses these areas as they apply to the infant, child, or
tives. In addition, adaptation of principles to the home, community, adolescent of a specific age or developmental level. Each chapter also
and school settings is illustrated throughout and has been increased in provides a review of physical and psychosocial changes unique to that
this edition. age-group and emphasizes the nurse’s role with children of specific
The text’s emphasis on health and wellness is found in a compre- ages and at varying developmental levels.
hensive unit covering growth and development, with anticipatory
guidance for families. This unit is organized around the recommended Child Advocacy
schedule of well-child visits as described by the American Academy of Legal and ethical responsibilities of nurses are identified and explained
Pediatrics. Health Promotion boxes assist students with information in such areas as violence, abuse, neglect, drug abuse, and access to
needed to understand developmental milestones, health promotion health care.
activities, and anticipatory guidance for infants and children of specific
ages and developmental levels. Communication
Legal and ethical issues add to the complexity of practice for today’s Communicating appropriately with children can be a challenge. The
nurse. The first chapter of our book discusses the ethical and legal fourth edition includes special Communication Cues and describes
obligations of nurses who work with children and how to meet these techniques to enhance therapeutic communication with children and
obligations while providing optimum client care. Issues such as includ- families. An entire chapter is devoted to communicating with children
ing children in research, what constitutes a mature minor, and the care and families.
of technology-dependent children are discussed where applicable
throughout the book. Culture
Contemporary nursing students have time demands from work, Cultural variety characterizes nursing practice today as the lines
family, and community activities in addition to their nursing edu� between individual nations become more blurred. The nurse must
cation. A significant number of students use English as a second assess for unique cultural needs of children and their families and
language. With those realities in mind, we have written a text to effec- incorporate them into care, promoting acceptance of nursing interven-
tively convey essential information that focuses on critical elements tions. Cultural influences are examined in many ways in our text, and
and that is concise without unnecessarily complex language. Impor- principles of culturally sensitive care are incorporated throughout as
tant items are highlighted within each chapter and defined in an important thread.


TEXT ORGANIZATION Learning Objectives

Similar to the third edition, the text uses an objective-oriented approach Learning Objectives provide direction for the reader to understand
that makes it easy for students to understand and retain important what is important to glean from the chapter. Many objectives ask that
material. Nursing care sections are organized around the nursing the learner use critical thinking and apply the nursing process—two
process to facilitate learning using a problem-solving method. The text crucial components of professional nursing.
begins with an overview of contemporary nursing of children, includ-
ing general principles of care. Comprehensive growth and develop- Nursing Process
ment chapters follow. Principles for adapting care of well children to Although all steps of the nursing process are used consistently in
those requiring admission to an emergency or hospital setting precede nursing process sections, nursing process appears in two different
the final chapters, which cover care of children with specific health formats throughout the text. The different formats show the student
alterations. Narrative coverage of important childhood disorders is that there is more than one way to communicate nursing process.
consistently organized in a nursing process format, again with NANDA Nursing process can be applied to care of children with the most
diagnoses, expected outcomes, and evaluation questions. Less common common childhood conditions through an in-text discussion that
disorders are grouped and discussed in tables in each body system demonstrates how the process relates to a typical child with a specific
chapter. condition. Nursing process for children with more complex nursing
problems is illustrated through the use of a care plan format, which
encompasses focused assessment, nursing diagnoses, expected out-
FEATURES comes, interventions, rationales, and evaluation criteria. This format
Visual appeal characterizes many features in the text. Beautiful full- helps the nursing instructor teach students how to individualize care
color illustrations and photographs convey clinical information and for their specific clients based on a generic plan of care.
also capture the essence of nursing care of children. Illustrations rein-
force knowledge of growth and development, explain pathophysiology, Pathophysiology Boxes
make learning procedures easier, show manifestations of diseases and Pathophysiology boxes give the student a brief overview of how various
disorders, and provide models of interactions with patients and illnesses occur. The boxes provide a scientific basis for understanding
families. the therapeutic management of the illness and its nursing care.

Clinical Reference Pages Patient-Centered Teaching

This edition continues the popular Clinical Reference pages, which are Because teaching is an essential part of nursing care, we give students
a resource for the student when reviewing basic anatomy and physiol- teaching guidelines for common client needs in terms that most lay
ogy and differences between children and adults as they pertain to the people can understand. Patient-Centered Teaching boxes provide
body system being discussed. They also include diagnostic studies, sample answers for questions that children or parents are most likely
laboratory values, and nursing care associated with these procedures. to ask.

Critical Thinking Exercises Procedure Boxes

Critical thinking is encouraged in multiple ways throughout Nursing Clinical skills are presented in Procedure boxes throughout the text.
Care of Children, but specific Critical Thinking Exercises are included The text includes two chapters that describe step-by-step general and
in most chapters in the text. These present scenarios of real-life situa- medication procedures used when caring for children. Many of these
tions or issues and ask the student to solve nursing care problems that procedures have been expanded to include home adaptations.
are not always obvious. Answers are given on the Evolve website, so the
students can check solutions to these problems. Safety Alerts and Nursing Quality Alerts
Safety Alert boxes provide critical information needed to deliver safe
Drug Guide Boxes nursing care. Nursing Quality Alert boxes contain condensed knowl-
Drug information is generally presented through Drug Guide boxes. edge on ways students can enhance and improve the care they provide
Drug guides for specific, commonly used medications provide the to children and families.
student nurse with detailed information.

Health Promotion Boxes ACKNOWLEDGMENTS

Health Promotion boxes summarize needed information to perform a We would first like to thank our families and friends who supported
comprehensive assessment of well infants and children at various ages. us in this endeavor by understanding when we were unavailable and
Organized around the American Academy of Pediatrics’ recommended encouraging us when we were overwhelmed.
schedule for well-child visits, examples are given of questions designed We express our sincere appreciation to the clinicians (listed on
to elicit developmental and behavioral information from parent and p. vi), experts in their fields, who contributed to the book. They pro-
child. These boxes also include what the student might expect to see vided the up-to-date clinical information needed in a teaching
for health screening or immunization and review specific topics for text. Thank you is also extended to the reviewers, who very conscien-
anticipatory guidance. tiously made suggestions to improve the text.
Both Emily McKinney and Sharon Murray, who, along with us, are
Key Concepts authors and editors of the combined book, Maternal-Child Nursing,
Key Concepts summarize important points of each chapter. They provided input that helped us focus on needed improvements for this
provide a general review for the material just presented to help the edition. Their suggestions are always invaluable. Heather Bays, devel-
student identify areas in which more study is needed. opmental editor, worked with us to make our vision for an improved

text a reality. Her untiring work on our behalf has kept the project Principles & Practice, fourth edition, have their origin in wonderful
moving forward, despite having to manage some unavoidable and dif- feedback given by our students about their learning needs. We hope
ficult obstacles. She and Michele Hayden, our Managing Editor, have that this edition supports and strengthens students’ ability and desire
used their excellent problem-solving skills every step of the way. Mary to learn about this exciting and ever-changing specialty of ours.
Stueck, project manager, saw to it that the production process pro-
ceeded in a timely fashion and responded quickly to our editing and Susan Rowen James, PhD, RN
production concerns. Kristine Ann Nelson, MN, RN
Finally, as educators we are teaching but also learning from our Jean Weiler Ashwill, MSN, RN
students. Some of the new features in Nursing Care of Children:

Chapter Opener pages contain A glossary is provided at the end

LEARNING OBJECTIVES of the text with definitions for the
to help guide the student’s corresponding Key Terms
understanding of material highlighted in color throughout
presented. each chapter to reinforce student


opens each alteration chapter,
providing a review of basic
anatomy and physiology,
discussion of pediatric differences, Clear, descriptive, full-color
and common diagnostic tests and Illustrations and Photographs
medications. throughout the book help
clarify information and
demonstrate important

boxes assist students to use research
and evidence-based guidelines to
evaluate nursing interventions in
relation to desired outcomes of
nursing care.


Marginal Notes are placed

throughout the text to highlight
additional exercises and resources
found on the Evolve website.

PROCEDURE boxes provide

clear, step-by-step instructions
for common nursing tasks to
assist students in clinical practice.

describe how disease conditions
develop, presenting a scientific
basis for understanding the Safety Alerts and Nursing
therapeutic management and Quality Alerts highlight vital
nursing care of an illness. information that is crucial to
delivering safe and effective nursing

boxes guide the student in answering
questions commonly asked and teaching
the parents and child about self-care.

UNIT I INTRODUCTION TO CHILD The Nursing Process in Pediatric Care, 18

Therapeutic Communication, 18
Critical Thinking, 18
1 Introduction to Nursing Care of Children, 1 Steps of the Nursing Process, 19
Principles of Caring for Children, 1 Complementary and Alternative Medicine, 20
Historical Perspectives, 1 Nursing Research and Evidence-Based
Societal Changes, 1 Practice, 21
Hygiene and Hospitalization, 2
Development of Family-Centered Child
Current Trends in Child Health Care, 3 DEVELOPMENT: THE CHILD
Cost Containment, 3 AND THE FAMILY
Effects of Cost Containment, 4
Home Care, 6 2 Family-Centered Nursing Care, 23
Community Care, 6 Family-Centered Care, 23
Access to Care, 6 Family Structure, 23
Health Care Assistance Programs, 7 Types of Families, 24
Statistics on Infant and Child Health, 8 Characteristics of Healthy Families, 25
Mortality, 8 High-Risk Families, 26
Morbidity, 9 Healthy versus Dysfunctional Families, 27
Adolescent Births, 9 Coping with Stress, 27
Ethical Perspectives in Child Health Nursing, 9 Coping Strategies, 27
Ethics and Bioethics, 9 Cultural Influences on Pediatric Nursing, 27
Ethical Dilemmas, 10 Implications of Cultural Diversity for
Ethical Principles, 10 Nurses, 28
Solving Ethical Dilemmas, 10 Western Cultural Beliefs, 28
Ethical Concerns in Child Health Cultural Influences on the Care of People
Nursing, 10 from Specific Groups, 28
Legal Issues, 11 Cross-Cultural Health Beliefs, 31
Safeguards for Health Care, 11 Cultural Assessment, 32
Standards of Care, 11 Parenting, 32
Agency Policies, 11 Parenting Styles, 32
Malpractice, 12 Parent-Child Relationship Factors, 32
Social Issues, 14 Discipline, 33
Poverty, 14 Dealing with Misbehavior, 33
Homelessness, 15 Nursing Process and the Family, 35
Allocation of Health Care Resources, 15 3 Communicating with Children and Families, 37
Care versus Cure, 15 Components of Effective Communication, 37
Health Care Rationing, 16 Touch, 37
Violence, 16 Physical Proximity and Environment, 37
The Professional Nurse, 16 Listening, 38
The Role of the Professional Nurse, 16 Visual Communication, 39
Advanced Roles for Pediatric Nurses, 18 Tone of Voice, 39
Nurse Practitioners, 18 Body Language, 39
Clinical Nurse Specialists, 18 Timing, 39
Clinical Nurse Leaders, 18 Family-Centered Communication, 40
Implications of Changing Roles for Establishing Rapport, 40
Nurses, 18 Availability and Openness to Questions, 40


Family Education and Empowerment, 41 Health Promotion, 68

Effective Management of Conflict, 41 Immunizations, 68
Feedback from Children and Families, 41 Nutrition and Activity, 71
Spirituality, 41 Physical Activity, 73
Transcultural Communication: Bridging the Safety, 74
Gap, 42 5 Health Promotion for the Infant, 77
Therapeutic Relationships: Developing and Growth and Development of the Infant, 77
Maintaining Trust, 42 Physical Growth and Maturation of Body
Nursing Care for Communicating with Systems, 78
Children and Families, 42 Motor Development, 80
Communicating with Children with Special Cognitive Development, 81
Needs, 47 Sensory Development, 82
The Child with a Visual Impairment, 48 Language Development, 82
The Child with a Hearing Impairment, 48 Psychosocial Development, 83
The Child Who Speaks Another Language, 48 Health Promotion for the Infant and
The Child with Other Communication Family, 84
Issues, 49 Immunization, 84
The Child with a Profound Neurologic Skin Care, 84
Impairment, 49 Feeding and Nutrition, 85
4 Health Promotion for the Developing Child, 50 Dental Care, 93
Overview of Growth and Development, 50 Sleep and Rest, 95
Definition of Terms, 50 Safety, 97
Stages of Growth and Development, 51 Concerns during Infancy, 100
Parameters of Growth, 51 Jaundice, 100
Principles of Growth and Development, 52 Circumcision, 100
Patterns of Growth and Development, 52 Patterns of Crying, 102
Critical Periods, 52 The Infant with Colic, 102
Factors Influencing Growth and 6 Health Promotion during Early Childhood, 106
Development, 52 Growth and Development during Early
Theories of Growth and Development, 54 Childhood, 106
Piaget’s Theory of Cognitive Physical Growth and Development, 106
Development, 54 Motor Development, 108
Freud’s Theory of Psychosexual Cognitive and Sensory Development, 109
Development, 57 Language Development, 112
Erikson’s Psychosocial Theory, 57 Psychosocial Development, 113
Kohlberg’s Theory of Moral Development, 58 Health Promotion for the Toddler or
Theories of Language Development, 58 Preschooler and Family, 116
Genetic and Genomic Influences on Growth Nutrition, 116
and Development, 59 Dental Care, 118
Genetics and Genomics, 59 Sleep and Rest, 118
Principles of Mendelian Inheritance, 60 Discipline, 119
Mendelian Inheritance Patterns, 61 Toddler Safety, 120
Chromosomal Abnormalities, 62 Preschooler Safety, 122
Numerical Abnormalities, 62 Selected Issues Related to the Toddler, 124
Multifactorial Birth Defects, 63 Selected Issues Related to the
Exposure to an Adverse Prenatal Preschooler, 126
Environment, 63 7 Health Promotion for the School-Age Child, 130
Genetic Counseling, 63 Growth and Development of the School-Age
Assessment of Growth, 64 Child, 130
Assessment of Development, 65 Physical Growth and Development, 130
Denver Developmental Screening Test II Motor Development, 132
(DDST-II), 65 Cognitive Development, 133
Nurse’s Role in Promoting Optimal Growth Sensory Development, 134
and Development, 65 Language Development, 134
Developmental Assessment, 66 Psychosocial Development, 134
Play, 66 Spiritual and Moral Development, 135

Health Promotion for the School-Age Child Skin, Hair, And Nails, 175
and Family, 136 Lymph Nodes, 176
Nutrition during Middle Childhood, 136 Head, Neck, and Face, 176
Dental Care, 136 Nose, Mouth, and Throat, 177
Sleep and Rest, 137 Eyes, 179
Discipline, 137 Ears, 182
Safety, 139 Thorax and Lungs, 183
Selected Issues Related to the School-Age Heart, 186
Child, 140 Peripheral Vascular System, 190
8 Health Promotion for the Adolescent, 149 Breast, 190
Adolescent Growth and Development, 149 Abdomen, 190
Physical Growth and Development, 149 Male Genitalia, 192
Psychosexual Development, Hormonal Female Genitalia, 193
Changes, and Sexual Maturation, 150 Musculoskeletal System, 193
Motor Development, 153 Neurologic System, 195
Cognitive Development, 153 Conclusion and Documentation, 201
Sensory Development, 153 10 Emergency Care of the Child, 202
Language Development, 154 General Guidelines for Emergency Nursing
Psychosocial Development, 154 Care, 202
Moral and Spiritual Development, 157 Growth and Development Issues in Emergency
Health Promotion for the Adolescent and Care, 204
Family, 157 The Infant, 204
Nutrition during Adolescence, 158 The Toddler, 205
Hygiene, 159 The Preschooler, 205
Dental Care, 159 The School-Age Child, 205
Sleep and Rest, 159 The Adolescent, 206
Exercise and Activity, 159 The Family of a Child in Emergency Care, 206
Safety, 161 Emergency Assessment of Infants and
Selected Issues Related to the Adolescent, 163 Children, 206
Primary Assessment, 206
Secondary Assessment, 209
UNIT III SPECIAL CONSIDERATIONS IN Cardiopulmonary Resuscitation of
Airway and Breathing, 211
9 Physical Assessment of Children, 168 Circulation, 211
General Approaches to Physical The Child in Shock, 212
Assessment, 168 Etiology, 213
Infants from Birth to 6 Months, 168 Manifestations, 213
Infants from 6 to 12 Months, 169 Diagnostic Evaluation, 214
Toddlers, 169 Therapeutic Management, 214
Preschoolers, 169 Nursing Care of the Child in Shock, 215
School-Age Children, 169 Pediatric Trauma, 216
Adolescents, 169 Mechanism of Injury, 216
Techniques for Physical Examination, 169 Multiple Trauma, 217
Inspection, 169 Nursing Considerations, 219
Palpation, 170 Ingestions and Poisonings, 220
Percussion, 170 Incidence, 220
Auscultation, 170 Manifestations, 220
Smell, 170 Diagnostic Evaluation, 220
Sequence of Physical Examination, 170 Therapeutic Management, 221
General Appearance, 170 Nursing Care of the Child Who Has Ingested a
History Taking, 171 Toxic Substance, 223
Recording Data, 171 Environmental Emergencies, 224
Vital Signs, 171 Animal, Human, Snake, and Spider
Anthropometric Measurement, 173 Bites, 224
Use of Growth Charts, 174 Submersion Injuries (Near Drowning), 225

Nursing Care of the Child with a Submersion Coping and Parental Responses to
Injury, 226 Developmental Issues, 253
Heat-Related Illnesses, 228 The Child with a Chronic Illness, 254
Dental Emergencies, 229 Ongoing Care, 255
Incidence and Etiology, 229 Caring for Parents, 256
Therapeutic Management, 229 Caring for Siblings, 257
Nursing Considerations, 229 Nursing Care Plan: The Child with a Chronic
11 The Ill Child in the Hospital and Other Care Condition in the Community Setting, 258
Settings, 231 The Terminally Ill or Dying Child, 260
Settings of Care, 231 Coping and the Child’s Concept
The Hospital, 231 of Death, 260
School-Based Clinics, 233 Coping and Responses to Death
Community Clinics, 234 and Dying, 261
Home Care, 234 Caring for the Dying Child, 262
Stressors Associated with Illness and Nursing Care Plan: The Terminally Ill or Dying
Hospitalization, 234 Child, 266
The Infant and Toddler, 235 13 Principles and Procedures for Nursing Care of
The Preschooler, 236 Children, 269
The School-Age Child, 237 Preparing Children for Procedures, 269
The Adolescent, 238 Explaining Procedures, 269
Fear of the Unknown, 238 Consent for Procedures, 270
Regression, 238 Holding and Transporting Infants and
Factors Affecting a Child’s Response to Illness Children, 271
and Hospitalization, 238 Safety Issues in the Hospital Setting, 271
Age and Cognitive Development, 239 Infection Control, 273
Parental Response, 239 Hand Hygiene, 273
Preparing the Child and Family, 241 Standard Precautions, 273
Coping Skills of the Child and Family, 241 Implementing Precautions, 273
Psychological Benefits of Hospitalization, 241 Family Teaching, 273
Play for the Ill Child, 241 Bathing Infants and Children, 273
Playrooms, 241 Special Considerations, 274
Therapeutic Play, 242 Documentation, 275
Emotional Outlet Play, 242 Parent Teaching, 275
Teaching through Play, 242 Oral Hygiene, 275
Enhancing Cooperation through Play, 242 Feeding, 275
Unstructured Play, 242 Special Considerations, 276
Evaluation of Play, 242 Documentation, 276
Admitting the Child to a Hospital Setting, 243 Parent Teaching, 276
Taking the History, 243 Vital Signs, 276
Physical Examination, 244 Measuring Temperature, 276
Nursing Care Plan: The Child and Family in a Measuring Pulse, 277
Hospital Setting, 244 Evaluating Respirations, 277
The Ill Child’s Family, 246 Measuring Blood Pressure, 277
Parents, 246 Documentation of Vital Sign
Siblings, 247 Measurement, 278
12 The Child with a Chronic Condition or Terminal Preparing the Child and Family, 279
Illness, 250 Parent Teaching, 279
Chronic Illness Defined, 250 Special Considerations: Cardiorespiratory
The Family of the Child with Special Health Monitors, 279
Care Needs, 250 Fever-Reducing Measures, 279
Family Dynamics and Impact on Description of Fever, 279
the Family, 250 Medications and Environmental
Coping and the Grieving Process, 252 Management, 279
The Child with Special Health Care Needs, 253 Specimen Collection, 280
Coping and Growth and Development Urine Specimens, 280
Concerns, 253 Stool Specimens, 283

Blood Specimens, 283 Intravenous Therapy, 310

Sputum Specimens, 285 Intravenous Catheter Insertion, 310
Throat and Nasopharyngeal Specimens, 285 Intravenous Catheter Monitoring, 312
Cerebrospinal Fluid Specimens, 285 Intravenous Infusion Monitoring, 312
Bone Marrow Aspiration, 285 Infusion Rates and Methods, 313
Gastrointestinal Tubes and Enteral Feedings, 286 Administering Intravenous Medications, 313
Tube Route and Placement, 286 Venous Access Devices, 314
Tube Selection, 286 Administration of Blood Products, 315
Safety Issues Related to Tube Placement, 288 Child and Family Education, 315
Contraindications to Tube Placement, 288 15 Pain Management for Children, 317
Enteral Feedings, 288 Definitions and Theories of Pain, 317
Gastrostomy Tubes and Buttons, 288 Gate Control Theory, 318
Enemas, 290 Acute and Chronic Pain, 318
Enema Administration, 290 Research on Pain in Children, 318
Solutions and Volumes, 290 Obstacles to Pain Management in Children, 319
Ostomies, 290 Assessment of Pain in Children, 319
Oxygen Therapy, 290 Assessment According to Developmental
Oxygen Administration, 290 Level, 320
Documentation, 291 Assessment Tools, 322
Parent Teaching, 291 Nonpharmacologic and Pharmacologic Pain
Assessing Oxygenation, 291 Interventions, 323
Chest Physiotherapy, 292 Nonpharmacologic Interventions, 323
Tracheostomy Care, 293 Pharmacologic Interventions, 326
Suctioning, 293
Surgical Procedures, 295 HEALTH PROBLEMS
Preparation for Surgery, 295
Preoperative Medication and Anesthesia 16 The Child with a Fluid and Electrolyte
Induction, 295 Alteration, 336
Postanesthesia Care, 296 Review of Fluid and Electrolyte Imbalances in
Postoperative Care, 296 Children, 336
14 Medication Administration and Safety for Infants Alterations in Acid-Base Balance in
and Children, 298 Children, 338
Pharmacokinetics in Children, 299 Dehydration, 341
Absorption, 299 Etiology and Incidence, 342
Distribution, 300 Manifestations, 343
Metabolism, 300 Therapeutic Management, 343
Excretion, 300 Nursing Care of the Child with Dehydration, 345
Concentration, 300 Diarrhea, 347
Psychological and Developmental Factors, 301 Etiology and Incidence, 347
Infants, 301 Manifestations, 347
Toddlers and Preschoolers, 301 Diagnostic Evaluation, 348
School-Age Children, 301 Therapeutic Management, 348
Adolescents, 301 Prognosis, 349
Calculating Dosages, 302 Nursing Care of the Child with Diarrhea, 349
Medication Administration Procedures, 302 Vomiting, 351
Medication Reconciliation, 302 Etiology, 351
Administering Oral Medications, 303 Manifestations, 351
Administering Injections, 304 Diagnostic Evaluation, 351
Rectal Administration, 307 Therapeutic Management, 351
Vaginal Administration, 308 Nursing Care of the Vomiting Child, 351
Ophthalmic Administration, 308 17 The Child with an Infectious Disease, 353
Otic Administration, 308 Review of Disease Transmission, 353
Nasal Administration, 308 Chain of Infection, 353
Topical Administration, 309 Transmission of Pathogens, 354
Inhalation Therapy, 309 Epidemiologic Investigations, 354

Infection and Host Defenses, 354 Common Laboratory and Diagnostic Tests of
Immunity, 354 Immune Function, 388
Viral Exanthems, 355 Immunodeficiencies, 388
Nursing Considerations for the Child with a Allergy, 388
Viral Exanthem Infection, 355 Human Immunodeficiency Virus
Rubeola (Measles), 355 Infection, 390
Nursing Care Plan: The Child with an Infection Etiology, 390
in the Community Setting, 357 Incidence, 390
Rubella (German Measles, 3-Day Manifestations, 390
Measles), 361 Diagnostic Evaluation, 391
Erythema Infectiosum (Fifth Disease, Therapeutic Management, 392
Parvovirus B19), 362 Nursing Care Plan: The Child with HIV
Roseola Infantum (Exanthem Infection in the Community, 394
Subitum), 362 Nursing Care Plan: The Adolescent with HIV
Enterovirus (Nonpolio) Infections Infection, 398
(Coxsackieviruses, Group A and Corticosteroid Therapy, 399
Group B), Echoviruses, and Incidence, 399
Enteroviruses, 363 Pathophysiology, 399
Varicella-Zoster Infections (Chickenpox, Manifestations, 399
Shingles), 364 Diagnostic Evaluation, 400
Other Viral Infections, 366 Therapeutic Management, 400
Mumps, 366 Nursing Care of the Child Receiving
Cytomegalovirus (CMV), 367 Corticosteroids, 400
Epstein-Barr Virus (Infectious Immune Complex and Autoimmune
Mononucleosis), 367 Disorders, 401
Rabies, 368 Immune Complex Disorders, 401
Bacterial Infections, 369 Autoimmune Disorders, 401
Pertussis (Whooping Cough), 369 Systemic Lupus Erythematosus, 401
Scarlet Fever, 370 Etiology, 401
Methicillin-Resistant Staphylococcus aureus Incidence, 401
(MRSA), 371 Manifestations, 402
Clostridium difficile, 372 Diagnostic Evaluation, 402
Neonatal Sepsis, 372 Therapeutic Management, 402
Rare Viral and Bacterial Infections, 374 Nursing Care of the Child with Systemic Lupus
Fungal Infections, 374 Erythematosus, 402
Rickettsial Infections, 375 Allergic Reactions, 403
Rocky Mountain Spotted Fever, 375 Anaphylaxis, 403
Borrelia Infections, 375 Etiology, 403
Relapsing Fever, 375 Incidence, 403
Lyme Disease, 376 Manifestations, 404
Helminths, 377 Diagnostic Evaluation, 404
Therapeutic Management, 377 Therapeutic Management, 404
Nursing Considerations, 377 Nursing Care of the Child with
Sexually Transmissible Infections, 378 Anaphylaxis, 405
Chlamydial Infection, 378 19 The Child with a Gastrointestinal
Gonorrhea, 379 Alteration, 407
Herpes Simplex Virus, 379 Review of the Gastrointestinal System, 407
Human Papillomavirus, 379 Upper Gastrointestinal System, 407
Bacterial Vaginosis, 380 Lower Gastrointestinal System, 408
Syphilis, 380 Prenatal Development, 412
Trichomoniasis, 380 Disorders of Prenatal Development, 412
18 The Child with an Immunologic Alteration, 384 Cleft Lip and Palate, 412
Review of the Immune System, 384 Esophageal Atresia with Tracheoesophageal
Nonspecific Immune Functions, 384 Fistula, 414
Specific Immune Functions, 385 Nursing Care Plan: The Child with a Cleft Lip
Development of Immunity, 387 or Palate, 415

Nursing Care of the Infant with Manifestations, 459

Tracheoesophageal Fistula, 417 Diagnostic Evaluation, 459
Upper Gastrointestinal Hernias, 419 Therapeutic Management, 459
Other Developmental Disorders, 419 Nursing Care of the Child with
Motility Disorders, 419 Enuresis, 459
Gastroesophageal Reflux Disease, 419 Urinary Tract Infections, 460
Nursing Care of the Infant with Etiology, 460
Gastroesophageal Reflux Disease Incidence, 460
(GERD), 423 Manifestations, 461
Constipation and Encopresis, 424 Diagnostic Evaluation, 461
Nursing Care of the Child with Constipation Therapeutic Management, 462
and Encopresis, 425 Nursing Care of the Child with a Urinary
Recurrent Abdominal Pain/Irritable Bowel Tract Infection, 462
Syndrome, 426 Cryptorchidism, 464
Inflammatory and Infectious Disorders, 427 Incidence, 464
Ulcers, 427 Manifestations, 464
Infectious Gastroenteritis, 428 Diagnostic Evaluation, 464
Nursing Care of the Child with Infectious Therapeutic Management, 464
Gastroenteritis, 430 Nursing Care of the Child with
Appendicitis, 431 Cryptorchidism, 464
Nursing Care of the Child with Hypospadias and Epispadias, 465
Appendicitis, 432 Etiology and Incidence, 465
Inflammatory Bowel Disease, 433 Manifestations and Diagnostic
Nursing Care of the Child with Inflammatory Evaluation, 465
Bowel Disease, 434 Therapeutic Management, 465
Obstructive Disorders, 436 Nursing Care of the Child with
Hypertrophic Pyloric Stenosis, 436 Hypospadias, 466
Nursing Care of the Child with Hypertrophic Miscellaneous Disorders and Anomalies of the
Pyloric Stenosis, 437 Genitourinary Tract, 466
Intussusception, 438 Acute Poststreptococcal
Nursing Care of the Child with Glomerulonephritis, 466
Intussusception, 439 Etiology and Incidence, 466
Volvulus, 440 Manifestations, 466
Hirschsprung Disease, 440 Diagnostic Evaluation, 466
Nursing Care of the Child with Hirschsprung Therapeutic Management, 467
Disease, 441 Nursing Care of the Child with Acute
Malabsorption Disorders, 442 Poststreptococcal Glomerulonephritis, 467
Lactose Intolerance, 442 Nephrotic Syndrome, 469
Nursing Care of the Child with Lactose Etiology, 469
Intolerance, 443 Incidence, 470
Celiac Disease, 443 Manifestations, 470
Nursing Care of the Child with Celiac Diagnostic Evaluation, 470
Disease, 445 Therapeutic Management, 470
Hepatic Disorders, 446 Nursing Care Plan: The Child with Nephrotic
Viral Hepatitis, 446 Syndrome, 472
Nursing Care of the Child with Viral Acute Renal Failure, 474
Hepatitis, 448 Etiology and Incidence, 474
Biliary Atresia, 449 Manifestations, 474
Cirrhosis, 451 Diagnostic Evaluation, 474
20 The Child with a Genitourinary Alteration, 454 Therapeutic Management, 475
Review of the Genitourinary System, 454 Nursing Considerations, 475
Structure, 454 Chronic Renal Failure and End-Stage Renal
Function, 455 Disease, 475
Enuresis, 458 Etiology, 477
Etiology, 458 Incidence, 477
Incidence, 458 Pathophysiology, 477

Manifestations, 477 Diagnostic Evaluation, 495

Diagnostic Evaluation, 477 Therapeutic Management, 495
Therapeutic Management, 477 Nursing Care of the Child with Croup, 496
Nursing Care of the Child with Chronic Renal Epiglottitis (Supraglottitis), 498
Failure and End-Stage Renal Disease, 478 Etiology and Incidence, 498
21 The Child with a Respiratory Alteration, 480 Manifestations, 498
Review of the Respiratory System, 480 Diagnostic Evaluation, 498
The Upper Airway, 480 Therapeutic Management, 498
The Lower Airway, 481 Nursing Considerations, 499
Prenatal Respiratory Development, 481 Bronchitis, 500
Postnatal Respiratory Changes, 482 Etiology and Incidence, 500
Gas Exchange and Transport, 482 Manifestations and Diagnostic
Diagnostic Tests, 483 Evaluation, 500
Blood Gas Analysis, 484 Therapeutic Management, 500
Pulmonary Function Tests, 484 Nursing Considerations, 500
Pulse Oximetry, 484 Bronchiolitis, 500
Transcutaneous Monitoring, 484 Etiology and Incidence, 500
End-Tidal Carbon Dioxide Monitoring, 485 Manifestations, 500
Respiratory Illness in Children, 485 Diagnostic Evaluation, 501
Allergic Rhinitis, 485 Therapeutic Management, 501
Etiology and Incidence, 485 Nursing Care of the Child with
Manifestations, 485 Bronchiolitis, 502
Diagnostic Evaluation, 486 Pneumonia, 503
Therapeutic Management, 486 Nursing Care of the Child with Pneumonia, 503
Nursing Considerations, 486 Foreign Body Aspiration, 504
Sinusitis, 487 Etiology and Incidence, 505
Etiology and Incidence, 487 Pathophysiology, 505
Manifestations, 487 Manifestations, 505
Diagnostic Evaluation, 487 Diagnostic Evaluation, 505
Therapeutic Management, 487 Therapeutic Management, 505
Nursing Considerations, 487 Nursing Considerations, 505
Otitis Media, 488 Pulmonary Noninfectious Irritation, 505
Etiology, 488 Acute Respiratory Distress Syndrome, 505
Incidence, 488 Passive Smoking, 506
Manifestations, 488 Smoke Inhalation, 507
Diagnostic Evaluation, 488 Respiratory Distress Syndrome, 507
Therapeutic Management, 488 Incidence, 507
Nursing Care of the Child with Otitis Pathophysiology, 507
Media, 489 Manifestations, 507
Pharyngitis and Tonsillitis, 491 Therapeutic Management, 507
Etiology, 491 Nursing Care of the Child with RDS, 508
Incidence, 491 Apnea, 508
Manifestations, 491 Manifestations, 508
Diagnostic Evaluation, 492 Diagnostic Evaluation, 509
Therapeutic Management, 492 Nursing Care of the Child with
Nursing Considerations, 493 Apnea, 509
Nursing Care of the Child Undergoing a Sudden Infant Death Syndrome, 510
Tonsillectomy, 493 Etiology and Incidence, 510
Laryngomalacia (Congenital Laryngeal Manifestations, 511
Stridor), 495 Diagnostic Evaluation, 511
Manifestations, 495 Nursing Care of the Family of the Infant Who
Therapeutic Management, 495 Has Died of Sudden Infant Death
Nursing Considerations, 495 Syndrome, 511
Croup, 495 Asthma, 512
Etiology and Incidence, 495 Etiology, 512
Manifestations, 495 Incidence, 512

Manifestations, 512 Arrhythmias, 559

Diagnostic Evaluation, 513 Etiology, 559
Therapeutic Management, 513 Diagnostic Evaluation, 560
Nursing Care Plan: The Child Hospitalized with Therapeutic Management, 560
Asthma, 517 Nursing Care of the Child with an
Bronchopulmonary Dysplasia, 520 Arrhythmia, 561
Etiology, 520 Rheumatic Fever, 562
Incidence, 520 Etiology, 562
Manifestations, 520 Incidence, 562
Diagnostic Evaluation, 520 Manifestations, 562
Therapeutic Management, 520 Diagnostic Evaluation, 563
Nursing Considerations, 521 Therapeutic Management, 563
Cystic Fibrosis, 521 Nursing Care of the Child with Rheumatic
Etiology, 522 Fever, 563
Incidence, 522 Kawasaki Disease, 564
Manifestations, 522 Etiology, 564
Diagnostic Evaluation, 524 Incidence, 564
Therapeutic Management, 524 Manifestations, 564
Nursing Care of the Child with Cystic Diagnostic Evaluation, 564
Fibrosis, 525 Therapeutic Management, 565
Tuberculosis, 526 Nursing Care of the Child with Kawasaki
Etiology, 526 Disease, 565
Incidence, 527 Hypertension, 565
Manifestations, 527 Etiology, 566
Diagnostic Evaluation, 527 Incidence, 566
Therapeutic Management and Nursing Manifestations, 566
Considerations, 527 Diagnostic Evaluation, 566
22 The Child with a Cardiovascular Alteration, 531 Therapeutic Management, 566
Review of the Heart and Circulation, 531 Nursing Care of the Child with
Normal Cardiac Anatomy and Hypertension, 567
Physiology, 531 Cardiomyopathies, 568
Fetal Circulation, 532 High Cholesterol Levels in Children and
Transitional and Neonatal Circulation, 533 Adolescents, 568
Congenital Heart Disease, 535 Assessment of Children at Risk, 568
Classification of Congenital Heart Therapeutic Management, 569
Disease, 535 Nursing Considerations, 569
Physiologic Consequences of Congenital Heart 23 The Child with a Hematologic Alteration, 571
Disease in Children, 535 Review of the Hematologic System, 571
Heart Failure, 535 Iron Deficiency Anemia, 573
Nursing Care Plan: The Child with Heart Etiology and Incidence, 573
Failure, 538 Manifestations, 573
Pulmonary Hypertension, 541 Diagnostic Evaluation, 573
Cyanosis, 541 Therapeutic Management, 573
Nursing Care of the Child with Cyanosis, 542 Sickle Cell Disease, 574
Assessment of the Child with a Cardiovascular Nursing Care Plan: The Child with Iron
Alteration, 543 Deficiency Anemia, 575
Cardiovascular Diagnosis, 544 Etiology, 575
Cardiac Catheterization, 546 Incidence, 575
The Child Undergoing Cardiac Manifestations, 575
Surgery, 547 Diagnostic Evaluation, 577
Preoperative Preparation, 547 Therapeutic Management, 578
Postoperative Management, 547 Nursing Care Plan: The Child with Sickle Cell
Acquired Heart Disease, 557 Disease, 579
Infective Endocarditis, 557 Thalassemia, 580
Nursing Care of the Child with Infective Etiology and Incidence, 580
Endocarditis, 558 Manifestations, 580

Diagnostic Evaluation, 581 24 The Child with Cancer, 596

Therapeutic Management, 581 Review of Cancer, 596
Nursing Care of the Child with Beta- The Child with Cancer, 599
Thalassemia, 582 Incidence, 599
Hemophilia, 583 Childhood Cancer and Its Treatment, 599
Etiology and Incidence, 583 Therapeutic Management, 599
Manifestations, 583 Leukemia, 605
Diagnostic Evaluation, 583 Etiology, 605
Therapeutic Management, 583 Incidence, 605
Nursing Care Plan: The Child with Manifestations, 605
Hemophilia, 584 Diagnostic Evaluation, 605
von Willebrand’s Disease, 585 Therapeutic Management, 606
Etiology, 585 Nursing Care Plan: The Child with Leukemia, 607
Pathophysiology, 585 Brain Tumors, 611
Manifestations, 586 Etiology, 611
Diagnostic Evaluation, 586 Incidence, 611
Therapeutic Management, 586 Manifestations, 611
Nursing Care of the Child with von Diagnostic Evaluation, 612
Willebrand’s Disease, 586 Therapeutic Management, 613
Immune Thrombocytopenic Purpura, 587 Nursing Care of the Child with a Brain
Etiology and Incidence, 587 Tumor, 613
Pathophysiology, 587 Malignant Lymphomas, 614
Manifestations, 587 Non-Hodgkin Lymphoma, 614
Diagnostic Evaluation, 587 Nursing Care of the Child with Non-Hodgkin
Therapeutic Management, 587 Lymphoma, 615
Nursing Care of the Child with Immune Hodgkin Disease, 616
Thrombocytopenic Purpura, 588 Neuroblastoma, 617
Disseminated Intravascular Etiology, 617
Coagulation, 589 Incidence, 617
Etiology, 589 Pathophysiology, 617
Manifestations, 589 Manifestations, 617
Diagnostic Evaluation, 589 Diagnostic Evaluation, 617
Therapeutic Management, 589 Therapeutic Management, 617
Nursing Considerations, 590 Nursing Care of the Child with
Aplastic Anemia, 590 Neuroblastoma, 618
Etiology and Incidence, 590 Osteosarcoma, 618
Manifestations, 590 Etiology, 618
Diagnostic Evaluation, 590 Incidence, 618
Therapeutic Management, 590 Pathophysiology, 618
Nursing Care of the Child with Aplastic Manifestations, 619
Anemia, 590 Diagnostic Evaluation, 619
ABO Incompatibility and Hemolytic Disease Therapeutic Management, 619
of the Newborn, 591 Nursing Care of the Child with
Incidence, 591 Osteosarcoma, 619
Manifestations, 591 Ewing Sarcoma, 620
Diagnostic Evaluation, 592 Etiology, 620
Therapeutic Management, 592 Incidence, 620
Nursing Considerations, 592 Pathophysiology, 620
Hyperbilirubinemia, 592 Manifestations, 620
Etiology, 593 Diagnostic Evaluation, 620
Incidence, 593 Therapeutic Management, 620
Manifestations, 593 Nursing Considerations, 620
Diagnostic Evaluation, 593 Rhabdomyosarcoma, 620
Therapeutic Management, 594 Etiology, 620
Nursing Care of the Child with Incidence, 620
Hyperbilirubinemia, 594 Pathophysiology, 620

Manifestations, 621 Incidence, 633

Diagnostic Evaluation, 621 Manifestations, 634
Therapeutic Management, 621 Diagnostic Evaluation, 634
Nursing Considerations, 621 Therapeutic Management, 634
Wilms Tumor, 621 Nursing Care of the Child with Impetigo, 634
Etiology, 621 Cellulitis, 635
Incidence, 621 Etiology and Incidence, 635
Pathophysiology, 621 Pathophysiology, 635
Manifestations, 621 Manifestations, 635
Diagnostic Evaluation, 621 Diagnostic Evaluation, 635
Therapeutic Management, 622 Therapeutic Management, 635
Nursing Care of the Child with Wilms Nursing Care of the Child with Cellulitis, 635
Tumor, 622 Candidiasis, 635
Retinoblastoma, 622 Etiology, 635
Etiology, 622 Incidence, 635
Incidence, 622 Manifestations, 636
Pathophysiology, 623 Diagnostic Evaluation, 636
Manifestations, 623 Therapeutic Management, 636
Diagnostic Evaluation, 623 Nursing Care of the Child with
Therapeutic Management, 623 Candidiasis, 636
Nursing Care of the Child with Tinea Infection, 637
Retinoblastoma, 623 Etiology, 637
Rare Tumors of Childhood, 624 Incidence, 637
25 The Child with Major Alterations in Tissue Manifestations, 637
Integrity, 625 Diagnostic Evaluation, 638
Review of the Integumentary System, 625 Therapeutic Management, 638
Common Variations in the Skin of Newborn Nursing Care of the Child with Tinea
Infants, 627 Infection, 638
Common Birthmarks, 627 Herpes Simplex Virus Infection, 639
Etiology, 627 Etiology, 639
Incidence, 627 Incidence, 639
Manifestations, 627 Manifestations, 639
Diagnostic Evaluation, 627 Diagnostic Evaluation, 640
Therapeutic Management, 627 Therapeutic Management, 640
Nursing Considerations, 627 Nursing Care of the Child with a Herpes
Skin Inflammation, 628 Simplex Infection, 640
Seborrheic Dermatitis, 628 Skin Infestations, 641
Contact Dermatitis, 629 Lice Infestation, 641
Etiology, 629 Etiology, 641
Incidence, 629 Incidence, 641
Manifestations, 629 Manifestations, 641
Diagnostic Evaluation, 629 Diagnostic Evaluation, 642
Therapeutic Management, 629 Therapeutic Management, 642
Nursing Care of the Child with Contact Nursing Care of the Child with
Dermatitis, 629 Pediculosis, 642
Atopic Dermatitis, 630 Mite Infestation (Scabies), 643
Etiology, 630 Etiology, 644
Incidence, 630 Incidence, 644
Manifestations, 631 Pathophysiology, 644
Diagnostic Evaluation, 631 Manifestations, 644
Therapeutic Management, 631 Diagnostic Evaluation, 644
Nursing Care of the Child with Atopic Therapeutic Management, 644
Dermatitis, 632 Nursing Considerations, 644
Skin Infections, 633 Acne Vulgaris, 644
Impetigo, 633 Etiology, 644
Etiology, 633 Incidence, 644

Manifestations and Diagnostic Manifestations, 676

Evaluation, 645 Diagnostic Evaluation, 676
Therapeutic Management, 645 Therapeutic Management, 677
Nursing Care of the Child with Acne Nursing Care of the Child with
Vulgaris, 645 Osteomyelitis, 677
Miscellaneous Skin Disorders, 646 Scoliosis, 678
Insect Bites or Stings, 648 Adolescent Idiopathic Scoliosis (AIS), 678
Burn Injuries, 649 Kyphosis, 681
Etiology, 649 Scheuermann’s Kyphosis, 681
Incidence, 650 Nursing Care Plan: The Adolescent Undergoing
Pathophysiology, 650 a Spinal Fusion, 681
Manifestations, 651 Other Causes of Hyperkyphosis, 683
Therapeutic Management, 651 Limb Differences, 683
Conditions Associated with Major Burn Etiology and Incidence, 683
Injuries, 655 Diagnostic Evaluation, 683
Nursing Care Plan: The Child with a Minor Therapeutic Management and Nursing
Partial-Thickness Burn, 656 Considerations, 683
Conditions Associated with Electrical Developmental Dysplasia of the Hip, 684
Injury, 657 Etiology and Incidence, 685
Cardiac Arrest or Arrhythmia, 659 Manifestations, 685
Tissue Damage, 659 Diagnostic Evaluation, 685
Myoglobinuria, 659 Therapeutic Management, 685
Metabolic Acidosis, 659 Nursing Care of the Child with
Other Complications, 659 Developmental Dysplasia of
26 The Child with a Musculoskeletal Alteration, 661 the Hip, 687
Review of the Musculoskeletal System, 661 Legg-Calvé-Perthes Disease, 688
Skeletal System, 661 Etiology and Incidence, 688
Articular System, 662 Manifestations, 689
Muscular System, 662 Diagnostic Evaluation, 689
Cartilage, 663 Therapeutic Management, 689
Growth and Development, 663 Nursing Care of the Child with Legg-Calvé-
Diagnostic and Laboratory Tests, 663 Perthes Disease, 689
Casts, Traction, and Other Immobilizing Slipped Capital Femoral Epiphysis, 690
Devices, 666 Etiology and Incidence, 690
Splints, 666 Pathophysiology, 690
Casts, 666 Manifestations and Diagnostic
Traction, 666 Evaluation, 690
External Fixation Devices, 668 Therapeutic Management and Nursing
Nursing Considerations, 668 Considerations, 690
Fractures, 671 Clubfoot, 690
Etiology, 671 Etiology and Incidence, 690
Incidence, 671 Manifestations and Diagnostic
Manifestations, 674 Evaluation, 690
Therapeutic Management, 674 Therapeutic Management, 690
Nursing Considerations, 674 Ponseti Casting Method, 691
Soft Tissue Injuries: Sprains, Strains, and Clubfoot Recurrence, 691
Contusions, 675 Nursing Considerations, 691
Etiology, 675 Syndromes and Conditions
Incidence, 675 with Associated Orthopedic
Manifestations and Diagnostic Anomalies, 692
Evaluation, 675 Muscular Dystrophies, 692
Therapeutic Management, 675 Etiology, 692
Nursing Considerations, 675 Incidence, 692
Osteomyelitis, 676 Pathophysiology, 692
Etiology, 676 Manifestations, 692
Incidence, 676 Diagnostic Evaluation, 692

Therapeutic Management, 692 Manifestations, 710

Nursing Considerations, 692 Diagnostic Evaluation, 710
Juvenile Idiopathic Arthritis, 694 Therapeutic Management, 710
Etiology, 695 Nursing Care of the Child with
Incidence, 695 Hyperthyroidism, 710
Manifestations, 695 Diabetes Insipidus, 711
Diagnostic Evaluation, 695 Etiology, 711
Therapeutic Management, 695 Incidence, 711
Nursing Care of the Child Manifestations, 711
with Juvenile Idiopathic Diagnostic Evaluation, 711
Arthritis, 696 Therapeutic Management, 712
27 The Child with an Endocrine or Metabolic Nursing Considerations, 713
Alteration, 700 Syndrome of Inappropriate Antidiuretic
Review of the Endocrine System, 700 Hormone, 713
Diagnostic Tests and Procedures, 702 Etiology, 713
Neonatal Hypoglycemia, 703 Manifestations, 713
Etiology, 703 Diagnostic Evaluation, 713
Incidence, 703 Therapeutic Management, 713
Manifestations, 703 Nursing Considerations, 713
Diagnostic Evaluation, 703 Precocious Puberty, 714
Therapeutic Management, 704 Etiology, 714
Nursing Considerations, 704 Incidence, 714
Neonatal Hypocalcemia, 704 Manifestations, 714
Phenylketonuria, 704 Diagnostic Evaluation, 714
Etiology, 704 Therapeutic Management, 714
Incidence, 704 Nursing Care of the Child with Precocious
Manifestations, 705 Puberty, 715
Diagnostic Evaluation, 705 Growth Hormone Deficiency, 716
Therapeutic Management, 705 Etiology, 716
Nursing Considerations, 705 Incidence, 716
Inborn Errors of Metabolism, 705 Manifestations, 716
Congenital Adrenal Hyperplasia, 705 Diagnostic Evaluation, 717
Etiology, 706 Therapeutic Management, 717
Manifestations, 706 Nursing Care of the Child with Growth
Diagnostic Evaluation, 706 Hormone Deficiency, 717
Therapeutic Management, 706 Diabetes Mellitus, 718
Nursing Considerations, 706 Type 1 Diabetes Mellitus, 718
Congenital Hypothyroidism, 707 Etiology, 718
Etiology, 707 Incidence, 718
Incidence, 707 Manifestations, 718
Manifestations, 707 Diagnostic Evaluation, 718
Diagnostic Evaluation, 708 Therapeutic Management, 718
Therapeutic Management, 708 Nursing Care Plan: The Child with Type 1
Nursing Care of the Child with Congenital Diabetes Mellitus in the Community
Hypothyroidism, 708 Setting, 724
Acquired Hypothyroidism, 709 Diabetic Ketoacidosis, 728
Etiology, 709 Etiology, 728
Pathophysiology, 709 Manifestations, 728
Manifestations, 709 Diagnostic Evaluation, 728
Diagnostic Evaluation, 709 Therapeutic Management, 728
Therapeutic Management, 709 Nursing Care Plan: The Child in Diabetic
Nursing Care of the Child with Acquired Ketoacidosis (DKA), 728
Hypothyroidism, 709 Long-Term Health Care Needs for the Child
Hyperthyroidism (Graves Disease), 710 with Type 1 Diabetes Mellitus, 729
Incidence, 710 Type 2 Diabetes Mellitus, 730
Pathophysiology, 710 Etiology, 730

Incidence, 730 Nursing Care of the Child with a Spinal Cord

Manifestations, 730 Injury, 752
Diagnostic Evaluation, 730 Seizure Disorders, 754
Therapeutic Management, 730 Etiology, 754
28 The Child with a Neurologic Alteration, 733 Incidence, 754
Review of the Central Nervous Pathophysiology, 754
System, 733 Manifestations, 754
Embryologic Development, 733 Diagnostic Evaluation, 754
The Myelin Sheath, 733 Therapeutic Management, 755
The Neural System, 733 Status Epilepticus, 756
The Axial Skeleton, 734 Etiology, 756
The Meninges, 735 Incidence, 756
The Brain, 735 Nursing Care Plan: The Child with a Seizure
The Cranial Nerves, 735 Disorder in a Community Setting, 757
The Spinal Cord, 735 Pathophysiology, 759
Cerebrospinal Fluid, 735 Manifestations, 759
Cerebral Blood Flow and Intracranial Diagnostic Evaluation, 759
Regulation, 735 Therapeutic Management, 759
Increased Intracranial Pressure, 737 Nursing Care of the Child with Status
Etiology, 737 Epilepticus, 759
Nursing Care Plan: The Child with a Neurologic Meningitis, 759
System Disorder, 738 Etiology, 760
Manifestations, 740 Incidence, 760
Diagnostic Evaluation and Therapeutic Manifestations, 760
Management, 742 Diagnostic Evaluation, 760
Spina Bifida, 742 Therapeutic Management, 760
Etiology and Incidence, 742 Nursing Care of the Child with
Manifestations, 742 Meningitis, 761
Diagnostic Evaluation, 744 Guillain-Barré Syndrome, 762
Therapeutic Management, 744 Incidence, 762
Hydrocephalus, 744 Pathophysiology, 762
Etiology, 744 Manifestations, 762
Incidence, 745 Diagnostic Evaluation, 762
Manifestations and Diagnostic Therapeutic Management, 762
Evaluation, 745 Nursing Care of the Child with Guillain-Barré
Therapeutic Management, 745 Syndrome, 763
Cerebral Palsy, 746 Neurologic Conditions Requiring Critical
Etiology and Incidence, 746 Care, 764
Manifestations, 746 Headaches, 764
Diagnostic Evaluation and Therapeutic Etiology, 764
Management, 747 Incidence, 764
Head Injury, 747 Manifestations, 764
Types of Head Injuries, 747 Diagnostic Evaluation, 764
Nursing Care Plan: The Child with Cerebral Nursing Care of the Child with
Palsy in the Community Setting, 748 Headaches, 764
Incidence, 749 29 Psychosocial Problems in Children and
Manifestations, 749 Families, 769
Diagnostic Evaluation, 749 Overview of Psychosocial Disorders of
Therapeutic Management, 750 Childhood, 769
Nursing Considerations, 750 Precipitating Factors, 770
Spinal Cord Injury, 751 Diagnostic Evaluation, 770
Etiology, 751 Emotional Disorders, 771
Incidence, 751 Anxiety Disorders, 771
Manifestations, 751 Mood Disorders, 773
Diagnostic Evaluation, 752 Etiology and Physiology of Emotional
Therapeutic Management, 752 Disorders, 774

Therapeutic Management of Children with Diagnostic Evaluation, 801

Emotional Disorders, 774 Management, 801
Nursing Care of the Child with an Emotional Nursing Care Plan: The Child with a
Disorder, 775 Developmental Disorder or Disability in the
Suicide, 776 Community Setting, 802
Manifestations and Risk Factors, 776 DISORDERS RESULTING IN INTELLECTUAL
Therapeutic Management, 777 OR DEVELOPMENTAL DISABILITY, 803
Nursing Care of the Child or Adolescent At Down Syndrome, 803
Risk for Suicide, 777 Etiology, 804
Behavioral Disorders, 778 Incidence, 804
Etiology, 778 Manifestations, 805
Manifestations, 779 Diagnostic Evaluation, 806
Diagnostic Evaluation, 779 Therapeutic Management, 806
Therapeutic Management, 779 Nursing Care of the Child with Down
Nursing Care of the Child with Attention Syndrome, 806
Deficit–Hyperactivity Disorder, 779 Fragile X Syndrome, 807
Eating Disorders: Anorexia Nervosa and Etiology, 807
Bulimia Nervosa, 780 Incidence, 807
Etiology, 781 Manifestations, 807
Manifestations, 781 Diagnostic Evaluation, 808
Diagnostic Evaluation, 781 Therapeutic Management, 808
Therapeutic Management, 781 Nursing Considerations, 808
Nursing Care of the Child or Adolescent with Rett Syndrome, 808
an Eating Disorder, 782 Fetal Alcohol Spectrum Disorder, 809
Substance Abuse, 783 Etiology and Incidence, 809
Etiology, 785 Manifestations, 809
Manifestations, 785 Diagnostic Evaluation, 809
Therapeutic Management, 785 Nursing Care of the Infant with Fetal Alcohol
Nursing Care of the Child or Adolescent with a Syndrome, 809
Substance Disorder, 785 Nonorganic Failure to Thrive, 810
Infant with Neonatal Abstinence Etiology, 810
Syndrome, 786 Incidence, 810
Incidence, 786 Manifestations and Risk Factors, 810
Manifestations, 786 Diagnostic Evaluation, 810
Diagnostic Evaluation, 786 Therapeutic Management, 810
Therapeutic Management, 786 Nursing Considerations, 811
Nursing Considerations, 787 Autism Spectrum Disorders, 811
Childhood Physical and Emotional Abuse and Asperger Syndrome, 811
Child Neglect, 787 Autism, 811
Etiology, 787 Incidence, 812
Incidence, 787 Manifestations, 812
Manifestations, 787 Diagnostic Evaluation, 813
Nursing Care Plan: The Abused Child, 790 Therapeutic Management, 813
30 The Child with a Developmental Disability, 795 Nursing Care of the Child with
Genetics and Genomics, 795 Autism, 813
Intellectual and Developmental 31 The Child with a Sensory Alteration, 816
Disorders, 797 Review of the Eye, 816
Developmental Disability and the Americans Structure and Function, 816
with Disabilities Act: The Impact of Neonatal Development, 816
Public Policy, 797 Review of the Ear, 816
Terminology, 798 Structure and Function, 816
Etiology of Intellectual Disabilities and Neonatal Development, 817
Pervasive Developmental Disorders, 799 Speech Development, 817
Incidence of Intellectual and Developmental Disorders of the Eye, 818
Disorders, 799 Nursing Considerations for the Child with
Manifestations, 799 Color Deficiency, 818

Nursing Considerations for the Child with a Eye Trauma, 825

Blocked Lacrimal Duct, 819 Nursing Considerations for the Child with a
Nursing Considerations for the Child with a Corneal Abrasion, 825
Refractive Error, 819 Nursing Considerations for the Child with
Nursing Considerations for the Child with Hemorrhage, 825
Amblyopia, 820 Nursing Considerations for the Child with
Nursing Considerations for the Child with Hyphema, 825
Strabismus, 820 Nursing Considerations for the Child with a
Nursing Considerations for the Child with Chemical Splash Injury, 826
Glaucoma, 821 Hearing Loss in Children, 826
Nursing Considerations for the Child with a Etiology, 826
Cataract, 822 Incidence, 826
Nursing Care Plan: The Child Having Eye Diagnostic Evaluation, 827
Surgery, 822 Therapeutic Management, 828
Eye Surgery, 824 Nursing Considerations for the Child with
Eye Infections, 824 Hearing Loss, 828
Nursing Considerations for the Child with Language Disorders, 829
Conjunctivitis, 824
Nursing Considerations for the Child with
Orbital Cellulitis, 824
Nursing Considerations for the Child with a Glossary, 831
Corneal Ulcer, 825 Index, 837

Introduction to Nursing
Care of Children

After studying this chapter, you should be able to:
• Describe the historical background of children’s health care. • Relate how major social issues, such as poverty and access to
• Identify trends that led to the development of family-centered health care, affect children’s health.
care of children. • Describe the legal basis for nursing practice.
• Describe issues that affect child health nursing, including cost • Identify measures used to defend malpractice claims.
containment, outcomes management, home care, and advances • Explain roles the nurse may assume in pediatric nursing practice.
in technology. • Explain the roles of nurses with advanced education for pediatric
• Discuss trends in infant and childhood mortality rates. nursing practice.
• Identify some of the effects of poverty and violence on children • Describe the steps of the nursing process and relate them to
and families. nursing care of children.
• Apply theories and principles of ethics to ethical dilemmas. • Explain issues surrounding the use of complementary and
• Discuss ethical conflicts that the nurse may encounter in pediatric alternative therapies.
nursing practice. • Discuss the importance of nursing research in clinical practice.

children have been highly valued and their birth considered a blessing.
Viewed by society as miniature adults, children in the past received the
To better understand contemporary child health nursing, the nurse same remedies as adults and during illness were cared for at home by
needs to understand the history of this field, trends and issues affecting family members, just as adults were.
contemporary practice, and the ethical and legal frameworks within
which pediatric nursing care is provided. Societal Changes
On the North American continent, as European settlements expanded
during the seventeenth and eighteenth centuries, children were valued
HISTORICAL PERSPECTIVES as assets to the community because of the desire to increase the popula-
The nursing care of children has been influenced by multiple historical tion and share the work. Public schools were established, and the
and social factors. Children have not always enjoyed the valued posi- courts began to view children as minors and protect them accordingly.
tion that they hold in most families today. Historically, in times of Devastating epidemics of smallpox, diphtheria, scarlet fever, and
economic or social instability, children have been viewed as expend- measles took their toll on children in the eighteenth century. Children
able. In societies in which the struggle for survival is the central issue often died of these virulent diseases within 1 day.
and only the strongest survive, the needs of children are secondary. The The high mortality rate in children led some physicians to examine
well-being of children in the past depended on the economic and common child-care practices. In 1748 William Cadogan’s “Essay Upon
cultural conditions of the society. At times parents have viewed their Nursing” discouraged unhealthy child-care practices, such as swad-
children as property, and children have been bought and sold, beaten, dling infants in three or four layers of clothing and feeding them thin
and, in some cultures, sacrificed in religious ceremonies. At times, gruel within hours after birth. Instead, Cadogan urged mothers to
infanticide has been a routine practice. Conversely, in other instances, breastfeed their infants and identified certain practices that were

2 CHAPTER 1â•… Introduction to Nursing Care of Children


Title V of Social Security Act Provides funds for maternal and child health programs
National Institute of Health and Human Development Supports research and education of personnel needed for maternal and child health programs
Title V Amendment of Public Health Service Act Established the Maternal and Infant Care (MIC) project to provide comprehensive prenatal and infant
care in public clinics
Title XIX of Medicaid program Provides funds to facilitate access to care by pregnant women and young children
Head Start program Provides educational opportunities for low-income children of preschool age
Women, Infants, and Children (WIC) program Provides supplemental food and nutrition information
Temporary Assistance to Needy Families (TANF) Provides temporary money for basic living costs of poor children and their families, with eligibility
requirements and time limits varying among states; tribal programs available for Native Americans
Replaces Aid to Families with Dependent Children (AFDC)
Healthy Start program Enhances community development of culturally appropriate strategies designed to decrease infant
mortality and causes of low birth weights
Individuals with Disabilities Education Act (PL 94-142) Provides for free and appropriate education of all disabled children
National School Lunch/Breakfast program Provides nutritionally appropriate free or reduced-price meals to students from low-income families

thought to contribute to childhood illness. Unfortunately, despite the vaccines against many communicable diseases saved the lives of tens
efforts of Cadogan and others, child-care practices were slow to change. of thousands of children. Technologic advances in the 1970s and 1980s,
Later in the eighteenth century, the health of children improved with which led to more children surviving conditions that had previously
certain advances such as inoculation against smallpox. been fatal (e.g., cystic fibrosis), resulted in an increasing number of
In the nineteenth century, with the flood of immigrants to eastern children living with chronic disabilities. An increase in societal concern
American cities, infectious diseases flourished as a result of crowded for children brought about the development of federally supported
living conditions; inadequate and unsanitary food; and harsh working programs designed to meet their needs, such as school lunch programs,
conditions for men, women, and children. It was common for children the Special Supplemental Nutrition Program for Women, Infants,
to work 12- to 14-hour days in factories, and their earnings were and Children (WIC), and Medicaid (Table 1-1), under which the
essential to the survival of the family. The most serious child health Early and Periodic Screening, Diagnosis, and Treatment program was
problems during the nineteenth century were caused by poverty and implemented.
overcrowding. Infants were fed contaminated milk, sometimes from
tuberculosis-infected cows. Milk was carried to the cities and pur- Development of Family-Centered Child Care
chased by mothers with no means to refrigerate it. Infectious diarrhea Family-centered child health care developed from the recognition that
was a common cause of infant death. the emotional needs of hospitalized children usually were unmet.
During the late nineteenth century, conditions began to improve Parents were not involved in the direct care of their children. Children
for children and families. Lillian Wald initiated public health nursing were often unprepared for procedures and tests, and visiting was
at Henry Street Settlement House in New York City, where nurses severely controlled and even discouraged.
taught mothers in their homes. In 1889 a milk distribution center Family-centered care is based on a philosophy that recognizes and
opened in New York City to provide uncontaminated milk to sick respects the pivotal role of the family in the lives of both well and ill
infants. children. It strives to support families in their natural caregiving roles
and promotes healthy patterns of living at home and in the commu-
Hygiene and Hospitalization nity. Finally, parents and professionals are viewed as equals in a part-
The discoveries of scientists such as Pasteur, Lister, and Koch, who nership committed to excellence at all levels of health care.
established that bacteria caused many diseases, supported the use of Most health care settings have a family-centered philosophy in
hygienic practices in hospitals and foundling homes. Hospitals began which families are given choices, provide input, and are given informa-
to require personnel to wear uniforms and limit contact among chil- tion that is understandable by them. The family is respected, and its
dren in the wards. In an effort to prevent infection, hospital wards were strengths are recognized.
closed to visitors. Because parental visits were noted to cause distress, The Association for the Care of Children’s Health (ACCH), an
particularly when parents had to leave, parental visitation was consid- interdisciplinary organization, was founded in 1965 to provide a forum
ered emotionally stressful to hospitalized children. In an effort to for sharing experiences and common problems and to foster growth
prevent such emotional distress and the spread of infection, parents in children who must undergo hospitalization. Today the organization
were prohibited from visiting children in the hospital. Because hospital has broadened its focus on child health care to include the community
care focused on preventing disease transmission and curing physical and the home.
diseases, the emotional health of hospitalized children received little Through the efforts of ACCH and other organizations, increasing
attention. attention has been paid to the psychological and emotional effects of
During the twentieth century, as knowledge about nutrition, hospitalization during childhood. In response to greater knowledge
sanitation, bacteriology, pharmacology, medication, and psychology about the emotional effects of illness and hospitalization, hospital
increased, dramatic changes in child health occurred. In the 1940s policies and health care services for children have changed. Twenty-
and 1950s medications such as penicillin and corticosteroids and four-hour parental and sibling visitation policies and home
CHAPTER 1â•… Introduction to Nursing Care of Children 3

care services have become common. The psychological preparation of

children for hospitalization and surgery has become standard nursing
practice. Many hospitals have established child life programs to help
children and their families cope with the stress of illness. Shorter hos- AHS-1 Increase the proportion of persons with health insurance.
pital stays, home care, and day surgery also have helped minimize the AHS-5.2 Increase the proportion of children and youth ages 17 and
emotional effects of hospitalization and illness on children. under who have a specific source of ongoing care.
AH-6 Reduce the proportion of individuals who are unable to obtain
or delay in obtaining necessary medical care, dental care, or
prescription medicines.
During recent years the government, insurance companies, hospitals, DH-20 Increase the proportion of children with disabilities, birth
and health care providers have made a concerted effort to reform through age 2 years, who receive early intervention services
health care delivery in the United States and to control rising health in home or community-based settings.
care costs. This trend has involved a change in where and how money EMC-1 Increase the proportion of parents who use positive parenting
is spent. In the past, most of the health care budget was spent in acute and communicate with their doctors or other health care
care settings, where the facility charged for services after the services professionals about positive parenting.
were provided. Because hospitals were paid for whatever materials and ECBP-1&2 Increase the proportion of preschool, elementary, middle, and
services they provided, they had no incentive to be efficient or cost senior high schools that provide comprehensive school health
conscious. More recently, the focus has been on health promotion, the education to prevent health problems in the following areas:
provision of care designed to keep people healthy and prevent illness. unintentional injury; violence; suicide; tobacco use and
In late 2010 the U.S. Department of Health and Human Services addiction; alcohol or other drug use; unintended pregnancy,
(USDHHS) launched Healthy People 2020, a comprehensive, nation- HIV/AIDS, and STD infection; unhealthy dietary patterns;
wide health promotion and disease prevention agenda that builds on and inadequate physical activity.
groundwork initiated 30 years ago. Developed with input from widely ECBP-11 (Developmental) Increase the proportion of local health
diverse constituencies, Healthy People 2020 expands on goals and departments that have established culturally appropriate
objectives developed for Healthy People 2010. While a major focus of and linguistically competent community health promotion
Healthy People 2010 was reducing disparities and increasing access to and disease prevention programs.
care, Healthy People 2020 re-emphasizes that goal and expands it to EH-8 Reduce blood lead levels in children.
address “determinants of health,” or those factors that contribute IID-7 Achieve and maintain effective vaccination coverage levels for
to keeping people healthy and achieving high quality of life (USDHHS, universally recommended vaccines among young children.
2010b). IVP-1 Reduce fatal and nonfatal injuries (includes: motor vehicle
Many of the national health objectives in Healthy People 2020 are crashes, poisoning, falls, suffocation, sports-related, firearm,
applicable to children and families. In fact, among the thirteen new homicide and self-harm).
and additional topic areas, two, Adolescent Health and Early and IVP-42 Reduce children’s exposure to violence.
Middle Childhood, are specifically directed to the health of children NWS-10 Reduce the proportion of children and adolescents who are
and adolescents. Benchmarks that will evaluate progress toward considered obese.
achieving the Healthy People 2020 objectives are called “Foundation OH-8 Increase the proportion of low-income children and
Health Measures” and these include general health status, health- adolescents who received any preventive dental service
related quality of life and well-being, determinants of health, and pres- during the past year.
ence of disparities (USDHHS, 2010b). National data measuring the PA-4 Increase the proportion of the Nation’s public and private
objectives are gathered from federal and state departments and from schools that require daily physical education for all students.
voluntary private, nongovernmental organizations.
*Abbreviations refer to specific topic areas.
The focus of nursing care of children has changed as national atten-
tion to health promotion and disease prevention has increased. Even
acutely ill children have only brief hospital stays because increased
technology has facilitated parents’ ability to care for children in the Cost Containment
home or community setting. Most acute illnesses are managed in Recently, the government, insurance companies, hospitals, and health
ambulatory settings, leaving hospital admission for the extremely care providers have made a concerted effort to reform health care
acutely ill or children with complex medical needs. Nursing care for delivery in the United States and control rising costs. This trend has
hospitalized children has become more specialized, and much nursing involved a change in where and how money is spent.
care is provided in community settings such as schools and outpatient One way in which those paying for health care have attempted to
clinics. control costs is by shifting to a prospective form of payment. In this
The current practice of child health nursing requires nurses to arrangement clients no longer pay whatever charges the hospital
understand the importance of adapting procedures to the specific decides on for service provided. Instead, a fixed amount of money is
needs of children and families and to think critically about children’s agreed to in advance for necessary services for specifically diagnosed
developmental differences. For example, why do infants and children conditions. Any of several strategies have been used to contain the cost
become so acutely ill so quickly? Is there a smaller margin of safety of services.
when administering fluids or medications to children? Other adapta-
tions are directed toward issues such as protecting children, providing Diagnosis-Related Groups
for their activity, assessing nonverbal behaviors, planning and carrying Diagnosis-related groups (DRGs) are a method of classifying related
out nursing care, and teaching home care to children and families. medical diagnoses based on the amount of resources that are generally
Table 1-2 presents principles of caring for children. required by the client. This method became a standard in 1987, when
4 CHAPTER 1â•… Introduction to Nursing Care of Children


Growth and The nurse applies growth and development principles to meet the child’s physical and emotional needs. Involves understanding the
development principles of maturation, physiologic immaturity, and response to illness. Nursing care is tailored to the child’s chronologic age and
developmental level.
Health promotion Guides the child and family toward independent responsibility for health. Anticipatory guidance is education that facilitates health
promotion by providing developmentally appropriate information about nutrition, exercise, safety, play, and wellness issues such as
immunizations and injury prevention.
Family focus Family-centered care is at the core of nursing of children because of the intimate relationship between the child and family in areas of
support, love, security, values, beliefs, attitudes, and health practices. Because the family is a partner in the child’s care, the nurse
provides information for appropriate decision making, assesses family needs, and refers the family to appropriate resources within
the community.
Child advocacy Includes specific responsibilities as child advocates in the areas of health promotion, violence, abuse, neglect, drug abuse, infant
morbidity and mortality, and access to care. Nurses exercise legal and ethical responsibilities cautiously, being aware of their
Communication Nurses use a variety of techniques to communicate with children and families in a developmentally appropriate manner. Includes use
of play and other developmentally appropriate verbal and nonverbal communication techniques for effective communication.
Concepts applied Integration of the principles of pediatric nursing care across many disorders and with all age-groups. Recognizes that with any health
across age groups encounter, children may have needs related to play and activity, chronicity, nutrition, safety, illness, and family. Knowing
pathophysiologic human development, family theory, and evidence-based principles enhances nursing care.

the federal government set the amount of money that would be paid Capitated Care
by Medicare for each DRG. If the facility delivers more services or has Capitation may be incorporated into any type of managed care plan.
greater costs than what it will be reimbursed for by Medicare, the facil- In a pure capitated care plan, the employer (or government) pays a set
ity must absorb the excess costs. Conversely, if the facility delivers the amount of money each year to a network of primary care providers.
care at less cost than the payment for that DRG, the facility keeps the This amount might be adjusted for age and sex of the client group. In
remaining money. Health care facilities working under this arrange- exchange for access to a guaranteed client base, the primary care pro-
ment benefit financially if they can reduce the client’s length of stay viders agree to provide general health care and to pay for all aspects of
and thereby reduce the costs for service. Although the DRG system the client’s care, including laboratory work, specialist visits, and hos-
originally applied only to Medicare clients, most states have adopted pital care.
the system for Medicaid payments, and most insurance companies use Capitated plans are of interest to employers as well as the govern-
a similar system. ment because they allow a predictable amount of money to be
budgeted for health care. Clients do not have unexpected financial
Managed Care burdens from illness. However, clients lose most of their freedom of
Health insurance companies also examined the cost of health care and choice regarding who will provide their care. Providers can lose money
instituted a health care delivery system that has been called managed (1) if they refer too many clients to specialists, who may have no
care. Examples of managed care organizations are health maintenance restrictions on their fees, (2) if they order too many diagnostic tests,
organizations (HMOs), point of service plans (POSs), and preferred or (3) if their administrative costs are too high. Some health care pro-
provider organizations (PPOs). HMOs provide relatively comprehen- viders and consumers fear that cost constraints might affect treatment
sive health services for people enrolled in the organization for a set fee decisions.
or premium. Similarly, PPOs are groups of health care providers who
agree to provide health services to a specific group of clients at a dis- Effects of Cost Containment
counted cost. When the client needs medical treatment, managed care Prospective payment plans have had major effects on infant care, pri-
includes strategies such as payment arrangements and preadmission marily in relation to the length of stay. Mothers who have a normal
or pretreatment authorization to control costs. vaginal birth are typically discharged from the hospital at 48 hours
Managed care, provided appropriately, can increase access to a full after birth and 96 hours for cesarean births, unless the woman and her
range of health care providers and services for children, but it must be health care provider choose an earlier discharge time. This leaves little
closely monitored. Nurses serve as advocates in the areas of preventive, time for nurses to adequately teach new parents newborn care and to
acute, and chronic care for children. The teaching time lines for pre- assess infants for subtle health issues. Nurses find providing adequate
ventive and home care have been shortened drastically, and the call to information about infant care is especially difficult when the mother
“begin teaching the moment the child enters the health care system” is still recovering from childbirth. Problems with earlier discharge of
has taken on a new meaning. Parents, the child, and other caregivers mother and infant often require readmission and more expensive
are being asked to do procedures at home that were once done by treatment than might have been needed if the problem had been iden-
professionals in a hospital setting. Systems must be in place to monitor tified early.
adherence, understanding, and the total care of a child. Assessment and Another concern in regard to cost containment is that some chil-
communication skills need to be keen, and the nurse must be able to dren with chronic health conditions have been denied care or denied
work with specialists in other disciplines. insurance coverage because of pre-existing conditions. Denying care
CHAPTER 1â•… Introduction to Nursing Care of Children 5

can exacerbate a child’s condition, resulting in greater cost for the Evidence-Based Nursing Care
health care system, not to mention greater emotional cost for the child The Agency for Healthcare Research and Quality (AHRQ), a branch of
and family. the U.S. Public Health Service, actively sponsors research in health
Despite efforts to contain costs related to the provision of health issues facing children. From research generated through this agency as
care in the United States, the percentage of the total government well as others, evidence can be accumulated to guide the best clinical
expenditures for services (Gross Domestic Product) allocated to health practices. Focus of research from AHRQ is primarily on access to care
care was 17.6% in 2009, markedly higher than many similar developed for children and adolescents. This includes such topics as: timeliness
countries (Centers for Medicare and Medicaid, 2011; Kaiser Family of care (care is provided as soon as necessary), patient-centeredness
Foundation, 2011). This percentage has nearly doubled since 1980 and, (quality of communication with providers), coordination of care for
without true health care reform, is expected to continue to increase. children with chronic illnesses, access to a medical home, and safe
In March, 2010, the Patient Protection and Affordable Care Act was medication delivery systems (AHRQ, 2011). Effectiveness of health
signed into law. Designed to reign in health care costs while increasing care also is a priority for research funding; this focus area includes
access to the underserved, provisions of this law are to be phased in immunizations, preventive vision care, preventive dental care, weight
over the course of four years (USDHHS, 2011b). In general improved monitoring, and mental health and substance abuse monitoring
access will occur through access to affordable insurance coverage for (AHRQ, 2011). Clinical practice guidelines are an important tool in
all citizens. Persons who do not have access to insurance coverage developing parameters for safe, effective, and evidence-based care for
through employer provided insurance plans will be able to purchase children and families. AHRQ has developed several guidelines related
insurance through an insurance exchange, which will offer a variety of to adult and child care, as have other organizations and professional
coverage options at competitive rates (USDHHS, 2011b). Several of groups concerned with children’s health. Important children’s health
the provisions of this law specifically address the needs of children and issues, which include quality and safety improvements, enhanced
families. They include the following (USDHHS, 2011b): primary care, access to quality care, and specific illnesses, are addressed
• Prohibiting insurance companies from denying care based on in available practice guidelines. For detailed information see the
pre-existing conditions for children younger than 19 years old. website at or
• Keeping young adults on their family’s health insurance plan The Institute of Medicine (IOM) (2011) has published standards
until age 26 years. for developing practice guidelines to maximize the consistency within
• Coordinated management for children and other individuals and among guidelines, regardless of guideline developers. The IOM
with chronic diseases. recommends inclusion of important information and process steps in
• Expanding the number of community health centers every guideline. This includes ensuring diversity of members of a clini-
• Increasing access to preventive health care. cal guideline group; full disclosure of conflict of interest; in-depth
• Providing for home visits to pregnant women and newborns. systematic reviews to inform recommendations; providing a rationale,
• Supporting states to expand Medicaid coverage. quality of evidence, and strength of recommendation for each recom-
• Providing additional funding for the Children’s Health Insur- mendation made by the guideline committee; and external review of
ance Program (CHIP). recommendations for validity (IOM). Standardization of clinical prac-
An additional provision of the Affordable Care Act is the creation tice guidelines will strengthen evidence-based care, especially for
of Accountable Care Organizations (ACO). These are groups of hos- guidelines developed by nurses or professional nursing organizations.
pitals, physicians’ offices, community agencies and any agency that
provides health care to patients. Enhancing patient-centered care, the Outcomes Management
ACO collaborates on all aspects of coordination, safety, and quality for The determination to lower health care costs while maintaining the
individuals within the organization. The ACO will reduce duplication quality of care has led to a clinical practice model called outcomes
of services, decrease fragmentation of care, and give more control to management. This is a systematic method to identify outcomes and to
patients and families (USDHHS, 2011a). focus care on interventions that will accomplish the stated outcomes
Cost containment measures have also altered traditional ways of for children with specific issues, such as the child with asthma.
providing patient-centered care. There is an increased focus on ensur- Nurse Sensitive Indicators.╇ In response to recent efforts to address
ing quality and safety through such approaches as case management, both quality and safety issues in health care, various government and
use of clinical practice guidelines and evidence-based nursing care, and privately funded groups have sponsored research to identify patient
outcomes management. care outcomes that are particularly dependent on the quality and
quantity of nursing care provided. These outcomes, called nurse sensi-
Case Management tive indicators, are based on empirical data collected by such organiza-
Case management is a practice model that uses a systematic approach tions as the AHRQ and the National Quality Forum (NQF), and
to identify specific clients, determine eligibility for care, arrange access represent outcomes that improve with optimal nursing care (American
to appropriate resources and services, and provide continuity of care Nurses’ Association [ANA], 2011; Lacey, Smith, & Cox, 2008). The
through a collaborative model (Lyon & Grow, 2011). In this model, a following are in the process of development and delineation for pedi-
case manager or case coordinator, who focuses on both quality and cost atric nurses: adequate pain assessment, peripheral intravenous infiltra-
outcomes, coordinates the services needed by the client and family. tion, pressure ulcer, catheter-related bloodstream infection, smoking
Inherent to case management is the coordination of care by all members cessation for adolescents, and obesity (ANA, 2011; Lacey, Smith, & Cox,
of the health care team. The guidelines established in 1995 by the Joint 2008). Nurses need to use evidence-based intervention to improve
Commission require an interdisciplinary, collaborative approach to these patient outcomes.
patient care. This concept is at the core of case management. Nurses Variances.╇ Deviations, or variances, may occur in either the time
who provide case management evaluate patient and family needs, estab- line or in the expected outcomes. A variance is the difference between
lish needs documentation to support reimbursement, and may be part what was expected and what actually happened. A variance may be
of long-term care planning in the home or a rehabilitation facility. positive or negative. A positive variance occurs when a child progresses
6 CHAPTER 1â•… Introduction to Nursing Care of Children

faster than expected and is discharged sooner than planned. A negative services a family may require, and they frequently supervise the work
variance occurs when progress is slower than expected, outcomes are of other care providers.
not met within the designated time frame, and the length of stay is
Clinical Pathways.╇ One planning tool used by the health care team
to identify and meet stated outcomes is the clinical pathway. Other A model for community care of children is the school-based health
names for clinical pathways include critical or clinical paths, care paths, center. School-based health centers provide comprehensive primary
care maps, collaborative plans of care, anticipated recovery paths, and health care services in the most accessible environment. Students can
multidisciplinary action plans. Clinical pathways are standardized, be evaluated, diagnosed, and treated on site. Services offered include
interdisciplinary plans of care devised for clients with a particular primary preventive care, including health assessments, anticipatory
health problem. The purpose, as in managed care and case manage- guidance, vision and hearing screenings, and immunizations; acute
ment, is to provide quality care while controlling costs. Clinical care; prescription services; and mental health and counseling services.
pathways identify client outcomes, specify time lines to achieve those Some school-based health centers are sponsored by hospitals, local
outcomes, direct appropriate interventions and sequencing of inter- health departments, and community health centers. Many are used in
ventions, include interventions from a variety of disciplines, promote off hours to provide health care to uninsured adults and adolescents.
collaboration, and involve a comprehensive approach to care. Home The role of the school nurse as a care provider has expanded rapidly
health agencies use clinical pathways, which may be developed in col- and school nurses are considered to be primary care providers who
laboration with hospital staff. function as a “safety net” for children (Robert Wood Johnson Founda-
Clinical pathways may be used in various ways. For instance, they tion, 2010). In addition to the health promotion activities described
may be used for change of shift reports to indicate information about previously, school nurses provide complex nursing care to children with
length of stay, individual needs, and priorities of the shift for each chronic conditions or disabilities, manage life-threatening and trau-
child. They also may be used for documentation of the child’s nursing matic events, assist families to access resources, and address students’
care plan and his or her progress in meeting the desired outcomes. health and illness concerns (Robert Wood Johnson Foundation, 2010).
Many pathways are particularly helpful in identifying families that
need follow-up care. Access to Care
Students’ Use of Clinical Pathways.╇ Clinical pathways are guide- Access to care is an important component when evaluating preventive
lines for care. Although a pathway provides insight into the scheduling care and prompt treatment of illness and injuries. Access to health care
of assessments and care, it is not meant to teach nursing skills and is strongly associated with having health insurance. The American
procedures. One purpose of this text is to provide ample information Academy of Pediatrics (2010) has issued a policy statement that states,
so that students can use clinical pathways in a clinical setting. This “All children must have access to affordable and comprehensive quality
involves teaching why and how to perform assessments and to interpret care” (p. 1018). This care should be ensured through access to com-
the significance of the data obtained. Moreover, the text emphasizes prehensive health insurance that can be carried to wherever the child
ways of providing information, care, and comfort for children and and family reside, provide continuous coverage, and allow for free
their families as they progress along a clinical pathway. choice of health providers (AAP, 2010).
Having health insurance coverage, usually employer sponsored,
often determines whether a person will seek care early in the course of
HOME CARE an illness. However, greater restrictions on private insurance are blur-
Home nursing care has experienced dramatic growth since 1990. ring the distinction between private and public health coverage. Many
Advances in portable and wireless technology, such as infusion pumps private health plans have restrictions such as prequalifications for pro-
for administering intravenous nutrition or subcutaneous medications cedures, drugs that the plan covers, and services that are covered.
and various monitoring devices, such as telemonitors, allow nurses, People with employer-sponsored health insurance often find that they
and often clients or family, to perform procedures and maintain must change providers each year because the available plans change, a
equipment in the home. Consumers often prefer home care because situation that may negatively affect the provider-client relationship. As
of decreased stress on the family when the child is able to remain at the Affordable Care Act is phased in over the next few years, these issues
home rather than be separated from the family support system may be resolved.
because of the need for hospitalization. Optimal home care also can
reduce re-admission to the hospital for children with chronic Public Health Insurance Programs
conditions. Despite improvements in federal and state programs that address chil-
Home care services may be provided in the form of telephone calls, dren’s health needs, the number of uninsured children in the United
home visits, information lines, and lactation consultations, among States was 7.5 million in 2009 (most recent figure reported); this rep-
others. Online and wireless technology allows nurses to evaluate data resents 10% of children younger than age 18 years (DeNavas-Walt,
transmitted from home. Infants with congenital anomalies, such as Proctor & Smith, 2010) (Figure 1-1). Health insurance coverage varies
cleft palate, may need care that is adapted to their condition. Moreover, among children by poverty, age, race, and ethnic origin (DeNavas-
increasing numbers of technology-dependent infants and children are Walt, Proctor & Smith, 2010). The proportion of children with health
now cared for at home. The numbers include those needing ventilator insurance is lowest among Hispanic children compared with white
assistance, total parenteral nutrition, intravenous medications, apnea children and lower among poor, near-poor, and middle-income chil-
monitoring, and other device-associated nursing care. dren compared with high-income children (Forum on Child and
Nurses must be able to function independently within established Family Statistics, 2011). Nearly 23% of children in the United States
protocols and must be confident of their clinical skills when providing are underinsured, meaning that their resources are not sufficient to
home care. They should be proficient at interviewing, counseling, and meet their health care needs (Health Resources and Services Adminis-
teaching. They often assume a leadership role in coordinating all the tration [HRSA], 2010a).
CHAPTER 1â•… Introduction to Nursing Care of Children 7

All children
Children in poverty
Household Income
Less than $25,000
$25,000 to $49,999
$50,000 to $74,999
$75,000 or more
Under 6 years
6 to 11 years
12 to 17 years
Race and Hispanic origin
White, not Hispanic
FIG 1-1╇ Uninsured Children by Poverty Status,
Black Household Income, Age, Race and Hispanic Origin,
Asian and Nativity, 2009. Federal surveys now give respon-
Hispanic (any race) dents the option of reporting more than one race.
This figure shows data using the race-alone concept
(e.g., Asian refers to people who reported Asian
Native born
and no other race). (From DeNavas-Walt, C., Proctor,
Naturalized citizen B.D., Smith, J.C., U.S. Census Bureau. [2010].
Not a citizen Current population reports: Income, poverty, and
health insurance coverage in the United States:
0 5 10 15 20 25 30 35 2009, P60-238, Washington, DC: U.S. Government
Percent Printing Office.)

Children in poor and near-poor families are more likely to be requirements, changes in family status, and the complexity of the
uninsured (15.1%) (DeNavas-Walt, Proctor & Smith, 2010), have enrollment process itself (HRSA, 2010b). One proposed approach is to
unmet medical needs, receive delayed medical care, have no usual provide continuity of information management using health informa-
provider of health care, and have higher rates of emergency room tion technology, with online source of information, online application,
service than children in families that are not poor. Greater than 6% of and maintaining an accessible database to verify eligibility (HRSA,
all children have no usual place of health care (Forum on Child and 2010b).
Family Statistics, 2011).
Public health insurance for children is provided primarily through Preventive Health
Medicaid, a federal program that provides health care for certain popu- Oral health of children in the United States has become a topic of
lations of people living in poverty, or the Children’s Health Insurance increasing focus. Services available through Medicaid are limited, and
Program (formerly the State Children’s health Insurance Program), a many dentists do not accept children who are insured by Medicaid.
program that provides access for children not poor enough to be eli- Racial and ethnic disparities exist in this area of health, with a high
gible for Medicaid but whose household income is less than 200% of percentage of non-Hispanic Black school-age children and Mexican-
poverty level. In 2009, funding was renewed for CHIP through the American children having untreated dental caries as compared to non-
Children’s Health Insurance Program Reauthorization Act (CHIPRA); Hispanic white children (Forum on Child and Family Statistics, 2011).
since that time, the number of children insured by Medicaid and CHIP In addition, maternal periodontal disease is emerging as a contributing
increased by 2.6 million (USDHHS, 2010a). factor to prematurity, with its adverse effects on the child’s long-term
Medicaid covered 34.5% of children younger than age 18 years in health.
2009 (National Center for Health Statistics [NCHS], 2011). Medicaid Besides the obvious implication of not having health insurance—
provides health care for the poor, aged, and disabled, with pregnant the inability to pay for health care during illness—another important
women and young children especially targeted. Medicaid is funded effect on children who are not insured exists: They are less likely to
by both the federal government and individual state governments. receive preventive care such as immunizations and dental care. This
The states administer the program and determine which services are places them at increased risk for preventable illnesses and, because
offered. In 2014, a provision of the Affordable Care Act will alter the preventive health care is a learned behavior, these children are more
income requirements for acceptance to Medicaid so that the number likely to become adults who are less healthy.
of eligible children will be increased (USDHHS, 2011a).
Medicaid can be frustrating for a family. The application process Health Care Assistance Programs
often takes weeks and needs to be renewed regularly with supporting Many programs, some funded privately, others by the government,
documentation. The family must fill out lengthy, complicated forms, assist in the care of infants and children. The WIC program, which was
provide documentation of citizenship and income, and then wait for established in 1972, provides supplemental food supplies to low-
determination of eligibility. Medicaid criteria may deny payment for income women who are pregnant or breastfeeding and to their chil-
some services that are routinely provided to those who hold private dren up to the age of 5 years. WIC has long been heralded as a
insurance. There are several barriers to children becoming enrolled and cost-effective program that not only provides nutritional support but
staying in public health insurance programs. These include children also links families with other services, such as prenatal care and
losing and regaining eligibility on a regular basis, changes in eligibility immunizations.
8 CHAPTER 1â•… Introduction to Nursing Care of Children

Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment 10

program was developed to provide comprehensive health care to Med-
icaid recipients from birth to 21 years of age. The goal of the program
is to prevent health problems before they become severe. This program
pays for well-child examinations and for the treatment of any medical 8
problems diagnosed during such checkups.

Deaths per 1000 live births

Public Law 99-457 is part of the Individuals with Disabilities Edu-
cation Act (IDEA) that provides financial incentives to states to estab-
lish comprehensive early intervention services for infants and toddlers 6
with or at risk for developmental disabilities. Services include screen-
ing, identification, referral, and treatment. Although this is a federal
law and entitlement, each state bases coverage on its own definition of
developmental delay. Thus coverage may vary from state to state. Some
states provide care for at-risk children.
The Healthy Start program, begun in 1991, is a major initiative to Postneonatal
reduce infant deaths in communities with disproportionately high 2
infant mortality rates. Strategies used include reducing the number
of high-risk pregnancies, reducing the number of low-birth-weight
and preterm births, improving birth-weight–specific survival, and
reducing specific causes of postneonatal mortality. 0
The March of Dimes, long an advocate for improving the health of 1997 1999 2001 2003 2005 2007
infants and children, has been conducting a Prematurity Campaign. Year
Designed to reduce the devastating toll that prematurity takes on the FIG 1-2╇ Infant, neonatal, and postnatal mortality rates: United
population, the campaign emphasizes education, research and advo- States, 1997–2007. (From National Center for Health Statistics.
cacy. Since 1981, the incidence of prematurity increased 30%, often [2011]. Health, United States, 2010: With Special Feature on Death
resulting in permanent health or developmental problems for survi- and Dying, Hyattsville, MD: U.S. DHHS.)
vors of early birth. Currently, one in every eight newborns (12.5%) in
the United States is born prematurely (March of Dimes, 2011).
2011). Much of the racial disparity for infant mortality is attributable
to prematurity (born before 37 weeks) and low birth weight (less than
STATISTICS ON INFANT AND CHILD HEALTH 2500╯g), both more common among African-American infants. Pre-
Statistics are important sources of information about the health of mature and low-birth-weight infants have a greater risk for short-term
groups of people. The newest statistics about infant and child health and long-term health problems as well as death (March of Dimes,
for the United States can be obtained from the National Center for 2011).
Health Statistics ( Poverty is an important factor. Proportionally more nonwhites than
whites are poor in the United States. Poor people are less likely to be
Mortality in good health, to be well nourished, or to get the health care they need.
Throughout history, infants have had high death rates, especially Obtaining care becomes vital during pregnancy and infancy, and lack
shortly after birth. Infant mortality rates began to fall when the health of care is reflected in the high mortality rates in all categories.
of the general population improved, basic principles of sanitation were International Infant Mortality.╇ One would expect that a nation
put into practice, and medical knowledge increased. A further large such as the United States would have one of the lowest infant mortality
decrease was a result of the widespread availability of antibiotics, rates when compared with other developed countries. The most recent
improvements in public health, and better prenatal care in the 1940s year for which comparative international data on infant mortality are
and 1950s. Today the infant mortality rate is falling, although the rate available is 2006. (Table 1-3) (NCHS, 2011). The estimate of the United
of change has slowed. Racial inequality of infant mortality continues, States’ ranking worldwide is 46th of 223 countries reporting (Central
with nonwhite groups having higher mortality rates than white groups. Intelligence Agency, 2011). International rankings are difficult to
compare because countries differ in how and when they compute
Infant Mortality statistics, but the numbers show the need for improvement in the
Between 1950 and 1990, the infant mortality rate (death before the age United States. One of the major reasons for the poor U.S. showing is
of 1 year) dropped from 29.2 to 9.2 deaths per 1000 live births. Cur- the large racial disparity as described previously (NCHS, 2011).
rently, the infant mortality rate is 6.8, which has been relatively stable
the past several years (NCHS, 2011) (Figure 1-2). The fall in infant Childhood Mortality
mortality is attributed to the mother’s health, increased availability of Death rates for children have significantly declined over the past 20
resources, socioeconomic status, and various public service campaigns. years. Table 1-4 shows the leading causes of death in children. Although
The Back to Sleep campaign, for example, has contributed to a reduc- death rates attributed to unintentional injury also have dropped, they
tion of more than 50% in the number of deaths attributed to sudden are still the leading cause of death in children aged 1 to 19 years. Motor
infant death syndrome in the United States since 1980 (NCHS, 2011). vehicle crashes lead the causes of death from unintentional injury, fol-
Racial Disparity for Mortality.╇ Although infant mortality rates in lowed by drowning, fire-related injury, and death by firearm (Forum
the United States have declined overall, they have declined faster for on Child and Family Statistics, 2011). Homicide has become the third
whites than for non-Hispanic black infants. The mortality rate in 2007 leading cause of death in children ages 1 to 4 years and is the fourth
for white infants was 5.6. For black infants the rate was 13.2 (NCHS, leading cause of death for children 5 to 14 years; homicide remains the
CHAPTER 1â•… Introduction to Nursing Care of Children 9

Morbidity describes illness. The morbidity rate is the ratio of sick to
FOR SELECTED COUNTRIES well people in a population and is presented as the number of ill people
(BASED ON 2006 DATA—MOST per 1000 population. This term is used in reference to acute and
RECENT COMPLETE DATASET) chronic illness as well as disability. Because morbidity statistics are
Iceland 1.4 collected and updated less frequently than mortality statistics, presen-
Luxembourg 2.5 tation of current data in all areas of child health is difficult.
Japan 2.6 Diseases of the respiratory system, which include bronchitis or
Sweden, Finland 2.8 bronchiolitis, asthma, and pneumonia, are a major cause of hospital-
Norway 3.2 ization for children younger than 18 years (NCHS, 2011). A reported
Czech Republic, Portugal 3.3 10% of children in the United States currently have asthma; approxi-
Austria 3.6 mately 5% of these report having one or more acute episodes during
Greece, Ireland, Italy 3.7 the previous year (Forum on Child and Family Statistics, 2011). Other
Denmark, France, Germany, Spain 3.8 health problems of significant concern include: obesity (19%), activity
Belgium 4.0 limitations related to chronic disease (9%), depression (8%), and emo-
Netherlands, Switzerland 4.4 tional or behavioral difficulties (5%) (Forum on Child and Family
Australia 4.7 Statistics, 2011). Dental decay is one of the most preventable of chronic
Canada, United Kingdom 5.0 diseases in children, yet between 25% and 50% of children in the
New Zealand 5.2 United States suffer from tooth decay. The prevalence of decay is higher
Hungary 5.7 for children living in poverty and those from some racial and ethnic
Poland 6.0 groups (Centers for Disease Control and Prevention [CDC], National
Slovak Republic 6.6 Center for Chronic Disease Prevention and Health Promotion, 2011).
United States 6.7 Statistics regarding morbidity related to particular disorders are pre-
sented throughout this text as the disorders are discussed.
From National Center for Health Statistics: Health, United States, The Youth Risk Behavior Surveillance System conducts a national
2010: With Special Feature on Death and Dying, Hyattsville, MD, survey of students in grades 9 to 12 every 2 years on the odd year. The
2011. Data from The Organisation for Economic Co-operation and CDC (2011) has identified categories of health risk behaviors among
Development (OECD) Health Data 2009, incorporating revisions to
youth that contribute to increased morbidity rates: tobacco use;
the annual update. Available from:
*Under 1 year of age.
unhealthy dietary behaviors; inadequate physical activity; alcohol and
other drug use; sexual risk behaviors and behaviors that result in inten-
tional injuries (violence, suicide) and unintentional injuries (motor
TABLE 1-4â•… LEADING CAUSES OF DEATH vehicle crashes). The YRBSS also monitors obesity and asthma in
A link exists between children living in poverty and poorer health
1 TO 14 YEARS outcomes. Children who live in families of higher income and higher
DEATH RATE PER 100,000 education have a better chance of being born healthy and remaining
Ages 1 to 4 Years
healthy. Access to health care, the health behaviors of parents and
Unintentional injury 8.5
siblings, and exposure to environmental risks are among the factors
Congenital malformations 2.8
contributing to the disparity in children’s health (Forum on Child and
Homicide 2.3
Family Statistics, 2011; NCHS, 2011).
Cancer 2.0
Adolescent Births
Heart disease 0.9
Adolescent birth rates in the United States decreased markedly over the
Ages 5 to 14 Years past 20 years, although they have increased slightly since 2006 in ado-
Unintentional injury 4.1 lescents aged 15 to 19 years old. The current birth rate for adolescent
Cancer 2.2 mothers is 42.5 per 1000. In adolescents ages 10 to 14 years, the rate is
Congenital malformations 0.9 significantly lower at 0.6 per 1000. The adolescent birth rate is lowest
Homicide 0.8 in the Asian/Pacific Islander group and highest in black Hispanic girls
Heart disease 0.5 (HRSA, 2009).

From Forum on Child and Family Statistics. (2011). Child injury and ETHICAL PERSPECTIVES IN CHILD
mortality: Death rates among children ages 1-14 by gender, race, and
Hispanic origin and all causes and all injury causes 1980–2009. In HEALTH NURSING
America’s Children: Key National Indicators of Wellbeing 2011.
Nurses who care for children often struggle with ethical and social
Retrieved from
dilemmas that affect families. Nurses must know how to approach
these issues in a knowledgeable and systematic way.
second leading cause of death for older adolescents, followed by suicide
(NCHS, 2011). Other common causes of death in children include Ethics and Bioethics
congenital malformations, cancer, and cardiac and respiratory diseases. Ethics involves determining the best course of action in a certain situ-
Self-inflicted injury is a leading cause of death in the adolescent popu- ation. Ethical reasoning is the analysis of what is morally right and
lation (Forum on Child and Family Statistics, 2011). reasonable. Bioethics is the application of ethics to health care. Ethical
10 CHAPTER 1â•… Introduction to Nursing Care of Children

The nurse, in all professional relationships, practices with compassion and • Beneficence. One is required to do or promote good for others.
respect for the inherent dignity, worth and uniqueness of every individual, • Nonmaleficence. One must avoid risking or causing harm to others.
unrestricted by considerations of social or economic status, personal attri- • Autonomy. People have the right to self-determination. This includes the
butes, or the nature of health problems. right to respect, privacy, and the information necessary to make decisions.
The nurse’s primary commitment is to the patient, whether an individual, • Justice. All people should be treated equally and fairly regardless of
family, group, or community. disease or social or economic status.
The nurse promotes, advocates for, and strives to protect the health, safety,
and rights of the patient.
The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse’s Solving Ethical Dilemmas
obligation to provide optimum patient care. Although using a specific approach does not guarantee a right decision,
The nurse owes the same duties to self as to others, including the responsibil- it provides a logical, systematic method for going through the steps of
ity to preserve integrity and safety, to maintain competence, and to con- decision making.
tinue personal and professional growth. Decision making in ethical dilemmas may seem straightforward,
The nurse participates in establishing, maintaining, and improving health care but it may not result in answers agreeable to everyone. Many agencies
environments and conditions of employment conducive to the provision of therefore have bioethics committees to formulate policies for ethical
quality health care and consistent with the values of the profession through situations, provide education, and help make decisions in specific
individual and collective action. cases. The committees include a variety of professionals such as nurses,
The nurse participates in the advancement of the profession through contribu- physicians, social workers, ethicists, and clergy members. The child and
tions to practice, education, administration, and knowledge development. family also participate, if possible. A satisfactory solution to ethical
The nurse collaborates with other health professionals and the public in dilemmas is more likely to occur when a variety of people work
promoting community, national, and international efforts to meet health together.
needs. Ethical dilemmas also may have legal ramifications, so nurses must
The profession of nursing, as represented by associations and their members, consider both ethical principles and what is legal in their field and place
is responsible for articulating nursing values, for maintaining the integrity of practice.
of the profession and its practice, and for shaping social policy.
Ethical Concerns in Child Health Nursing
Reprinted from American Nurses Association. (2001). Code for nurses
with interpretive statements. Washington, DC: Author. Ethical concerns can arise in many areas of child health care. For
example, disclosure of HIV status to HIV positive children who are
entering middle school is an issue that brings up ethical differences
between pediatric providers and parents (see Chapter 18). Two impor-
behavior for nurses is discussed in various codes, such as the American tant areas are cessation of treatment and terminating life support.
Nurses Association Code for Nurses (Box 1-1). Ethical issues have
become more complex as developing technology has allowed more Cessation of Treatment
options in health care. These issues are controversial because there is The decision to cease treatment is an ethical situation that is always
lack of agreement over what is right or best and because moral support difficult and seems to be compounded when the client is an infant or
is possible for more than one course of action. child. Children who would have died in the past can now have their
lives extended through the use of life support. Parents must be involved
Ethical Dilemmas in the decision-making process immediately and informed about avail-
An ethical dilemma is a situation in which no solution seems com- able options. Laws in some states permit parents to provide advance
pletely satisfactory. Opposing courses of action may seem equally directives for their minor children. When older children are involved,
desirable, or all possible solutions may seem undesirable. Ethical their views are considered.
dilemmas are among the most difficult situations in nursing practice. In this age of resource allocation, debate centers on how to manage
Finding solutions involves applying ethical theories and principles and critical care resources. Many believe that these decisions should not be
determining the burdens and benefits of any course of action. made at the bedside. The American Academy of Pediatrics, in its state-
ment Ethics and the Care of Critically Ill Infants and Children (1996),
Ethical Principles encouraged society to engage in a thorough debate about the eco-
Ethical principles are important in solving ethical dilemmas. Four of nomic, cultural, religious, social, and moral consequences of imposing
the most important principles are beneficence, nonmaleficence, auton- limits on which clients should receive intensive care.
omy, and justice (Box 1-2). Although principles guide decision making,
in some situations it may be impossible to apply one principle without Terminating Life Support
encountering conflict with another. In such cases, one principle may Decisions to terminate life-support systems continue to present gut-
outweigh another in importance. wrenching ethical and legal situations to nurses, especially when an
For example, treatments designed to do good may also cause some infant or child is involved. Contrary to the common belief that such
harm. A child who undergoes chemotherapy may see improvement or decisions should be determined by what is termed quality of life, the
disappearance of the cancer. However, the chemotherapy that cures the legal system plays a major role in this area of health care.
cancer can harm other body organs. In this instance the caregiver and Frequently parents become attached to a primary care nurse and
parent need to weigh the principle of beneficence against the principle request that the nurse participate in the decision as to whether to
of nonmaleficence. terminate life support for their child. A nurse might be faced with such
CHAPTER 1â•… Introduction to Nursing Care of Children 11

a situation in the neonatal intensive care unit (NICU) with a teenage primary specialty organization that sets standards for pediatric nurses
parent of a premature infant with a congenital defect or in a chronic (
care oncology unit with a terminally ill child. Other regulatory bodies, such as the U.S. Occupational Safety and
In such instances a team conference should be arranged with the Health Administration (OSHA), the U.S. Food and Drug Administra-
parent, primary nurse, physician, and a hospital staff attorney who is tion (FDA), and the Centers for Disease Control and Prevention
knowledgeable about applicable laws in that particular state. Problems (CDC), also provide guidelines for practice. Accrediting agencies, such
may arise when there is a discrepancy among what families, physicians, as The Joint Commission and the Community Health Accreditation
and nurses think is best. Program, give their approval after visiting facilities and observing
The issue of when first to discuss with adolescents the idea of car- whether standards are being met in practice. Governmental programs
diopulmonary resuscitation, mechanical ventilation, and do-not- such as Medicare, Medicaid, and state health departments require that
resuscitate (DNR) orders is always sensitive. Adolescents who have their standards be met for the facility to receive reimbursement for
reached majority age must give consent if they are of sound mind. In services.
most states, minority status ends at the age of 18 years.
Agency Policies
Each health care facility sets specific policies, procedures, and protocols
LEGAL ISSUES that govern nursing care. All nurses should be familiar with those that
The legal foundation for the practice of nursing provides safeguards apply in the facilities in which they work. Nurses are involved in
for health care and sets standards by which nurses can be evaluated. writing evidence-based nursing policies and procedures that apply to
Nurses need to understand how the law applies specifically to them. their practice and in reviewing or revising them regularly.
When nurses do not meet the standards expected, they may be held
legally accountable. Accountability
Nursing accountability involves knowing current laws. Accountability
Safeguards for Health Care in child health nursing requires special consideration because the nurse
Three categories of safeguards determine how the law views nursing must be accountable to the family as well as the child. For example, the
practice: (1) state nurse practice acts, (2) standards of care set by pro- Individuals with Disabilities Education Act (PL 94-142), which man-
fessional organizations, and (3) rules and policies set by the institution dates free and appropriate education for all children with disabilities,
employing the nurse. Additional information about nursing responsi- provides for school nurses to be part of a team that develops an indi-
bilities is presented later in this chapter. vidual education plan for each child who is eligible for services. In school
districts that are reluctant to involve the school nurse as part of the
Nurse Practice Acts team, nurses may need to advocate for services for the child and family.
Every state has a nurse practice act that determines the scope of prac- Federal as well as state legislative bodies have addressed the issue
tice for registered nurses in that state. Nurse practice acts define what of child abuse. Considerable variation exists among state laws in the
the nurse is and is not allowed to do in caring for clients. Some parts investigative authority and procedures granted to child protective
of the law may be very specific, whereas others are stated broadly workers. When child abuse is suspected, issues often arise as to whether
enough to permit flexibility in the role of nurses. Nurse practice acts a health care provider may investigate the home situation and obtain
vary from state to state, and nurses must be knowledgeable about these relevant records.
laws wherever they practice. A recent issue pertaining to nursing accountability is inadequate
In 1998 the National Council of State Boards of Nursing initiated hospital staffing as a result of budget cuts. A nurse has a duty to com-
a nurse licensure compact program. A nurse licensure compact allows municate concerns about staffing levels immediately through estab-
a nurse who is licensed in one state to practice nursing in another lished channels. A nurse will not be excused from responsibility (e.g.,
participating state without having to be licensed in that state. Nurses late medication administration or injury resulting from inadequate
must comply with the practice regulations in the state in which they supervision of a client), just as a hospital will not be excused for insuf-
practice. Since 1998, 24 states have become participants in the nurse ficient staffing because of budget cuts.
licensure compact program (National Council of State Boards of Accountability also involves competency. If a nurse is not compe-
Nursing, 2011). To learn current status, visit tent to perform a nursing task (e.g., to administer a new chemothera-
Laws relating to nursing practice also delineate methods, called peutic drug), or if a patient’s status worsens to the point at which the
standard procedures or protocols, by which nurses may assume certain care needs are beyond the nurse’s competency level (e.g., a child requir-
duties commonly considered part of health care practice. The proce- ing hemodynamic monitoring), the nurse must immediately commu-
dures are written by committees of nurses, physicians, and administra- nicate this fact to the nursing supervisor or physician. The fact that a
tors. They specify the nursing qualifications required for practicing the patient’s transfer to the intensive care unit (ICU) was requested but
procedures, define the appropriate situations, and list the education denied because the ICU was at full capacity is an insufficient defense
required. Standard procedures allow for changing the role of the nurse in a charge of nursing negligence. In addition, the fact that a call was
to meet the needs of the community and to reflect expanding placed to a physician but there was no return call is no excuse for harm
knowledge. caused to a child because of delayed treatment. The nurse has an obli-
gation to pursue needed care through the established chain of
Standards of Care command at the facility.
Courts have generally held that nurses must practice according to
established standards and health agency policies, although these stan- Use of Unlicensed Assistive Personnel
dards and policies do not have the force of law. Standards of care are In an effort to reduce health care costs, many agencies have increased
set by professional associations and describe the level of care that can the use of unlicensed assistive personnel to perform direct client care
be expected from practitioners. The Society of Pediatric Nurses is the and have decreased the number of nurses who supervise them. An
12 CHAPTER 1â•… Introduction to Nursing Care of Children

unlicensed person may be trained to do everything from housekeeping

tasks to drawing blood and performing other diagnostic testing to
giving medications, all in the same day. This practice raises grave con- Elements of Negligence
cerns about the quality of care clients receive when the nurse is respon- • Duty. The nurse must have a duty to act or give care to the client. It must
sible and accountable for the care of more clients but must rely on be part of the nurse’s responsibility.
unlicensed personnel to perform much of the care formerly provided • Breach of Duty. A violation of that duty must occur. The nurse fails to
only by professionals. At the same time, use of an expert nurse for conform to established standards for performing that duty.
housekeeping and other mundane, but necessary, unit tasks is ineffi- • Damage. There must be actual injury or harm to the client as a result of
cient and detracts from available time for care. A balanced approach the nurse’s breach of duty.
is needed when incorporating unlicensed assistive personnel into an • Proximate Cause. The nurse’s breach of duty must be proved to be the
agency’s work. cause of harm to the client.
Nurses must be aware of their legal responsibilities in these situa-
tions. They must know that the nurse is always responsible for assess-
ments and must make the critical judgments that are necessary to defensively, accumulating evidence that they are acting in the client’s
ensure safety. Nurses must know what each unlicensed person caring best interest. For example, nurses must be careful to include detailed
for children is able to do and must supervise them closely enough to data when they chart.
ensure that they perform delegated tasks competently. Prevention of claims is sometimes referred to as risk management
One area in which unlicensed assistive personnel may have greater or quality assurance. Although it is not possible to prevent all malprac-
responsibilities is in the school setting. Registered nurses who practice tice lawsuits, nurses can help defend themselves against malpractice
in schools are caring for children with more complex medical and judgments by following guidelines for informed consent, refusal of
nursing needs, responding to increased requirements for routine health care, and documentation; acting as a client advocate; working within
screenings, and dealing with budgetary cuts that result in a nurse caring accepted standards and the policies and procedures of the facility; and
for children in more than one school. These pressures have led to maintaining their level of expertise.
increased use of unlicensed assistive personnel to provide routine care Informed Consent.╇ When clients receive adequate information, in
to children with uncomplicated needs, including medication adminis- other words, when an agency’s emphasis is on transparency, they are
tration. The American Academy of Pediatrics (2009b) has issued a less likely to file malpractice suits. Informed consent is an ethical
policy statement that strongly recommends that a nurse be present in concept that has been enacted into law. Clients and families have the
every school. If this is not possible, then the school nurse can consider right to decide whether to accept or reject treatment options as part
delegating certain responsibilities to properly trained and competent of their right to function autonomously. To make wise decisions they
unlicensed assistive personnel. Nurses who consider delegation must need full information about treatments offered. Without proper
be familiar with their state’s nurse practice act and appropriate profes- informed consent, assault and battery charges can result.
sional standards (Resha, 2010). Prior to delegating, the nurse needs to The law mandates what procedures require informed consent and
determine tasks that are appropriate and safe, the complexity of chil- what to inform about as “risks” specific to each procedure. Nurses must
dren’s needs, and school district policy (AAP, 2009b; Resha, 2010). The be familiar with those procedures requiring consent.
nurse needs to work with the school administration to develop a com-
prehensive school-based policy (e.g., the nurse, not the administrator,
decides what responsibilities will be delegated) before any responsibili-
ties are delegated to others. The nurse is also responsible for educating Requirements of Informed Consent
and evaluating the competency of the unlicensed personnel; this • Competence to consent
includes requiring return demonstrations of procedures and regular • Full disclosure of information
onsite supervision (Resha, 2010). Most important is that delegation • Understanding of information
does not relieve the nurse from regular assessment of the children’s • Consent is voluntary
responses to all treatments and medications (AAP, 2009b; Resha, 2010).

Malpractice Competence.╇ Certain requirements must be met before consent

Negligence is failure to perform the way a reasonable, prudent person can be considered informed. The first requirement is that the person
of similar background would act in a similar situation. Negligence may giving the consent be competent, or able to think through a situation
consist of doing something that should not be done or failing to do and make rational decisions. A person who is comatose or severely
something that should be done. mentally retarded is incapable of making such decisions. Minors are
Malpractice is negligence by professionals, such as nurses or physi- not allowed to give consent; however, children should have procedures
cians, in the performance of their duties. Nurses may be accused of explained to them in terms appropriate for their age. In most states,
malpractice if they do not perform according to established standards minority status for informed consent ends at the age of 18 years.
of care and in the manner of a reasonable, prudent nurse with similar Most states allow some exceptions for parental consent in cases
education and experience. Four elements must be present to prove involving emancipated minors. An emancipated minor is a minor child
negligence. They are duty, breach of duty, damage, and proximate who has the legal competency of an adult because of circumstances
cause. involving marriage, divorce, parenting of a child, living independently
without parents, or enlistment in the armed services. Legal counsel
Prevention of Malpractice Claims may be consulted to verify the status of the emancipated minor for
Malpractice awards have escalated in both number and amount of consent purposes.
awards to plaintiffs, resulting in high malpractice insurance for all Most states allow minors to obtain treatment for drug or alcohol
health care providers. In addition, more health care workers practice abuse or sexually transmitted diseases and to have access to birth
CHAPTER 1â•… Introduction to Nursing Care of Children 13

control without parental consent. At present, laws governing adoles- Refusal of Care
cent abortion vary widely from state to state. Sometimes parents or children decline treatment, including hospital-
Full disclosure.╇ The second requirement is that of full disclosure ization, offered by health care workers. They may refuse treatment
of information, including the treatment’s purpose and the expected when they believe that the benefits of treatment do not outweigh the
results. The risks, side effects, and benefits as well as other treatment burdens of the treatment or the quality of life they can expect after
options must be explained to parents and children. They must also that treatment. Parents have the right to refuse care, and they can
be informed as to what would happen if no treatment were chosen. withdraw agreement to treatment at any time. When a person makes
For example, the National Childhood Vaccine Injury Act mandates this decision, a number of steps should be taken.
that explanations about the risks of communicable diseases and the First, the physician or nurse should establish that the parent and
risks and benefits associated with immunizations should be given to child understand the treatment and the results of refusal. The physi-
all parents to enable them to make informed decisions about their cian, if unaware of the decision, should be notified by the nurse. The
child’s health care. Parents need to know the common side effects and nurse documents on the chart the refusal, explanations given to the
what to do in an emergency if any occur. The law stipulates that chil- parent, and notification of the physician. If the treatment is considered
dren injured by the vaccine must go through the administrative com- vital to the child’s well-being, the physician discusses the need with the
pensation system (funds from an excise tax levied on the vaccines) and parent and documents the discussion. Opinions by other physicians
reject an award before attempting to sue in a civil suit either the manu- may be offered as well.
facturer or the person who gave the vaccine. Furthermore, the law Parents may be asked to sign a form indicating that they understand
mandates certain record-keeping and reporting requirements for the possible results of rejecting treatment. This measure is to prevent
nurses. a later lawsuit in which a parent claims lack of knowledge of the pos-
Understanding of information.╇ The parent or legal guardian of a sible results of a decision. If there is no ethical dilemma, the client’s
child must comprehend information about proposed treatment. decision stands.
Health professionals need to explain the facts in terms the person can When parents refuse to give consent for what is deemed necessary
understand. Nurses must be advocates when they find that a parent treatment of a child, the state may be petitioned to intervene. The court
does not fully understand a treatment or has questions about it. If it may place the child in the temporary custody of the government or a
is a minor point, the nurse may be able to explain it. Otherwise the private agency. The nurse may be asked to witness such a transaction
nurse must inform the provider so that the parent’s misunderstandings when physicians act in cases of emergencies, such as a lifesaving blood
can be clarified. transfusion for a child despite parental objections based on religious
Throughout hospitalization and discharge preparations, consider- beliefs.
ations should be given to those who do not understand the prevailing
language and to the hearing impaired. Foreign language and sign lan-
guage interpreters must be obtained when indicated. Provision for Adoption
those who cannot read any language or adults with a low education Nurses may care for infants involved in adoptions. The nurse may
level must be considered as well. need to consult with the birth parents, adoptive parents, social
Voluntary consent.╇ Parents and children should be allowed to workers, obstetrician, or pediatrician to determine the various
make choices voluntarily without undue influence or coercion from rights of the child, birth parents, and adoptive parents (e.g., in
others. Although others can give information, the parent or legal matters concerning visitation rights, informed consent, or discharge
guardian of a child makes the decision. Families should not feel pres- planning).
sured to choose in a certain way or feel that their future care depends In open adoptions, the birth mother may opt to room in with the
on their decision. infant during hospitalization. The birth mother and adoptive parents
Children cannot legally consent for treatment or participation in typically have had contact before the delivery and have an informal
research. However, they should be given the opportunity to give vol- agreement regarding shared responsibility for the infant. The birth
untary assent for research participation. Assent involves the principles parent may even participate in discharge planning because she may
of competence and full disclosure. Children should be given informa- have extended rights to visit the child after adoption.
tion in a developmentally appropriate format. Clients 18 years and Issues may develop as to the state of mind of the birth mother at
older must provide full consent. When seeking assent from children, the time of relinquishing parental rights (which cannot occur until
the nurse considers both the child’s age and development. In general, after birth, unlike the relinquishment of the birth father’s rights). State
when children have reached 14 years old, they are competent to under- laws vary as to the legal time period necessary (1 day to several weeks
stand ramifications of treatment or participation in research; some after the birth of the child) before a birth mother can lawfully relin-
children are competent at a somewhat younger age (Masty & Fisher, quish her rights to the child.
2008). Other factors to consider are the child’s physical and emotional Some state laws allow the birth mother to relinquish her rights
condition and behaviors, cognitive ability, history of family shared immediately after birth. In such cases, the nurse has the responsibility
decision making, anxiety level, and disease context (Masty & Fisher, of protecting the birth mother and child to ensure that the birth
2008). In some states, the child’s dissent to participate in research is mother is not coerced into making a decision while under the effects
legally binding, so nurses need to be aware of the legal issues in the of medication. Factual documentation of such circumstances may be
states in which they practice. The Committee on Pediatric Emergency requested if the birth mother later asserts her rights to the child, claim-
Medicine has issued a policy regarding consent for emergency medical ing “undue influence” or “coercion.”
services for children and adolescents. The policy recommends that Birth fathers have the same rights as the birth mother. Unless the
every effort be made to secure consent from a parent or legal guardian, birth father relinquishes his legal rights to the child, he may later assert
but emergency treatment should not be denied if there are problems his rights to the child after attachment has occurred with the adoptive
obtaining the consent (American Academy of Pediatrics Committee parents. This situation may occur if the birth mother denies knowledge
on Pediatric Emergency Medicine, 2011). of the father’s identity.
14 CHAPTER 1â•… Introduction to Nursing Care of Children

Documentation interests are not being served, they are obligated to seek help for
Documentation, whether on paper or electronic, is the best evidence the child from appropriate sources. This usually involves taking the
that a standard of care has been maintained. All information recorded problem through the chain of command established at the facility. The
about a child should reflect that standard of care. This information nurse consults a supervisor and the child’s physician. If the results are
includes both electronic and written nurses’ notes, flow sheets, and any not satisfactory, the nurse continues through administrative channels
other data in the child’s record. In many instances, notations on hos- to the director of nurses, hospital administrator, and chief of the
pital records are the only proof that care has been given. Expert wit- medical staff, if necessary. All nurses should know the chain of
nesses, often registered nurses in the appropriate specialty, will search command for their workplaces.
for evidence that the standard of care at the time of the incident was Nurses must be advocates for health promotion and illness preven-
met. If not found in case documents, the expert witness must conclude tion for vulnerable groups such as children. Nurses can participate in
that what should have been done was not done. When documentation groups dedicated to the welfare of children and families, such as pro-
is not present, juries tend to assume that care was not given. Although fessional nursing societies, parent support groups, religious organiza-
documentation is not listed as a step in the nursing process, it is an tions, and voluntary organizations. Through involvement with health
integral part of the process. care planning on a political or legislative level and by working as
Documentation must be specific and complete. Nurses are unlikely consumer advocates, nurses can initiate changes for better quality
to be able to recall situations that happened years ago and must rely health care.
on their documentation to explain their care if sued. Documentation
must show that the standards of care and facility policies and proce- Maintaining Expertise
dures in effect at the time of the incident were met. Documentation Maintaining expertise is another way for nurses and other health pro-
must demonstrate that the child was appropriately assessed, that con- fessionals to prevent malpractice liability. To ensure that nurses main-
tinuing monitoring of problems was provided, that problems were tain their expertise to provide safe care, most states require proof of
identified and correct interventions were instituted, and that changes continuing education for renewal of nursing licenses. Nursing knowl-
in the child’s condition were reported to the primary care provider. If edge changes rapidly, and it is essential that all nurses keep current.
the nurse believes that the primary care provider has responded inap- Incorporating new information learned by attending classes or confer-
propriately, the nurse must refer the provider response through the ences and reading nursing journals can help nurses perform the way a
appropriate chain of command for the facility and must document the reasonably prudent peer would perform. Journals provide information
notification. from nursing research that may be important in updating nursing
Documenting Discharge Teaching.╇ Because of brief hospital stays, practice. It is important for all nurses to analyze research articles to
discharge teaching is essential to ensure that parents know how to care determine whether changes in pediatric care are indicated.
for their child at home. Nurses must document the teaching they Employers often provide continuing education classes for their
perform as well as the parents’ and child’s understanding, if appropri- nurses. Many workshops and seminars are available on a wide variety
ate, of that teaching. The nurse should also note the need for reinforce- of nursing subjects. Membership in professional organizations, such as
ment and how that reinforcement was provided. If follow-up home state branches of the American Nurses Association or specialty orga-
care is planned, teaching can be continued at home and documented nizations such as the Society of Pediatric Nurses, gives nurses access to
on forms by the home care nurse. new information through publications as well as nursing conferences
Documenting Incidents.╇ A type of documentation used in risk and other educational offerings.
management is the incident report, often called a quality assurance, Maintaining expertise may be a concern when nurses “float” or are
occurrence, or variance report. The nurse completes a report when required to work with children who have needs different from those
something occurs that might result in legal action, such as in injury to of their usual clients. In these situations, the employer must provide
a child or a departure from the expectations in a situation. The report orientation and education so that the nurse can perform care safely in
warns the agency’s legal department that there may be a problem. It new areas. Nurses who work outside their usual areas of expertise must
also helps identify whether changing processes within the system might assess their own skills and avoid performing tasks or taking on respon-
reduce the risk for similar incidents in the future. Incident reports are sibilities in areas in which they are not competent. Many nurses learn
not a part of the child’s chart and should not be referred to on the to provide care in two or three different areas and are floated only to
chart. Documentation of the incident on the chart should be restricted those areas. This system meets the need for flexible staffing while pro-
to the same type of factual information about the child’s condition that viding safe care.
would be recorded in any other situation.
The analysis of medical error from a systems perspective is called a
root cause analysis. The process involves identifying errors or near
misses as soon as they occur, asking relevant questions about the Nurses are exposed to many social issues that influence health care and
factors that might have contributed to the error, analyzing the contrib- often have legal or ethical implications. Some of the issues that affect
uting causes, and developing interventions to prevent a similar error child health care include poverty, homelessness, access to care, and
from occurring in the future. A root cause analysis is not intended to allocation of funds.
be punitive if an error was made. Instead, root cause analysis is used
as a tool to prevent future error or near misses. Poverty
Poverty is an underlying factor in problems such as inadequate access
The Nurse as Child and Family Advocate to health care and homelessness and is a major predictor for unmet
Malpractice suits may be brought if nurses fail in their role of child health needs in children and adults. The percentage of children in the
and family advocate. Nurses are ethically and legally bound to act as United States who are living in poverty (21%) has increased with the
the child’s advocate. This means that the nurse must act in the child’s downturn in the national economy. Children younger than 5 years are
best interests at all times. When nurses believe that the child’s best more often found in families with incomes below the poverty line than
CHAPTER 1â•… Introduction to Nursing Care of Children 15

are older children. Children in female-headed households are more of affordable housing, decrease in government assistance programs,
likely to be living in poverty and the poverty rate is three times higher family violence, and poverty (National Coalition for the Homeless,
in black and Hispanic households than in white non-Hispanic house- 2009). Some homeless women are substance abusers and others are
holds (Forum on Child and Family Statistics, 2011). fleeing domestic violence. Homeless children are poorly nourished, are
Poverty affects the ability to access health care for any age-group more susceptible to illness, may be exposed to violence, experience
and decreases opportunities linked with health promotion. Nurses can school absences with subsequent learning difficulties, and are at risk
play a role in helping to meet the health care needs of infants and for depression and other emotional consequences (National Coalition
children by recognizing the adverse effect of poverty on health and for the Homeless, 2009).
identifying poverty as a practice concern. Several of the Healthy People Pregnancy and birth, especially among teenagers, are important
2020 goals (USDHHS, 2010b) have implications for pediatric nurses: contributors to homelessness. Adolescent mothers are more likely to
• To reduce the infant mortality rate to no more than 6.0 per 1000 be single mothers and poor. Pregnancy interferes with a woman’s
live births and the childhood mortality rate to 25.7 per 100,000 ability to work and may decrease her income to the point at which she
for children 1 to 4 years old and 12.3 per 100,000 for children loses her housing. Without child care or a home address, she may have
5 to 9 years old and to similarly reduce the rate of adolescent less chance of obtaining and keeping employment. In addition, her
deaths children are more likely to be sick because of inadequate food and
• To reduce the incidence of low birth weight to no more than shelter. Without money to pay for insurance or early health care, there
7.8% (from 8.2% in 2007) of live births and the incidence of is an increased chance that children will need hospitalization (Little,
very low birth weight to 1.4% of live births Gorman, Dzendoletas, & Moravac, 2007).
• Reduce preterm births to 11.4% Federal funding has provided assistance with shelter and health care
• To achieve and maintain effective vaccination coverage levels for for homeless people. The homeless, however, have the same difficulties
universally recommended vaccines in children from 19 to 35 in obtaining health care as other poor people because of lack of trans-
months of age and increase routine vaccination coverage for portation, inconvenient hours, and lack of continuity of care.
• To reduce, eliminate or maintain elimination of cases of Allocation of Health Care Resources
vaccine-preventable diseases To increase to 100% the propor- Expenditures for health care in the United States in 2009 totaled $2.5
tion of people with health insurance trillion, which represents 17.6% of the total expenditures on services
Poverty tends to breed poverty. In low-income families children and goods in the United States and a 4% increase from the previous
may leave the educational system early, making them less likely to learn year (Centers for Medicare and Medicaid, 2011). These expenditures
skills necessary to obtain good jobs. The cycle of poverty (Figure 1-3) are expected to continue to increase, as the population of baby boomers,
may continue from one generation to another as a result of hopeless- born from 1946 through 1964, is expected to need more health care
ness and apathy. dollars as it ages.
Reforming health care delivery and financing is a complex area of
Homelessness national concern. How to provide care for the poor, the uninsured or
Homeless families make up over 40% of the homeless population underinsured, and those with long-term care needs are some areas that
(Forum on Child and Family Statistics, 2011; National Coalition for must be addressed. In addition, major acute care facilities often deal
the Homeless, 2009). This percentage is increasing due to multiple with greater financial burdens because of the growing numbers of
factors that include the national economic downturn, job loss, shortage uninsured clients presenting for treatment who are often very ill or
severely injured. Escalating liability costs are another drain on health
care dollars, leading some states to enact legislation that places a cap
Poor children are on awards for damages in malpractice cases.
more likely to
A child leave school Care versus Cure
born into before
poverty is graduating. One problem to be addressed is whether the focus of health care should
likely to be on preventive and caring measures or on cure of disease. Medicine
be poor has traditionally centered more on treatment and cure than on preven-
as an adult.
tion and care. Yet prevention not only avoids suffering but also is less
expensive than treating diseases once they are diagnosed.
The focus on cure has resulted in technologic advances that have
enabled some people to live longer, healthier lives. Financial resources
are limited, however, and the costs of expensive technology needs to
be balanced against the benefits obtained. Indeed, the cost of one organ
transplant would pay for the prenatal care of many low-income
mothers, possibly preventing the births of many low-birth-weight
infants who may suffer disability throughout life.
In addition, quality-of-life issues are important in regard to tech-
nology. Neonatal nurseries are able to keep very-low-birth-weight
Childbearing at an babies alive because of advances in knowledge. Some of these infants
early age is common, go on to lead normal or near-normal lives. Others gain time but not
interfering with
education and the quality of life. Families and health care professionals face difficult deci-
ability to work. sions about when to treat, when to terminate treatment, and when
FIG 1-3╇ The cycle of poverty. suffering outweighs the benefits.
16 CHAPTER 1â•… Introduction to Nursing Care of Children

Health Care Rationing personal experience with violent behavior. In some cases it may be
Modern technology has had a great impact on health care rationing. necessary to contact parents, human resource departments, police, or
Some might argue that such rationing does not exist, but it occurs other authorities to protect children and adolescents who are either in
when some people have no access to care and there is not enough violent situations or at risk for violence.
money for all people to share equally in the technology available.
Health care also is rationed when it is more freely given to those who
have money to pay for it than to those who do not.
Many questions will need answers as the costs of health care As nursing care changed from the category-specific care of the child to
increase faster than the funds available. Is health care a fundamental family-centered care, pediatric nursing entered a new era of autonomy
right? Should a certain level of care be guaranteed to all citizens? What and independence. Nurses today must be able to communicate with
is that basic level of care? Should the cost of treatment and its effective- and teach effectively children of many ages and levels of development
ness be considered when one is deciding how much government or and education. They must be able to think critically, have appropriate
third-party payers will cover? Nurses will be instrumental in finding clinical judgment, and use the nursing process to develop a plan of care
solutions to these vital questions. that meets the unique needs of each child and family. They are expected
to incorporate evidence-based nursing to solve problems, to answer
Violence clinical questions related to high-quality patient-centered care, and to
In today’s society, women and children are the victims and sometimes practice interdisciplinary collaboration with other health care
the perpetrators of violence. Violence is not only a social problem but providers.
also a health problem. Acts of violence can include child abuse, domes-
tic abuse, and murder. Children who live in an environment of violence The Role of the Professional Nurse
feel helpless and ineffective. These children have difficulty sleeping and The professional nurse has a responsibility to provide the highest
show increased anxiety and fearfulness. They may perpetuate the vio- quality care to every child and family. The American Nurses Associa-
lence they see in their homes when they are adults because they have tion (ANA) Code of Ethics for Nurses (see Box 1-1) provides guidelines
known nothing else in family relationships. for ethical and professional behavior. The code emphasizes a nurse’s
Although violent crimes among children have decreased over the accountability to children and families, the community, and the profes-
past decade, violence in schools continues to rise, and for many chil- sion. The nurse should understand the implications of this code and
dren it is a daily stressor. Experts in the field of education have cited strive to practice accordingly. Professional nurses have a legal obliga-
socioeconomic disparity, language barriers, diverse cultural upbring- tion to know and understand the standard of care imposed on them.
ing, lack of supervision and behavioral feedback, domestic violence, It is critical that nurses maintain competence and a current knowledge
and changes within the family as possible causes for the increased base in their areas of practice.
violence. Traditional approaches to aggressive behavior in the school, Standards of practice describe the level of performance expected of
such as suspension, detention, and being sent to the principal’s office, a professional nurse as determined by an authority in the practice.
have been ineffective in changing behavior and serve only to exclude Nurses who care for children in all clinical settings can use the ANA/
the student from education, leading to an increased dropout rate. Society of Pediatric Nurses (SPN) Standards of Care and Standards of
Nurses need to educate themselves on the issue of violence and work Professional Performance for Pediatric Nurses and the SPN/ANA
with schools and parents to combat the problem. In addition, they Guide to Family Centered Care as guides for practice. Other standards
should not ignore the child who is afraid to go to school or is having of practice for specific clinical areas, such as pediatric oncology nursing
other school-related problems. or emergency nursing, are available from nursing specialty groups.
Children and adolescents are also exposed to violence via television, As health care continues to move to family-centered and
movies, video games, and youth-oriented music. Nurses should make community-based health services, all nurses should expect to care for
this issue a part of anticipatory guidance. The American Academy of children, adolescents, and their families. Under the leadership of the
Pediatrics (2009a)encourages parents to monitor their children’s media Child and Family Expert Panel of the American Academy of Nursing,
exposure and limit their children’s screen time (TV, computer, video representatives from 10 pediatric and subspecialty organizations met
games) to no more than 1 to 2 hours per day. The AAP (2009a) also to identify the commonalities of practice across all areas of pediatric
recommends that parents remove televisions and computers from chil- practice and produced the document Health Care Quality and Outcome
dren’s bedrooms, limit viewing of programs and video games that have Guidelines for Nursing of Children and Families. The guidelines set forth
sexual or violent content, view television programs with children and in the document can serve as a framework for practice when caring for
discuss these, and educate children and adolescents about media children and their families. Educators and administrators in health
literacy. care should find them useful when planning programs (Betz, 2005).
The AAP (2009a) suggests that clinicians ask parents and children Pediatric nurses function in a variety of roles, including those of
about media exposure at every well visit. Providers also need to be care provider, teacher, collaborator, researcher, advocate, and manager.
concerned about adolescents who display aggressive or acting-out
behaviors, such as lying, stealing, temper outbursts, vandalism, exces- Care Provider
sive fighting, and destructiveness. It further recommends that health The nurse provides direct patient-centered care to infants, children,
care providers promote the responsibility of every family to create a and their families in times of illness, injury, recovery, and wellness.
gun-safe home environment. This includes asking about the presence Nursing care is based on the nursing process. The nurse obtains health
of guns in the home at every well visit and counseling children, parents, histories, assesses child and family needs, monitors growth and devel-
and relatives on the importance of firearm safety and the dangers of opment, performs health-screening procedures, develops comprehen-
having a gun, especially a handgun. sive plans of care, provides treatment and care, makes referrals, and
Nurses working with children should ask them about violence in evaluates the effects of care. Nursing of children is especially based on
their school, home, or neighborhood, and whether they have had any an understanding of the child’s developmental stage and is aimed at
CHAPTER 1â•… Introduction to Nursing Care of Children 17

meeting the child’s physical and emotional needs at that level. Develop- participants to ask questions of concern to all members of the
ing a therapeutic relationship with and providing support to children group.
and their families are essential components of nursing care. Pediatric • Organization and skill of the teacher. The teacher must determine
nurses practice family-centered care, embracing diversity in family the objectives of the teaching, develop a plan to meet the objec-
structures and cultural backgrounds. These nurses strive to empower tives, and gather all materials before teaching. The nurse must
families, encouraging them to participate in their self-care and the care determine the best way to present the material for the intended
of their child. audience. A summary of the information is helpful when con-
cluding a teaching session.
Education is an essential role of today’s nurse. Nurses who care for Collaborator
children prepare them for procedures, hospitalization, or surgery, Nurses collaborate with other members of the health care team, often
using knowledge of growth and development to teach children at coordinating and managing the child’s care. Care is improved by an
various levels of understanding. Families need information as well as interdisciplinary approach as nurses work together with dietitians,
emotional support so that they can cope with the anxiety and uncer- social workers, physicians, and others.
tainty of a child’s illness. Nurses teach family members how to provide Managing the transition from a hospital or any other acute-care
care, watch for important signs, and increase the child’s comfort. They setting to the child’s home or another facility involves discharge plan-
also work with new parents and parents of ill children so that the ning and collaboration with other health care professionals. The trend
parents are prepared to assume responsibility for care at home after toward home care makes collaboration increasingly important. The
the child has been discharged from the hospital. nurse needs to be knowledgeable about community resources, appro-
Education is essential to promote health. The nurse applies prin- priate home care agencies for the type of family or problem, and
ciples of teaching and learning to change the behavior of family financial resources. Cooperation and communication are essential
members. Nurses motivate children and families to take charge of and because parents and caregivers of children are encouraged to partici-
make responsible decisions about their own health. For teaching to be pate in their care.
effective, it must incorporate the family’s values and health beliefs.
Nurses caring for children and families play an important role in Researcher
preventing illness and injury through education and anticipatory guid- Nurses contribute to their profession’s knowledge base by systemati-
ance. Teaching about immunizations, safety, dental care, socialization, cally investigating theoretic or practice issues in nursing. Nursing does
and discipline is a necessary component of care. Nurses offer guidance much more than simply “borrow” scientific knowledge from medicine
to parents with regard to child-rearing practices and preventing poten- and basic sciences. Nursing generates and answers its own questions
tial problems. They also answer questions about growth and develop- based on evidence within its unique subject area. The responsibility
ment and assist families in understanding their children. Teaching for providing evidence-based, patient-centered care is not limited to
often involves providing emotional support and counseling to children nurses with graduate degrees. It is important that all nurses appraise
and families. and apply appropriate research findings to their practice, rather than
Factors that influence learning at any age include the following: basing care decisions merely on intuition or tradition.
• Developmental level. Teenage parents often have very different Evidence-based practice is no longer just an ideal but an expecta-
concerns than older parents. Grandparents who must assume tion of nursing practice. Nurses can contribute to the body of profes-
long-term care of a child often need information that may not sional knowledge by demonstrating an awareness of the value of
have existed when their own child was the same age. Develop- nursing research and assisting in problem identification and data col-
mental level also influences whether a person learns best by lection. Nurses should keep their knowledge current by networking
reading printed material, using computer-based materials, and sharing research findings at conferences, by publishing, and by
watching videos, participating in group discussions, play, or evaluating research journal articles.
other means. When teaching children, teaching must be adapted
to the child’s developmental level rather than the child’s chrono- Advocate
logical age. An advocate is one who speaks on behalf of another. Care can become
• Language. The ability to understand the language in which impersonal as the health care environment becomes more complex.
teaching is done determines how much the family learns. Fami- The wishes and needs of children and families are sometimes dis-
lies for whom English is not the primary language may not counted or ignored in the effort to treat and to cure. As the health
understand idioms, nuances, slang terms, informal use of words, professional who is closest to the child and family, the nurse is in an
or medical words. An interpreter for the deaf may be necessary ideal position to humanize care and to intercede on their behalf. As an
for the client who is hearing impaired. advocate the nurse considers the family’s wishes and preferences in
• Culture. People tend to forget or disregard content with which planning and implementing care. The nurse informs families of treat-
they disagree. The nurse’s teaching can be most effective if cul- ments and procedures, ensuring that the families are involved directly
tural considerations are weighed and incorporated into the in decisions and activities related to their care. The nurse must be
education. sensitive to families’ values, beliefs, and customs.
• Previous experiences. Parents who have other children may need Nurses need to be advocates for health promotion for vulnerable
less education about infant and child care. They may, however, groups. Nurses can promote the rights of children and families by
have additional concerns about meeting the needs of several participating in groups dedicated to their welfare, such as professional
children and about sibling rivalry. nursing societies, support groups, religious organizations, and volun-
• Physical environment. The nurse must consider privacy when tary organizations. Through involvement with health care planning on
discussing sensitive issues such as adolescent sexuality or a political or legislative level and by working as consumer advocates,
domestic violence. A group discussion, however, may prompt nurses can initiate changes for better quality health care. Nurses possess
18 CHAPTER 1â•… Introduction to Nursing Care of Children

unique knowledge and skills and can make valuable contributions in educator, researcher, and consultant. These professionals often func-
developing health care strategies to ensure that all children and families tion as role models, advocates, and change agents. Unlike nurse prac-
receive optimal care. titioners, clinical nurse specialists have an acute care focus.

Manager of Care Clinical Nurse Leaders

Because of shorter stays in acute care facilities, nurses often are unable As newly defined by the American Association of Colleges of Nursing
to provide total direct care. Instead they delegate concrete tasks, such (2011), the Clinical Nurse Leader is a master’s prepared generalist
as giving a bath or taking vital signs, to others. As a result, nurses spend whose focus is on quality, safety, and optimal patient outcomes at point
more time teaching and supervising unlicensed assistive personnel, of care. All CNLs receive the same basic preparation in a master’s
planning and coordinating care, and collaborating with other profes- program, which includes advanced pathophysiology, pharmacology,
sionals and agencies. Nurses are expected to understand the financial and health assessment, among other courses that prepare them to
effects of cost-containment strategies and to contribute to their institu- assume leadership roles within their specific practice settings. Exten-
tions’ economic viability. At the same time they must continue to act sive practicum experiences assist them with assessing quality and safety
as advocates and to maintain a standard of care. at the micro- and macrosystems levels in order to improve direct
patient care. A certification examination is available. CNLs work in a
variety of pediatric settings, providing safe and optimal care to chil-
The increasing complexity of care and a focus on cost containment,
error reduction, and quality of care have led to a greater need for nurses Implications of Changing Roles for Nurses
with advanced educational preparation. Pediatric nurses who have As nursing care has changed, so also have the roles of pediatric nurses
obtained advanced education may practice as nurse practitioners, with both basic and advanced preparation. Nurses now work in a
clinical nurse specialists, or clinical nurse leaders (CNL®). They may variety of areas. Although they previously worked almost exclusively
also practice in administrative, education, or research roles. Prepara- in the hospital setting, many now provide home care and community-
tion for these roles usually involves obtaining a master’s or doctoral based care. Some of the settings for care children and families include:
degree. • Acute-care settings: general hospital units, intensive care units,
surgical units, postanesthesia care units, emergency care facili-
Nurse Practitioners ties, and onboard emergency transport craft
Nurse practitioners are advanced practice nurses who work according • Clinics and physicians’ offices
to protocols and provide many primary care services that were once • Home health agencies
provided only by physicians. Most nurse practitioners collaborate with • Schools
a physician, but, depending on their scope of practice and their indi- • Rehabilitation centers and long-term care facilities
vidual state’s board of nursing mandates, they may work indepen- • Summer camps and daycare centers
dently and prescribe medications. Nurse practitioners provide care for • Hospice programs and respite care programs
children and families in a variety of settings (primary-care facilities, • Psychiatric centers
schools, acute-care facilities, rehabilitation centers). They may address
occupational health, women’s health, family health, and the health of
the elderly or the very young.
Pediatric nurse practitioners use advanced skills to assess and treat The nursing process is the foundation for all nursing. The nursing
well and ill children according to established protocols. The health care process is a problem-solving process used to provide unique, individu-
services they provide range from physical examinations and anticipa- alized, and patient-centered nursing care. Underlying successful use of
tory guidance to the treatment of common illnesses and injuries. It is the nursing process are techniques of therapeutic communication and
becoming more common for newborn nurseries and some children’s exercise of appropriate clinical judgment using critical thinking.
hospital specialty units to be staffed by neonatal or pediatric nurse
practitioners. Therapeutic Communication
School nurse practitioners receive education and training that is Therapeutic communication is a skill nurses require to carry out the
similar to that of pediatric nurse practitioners. However, because of many facets of providing patient-centered care. Therapeutic commu-
the setting in which they practice, the school nurse practitioners receive nication, unlike social communication, is purposeful, goal directed,
advanced education in managing chronic illness, disability, and mental and focused. Although it may seem simple, therapeutic communica-
health problems in a school setting, as well as developing skills required tion requires conscious effort and considerable practice. Fluency in
to communicate effectively with students, teachers, school administra- therapeutic communication relies on active listening, being aware of
tors, and community health care providers. School nurse practitioners nonverbal messages, incorporating cultural communication differ-
expand the traditional role of the school nurse by providing on-site ences, and focusing on specific child and family needs.
treatment of acute care problems and providing extensive well-child
examinations and services. Critical Thinking
Nursing process also relies on the nurse’s expertise in clinical judg-
Clinical Nurse Specialists ment. Critical thinking, as a component of clinical judgment, under-
Clinical specialists are registered nurses who, through study and super- lies the nursing process steps (Huckabay, 2009). Unlike undirected
vised practice at the graduate level (master’s or doctorate), have thinking, which is random and unfocused, critical thinking is con-
become expert in the care children and families. Four major subroles trolled, purposeful, directed toward solving problems and achieving
have been identified for clinical nurse specialists: expert practitioner, outcomes based on evidence. Critical thinking involves thorough
CHAPTER 1â•… Introduction to Nursing Care of Children 19

reflection and analysis of one’s own thought processes. The critical example, the nurse would perform a focused assessment of the respira-
thinker examines and questions assumptions (Alfaro-LeFevre, 2009). tory system several times during the child’s hospitalization for the child
Critical thinking improves clinical judgment by reducing habits that with acute asthma.
result in poor decision making and increases the ability to apply
knowledge to clinical situations. It reduces the risk for decision Nursing Diagnosis
making based on emotion, fatigue, or anxiety. Critical thinking begins The data gathered during assessment must be analyzed to identify
when nurses realize that it is not enough to accumulate a fund of problems or potential problems. Data are validated and grouped in a
knowledge from texts and lectures. They must also be able to apply process of critical thinking so that cues and inferences can be deter-
the knowledge to specific clinical situations to provide the most effec- mined. The nurse identifies the child and family’s responses to actual
tive patient-centered care. or potential health problems and to normal life processes. The nursing
diagnosis provides a basis for nursing accountability for interventions
Steps of the Nursing Process and outcomes.
The nursing process consists of five distinct steps: (1) assessment, (2) There are three types of nursing diagnoses. An actual nursing diag-
nursing diagnosis, (3) planning, (4) implementation of the plan (inter- nosis describes a human response to a health condition or life process
ventions), and (5) evaluation. Despite the apparent complexity of the affecting an individual, family, or community. It is supported by defin-
process, the nurse soon learns to use the steps of the nursing process ing characteristics (manifestations, signs, and symptoms) that can be
in order when caring for children and families. clustered in patterns of related cues or inferences. Risk nursing diagno-
Pediatric nursing, including care of a newborn, presents a challenge ses describe human responses to health conditions or life processes that
for many nursing students. Whereas use of the nursing process when may develop in a vulnerable individual, family, or community. They
caring for adults may involve only the patient, in caring for infants and are supported by risk factors that contribute to increased vulnerability.
children it must involve their family as well. Therefore it is common Wellness nursing diagnoses describe human responses to levels of well-
for planning and interventions to state what the parent is expected to ness in an individual, family, or community that have a potential for
do or to specify interventions such as teaching a parent. The involve- enhancement to a higher state.
ment of a third party (the family) may be different to the nursing Each nursing diagnosis is a concise term or phrase that represents
student who has applied the nursing process only to care of adults in a pattern of related cues or signs and symptoms. One problem that
the past. nurses often encounter is writing nursing diagnoses that nursing
actions cannot address. For example, a medical diagnosis, such as
Assessment pyloric stenosis, cannot be treated by a nurse. It is appropriate, however,
Nursing assessment is the systematic collection of relevant data to to say that there are nursing actions that can decrease the fluid volume
determine the child’s and family’s current health status, coping pat- deficit associated with pyloric stenosis.
terns, needs, and problems. The data collected include not only physi- A nursing diagnosis consists of two sections joined by the phrase
ologic data but also psychological, social, and cultural data relevant to “related to.” The statement begins with the response to the current
life processes. Nurses must assess the belief systems, available support, problem and then describes the causative factor or factors. An example
perceptions, and plans of other family members in an effort to provide is Interrupted Family Processes related to the diagnosis of a child with
the best nursing care. cancer. The causative factors can be physiologic, psychological, socio-
During the assessment phase, three activities take place: collecting cultural, environmental, or spiritual. They assist the nurse in identify-
data, grouping findings, and writing the nursing diagnoses. Data can ing nursing interventions as planning takes place.
be collected through interview, physical examination, observation,
review of records, and diagnostic reports, as well as through collabora- Planning
tion with other health care workers and the family. Two levels of The nurse next plans care for problems that were identified during
nursing assessment are used to collect comprehensive data: (1) screen- assessment and are reflected in the nursing diagnoses. During this step
ing, or database, assessment; and (2) focused assessments. nurses set priorities, develop goals or outcomes that state what is to be
Screening Assessment.╇ The screening, or database, assessment is accomplished by a certain time, and plan interventions to accomplish
usually performed during the initial contact with the child and family. those goals.
Its purpose is to gather information about all aspects of the child’s Setting Priorities.╇ Setting priorities includes (1) determining what
health. This information, called baseline data, describes the child’s problems need immediate attention (i.e., life-threatening problems)
health status before interventions begin. It forms the basis for identify- and taking immediate action; (2) determining whether there are prob-
ing both strengths and problems. An example of baseline data would lems that call for a physician’s orders for diagnosis, monitoring, or
be the child’s immunization and developmental history. treatment; and (3) identifying actual nursing diagnoses, which take
A variety of methods may be used to organize the assessment. For precedence over at-risk diagnoses. For children with many health and
example, information may be grouped according to body systems. psychosocial problems, a realistic number of nursing diagnoses must
Assessment can also be organized around nursing models that are be chosen.
based on nursing theory, such as Roy’s adaptation model, Gordon’s Establishing Goals and Expected Outcomes.╇ Although the terms
functional health patterns, NANDA International’s human response goals and outcome criteria are sometimes used interchangeably, they are
patterns, or Orem’s self-care deficit theory. different. Generally, broad goals do not state the specific outcome
Focused Assessment.╇ A focused assessment is used to gather criteria and are less measurable than outcome statements. If broad
information that is specifically related to an actual health problem or goals are developed, they should be linked to more specific and mea-
a problem that the child or family is at risk for acquiring. A focused surable outcome criteria. For example, if the goal is that the parents
assessment is often performed at the beginning of a shift and centers will demonstrate effective parenting by discharge, outcome criteria that
on areas relevant to the child’s diagnosis and current status. For serve as evidence might be steps in that process such as prompt,
20 CHAPTER 1â•… Introduction to Nursing Care of Children

consistent responses to infant signals and competence in bathing, These are sometimes termed collaborative problems—physiologic com-
feeding, and comforting the infant. plications that usually occur in association with a specific pathologic
Certain rules should be followed when writing outcomes. condition or treatment.
• Outcomes should be stated in client terms. This wording identi- Nurses monitor to detect the onset of the complication and col-
fies who is expected to achieve the goal (the infant or child, or laborate with physicians to manage changes in status. Both physician-
family). and nursing-prescribed interventions are necessary to minimize
• Measurable verbs must be used. For example, “identify,” “dem- complications (Carpenito-Moyet, 2008).
onstrate,” “express,” “walk,” “relate,” and “list” are verbs that are Planning.╇ It is inappropriate to identify patient-centered goals for
observable and measurable. Examples of verbs that are difficult a collaborative problem because the goals cannot be achieved by inde-
to measure are “understand,” “appreciate,” “feel,” “accept,” pendent nursing action. Collaborative problems should reflect the
“know,” and “experience.” nurse’s responsibility in situations requiring physician-prescribed
• A time frame is necessary. When is the person expected to interventions. The nurse’s responsibility includes (Carpenito-Moyet,
perform the action? After teaching? Before discharge? By 1 day 2008):
after hospitalization? • Monitoring for signs of complications
• Goals and outcomes must be realistic and attainable by nursing • Managing the complications with nursing- and physician-
interventions only. prescribed interventions
• Goals and outcomes are worked out in collaboration with the Interventions.╇ Nursing interventions for collaborative problems
child and family to ensure their participation in the plan of care. include (1) performing frequent assessments to monitor the child’s or
family’s status and detect signs and symptoms of complications; (2)
Implementation communicating with the physician when signs and symptoms of com-
Implementation is the action phase of the nursing process. Once the plications are noted; (3) performing physician-prescribed interven-
goals and desired outcomes are developed, it is necessary to select tions, including standing orders and protocols, to prevent or correct
nursing interventions that will help the child and family meet the the complication; and (4) performing nursing interventions described
established outcomes. During this phase the nurse is constantly evalu- in the standards of care or policy and procedure manuals.
ating and reassessing to determine that the interventions remain Evaluation.╇ Although client-centered goals or outcomes are not
appropriate. As the child’s condition changes, so does the plan of care. developed for collaborative problems, the nurse collects data, compares
The type of nursing interventions implemented depends on the data with established norms, and judges whether the data are
whether the nursing diagnosis was an actual, risk, or wellness diagno- within normal limits. If the data are not within normal limits, the nurse
sis. Nursing interventions for actual nursing diagnoses are aimed at consults the physician for additional direction and implements
reducing or eliminating the causes or related factors. Interventions for physician-prescribed interventions as well as nursing interventions.
risk nursing diagnoses are aimed at (1) monitoring for onset of the
problem, (2) reducing or eliminating risk factors, and (3) preventing
the problem. For a wellness nursing diagnosis, interventions focus on
supporting the child’s or family’s coping mechanisms and promoting Today’s nurse will likely encounter clients who use complementary and
a higher level of wellness. alternative medicine (CAM). Complementary and alternative medi-
Nursing interventions in care plans or protocols are most easily cine can be defined as those systems, practices, interventions, therapies,
implemented if they are specific and spell out exactly what should be applications, theories, or claims that are currently not an integral part
done. A well-written nursing intervention is specific: “Provide 5╯mL of of the dominant or conventional medical system in North America
fluid (water or juice of choice) at least every 10 minutes while the child (National Center for Complementary and Alternative Medicine, 2010).
is awake.” Vague interventions, such as “keep the child hydrated,” do The therapies may be used instead of conventional medical therapy
not provide specific steps to follow. (alternative therapy) or in addition to conventional medical therapy
(complementary therapy). Integrative medicine combines conven-
Evaluation tional medical therapies with CAM therapies that have substantial
The evaluation determines how well the plan worked or how well the evidence as to their safety and effectiveness.
goals or outcomes were met. To evaluate, the nurse must assess the A major concern in the use of CAM is safety. Those who use these
child’s or family’s status and compare the current status with the goals techniques may delay needed care by a conventional health care pro-
or outcome criteria that were developed during the planning step. The vider, or they may take herbal remedies or other substances that are
nurse then judges how well the child or family is progressing toward toxic when combined with conventional medications or when taken in
goal achievement, and makes a decision. Should the plan be continued? excess. Adverse effects of CAM therapies may be unknown for children.
Modified? Abandoned? Are the problems resolved or the causes dimin- Safety and effectiveness of botanical or vitamin therapies are often
ished? Is another nursing diagnosis more relevant? unregulated. Thus people may take in variable amounts of active ingre-
The nursing process is dynamic, and evaluation frequently results dients from these substances. Some may not consider these therapies
in expanded assessment and additional or modified nursing diagnoses to be medicine and may not report them to their conventional health
and interventions. Nurses are cautioned not to view lack of goal care provider, setting the stage for interactions between conventional
achievement as a failure. Instead it is simply time to reassess and begin medications and CAM therapies that have pharmacologic properties.
the process anew. Many people may not consider some of these therapies “alternative” at
all because the therapy is mainstream in their culture.
Collaborative Problems Nurses may find that their professional values do not conflict with
In addition to nursing diagnoses, which describe problems that many of the CAM therapies. Nursing as a profession supports a self-
respond to independent nursing functions, nurses must also deal with care and preventive approach to health care in which the individual
problems that are beyond the scope of independent nursing practice. bears much of the responsibility for his or her health. Nursing practice
CHAPTER 1â•… Introduction to Nursing Care of Children 21

has traditionally emphasized a holistic, or body-mind-spirit, model of

health that fits with CAM. Nurses already practice CAM therapies such
as therapeutic touch fairly often. The rising interest in CAM provides EVIDENCE
an opportunity for nurses to participate in research related to the LEVEL DESCRIPTION
legitimacy of these treatment modalities. I Evidence from a systematic review or meta-analysis of
The National Center for Complementary and Alternative Medicine, all relevant RCTs
a division of the National Institutes of Health, has a website II Evidence obtained from well-designed RCTs
( for information and classification of the III Evidence obtained from well-designed controlled trials
therapies. without randomization
IV Evidence from well-designed case-control and cohort
NURSING RESEARCH AND V Evidence from systematic reviews of descriptive and
EVIDENCE-BASED PRACTICE qualitative studies
VI Evidence from single descriptive or qualitative studies
As nursing and the health care system change, nurses will be challenged VII Evidence from the opinion of authorities and/or reports
to demonstrate that what they do improves child outcomes and is of expert committees
cost-effective. To meet this challenge nurses must participate in
research and use evidence that is based on current research to improve Reprinted with permission from Melnyk, B. & Fineout-Overholt, E.
patient-centered care. With the establishment of the National Institute (2011). Evidence-based practice in nursing and healthcare (2nd ed.,
p. 12). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
of Nursing Research as a member of the National Institutes of Health
(, nurses now have an infrastructure in place to
ensure that nursing research is supported and that a group of well-
prepared nurse researchers will be educated.
The amount of clinically based nursing research conducted is using high-quality evidence presented in integrative, or systematic,
increasing rapidly as nurse researchers strive to develop an indepen- reviews (reviews of collected research on a particular health issue)
dent body of knowledge that demonstrates the value of nursing inter- conducted by a variety of health professionals that includes nurses.
ventions. The challenge is to move the knowledge acquired by nurse One source of high-quality systematic reviews is the Cochrane Data-
researchers into the clinical area. One way of doing this is through base of Systematic Reviews; another, as mentioned previously, is the
using the principles of evidence-based nursing practice. National Guideline Clearinghouse. Nurses should not exclude descrip-
Evidence-based practice to improve patient outcomes is a combina- tive or qualitative studies from consideration of a practice change
tion of asking an appropriate clinical question; acquiring, appraising because often, these studies provide more in-depth information about
and using the highest level of published research; clinical expertise; and a particular clinical issue.
patient values and preferences (Melnyk & Fineout-Overholt, 2011). Finally, practice change should not be made without including the
When considering a change in practice, nurses need to take into nurse’s expertise and abilities to assess what can or cannot be effective
account both evidence level and evidence quality (rigor, consistency, for patient outcomes. In some instances, it is not practical or cost effec-
and sufficiency) of research to determine the strength of evidence tive to make a particular practice change. Nurses should also strongly
(Melnyk & Fineout-Overholt, 2011). To accomplish this effectively, consider whether a practice change will be acceptable to patients; if the
nurses need to be familiar with what constitutes the highest levels of change is not accepted, patients will not incorporate it into their self-
evidence. Evidence level is based on the research design of a study or care (Melnyk & Fineout-Overholt, 2011).
studies. There are several different approaches to categorizing levels of Although students and inexperienced nurses may not directly par-
evidence for nursing, although all are very similar. Table 1-5 summa- ticipate in research projects, they must learn how useful knowledge
rizes one approach. obtained by the research team is to their practice. Professional, peer-
Although the area of outcomes research in nursing is expanding, reviewed journals are the best sources of new information that can help
there are not many randomized controlled trials (RCTs) that have been nurses provide improved care and demonstrate that what they do
conducted and published by nurses. Nurses can, however, consider makes a difference in outcomes.

• Technologic advances, increasing knowledge, government involve- • Infant mortality rates have declined dramatically in the past 50
ment, and consumer demands have affected changes in child health years; however, the United States continues to rank well below other
care in the United States. developed nations, and infant mortality rates still vary widely across
• Family-centered child health care, based on the principle that fami- ethnic groups. Unintentional injuries are the leading cause of death
lies can make decisions about health care if they have adequate in children aged 1 to 19 years.
information, has greatly increased the autonomy of families and the • Poverty is a major social issue that leads to questions about alloca-
responsibility of pediatric nurses. tion of health care resources, access to care, government programs
• Provision of appropriate health care to children relies on ade- to increase health care to indigent women and children, and health
quate health care access, which has been influenced by govern- care rationing.
ment and health insurers’ responses to efforts to control the costs • Pediatric nurses encounter both ethical and legal issues in their
of health care. practice and should become familiar with information sources and
22 CHAPTER 1â•… Introduction to Nursing Care of Children

standards to assist them with solving ethical dilemmas and adher- and evaluation. The nursing process results in individualized, high-
ing to legal regulations. quality, and safe care for children and families.
• Pediatric nurses function in a variety of roles in multiple practice • Nurses must consider the effect of complementary and alternative
settings, which include acute care, clinics, physicians’ offices, home therapies when assessing the child and planning care.
health agencies, schools, rehabilitation centers, summer camps, • Becoming competent in the collection and application of best evi-
daycare centers, and hospices. dence for specific care of common problems in nursing practice is
• The steps of the nursing process, which is integrally related to criti- now part of the role of every nurse. Relying on traditional care
cal thinking, include assessment (screening and focused), analysis methods rather than determining if evidence supports the methods
that may result in nursing diagnoses, planning, implementation, is no longer sufficient.

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from Lacey, S., Smith, J., & Cox, K.. (2008). Patient safety and (2010a). Children’s Health Insurance Program Reauthori-
Betz, C. (2005). Health care quality and outcome guidelines quality: An evidence-based handbook for nurses (Chapter zation Act: One year later, connecting kids to coverage.
for nursing of children and families. Journal of Pediatric 15). Retrieved from Retrieved from
Nursing, 20(3), 149-152. Little, M., Gorman, A., Dzendoletas, D., & Moravac, C. United States Department of Health and Human Services.
Carpenito-Moyet, L. (2008). Handbook of nursing diagnosis (2007). Caring for the most vulnerable: A collaborative (2010b). Healthy People 2020. Retrieved from
(12th ed.). Philadelphia: Lippincott. approach to supporting pregnant homeless youth.
Center for Medicare and Medicaid. (2011). NHE fact sheet. Nursing & Women’s Health, 11(5), 458-466. United States Department of Health and Human Services.
Retrieved from Lyon, F., & Grow, K. (2011). Case management. In M. Nies (2011a). Accountable care organizations: Improving care
Centers for Disease Control and Prevention. (2011). YRBSS & M. McEwen (Eds.). Community/public health nursing: coordination for people with Medicare. Retrieved from
in brief. Retrieved from Promoting the health of populations (5th ed., pp.152-162).
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Center for Chronic Disease Prevention and Health Pro- March of Dimes. (2011). The serious problem of premature (2011b). Understanding the Affordable Care Act.
motion. (2011). Oral health: Preventing cavities, gum birth. Retrieved from Retrieved from

Family-Centered Nursing Care

After studying this chapter, you should be able to:
• Explain how important families are for the provision of effective • Describe the effect of cultural diversity on nursing practice.
nursing care to children. • Describe common styles of parenting that nurses may encounter.
• Describe different family structures and their effect on family • Explain how variables in parents and children may affect their
functioning. relationship.
• Differentiate between healthy and dysfunctional families. • Discuss the use of discipline in a child’s socialization.
• List internal and external coping behaviors used by families when • Evaluate the effects of an ill child on the family.
they face a crisis.
• Compare Western cultural values with values of other cultural

No factor influences a person as profoundly as the family. Families Pediatric Nurses, 2003). Family-centered care can be defined as an
protect and promote children’s growth, development, health, and well- innovative approach to the planning, delivery and evaluation of health
being until the children reach maturity. A healthy family provides care that is grounded in a mutually beneficial partnership among
children and adults with love, affection, and a sense of belonging and patients, families, and health care professionals (O’Malley, Brown, &
nurtures feelings of self-esteem and self-worth. Children need stable Krug, 2008). The American Academy of Pediatrics (AAP) Committee
families to grow into happy, functioning adults. Family relationships on Hospital Care (2003) noted that family-centered care is grounded
continue to be important during adulthood. Family relationships in collaboration among patients, families, physicians, nurses, and other
influence, positively or negatively, people’s relationships with others. professionals for the planning, delivery, and evaluation of health care
Family influence continues into the next generation as a person selects as well as in the education of health care professionals. The level to
a mate, forms a new family, and often rears children. which this concept is implemented varies among practitioners. Some
For nurses in pediatric practice, the whole family is the client. The of the identified roadblocks are lack of skills in communication, role
nurse cares for the child in the context of a dynamic family system negotiation, and developing relationships. Other issues that interfere
rather than caring for just an infant or a child. The nurse is responsible with the full implementation of family-centered care are lack of time,
for supporting families and encouraging healthy coping patterns fear of losing one’s role, and lack of support from the health care
during periods of normal growth and development or illness. system and other disciplines (Harrison, 2010). Clearly, there is a need
for increased education in this area, based on research, to help nurses
and other health care professionals implement this concept.
In 1998 the fourth Report of the Pew Health Professions Committee Family Structure
identified 21 competencies for the twenty-first century health profes- Family structures in the United States are changing. The number of
sional. One of the competencies is to practice relationship-centered families with children that are headed by a married couple has declined,
care with individuals and families. In 2003, family-centered care was and the number of single-parent families has increased. In addition,
adopted as a philosophy of care for pediatric nursing (Society of roles have changed within the family. Whereas the role of the provider

24 CHAPTER 2â•… Family-Centered Nursing Care

was once almost exclusively assigned to the father, both parents now
may be providers, and many fathers are active in nurturing and disci- Nontraditional Families
plining their children. The growing number of nontraditional families, designated as
“complex households” by the U.S. Census Bureau, includes single-
Types of Families parent families, blended families, adoptive families, unmarried couples
Families are sometimes categorized into three types: traditional, non- with children, multigenerational families, and homosexual parent
traditional, and high risk. Nontraditional and high-risk families often families (Figure 2-2).
need care that differs from the care needed by traditional families. Single-Parent Families.╇ Millions of families are now headed by a
Different family structures can produce varying stressors. For example, single parent, most often the mother, who must function as home-
the single-parent family has as many demands placed on it for resources, maker and caregiver and also is often the major provider for the fam-
such as time and money, as the two-parent family. Only one parent, ily’s financial needs. Factors contributing to this demographic include
however, is able to meet these demands. divorce, widowhood, and childbirth or adoption among unmarried
women. Among the 26% of children who live with one parent, 79%
Traditional Families live with their mothers (Forum on Child and Family Statistics, 2010).
Traditional families (also called nuclear families) are headed by two Single parents may feel overwhelmed by the prospect of assuming
parents who view parenting as the major priority in their lives and all child-rearing responsibilities and may be less prepared for illness or
whose energies may not be depleted by stressful conditions such loss of a job than two-parent families.
as poverty, illness, and substance abuse. Traditional families can Blended Families.╇ Blended families are formed when single,
be single-income or dual-income families. Generally, traditional divorced, or widowed parents bring children from a previous union
families are motivated to learn all they can about pregnancy, into their new relationship. Many times the couple desires children
childbirth, and parenting (Figure 2-1). Today a family structure com- with each other, creating a contemporary family structure commonly
posed of two married parents and their children represents 70% of described as “yours, mine, and ours.” These families must overcome
families with children, up 3% from when last reported in 2007. differences in parenting styles and values to form a cohesive blended
Twenty-six percent of children live with one parent and the remain- family. Differing expectations of children’s behavior and development
ing 4 percent with no parents (Forum on Child and Family Statistics, as well as differing beliefs about discipline often cause family conflict.
2010). Financial difficulties can result if one parent is obligated to pay child
Single-income families in which one parent, usually the father, is support from a previous relationship. Older children may resent the
the sole provider are a minority among households in the United introduction of a stepmother or stepfather into the family system. This
States. Most two-parent families depend on two incomes, either to can cause tension between the biologic parent, the children, and the
make ends meet or to provide nonessentials that they could not afford stepmother or stepfather.
on one income. One or both parents may travel as a work responsibil- Adoptive Families.╇ People who adopt a child may have problems
ity. Dependence on two incomes has created a great deal of stress on that biologic parents do not face. Biologic parents have the long period
parents, subjecting them to many of the same problems that single- of gestation and the gradual changes of pregnancy to help them adjust
parent families face. For instance, reliable, competent child care is a emotionally and socially to the birth of a child. An adoptive family,
major issue that has increased the stress traditional families experience. both parents and siblings, is expected to make these same adjustments
A high consumer debt load gives them less cushion for financial set- suddenly when the adopted child arrives. Adoptive parents may add
backs such as job loss. Having the time and flexibility to attend to the pressure to themselves by having an unrealistically high standard for
requirements of both their careers and their children may be difficult themselves as parents. Additional issues with adoptive families include
for parents in these families. possible lack of knowledge of the child’s health history, the difficulty
assimilating if the child is adopted from another country, and the ques-
tion of when and how to tell the child about being adopted. Adoptive
parents and biologic parents need information, support, and guidance
to prepare them to care for the infant or child and maintain their own
Multigenerational Families.╇ The multigenerational or extended
family consists of members from three or more generations living
under one roof. Older adult parents may live with their adult children,
or in some cases adult children return to their parents’ home, either
because they are unable to support themselves or because they want
the additional support that the grandparents provide for the grand-
children. The latter arrangement has given rise to the term boomerang
families. Extended families are vulnerable to generational conflicts and
may need education and referral to counselors to prevent disintegra-
tion of the family unit.
Grandparents or other older family members, because of the inabil-
ity of the parents to care for their children, now head a growing
number of households with children. Fifty-two percent of children
who do not live with either parent live with a grandparent (Forum on
FIG 2-1  Traditional, two-parent families typically have the resources Child and Family Statistics, 2010). The strain of raising children a
to prepare for childbirth and the needs of infants. (Copyright Getty second time may cause tremendous physical, financial, and emotional
Images, 2011.) stress.
CHAPTER 2â•… Family-Centered Nursing Care 25

Busy parents may rely on grandparents for child care or for an additional
measure of love and attention for their children. Some grandparents raise
grandchildren because of their own children’s inability to do so.

A single parent often experiences financial and time constraints. Chil- Fathers are the primary child-care providers in a growing number of
dren in single-parent families are often given more responsibility to families. Fathers who are not the primary caregivers often participate
care for themselves and younger siblings. more actively in caring for their children than the fathers of previous
FIG 2-2  A nurse caring for a child needs to know the child’s family structure and the identity of the
child’s primary caregiver. This background becomes the context in which the nurse provides care. If
family support is a concern, the nurse can provide information about local community resources. For
example, in some communities, after-school programs and “warm lines” can help children with
schoolwork and alleviate loneliness and fear.

Same-Sex Parent Families.╇ Families headed by same-sex parents Characteristics of Healthy Families
have increasingly become more common in the United States. The In general, healthy families are able to adapt to changes that occur in
children in such families may be the offspring of previous heterosexual the family unit. Pregnancy and parenthood create some of the most
unions, or they may be adopted children or children conceived by an powerful changes that a family experiences.
artificial reproductive technique such as in vitro fertilization. The Healthy families exhibit the following common characteristics,
couple may face many challenges from a community that is unaccus- which provide a framework for assessing how all families function
tomed to alternative lifestyles. The children’s adaptation depends on (Cooley, 2009):
the parents’ psychological adjustment, the degree of participation and • Members of healthy families communicate openly with one
support from the absent biologic parent, and the level of community another to express their concerns and needs.
support. • Healthy family members remain flexible in their roles, with roles
Communal Families.╇ Communal families are groups of people changing to meet changing family needs.
who have chosen to live together as extended family groups. Their • Adults in healthy families agree on the basic principles of par-
relationship to one another is motivated by social value or financial enting so that minimal discord exists about concepts such as
necessity rather than by kinship. Their values are often spiritually based discipline and sleep schedules.
and may be more liberal than those of the traditional family. Tradi- • Healthy families are adaptable and are not overwhelmed by life
tional family roles may not exist in a communal family. changes.
26 CHAPTER 2â•… Family-Centered Nursing Care

• Members of healthy families volunteer assistance without 2011). Those who become parents during adolescence are unlikely to
waiting to be asked. attain a high level of education and, as a result, are more likely to be
• Family members spend time together regularly but facilitate poor and often homeless. An adolescent father often does not contrib-
autonomy. ute to the economic or psychological support of his child. Moreover,
• Healthy families seek appropriate resources for support when the cycle of teen parenting and economic hardship is more likely to be
needed. continued because children of adolescent parents are themselves more
• Healthy families transmit cultural values and expectations to likely to become teenage parents.
Factors that Interfere with Family Functioning Violence is a constant stressor in some families. Violence can occur in
Factors that may interfere with the family’s ability to provide for the any family of any socioeconomic or educational status. Children
needs of its members include lack of financial resources, absence of endure the psychological pain of seeing their mother victimized by the
adequate family support, birth of an infant who needs specialized care, man who is supposed to love and care for her. In addition, because of
an ill child, unhealthy habits such as smoking and abuse of other sub- the role models they see in the adults, children in violent families may
stances, and inability to make mature decisions that are necessary to repeat the cycle of violence when they are adults and become abusers
provide care for the children. Needs of aging members at the time or victims of violence themselves.
children are going through adolescence or the expenses of college Abuse of the child may be physical, sexual, or emotional or may
add pressure on middle-aged parents, often called the “sandwich take the form of neglect (see Chapter 29). Often one child in the family
generation.” is the target of abuse or neglect, whereas others are given proper care.
As in adult abuse, children who witness abuse are more likely to repeat
High-Risk Families that behavior when they are parents themselves, because they have not
All families encounter stressors, but some factors add to the usual stress learned constructive ways to deal with stress or to discipline children.
experienced by a family. The nurse needs to consider the additional
needs of the family with a higher risk for being dysfunctional. Exam- Substance Abuse
ples of high-risk families are those experiencing marital conflict and Parents who abuse drugs or alcohol may neglect their children because
divorce, those with adolescent parents, those affected by violence obtaining and using the substance(s) may have a stronger pull on the
against one or more of the family members, those involved with sub- parents than does care of their children. Parental substance abuse inter-
stance abuse, and those with a chronically ill child. rupts a child’s normal growth and development. The parent’s ability
to meet the needs of the child are severely compromised, increasing
Marital Conflict and Divorce the child’s risk for emotional and health problems (Children of Alco-
Although divorce is traumatic to children, research has shown that holics Foundation, 2011).
living in a home filled with conflict is also detrimental (Sobolewski & The child may be the substance abuser in the home. The drug habit
Amato, 2007). Divorce can be the outcome of many years of unresolved can lead a child into unhealthy friendships and may result in criminal
family conflict. It can result in continuing conflict over child custody, activity to maintain the habit. School achievement is likely to plummet,
visitation, and child support; changes in housing, lifestyle, cultural and the older adolescent may drop out of school. Children as well as
expectations, friends, and extended family relationships; diminished adults can die as a result of their drug activity, either directly from the
self-esteem; and changes in the physical, emotional, or spiritual health drugs or from associated criminal activity or risk-taking behaviors.
of children and other family members.
Divorce is loss that needs to be grieved. The conflict and divorce Child with Special Needs
may affect children, and young children may be unable to verbalize When a child is born with a birth defect or has an illness that requires
their distress. Nurses can help children through the grieving process special care, the family is under additional stress (see Chapters 12 and
with age-appropriate activities such as therapeutic play (see Chapter 30). In most cases their initial reactions of shock and disbelief gradu-
11). Principles of active listening (see Chapter 3) are valuable for adults ally resolve into acceptance of the child’s limitations. However, the
as well as children to help them express their feelings. Nurses can also parents’ grieving may be long term as they repeatedly see other chil-
help newly divorced or separated parents through listening, encourage- dren doing things that their child cannot and perhaps will not ever do.
ment, and referrals to support groups or counselors. These families often suffer financial hardship. Health insurance
benefits may quickly reach their maximum. Even if the child has public
Adolescent Parenting assistance for health care costs, the family often experiences a fall in
The teenage birth rate in the United States fell by more than one third income because one parent must remain home with the sick child
from 1991 through 2005 but increased by 5% over the next 2 years. rather than work outside the home.
Current data show another downward trend, reaching a historic low Strains on the marriage and the parents’ relationships with their
of 39.1 per 1000 teen births. Adolescent birth rates vary by race; other children are inevitable under these circumstances. Parents have
however, there has been a steady decline in teen birth rates for all racial little time or energy left to nurture their relationship with each other,
and ethnic groups. The birth rate for Hispanic teenagers showed the and divorce may add yet another strain to the family. Siblings may
largest decline of all race and ethnicity groups. From 2008 to 2009, the resent the parental time and attention required for care of the ill child
rated declined by 11% (National Center for Health Statistics, 2011). yet feel guilty if they express their resentment.
Teenage parenting often has a negative effect on the health and The outlook is not always pessimistic in these families, however. If
social outcomes of the entire family. Adolescent girls are at increased the family learns skills to cope with the added demands imposed on it
risk for a number of pregnancy complications, such as preterm birth, by this situation, the potential exists for growth in maturity, compas-
low birth weight, and death during infancy (Ventura & Hamilton, sion, and strength of character.
CHAPTER 2â•… Family-Centered Nursing Care 27


Family conflict is unavoidable. It is a natural result of a perceived
unequal exchange or an imbalance in the use of resources by individual Internal Coping Strategies
members. Conflict should not be viewed as bad or disruptive; Relationship Strategies
the management of the conflict, not the conflict itself, may be prob- • Family group reliance
lematic. Conflict can produce growth and improve family functioning • Greater sharing together
if the outcome is resolution as opposed to dissolution or continued • Role flexibility
conflict. The following three ingredients are required to resolve
conflict: Cognitive Strategies
1. Open communication • Normalizing
2. Accurate perceptions about the nature and degree of conflict • Controlling the meaning of the problem by reframing and passive
3. Constructive efforts to resolve the conflict, such as willingness appraisal
to consider the view of the other, consider alternate solutions, • Joint problem solving
and compromise • Gaining of information and knowledge
Dysfunctional families have problems in any one or a combination
of these areas. They tend to become trapped in patterns in which they Communication Strategies
maintain conflicts rather than resolve them. The conflicts create stress, • Being open and honest
and the family must cope with the resultant stress. • Use of humor and laughter

Coping with Stress External Coping Strategies

Community Strategy
If the family is considered a balanced system that has internal and
• Maintaining active linkages with the community
external interrelationships, stressors are viewed as forces that change
the balance in the system. Stressful events are neither positive nor Social Support Strategies
negative, but rather neutral until they are interpreted by the individual. • Extended family
Positive as well as negative events can cause stress (Smith, Hamon, • Friends
Ingoldsby, Miller 2009). For example, the birth of a child is usually a • Neighbors
joyful event, but it can also be stressful. • Self-help groups
Some families are able to mobilize their strengths and resources, • Formal social supports
thus effectively adapting to the stressors. Other families fall apart. A
family crisis is a state or period of disorganization that affects the Spiritual Strategies
foundation of the family (Smith et╯al., 2009). • Seeking advice of clergy
Pediatric Skills—Providing Culturally Sensitive Care

• Becoming more involved in religious activities

Coping Strategies • Having faith in God
Nurses can help families cope with stress by helping each family iden- • Prayer
tify its strengths and resources. Friedman, Bowden, and Jones (2003)
Reprinted from Friedman, M., Bowden, V., & Jones, E. (2003). Family
identified family coping strategies as internal and external. Box 2-1
nursing: Theory, research, and practice (5th ed.). Upper Saddle River,
identifies family coping strategies and further defines internal strategies
NJ: Prentice-Hall.
as family relationship strategies, cognitive strategies, and communica-
tion strategies. External strategies focus on maintaining active com-
munity linkages and using social support systems and spiritual for many conflicts that occur when people from different cultural
strategies. Some families adjust quickly to extreme crises, whereas groups have frequent contact.
other families become chaotic with relatively minor crises. Family Nurses must be aware that culture is composed of visible and invis-
functional patterns that existed before a crisis are probably the best ible layers that could be said to resemble an iceberg (Figure 2-3). The
indicators of how the family will respond to it. observable behaviors can be compared with the visible tip of the
iceberg. The history, beliefs, values, and religion are not observed but
are the hidden foundation on which behaviors are based and can be
likened to the large, submerged part of the iceberg. To comprehend
CULTURAL INFLUENCES ON PEDIATRIC NURSING cultural behavior fully, one must seek knowledge of the hidden beliefs
╇ Culture is the sum of the beliefs and values that are learned, that behaviors express. One must also have the desire or motivation to
shared, and transmitted from generation to generation by a particular engage in the process of becoming culturally competent to be effective
group. Cultural values guide the thinking, decisions, and actions of in caring for diverse populations.
the group, particularly regarding pivotal events such as birth, sexual Nurses must first understand their own culture and biases and then
maturity, and death. Ethnicity is the condition of belonging to a begin to acquire the knowledge and understanding of other cultures.
particular group that shares race, language and dialect, religious Applying the knowledge completes the process (Galanti, 2008).
faiths, traditions, values, and symbols as well as food preferences, Religious beliefs often have a strong influence on families as they
literature, and folklore. Cultural beliefs and values vary among dif- face the crisis of illness. Specific beliefs about the causes, treatment,
ferent groups and nurses must be aware that individuals often believe and cure of illness are important for the nurse to know to empower
their cultural values and patterns of behavior are superior to those the family as they deal with the immediate crisis. Table 2-1 describes
of other groups. This belief, termed ethnocentrism, forms the basis how some religious beliefs affect health care.
28 CHAPTER 2â•… Family-Centered Nursing Care

7. Admiration of self-sufficiency and financial success may conflict

with the beliefs of other societies that place less value on wealth
Behaviors and more value on less tangible things such as spirituality.

History Cultural Influences on the Care of People from

Values Specific Groups
Beliefs To provide the best care for all clients, the nurse should know common
Religion cultural beliefs and practices that influence nursing care. Because com-
munication is an essential component of nursing assessment and
teaching, the nurse must understand cultural influences that may form
barriers to communicating with people from another culture.

Asians and Pacific Islanders

“Asian” refers to populations with origins in many areas, such as the
FIG 2-3  Visible and hidden layers of culture are like the visible and Far East, Southeast Asia, and the Indian subcontinent, including
submerged parts of an iceberg. Many cultural differences are Vietnam, China, Japan, and the Philippines. “Pacific Islander” refers to
hidden below the surface. the original peoples of Hawaii, Guam, Samoa, and other Pacific islands.
Their roots are in their ethnic viewpoint as well as their country of
origin. They are not a homogeneous group, but differ in language,
culture, and length of residence in the United States. Asians and Pacific
Implications of Cultural Diversity for Nurses Islanders constitute 4.8% of the U.S. population (United States Census
Many immigrants and refugees are relatively young, so nurses in most Bureau, 2011).
localities will provide care for families in culturally diverse circum- In the Asian culture the family is highly valued and often consists
stances. To provide effective care, nurses must be aware that culture is of many generations that remain close to one another. The elders of
among the most significant factors that influence parenthood, health the family are highly respected. Self-sufficiency and self-control are
and illness, and aging. Many health care workers’ knowledge of other highly valued. Asian-Americans place a high value on “face,” or honor,
cultures and how to care for children and families in a culturally sensi- and may be unwilling to do anything that causes another to “lose face.”
tive manner is limited. The following discussion summarizes the char- When medication or therapy is recommended, they seldom say no.
acteristics of family roles, health care beliefs and practices, and They may accept the prescription or medication sample but not take
communication styles of some cultural groups. These descriptions are the medicine, or they may agree to undergo a procedure but not keep
merely generalizations. Each family is unique and should be assessed the appointment. Stoicism may make pain assessment difficult. Herbal
and evaluated individually. medicines and practices such as acupressure and music therapy may
play an important part in healing for this culture.
Western Cultural Beliefs Besides the national languages of Vietnam, Cambodia, and Laos,
Nursing practice in the United States is based largely on Western numerous languages are spoken within subgroups in each country.
beliefs. Nurses need to recognize that these beliefs may differ signifi- People from Southeast Asia speak softly and avoid prolonged eye
cantly from those of other societies and that the differences may cause contact, which they consider rude. Even people who have been in the
a great deal of conflict. United States for many years often do not feel competent in English.
Leininger (1978) identified the following seven dominant Western The nurse should avoid “yes” or “no” questions and have the parent or
cultural values; these values continue to greatly influence the thinking child demonstrate understanding of any patient teaching (Galanti,
and action of nurses in the United States but may not be shared by 2008).
their clients: Families of some hospitalized Pacific Islander clients are involved
1. Democracy is a cultural value not shared by families who believe in their direct care, which may include direct provision of food. Some
that elders or other higher authorities in the group make deci- individuals consult traditional healers. Education related to obesity,
sions. Fatalism, or a belief that events and results are predes- diabetes, and hypertension is quite often needed (D’Avanzo, 2008).
tined, may also affect health care decisions.
2. Individualism conflicts with the values of many cultural groups Hispanics
in which individual goals are subordinated to the greater good Hispanics, also called Latinos, include those whose origins are Mexico,
of the group. Central and South America, Cuba, and Puerto Rico. They are a very
3. Cleanliness is an American “obsession” viewed with amazement diverse group. This group is growing rapidly in the United States,
by many people of other cultures. accounting for 14% of the total population in 2005, compared with
4. Preoccupation with time, which is measured by health care pro- 16.3% in 2010 (United States Census Bureau, 2011).
fessionals in minutes and hours, is a major source of conflict Men are usually the head of household and considered strong
with those who mark time by different standards, such as (macho). Women are the homemakers. Hispanics usually have a close
seasons or body needs. extended family and place a high value on children. Family is valued
5. Reliance on machines and equipment may intimidate families above work and other aspects of life.
who are not comfortable with technology. Hispanics tend to be polite and gracious in conversation. Prelimi-
6. The belief that optimal health is a right is in direct conflict with nary social interaction is particularly important, and Hispanics may be
beliefs in many cultures in the world in which health is not a insulted if a problem is addressed directly without time first being
major emphasis or even an expectation. taken for “small talk.” This is counter to the value of “getting to the
CHAPTER 2â•… Family-Centered Nursing Care 29


Christianity is generally accepted to be the largest religious group in the world. There are three major branches of Christianity and a number of religious traditions
considered to be Christian. These traditions have much in common relative to beliefs and practices. Belief in Jesus Christ as the son of God and the Messiah
comprises the central core of Christianity. Christians believe that it is through Jesus’ death and resurrection that salvation can be attained. They also believe that
they are expected to follow the example of Jesus in daily living. Study of biblical scripture; practicing faith, good works, and sacramental rites (e.g., baptism,
communion, and others); and prayer are common among most Christian faiths.

Christian Science
Based on scientific system of healing. Birth: Use physician or midwife during childbirth. No baptism ceremony.
Beliefs derived from both the Bible and the book Science, and Health with Dietary practices: Alcohol and tobacco are considered drugs and are not used.
Key to Scriptures.* Coffee and tea also may be declined.
Prayer is the basis for spiritual, physical, emotional, and mental healing, as Death: Autopsy and donation of organs are usually declined.
opposed to medical intervention (Christian Science, 2011). Health care: May refuse medical treatment. View health in a spiritual framework.
Healing is divinely natural, not miraculous. Seek exemption from immunizations but obey legal requirements. When
Christian Science believer is hospitalized, parent or client may request that a
Christian Science practitioner be notified.

Jehovah’s Witness
Expected to preach house to house about the good news of God. Baptism: No infant baptism. Adult baptism by immersion.
Bible is doctrinal authority. Dietary practices: Use of tobacco and alcohol discouraged.
No distinction is made between clergy and laity. Death: Autopsy decided by persons involved. Burial and cremation acceptable.
Birth control and abortion: Use of birth control is a personal decision. Abortion
opposed on basis of Exodus 21:22-23.
Health care: Blood transfusions not allowed. May accept alternatives to
transfusions, such as use of non-blood plasma expanders, careful surgical
technique to minimize blood loss, and use of autologous transfusions. Nurses
should check an unconscious client for identification that states that the person
does not want a transfusion. Jehovah’s Witnesses are prepared to die rather
than break God’s law. Respect the health care given by physicians, but look to
God and His laws as the final authority for their decisions.

The Church of Jesus Christ of Latter-Day Saints (Mormon)

Restorationism: True church of Christ ended with the first generation of Baptism: By immersion. Considered essential for the living and the dead. If a
apostles but was restored with the founding of Mormon Church. child older than 8 years is very ill, whether baptized or unbaptized, a member
Articles of faith: Mormon doctrine states that individuals are saved if they of the church’s clergy should be called.
are obedient to God’s divine ordinances (faith, repentance, baptism by Anointing of the sick: Mormons frequently are anointed and given a blessing
immersion and laying on of hands). before going to the hospital and after admission by laying on of hands.
Holy Communion: Hospitalized client may desire to have a member of the Dietary practices: Tobacco and caffeine are not used. Mormons eat meat
church’s clergy administer the sacrament. (limited) but encourage the intake of fruits, grains, and herbs.
Scripture: Word of God can be found in the Bible, Book of Mormon, Doctrine Death: Prefer burial of the body. A church elder should be notified to assist the
and Covenants, Pearl of Great Price, and current revelations. family.
Christ will return to rule in Zion, located in America. Birth control and abortion: Abortion is opposed unless the life of the mother is in
danger. Only natural methods of birth control are recommended. Other means
are used only when the physical or emotional health of the mother is at stake.
Other practices: Believe in the healing power of laying on of hands. Cleanliness
is important. Believe in healthy living and adhere to health care requirements.
Families are of great importance, so visiting should be encouraged. The church
maintains a welfare system to assist those in need.

Adapted from Carson, V.B. (1989). Spiritual dimensions of nursing practice (pp. 100-102). Philadelphia: Saunders; Betz, C.L., Hunsberger, M., &
Wright, S. (1994). Family-centered nursing care of children (2nd ed., pp. 2230-2236). Philadelphia: Saunders; Taylor, E.J. (2002). Spiritual care:
nursing theory, research, and practice. Upper Saddle River, NJ: Prentice-Hall; Spector, R.E. (2004). Cultural diversity in health and illness (6th
ed.). Upper Saddle River, NJ: Prentice-Hall; Graham, L., & Cates, J. (2006). Health care and sequestered cultures: A perspective from the old
order Amish. Journal of Nursing and Health, 12(3), 60-66.
*Eddy, M. B. G. (1875). Science and Health with Key to Scriptures. Boston: Christian Science Board of Directors.
30 CHAPTER 2â•… Family-Centered Nursing Care


Roman Catholicism
Belief that the Word of God is handed down to successive generations Baptism: Infant baptism by affusion (sprinkling of water on head) or total
through scripture and tradition, and is interpreted by the magisterium (the immersion. Original sin is believed to be “washed away.” If death is imminent
Pope and bishops). or a fetus is aborted, anyone can perform the baptism by sprinkling water on
Pope has final doctrinal authority for followers of the Catholic faith, which the forehead, saying “I baptize thee in the name of the Father, Son, and Holy
includes interpreting important doctrinal issues related to personal practice Spirit.”
and health care. Anointing of the Sick: Encouraged for anyone who is ill or injured. Always done if
prognosis is poor.
Dietary practices: Fasting and abstinence from meat optional during Lent. Fasting
required for all, except children, elders, and those who are ill, on Ash
Wednesday and Good Friday. Avoidance of meat on Ash Wednesday and on
Fridays during Lent strongly encouraged.
Death: Organ donation permitted.
Birth control and abortion: Abortion is opposed. Only natural methods of birth
control are recommended.

Christians who practice their religion and beliefs within the context of strong Baptism: Late teen/early adult. Must marry within the church.
community ties. Death: Do not normally use extraordinary measures to prolong life.
Focused on salvation and a happy life after death. Other practices: May have a language issue (modified German or Dutch) and
Powerful bishops make health care decisions for the community. need an interpreter. At increased risk for genetic disorders; refuse
Problems solved with prayer and discussion. contraception or prenatal testing. May appear stoical or impassive—personally
Primarily agrarian; eschew many modern conveniences. humble. Reject health insurance; rely on the Church and community to pay for
health care needs. Use holistic and herbal remedies, but accept Western
medical approaches.

Belief in reincarnation and that the soul persists even though the body Circumcision is observed by ritual.
changes, dies, and is reborn. Dietary practices: Dietary restrictions vary according to sect; vegetarianism is not
Salvation occurs when the cycle of death and reincarnation ends. uncommon.
Nonviolent approach to living. Death: Death rituals specify practices and who can touch corpse. Family must be
Congregation worship is not customary; worship is through private shrines in consulted, as family members often provide ritualistic care.
the home. Other practices: May use ayurvedic medicine—an approach to restoring balance
Disease is viewed holistically, but Karma (cause and effect) may be blamed. through herbal and other remedies. Same-sex health providers may be

Belief in one God that humans can approach directly in prayer. Dietary practices: Prohibit eating pork and using alcohol. Fast during Ramadan
Based on the teachings of Muhammad. (ninth month of Muslim year).
Five Pillars of Islam. Death: Oppose autopsy and organ donation. Death ritual prescribes the handling
Compulsory prayers are said at dawn, noon, afternoon, after sunset, and of corpse by only family and friends. Burial occurs as soon as possible.
after nightfall.

Beliefs are based on the Old Testament, the Torah, and the Talmud, the oral Circumcision: A symbol of God’s covenant with Israel. Done on eighth day after
and written laws of faith. birth.
Belief in one God who is approached directly. Bar Mitzvah/Bat Mitzvah: Ceremonial rite of passage for boys and girls into
Believe Messiah is still to come. adulthood and taking personal responsibility for adherence to Jewish laws and
Believe Jews are God’s chosen people. rituals.
Death: Remains are washed according to Jewish rite by members of a group
called the Khevra Kadisha. This group of men and women prepare the body for
burial and protect it until burial occurs. Burial occurs as soon as possible after
CHAPTER 2â•… Family-Centered Nursing Care 31

point” for many whites in the United States and may cause frustration affairs be kept within the family. Personal information is shared
for the client as well as the health care worker. only with friends, and the health assessment must be done gradually.
Religion and health are strongly associated. The curandero, a folk When interpreters are used, they should be of the same country and
healer, may be consulted for health care before an American health care religion, if possible, because of regional differences and hostilities.
worker is consulted. Hispanics have great respect for health care pro- Because Islamic society tends to be paternalistic, asking the husband’s
viders; however, undocumented Hispanics may fear that a health care permission or opinion when family members need health care is
worker will disclose their illegal status (Purnell & Paulanka, 2003). helpful.

African-Americans Cross-Cultural Health Beliefs

African-Americans constitute 12.6% of the U.S. population (United More than 100 different ethnocultural groups reside in the United
States Census Bureau, 2011). African-Americans are often part of a States, and numerous traditional health beliefs are observed among
close extended family, although many heads of household are single these groups. For example, definitions of health are often culturally
women. They have a sense of loyalty to their people and community, based. People of Asian origin may view health as the balance of yin
but sometimes distrust the majority group. and yang. Those of African or Haitian origin may define health as
Not all black people in the United States were born in this country, harmony with nature. Those from Mexico, Central and South America,
however. Natives of Africa and other countries are often found in both and Puerto Rico often see health as a balance of hot and cold.
health care provider and client populations within the United States.
The African-American minister is highly influential, and religious Traditional Methods of Preventing Illness
rituals such as prayer are frequently used. Illness may be seen as the The traditional methods of preventing illness rest in a person’s ability
will of God. to understand the cause of a given illness in his or her culture. These
causes may include the following:
American Indians and Alaska Natives • Agents such as hexes, spells, and the evil eye, which may
The terms American Indian and Alaska Native refer to people who have strike a person (often a child) and cause injury, illness, or
origins in any of the original peoples of North and South America and misfortune
who maintain tribal affiliation or community attachment. This group • Phenomena such as soul loss and accidental provocation of
makes up 0.9% of the total U.S. population (United States Census envy, jealousy, or hate of a friend or acquaintance
Bureau, 2011). Many who consider themselves Native Americans are • Environmental factors such as bad air, and natural events such
of mixed race. The largest American Indian tribal groups are Cherokee, as a solar eclipse
Navajo, Latin American Indian, Sioux, Chippewa, and Choctaw. The Practices to prevent illness developed from beliefs about the cause
largest tribe among Alaska Natives are the Yupik (United States Census of illness. People must avoid those known to transmit hexes and spells.
Bureau, 2011). Elaborate methods are used to prevent inciting envy or jealousy of
Native Americans may consider a willful child to be strong and a others and to avoid the evil eye. Protective or religious objects, such as
docile child to be weak. They have close family relationships, and respect amulets with magic powers or consecrated religious objects (talis-
for their elders is the norm. Although each American Indian nation or mans), are frequently worn or carried to prevent illness. Numerous
tribe has its own belief system regarding health, the overall traditional food taboos and traditional combinations are prescribed in traditional
belief is that health reflects living in total harmony with nature and belief systems to prevent illness. For instance, people from many ethnic
disease is associated with the religious aspect of society, because super- backgrounds eat raw garlic to prevent illness.
natural powers are associated with the causing and curing of disease
(Spector, 2009). Native Americans may highly respect a medicine man, Traditional Practices to Maintain Health
whom they believe to be given power by supernatural forces. The use A variety of traditional practices are used to maintain health. Mental
of herbs and rituals is part of the medicine man’s curative practice. and spiritual health is maintained by activities such as silence, medita-
tion, and prayer. Many people view illness as punishment for breaking
Middle Easterners a religious code and adhere strictly to religious morals and practices
Middle Eastern immigrants come from several countries, including to maintain health.
Lebanon, Syria, Saudi Arabia, Egypt, Turkey, Iran, and Palestine. Islam
is the dominant, and often the official, religion in these countries; its Traditional Practices to Restore Health
followers are known as Muslims. The man is typically the head of the Traditional practices to restore health sometimes conflict with Western
household in Muslim families. Islam requires believers to kneel and medical practice. Some of the most common practices include the use
pray five times a day, at dawn, noon, during the afternoon, after sunset, of natural substances, such as herbs and plants, to treat illness. Reli-
and after nightfall. Muslims do not eat pork and do not use alcohol. gious charms, holy words, or traditional healers may be tried before
Many are vegetarians. Other dietary standards vary according to the an individual seeks a medical opinion. Wearing religious medals, car-
branch of Islam and may include standards such as how the acceptable rying prayer cards, and performing sacrifices are other practices used
animal is slaughtered for food. to treat illness.
Muslim women often prefer a female health care provider because Homeopathic care, often referred to as “complementary medicine”
of laws of modesty. Many Muslim women cover the head, arms to the or “alternative medicine,” is becoming more common in health care
wrists, and legs to the ankles although there are many variations in the settings. Acupuncture, massage therapy, and chiropractic medicine are
acceptable degree of coverage. Ritual cleansing before leaving the home examples of homeopathic care (Spector, 2009).
or hospital room may be required before the woman dresses in her A variety of substances may be ingested for the treatment of ill-
required modest apparel. nesses. The nurse should try to identify what the child is taking and
Communication in these countries is elaborate, and obtaining determine whether the active ingredient may alter the effects of pre-
health information may be difficult because Islam dictates that family scribed medication.
32 CHAPTER 2â•… Family-Centered Nursing Care

Practices such as dermabrasion, the rubbing or irritation of the skin also expect the child to accept the family beliefs and principles without
to relieve discomfort, are common among people of some cultures. question. Give and take is discouraged.
The most frequently seen form is coining, in which an area is covered Children raised with this style of parenting can be shy and with-
with an ointment and the edge of a coin is rubbed over the area. All drawn because of a lack of self-confidence. If the parents are somewhat
dermabrasion methods leave marks resembling bruises or burns on the affectionate, the child may be sensitive, submissive, honest, and
skin and may be mistaken for signs of physical abuse. dependable. If affection has been withheld, however, the child may
exhibit rebellious, antisocial behavior.
Cultural Assessment Authoritative parents tend to show respect for the opinions of each
All health care professionals must develop skill in performing a cultural of their children by allowing them to be different. Although the house-
assessment so they can understand the meanings of health and illness hold has rules, the parents permit discussion if the children do not
to the cultural groups they encounter. When assessing a woman, child, understand or agree with the rules. The parents emphasize that even
or family from a cultural perspective, the nurse considers the though they (the parents) are the ultimate authority, some negotiation
following: and compromise may take place. This style of parenting tends to result
• Ethnic affiliation in children who have high self-esteem and are independent, inquisitive,
• Major values, practices, customs, and beliefs related to preg- happy, assertive, and highly interactive.
nancy and birth, parenting, and aging Permissive parents have little or no control over the behavior of their
• Language barriers and communication styles children. If any rules exist in the home, they are inconsistent and unclear.
• Family, newborn, and child-rearing practices Underlying reasons for rules may be given, but the children are generally
• Religious and spiritual beliefs; changes or exemptions during allowed to decide whether they will follow the rules and to what extent.
illness, pregnancy, or after birth Limits are not set, and discipline is inconsistent. The children learn that
• Nutrition and food patterns they can get away with any behavior. Role reversal occurs: The children
• Ethnic health care practices, such as how time is marked and are more like the parents, and the parents are like the children.
views of life and death Children who come from this type of home are typically disrespect-
• Health promotion practices ful, disobedient, aggressive, irresponsible, and defiant. They tend to be
• How health care professionals can be most helpful insecure because of a lack of guidelines to direct their behavior. They
After such an assessment, plans for care should show respect for are searching for true limits but not finding them. These children tend
cultural differences and traditional healing practices. A guiding prin- to be creative and spontaneous.
ciple for nurses should be one of acceptance of nontraditional methods Regardless of the primary parenting style, parenting is more effec-
of health care as long as the practice does not cause harm. In some tive when parents are able to adjust their parenting techniques accord-
instances, cultural practices may actually cause unintentional harm; in ing to each child’s developmental level and when parents are involved
these circumstances the nurse may need to consult other professionals and interested in their children’s activities and friends.
familiar with the particular cultural practice to provide appropriate care
and information for the family. Additional cultural information is Parent-Child Relationship Factors
presented throughout this book relating to specific areas in child health Relationships between parents and children are bidirectional, with the
care. parents’ behavior affecting the child and the child’s behavior affecting
the parenting. The parents’ age, experience, and self-confidence affect
the quality of the parent-child relationship, the stability of the marital
PARENTING relationship, and the interplay between the child’s individualism and
Parenting implies the commitment of an individual or individuals to the parents’ expectations of the child.
provide for the physical and psychosocial needs of a child. Many believe
that parenting is the most difficult and yet rewarding experience an Parental Characteristics
individual can have. Many parents assume this important job with little Parenting is multidimensional. Parents have an obligation to nurture
education in parenting or child rearing. If the parents themselves have and care for their children and to provide a moral education through
had parents that are positive role models and if they seek appropriate example (Richards, 2010). Parent personality type, personal history of
resources for parenting, the transition to parenting is easier. Nurses are parenting as a child, abilities and competencies, parental skills and
in a good position to provide parents with information on effective expectations, personal health, quality of marital relationship, and rela-
parenting skills through many venues, such as formal classes, anticipa- tionship quality with others all play a part in determining how a person
tory guidance at well-child checkups, and role modeling. parents. Parenting behaviors that promote the development of social-
emotional, cognitive, and language development are warmth, respon-
Parenting Styles siveness, encouragement, and communication (Roggman, Boyce, &
Baumrind (1991) described three major parenting styles, which have Innocenti, 2008).
been generally accepted by experts in child and family development. In addition, parents who have had previous experience with chil-
Parenting style, which is the general climate in which a parent socializes dren, whether through younger siblings, a career, or raising other
a child, differs from parenting practices, the specific behavioral guid- children, bring an element of experience to the art of parenting. Self-
ance parents offer children across the age span. Although the charac- confidence and age also can be factors in a person’s ability to parent.
teristics of parenting styles are described later in their general categories, How an individual was parented has a major effect on how he or she
many specialists in child development acknowledge that characteristics will assume the role. The strength of the parents’ relationship also
of several parenting styles may be present in parents. In addition, affects their parenting skills, as does the presence or absence of support
researchers recognize that parenting styles may work in different ways systems. Support can come from the family or community. Peer groups
in different cultures. can provide an arena for parents to share experiences and solve prob-
Authoritarian parents have rules. They expect obedience from the lems. Parents with more experience are often an important resource
child without any questioning about the reasons behind the rule. They for new parents.
CHAPTER 2â•… Family-Centered Nursing Care 33

Characteristics of the Child themselves as wild, and soon their actions consistently reinforce their
Characteristics that may affect the parent-child relationship include the self-image. In this way the children will not disappoint the parents.
child’s physical appearance, sex, and temperament. At birth the infant’s This pattern is called a self-fulfilling prophecy and is a cyclic process.
physical appearance may not meet the parents’ expectations, or the Discipline is designed to teach a child how to function effectively
infant may resemble a disliked relative. As a result, the parent may sub- within society. It is the foundation for self-discipline. A parent’s
consciously reject the child. If the parents desired a baby of a particular primary goal should be to help the child feel lovable and capable. This
sex, they may be disappointed. If parents are not given the opportunity goal is best accomplished by the parent’s setting limits to enhance a
to talk about this disappointment, they may reject the infant. sense of security until the child can incorporate the family’s values and
is capable of self-discipline.
Temperament and Parental Expectations When a child is in the health care system, the nurse has the oppor-
Temperament can be described as the way individuals behave or their tunity to aid in the socialization of the child to some degree. Scholer,
behavioral style. Several researchers have studied temperament. Chess Hudnut-Beumler, and Dietrich (2010) suggest that while parents
and Thomas (1996) developed the following three temperament cat- look to physicians and nurses to provide information about child
egories, which are based on nine characteristics of temperament they discipline, time spent assisting parents in this area is not routine in
identified in children (Box 2-2). pediatric primary care. In a Level II randomized controlled study,
1. Easy: These children are even tempered, predictable, and regular Scholer and colleagues (2010) demonstrated that even a brief interven-
in their habits. They react positively to new stimuli. tion in a primary care setting, designed to raise awareness of how to
2. Difficult: These children are highly active, irritable, moody, and effectively discipline children significantly assisted parents to develop
irregular in their habits. They adapt slowly to new stimuli and positive disciplinary approaches. Through both formal instruction
often express intense negative emotions. and informal role modeling, the nurse can help the parent learn
3. Slow to warm up: These children are inactive, moody, and mod- how to discipline a child effectively. Box 2-3 lists ways in which a parent
erately irregular in their habits. They adapt slowly to new stimuli or nurse can facilitate children’s socialization and increase their
and express mildly intense negative emotions. self-esteem.
Some objection to the term difficult has been raised because it tends
to have a negative connotation. That is the term established in tem- Dealing with Misbehavior
perament research, however, and parents should recognize that a “dif- A child’s misbehavior may be defined as behavior outside the norms of
ficult” child is quite normal. As is true for other characteristics, such acceptance within the family. Misbehavior stretches the limits of toler-
as appearance, the parent-child relationship is likely to have less con- ance in all parents, even the most patient. A parent’s response to the
flict if the child’s temperament meets the parents’ expectations. child’s misbehavior can have minor consequences such as short-term
frustration or major consequences such as child abuse. To prevent
these negative consequences, the nurse can help teach parents various
DISCIPLINE strategies for effective discipline. Whenever disciplinary strategies are
Children’s behavior challenges most parents. The manner in which used, the parent needs to consider the individual child’s developmental
parents respond to a child’s behavior has a profound effect on the level. In addition, discipline should be consistent, the parent should
child’s self-esteem and future interactions with others. Children learn not “give in” to manipulation or tantrums, and the child’s feelings
to view themselves in the same way that the parent views them. Thus should be acknowledged (AAP, 2011). The following are three essential
if parents view their children as wild, the children begin to view components of effective discipline (AAP Committee on Psychosocial
Aspects of Child and Family Health, 1998, reaffirmed 2004):
1. Maintaining a positive, supportive, loving relationship between
the parents and the child
BOX 2-2â•… CHARACTERISTICS OF 2. Using positive reinforcement and encouragement to promote
TEMPERAMENT IN CHILDREN cooperation and desired behaviors
3. Removing reinforcement or applying punishment to reduce or
1. Level of activity: The intensity and frequency of motion during playing,
eliminate undesired behaviors
eating, bathing, dressing, or sleeping
2. Rhythmicity: Regularity of biologic functions (e.g., sleep patterns, eating
patterns, elimination patterns)
3. Approach/withdrawal: The initial response of a child to a new stimulus,
such as an unfamiliar person, unfamiliar food, or new toys BOX 2-3â•… EFFECTIVE DISCIPLINE
4. Adaptability: Ease or difficulty in adjustment to a new stimulus FOR POSITIVE SOCIALIZATION
5. Intensity of response: The amount of energy with which the child responds AND SELF-ESTEEM
to a new stimulus
6. Threshold of responsiveness: The amount or intensity of stimulation neces- • Attend promptly to an infant’s and young child’s needs.
sary to evoke a response • Provide structure and consistency for young children.
7. Mood: Frequency of cheerfulness, pleasantness, and friendly behavior • Give positive attention for positive behavior; use praise when deserved.
versus unhappiness, unpleasantness, and unfriendly behavior • Listen.
8. Distractibility: How easily the child’s attention can be diverted from an • Set aside time every day for one-on-one attention.
activity by external stimuli • Demonstrate appreciation of the child’s unique characteristics.
9. Attention span/persistence: How long the child pursues an activity and • Encourage choices and decision making, and allow the child to experience
continues despite frustration and obstacles consequences of mistakes.
• Model respect for others.
Adapted from Chess, S., & Thomas, A. (1996). Temperament: Theory • Provide unconditional love.
and practice. New York: Brunner-Mazel.
34 CHAPTER 2â•… Family-Centered Nursing Care

Punishment is used to eliminate a behavior and can be in the form Some parents have difficulty allowing their children to face the
of a verbal reprimand or physical action to emphasize a point. The consequences of their actions. When parents choose to deny their child
AAP discourages the use of spanking and other forms of physical this experience, the child loses an important opportunity to teach
punishment (AAP, 2011). responsibility for one’s actions.

Redirection Behavior Modification

Redirection is a simple and effective method in which the parent The behavior modification technique of discipline rewards positive
removes the problem and distracts the child with an alternative activity behavior and ignores negative behavior. This technique requires
or object. This method is helpful with infants through preadolescents. parents to choose selected behaviors, preferably only one at a time,
that they desire to stop. They choose others that they want to encour-
Reasoning age. The basic technique is useful for any age from toddlerhood
Reasoning involves explaining why a behavior is not permitted. through adolescence. For a young child, the selected positive behav-
Younger children lack the cognitive skills and developmental abilities iors are marked on a chart and explained to the child. For an older
to comprehend reasoning fully. For example, a 4-year-old may better child, a contract can be written. The negative behaviors are kept in
understand the consequence that he will have to spend time in his mind by the parents but are not recorded where the child can see
room if he breaks his brother’s toy than the concept of respecting the them. A system of rewards is established. Stickers or stars on a chart
property of others. for young children and tokens for older children are effective ways
When this technique is used with older children, the behavior to record the behaviors. Children should receive a predetermined
should be the object of focus, not the child. The child should not be reward (e.g., a movie, book, or outing, but not food) after they suc-
made to feel guilt and shame, because these feelings are counterpro- cessfully perform the behavior a set number of times. This system
ductive and can damage the child’s self-esteem. The parent can focus should continue for several months until the behavior becomes a
on the behavior most effectively by using “I” rather than “you” habit for the child. Then the external reward should be gradually
messages. withdrawn. The child develops internal gratification for successful
A “you” message criticizes children and uses guilt in an attempt to behavior rather than relying on external reinforcement. Children gain
get them to change their behavior. An example of a “you” message is a sense of mastery and actually enjoy the process, often viewing it as
“Don’t take your little sister’s toys away and make her cry. You’re being a game.
a bad boy!” By contrast, an “I” message focuses on the misbehavior by
explaining its effect on others. An example of an “I” message is, “Your
little sister cries when you take her toys away because she doesn’t know
that you will give them back to her.”
Avoiding the Use of Corporal Punishment
Time-Out as Discipline
Time-out is a method of removing the attention given to a child Corporal punishment can lead to child abuse if the disciplinarian loses control.
who is misbehaving. It involves placing the child in a nonstimulating It can also lead to false accusations of child abuse by either the child or other
environment where the parent can observe unobtrusively. For adults. Because of the high cost and low benefit of this form of punishment,
example, a chair could be placed facing a wall in a hall or nearby parents should avoid its use.
room. The child is told to sit on the chair for a predetermined time,
usually 1 minute per year of age. If the child cries or fights, the timing
is not begun until the child is quiet. The use of a kitchen timer with
a bell is effective because the child knows when the time begins and Negative behaviors are simply ignored. If the parent refuses to give
when it has elapsed and the child can get up. After the child has the child attention for the behavior, the child soon gives up that strat-
calmed and the time is completed, discussion of the behavior that egy. Consistency is the key to success for this technique, and many
prompted the time-out at a level appropriate to the child’s age may parents find this method difficult to enforce. Parents need to be warned
be helpful. that children frequently test the seriousness of this attempt by increas-
ing their negative behavior soon after the parents begin ignoring it. If
Consequences this technique is to be successful, the parents need to ignore the nega-
The consequences technique helps children learn the direct result tive behavior every time.
of their misbehavior and can be used with toddlers through adoles-
cents. If children must deal with the consequences of their behavior Corporal Punishment
and the consequences are meaningful to them, they are less likely Corporal punishment usually takes the form of spanking. It is highly
to repeat the behavior. Consequences fall into the following three controversial and should be discouraged. Corporal punishment has
categories: many undesirable results, which include physical aggression toward
1. Natural: Consequences that occur spontaneously. For example, others and the belief that causing pain to others is acceptable (AAP,
a child loses a favorite toy after leaving it outside and the parent 2011). Adults who were spanked as children are more likely than those
does not replace it. who were not spanked to experience depression, use substances, and
2. Logical: Consequences that are directly related to the misbehav- commit domestic violence (AAP, 2011). Use of spanking as discipline
ior. For example, when two children are fighting over a toy, the can result in loss of control and child injury.
parent removes the toy from both of them for a day. Because of the negative consequences of spanking and because it is
3. Unrelated: Consequences that are purposely imposed. For no more effective than other methods of discipline, the AAP (2011)
example, a child comes in late for dinner and, as a consequence, recommends that parents be encouraged and helped to develop
is not allowed to watch TV that evening. methods of discipline other than spanking.
CHAPTER 2â•… Family-Centered Nursing Care 35

Create a genogram of your family. Can you identify health issues and trends
Family Assessment from looking at the genogram? What are the implications for nursing care?
When assessing family health, the nurse first must determine the struc-
ture of the family. The structure is the actual physical composition of
the family, the family’s environment, and the occupations and educa- Nursing Diagnosis and Planning
tion of its members. Diagrams can assist with this process. A genogram, After using the various tools to assess the child’s family completely, the
also known as a pedigree, which illustrates family relationships and nurse identifies the appropriate nursing diagnoses. These will differ
health issues, looks like a family tree with three generations of family according to the specific family assessment data. The following general
members represented. An ecomap is a pictorial representation of the nursing diagnoses can be used for families:
family structure and relationships with factors in the external • Risk for Caregiver Role Strain
environment. • Compromised Family Coping
Next the nurse needs to determine how well the family is fulfilling • Interrupted Family Processes
its five major functions as described by Friedman, Bowden, & Jones • Impaired Parenting
(2003): • Risk for Impaired Attachment
1. Affective function (personality maintenance function): to meet • Ineffective Family Therapeutic Regimen Management
the psychological needs of family members—trust, nurturing, • Social Isolation
intimacy, belonging, bonding, identity, separateness and con- Other diagnoses may also be appropriate. The expected outcomes
nectedness, need-response patterns, and the therapeutic role of for each diagnosis would be specifically tailored to the family’s needs.
the individuals in the family.
2. Socialization function (social placement): to guide children to be Intervention and Evaluation
productive members of society and transmit cultural beliefs to Interventions also are specific for the child and family, but most family
the next generation. interventions are directed toward enhancing positive coping strategies
3. Reproductive function: to ensure family continuity and societal and directing the family to appropriate resources. The nurse adapts
survival. general family interventions to each family’s unique needs but in par-
4. Economic function: to provide and effectively allocate economic ticular helps the family to do the following:
resources. • Identify and mobilize internal and external strengths
5. Health care function: to provide the physical necessities of life • Access appropriate resources in the extended family and
(e.g., food, clothing, shelter, health care), to recognize illness in community
family members and provide care, and to foster a healthy life- • Recognize and enhance positive communication patterns
style or environment based on preventive medical and dental • Decide on a consistent discipline approach and access parenting
health practices. programs if needed
Health problems can arise from structural problems, such as too few • Maintain comforting cultural and religious traditions and
or too many people sharing the same living quarters. If too few people sources of healing
are present, children may be left unattended; too many people may lead • Engage in joint problem solving
to overcrowding, stress, and the spread of communicable diseases. • Acquire new knowledge by providing information about a spe-
Environmental problems include impure drinking water, inadequate cific health problem or issue
sewage facilities, damaged electric wiring and outlets, and inadequate • Become empowered
sleeping conditions. Other environmental factors, such as rodents, • Allocate sufficient privacy, space, and time for leisure activities
crime, and noise, can affect health. Occupation and education can affect • Promote health for all family members during times of crisis
health through lack of adequate supervision of children; inability to Once families have participated in needed intervention, evaluation
purchase physical necessities, such as food; inability to purchase health criteria are tailored to the specific intervention and individualized for
insurance; and stress from employment dissatisfaction. the family.

• Traditional families may be single-income or dual-income families. • Identifying healthy versus dysfunctional family patterns can help
Two-income families are much more common at present. the nurse implement effective strategies to care for the child and
• Nontraditional family structures (single-parent, blended, adoptive, the family.
multigenerational [extended], and same-sex parent families) may • Clients during health and illness are cared for within the framework
require nursing care that is different from that required by tradi- of their families and their cultures.
tional families. • Traditional cultural beliefs may be used to prevent illness, maintain
• High-risk families have additional stressors that affect their health, and restore health.
functioning. Examples are families headed by adolescents; • Differing cultural beliefs and expectations between the health care
families affected by marital discord or divorce, violence, or provider and the family can create conflict.
substance abuse; and families with a severely or chronically ill • The nurse can help parents learn effective discipline methods by
member. teaching and role modeling.
• All families experience stress; how the family deals with stress is the • Assessing the structure and function of the family is a basic part of
important factor. caring for any child.
36 CHAPTER 2â•… Family-Centered Nursing Care

American Academy of Pediatrics. (2011, May). Disciplining D’Avanzo, C. E. (2008). Mosby’s pocket guide to cultural Roggman, L. A., Boyce, L. K., & Innocenti, M. S. (2008).
your child. Retrieved from health assessment (4th ed.). St. Louis: Mosby. Developmental parenting. Baltimore, MD: Paul H
American Academy of Pediatrics Committee on Hospital Forum on Child and Family Statistics. (2010). America’s Brookes Publishing Co.
Care. (2003). Family-centered care and the pediatrician’s children in brief: Key national indicators of well-being, Scholer, S., Hudmut-Beumler, J., & Dietrich, M. (2010). A
role. Pediatrics, 112(3), 691-696. 2010. Washington, DC: U.S. Government Printing Office. brief primary care intervention helps parents develop
American Academy of Pediatrics Committee on Psychoso- Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). plans to discipline. Pediatrics, 125, e242-e249.
cial Aspects of Child and Family Health. (1998). Guid- Family nursing: Theory, research and practice (5th ed., pp. Smith, S. R., Hamon, R. R., Ingoldsby, B. B., & Miller, J. E.
ance for effective discipline. Pediatrics, 101(4), 723-728. 593-594). Upper Saddle River, NJ: Prentice-Hall. (2009). Exploring family theories. New York: Oxford Uni-
Policy reaffirmed in 2004. Galanti, G. A. (2008). Caring for patients from different cul- versity Press.
Baumrind, D. (1991). Effective parenting during the early tures. Philadelphia: University of Pennsylvania Press. Sobolewski, F., & Amato, P. (2007). Parents’ discord and
adolescent transition. In P. Cowan & M. Hetherington Harrison, T. M. (2010). Family-centered pediatric nursing divorce, parent-child relationships and subjective well-
(Eds.), Family transitions (Chapter 5). Hillsdale, NJ: Law- care: State of the science. Journal of Pediatric Nursing, 25, being in early adulthood: Is feeling close to two parents
rence Erlbaum. 335-343. always better than feeling close to one? Social Forces,
Carson, V. B. (1989). Spiritual dimensions of nursing practice. Leininger, M. (1978). Transcultural nursing: Concepts, theo- 85(3), 1105-1124.
Philadelphia: Elsevier. ries, practices. New York: Wiley. Society of Pediatric Nurses. (2003). Family centered care:
Chess, S., & Thomas, A. (1996). Temperament theory and National Center for Health Statistics. (2011). Data Brief: Putting it into action. SPN/ANA Guide to Family-Centered
practice. New York: Brunner-Mazel. U.S. Teenage birth rate resumes decline. Retrived from Care. Washington, DC.: Society of Pediatric Nurses/
Children of Alcoholics Foundation. (2011). Effects of parental American Nurses Association.
substance abuse on children and families. Retrieved from O’Malley, P. J., Brown, K., & Krug, S. E. (2008). Patient and Spector, R. E. (2009). Cultural diversity in health and illness family-centered care of children in the emergency (7th ed.). Upper Saddle River, NJ: Prentice-Hall.
Christian Science. (2011). About Christian Science: Core department. Pediatrics, 122(2), e511-e512. United States Census Bureau. (2011). 2010 Census Briefs.
beliefs. Retrieved from Purnell, L. D., & Paulanka, B. J. (2003). Transcultural health Retrieved from
Cooley, M. (2009). A family perspective in community/ care: A culturally competent approach (2nd ed.). Philadel- Ventura, M. A., & Hamilton, B. E. (2011). U.S. teenage
public health nursing. In F. Maurer & C. Smith (Eds.), phia: F.A. Davis. birth rate resumes decline. Centers for Disease Control
Community/Public Health Nursing (4th ed., p. 340). St. Richards, N. (2010). The ethics of parenthood. New York, and Prevention. NCHS Data Brief. Retrieved from
Louis: Elsevier. Oxford Press.
Pediatric Nursing Skill e1


Providing Culturally Sensitive Care
Culture is defined as an acquired knowledge people use to interpret experience Related Text
and generate behavior. A culture is composed of individuals with a common set • Chapter 2, Family-Centered Nursing Care
of values, beliefs, practices, and information that is learned, integrative, social,
and satisfying. When attempting to understand behavior, one should consider Nursing Diagnoses
the family’s heritage. Spiritual Distress related to conflict between cultural beliefs and prescribed
There are variations in health care practices and beliefs among and even health regimen; Altered Health Maintenance related to cultural beliefs;
within different cultures. Effective health care and nursing care require knowl- Anxiety related to unconscious conflict about essential values; Decisional Con-
edge of and sensitivity to cultural variation in beliefs and customs, health care flict related to perceived threat to value system; and Impaired Verbal Communi-
practices, language, child-rearing methods, dietary practices, and physical dif- cation related to language or cultural barriers
ferences. Although general information about a culture can be helpful, variations
are numerous even within specific cultural groups. For this reason, individual
and family assessments are vital.
Cultural variables can exert great influence on the family’s acceptance or
rejection of care. Culturally informed planning, implementation, and evaluation
can increase effectiveness and acceptability of care.

1. Assess the family structure by discussion and direct observation.
a. Determine who are considered to be family members. The concept of family varies among cultures. Family ties within some cultures or
subcultures may be especially strong.

b. Identify the decision maker regarding the child’s care. Family groups rather than the parents may be decision makers, or responsibility
for making decisions may be allocated to one or two specific family members,
such as a grandfather or maternal uncle.

c. Identify the child’s caregivers.

d. Determine who is the primary caregiver.
e. Determine what roles each family member plays.
e2 Nursing Care of Children


Providing Culturally Sensitive Care—cont’d
2. Review the beliefs and customs of the child’s culture. There is wide variation among different cultures in regard to health care beliefs
a. Talk with individuals of the cultural group to learn about general and practices. For example, some cultural groups believe that illness results
beliefs and customs. from opposing forces within the body, whereas other cultures may attribute
b. Review literature and maintain a file of written information related to illness to witchcraft and the manipulation of evil spirits. Conflicts with the
specific ethnic or cultural groups. dominant culture may arise because the family may believe that the child is
c. Ask the child and family about their beliefs and customs: What do you not receiving the correct treatment.
think causes illness? How do you usually treat illness? What do you Gaining an awareness of culturally related views can increase sensitivity of care.
think will help you get well? What things would you like us to do? Special Considerations: Beliefs about causes of illness may be inconsistent
with scientific information. Religious beliefs and health care practices are
frequently intertwined.
3. Assess the health care practices of the family. There is variation in health care practices in different cultural groups.
a. Determine what the family usually does about particular illnesses or Special Considerations: Use of folk healers and folk medicines is common
problems. among some groups. It is not uncommon for Western medicine to be used in
b. Ask family members how they usually maintain health. conjunction with folk remedies.
4. Determine the primary language or form of communication used by the Language barriers may exist when the child or family is not fluent in the
family. language of the health care giver. Subtle variations in the meaning and
interpretation of words may occur even within a language.
Special Considerations: Interpreters must be well versed in both languages
and understand clearly the message being conveyed. They must also be
carefully selected because different dialects within a language may contribute
to misunderstanding.
5. Determine the family’s dietary patterns and preferences. Food selection and preparation often vary from culture to culture.
a. Ask about a typical day’s diet. Special Considerations: Beliefs about curative and restorative effects of food
b. Ask about food preferences and dislikes. may exist; some groups use specific foods to restore body imbalances,
c. Ask if certain foods are regarded as having special benefits. especially for “hot” and “cold” diseases.
6. Assess the child in accordance with known information about physical A knowledge base of physical differences is necessary for accurate assessments.
differences. Special Considerations: Growth patterns for different racial groups may reflect
norms that are different from standard norms of height and weight charts
established in North American populations. Risk factors for different groups
(e.g., sickle cell disease and thalassemia) also should be recognized and
7. Review cultural taboos and sanctions of this culture. These may affect acceptance or rejection of a treatment, intervention, or the
a. Use information from review of cultural beliefs. health care provider.
b. Ask if there are any special limitations or proscriptions for children or Special Considerations: For example, in some Caribbean societies it is
pregnant women. considered dangerous for someone to stare at a baby or young child. Certain
dietary restrictions may apply to pregnant women, infants, and children.
Violations of these taboos are believed to adversely affect their health and
8. Determine the family’s degree of adherence to cultural heritage. General patterns may not apply to any individual in a group because cultural
groups are not homogeneous. Stereotyping should be avoided. For example, it
would be incorrect to assume that if a family is from Latin America, the
members necessarily endorse the hot-cold theory of disease.


1. Develop a care plan in collaboration with the child and family, including Goals and plans must be acceptable to the family and the designated decision
the designated decision maker. maker who will carry them out. If such plans are not culturally informed, they
are unlikely to be fulfilled.
2. Make special arrangements as required to meet cultural needs (e.g., Implementing culturally sensitive care may require resources not readily
obtain a qualified interpreter or consult with a dietitian). available.
3. Develop an individualized goal of nursing care:
• To incorporate the family’s cultural beliefs and practices in providing
Pediatric Nursing Skill e3


Providing Culturally Sensitive Care—cont’d
1. Incorporate use of cultural practices related to health care that are not Adapting existing practices rather than attempting to change long-standing
detrimental to the child (e.g., allow child to wear amulet or religious relics beliefs will be more acceptable to the child and family and will foster
during procedures). compliance.
2. Accept the family’s use of folk healers and folk remedies when not The integration of these practices may increase acceptance of the health care.
contraindicated by state health regulations, safety, or treatment
3. Plan diet and dietary changes around food preferences. Allow family to Planning diet around preferred and acceptable foods will increase adherence to
bring food from home. the regimen. Some groups prefer highly seasoned foods or types of food that
may not be available in the hospital.
4. Arrange for caregiver who speaks the same language or a translator if Communication is necessary to validate understanding.
5. Interpret behavior nonjudgmentally in relation to culture but avoid labels. Behavior that may seem unusual may be understandable within the framework of
a specific culture, but not all families adhere to all practices prescribed by the
culture. For instance, there are variations in the way or degree to which
emotions are expressed.
6. When conflict occurs between cultural practices and the health, safety, Some cultural practices may conflict with the dominant culture’s beliefs and
and treatment intervention, explain why the practice is considered harmful values regarding health and safety, or there may be potentially harmful
and encourage the family to seek less harmful ways of treating the interactions with the medical intervention. Some folk remedies may be
problem. contraindicated because of pharmacologic prescriptions. It is important to
explain why a familiar and tried remedy may now be harmful. Sensitivity to the
importance of cultural practices must be balanced with concern for the child’s
welfare, health, and safety.
Special Considerations: Some child care and child-rearing practices that are
accepted by a cultural group may be viewed as abusive by the dominant
culture. For example, some Southeast Asian groups treat enuresis and temper
tantrums by burning small areas of skin. Some Caribbean groups use child
discipline measures such as forced kneeling for long periods. It is important
that the family understand how such practices can place them in jeopardy with
child protective services and explore alternative measures that are more
acceptable to the dominant culture.


1. Health care is accepted by the child and the family. The family carries out the health care regimen.
2. The family is satisfied that care provided respects their cultural beliefs. The family seeks health care for follow-up or for new health care needs. The
family states that they are pleased with the care and the caregivers.

• Communicate the plan of care to co-workers by recording it on patient’s record.
• Document special considerations such as dietary preferences.
• Make notation regarding decision makers in family, and communicate variation in family structure that should be considered in care (e.g., visitation and
rooming policy adjustments that may be needed).
• Note areas of continued noncompliance with care; they should be reexamined in light of continuing assessment of cultural factors.

Communicating with Children
and Families

After studying this chapter, you should be able to:
• Describe six components of effective communication with • Describe effective family-centered communication strategies.
children. • Describe effective strategies for communicating with children
• Describe communication strategies that assist nurses in working with special needs.
effectively with children. • Describe warning signs of overinvolvement and
• Explain the importance of avoiding communication pitfalls in underinvolvement in child/family relationships.
working with children.

To work effectively with children and their families, nurses need to Touch
develop keen communication skills. Because parents and other family Touch can be a positive, supportive technique that is effective from
members play a crucial role in the lives of pediatric clients, nurses need birth through adulthood. Touch can convey warmth, comfort, reassur-
to establish rapport with the family in order to identify mutual goals ance, security, trust, caring, and support.
and facilitate positive outcomes. An awareness of body language, eye In infancy, messages of love, security, and comfort are conveyed
contact, and tone of voice must accompany good verbal communica- through holding, cuddling, gentle stroking, and patting. Infants do not
tion skills when one is listening to children and their families. The same have cognitive understanding of the words they hear, but they sense
awareness helps nurses assess their own communication styles. the emotional support and they can feel, interpret, and respond to
gentle, loving, supportive hands caring for them. Toddlers and pre-
schoolers find it soothing and comforting to be held and rocked as well
COMPONENTS OF EFFECTIVE COMMUNICATION as stroked gently on the head, back, arms, and legs (Figure 3-1).
Communication is much more than words going from one person’s School-age children and adolescents appreciate giving and receiv-
mouth to another person’s ears. In addition to the words themselves, ing hugs and getting a reassuring pat on the back or a gentle hand on
the tone and quality of voice, eye contact, physical proximity, visual the hand. The nurse, however, needs to request permission for any
cues, and overall body language convey messages. These nonverbal contact beyond a casual touch with these clients.
communications are often undervalued. Research has shown that
verbal content makes up only 7% of a message, whereas body language Physical Proximity and Environment
accounts for 55% and paralanguage (intonation, pauses, sighs) repre- Children’s familiarity and comfort with their physical surroundings
sents the remaining 38% (Topper, 2004). In choosing communication affect communication. Normally, children are most at ease in their
techniques to be used with children and families, the nurse considers home environments. Once they enter a clinic, emergency department,
cultural differences, particularly with regard to touch and personal or patient care unit, they are in an unfamiliar environment and they
space (see Chapter 2). Communication provides an important linkage experience heightened anxiety. Hospital and clinic staff members have
between parents and providers that is based on honesty, caring, respect, a tremendous advantage in knowing their clinic or unit as a familiar
and a direct approach (Fisher & Broome, 2011). Good communication workplace. Nurses can gain a better picture of what a child is experi-
is key to the identification of health issues, adherence to a treatment encing by trying to place themselves in the child’s position and imagin-
plan, and improved psychological and behavioral outcomes (Levetown ing the child’s first impression of the triage desk, the reception desk,
& Committee on Bioethics, 2008). the admitting office, the treatment room, and the hospital room. A

38 CHAPTER 3â•… Communicating with Children and Families

A child can communicate more easily with a

nurse who is at eye level and at a comfort-
able conversational distance. The nurse may
need to squat or even sit on the floor to talk
with very young children.

Touch is a powerful means of communicating. Toddlers and preschool-

ers often find touch in the form of cuddling and stroking to be soothing.
Even older children who prize their independence find that a parent’s
hug or pat on the back helps them feel more secure.
FIG 3-1  Communication with children is enhanced by direct eye contact and by body language that
conveys attentiveness and openness.

child’s perspective is probably very different from an adult’s. Creating

a supportive, inviting environment for children includes the use of
child-size furniture, colorful banners and posters, developmentally
appropriate toys, and art displayed at a child’s eye level.
Individuals have different comfort zones for physical distance. The
nurse should be aware of differences and should move cautiously when
meeting new children and families, respecting each individual’s per-
sonal space. For example, standing over the child and family can be
intimidating. Instead, the nurse should bring a chair and sit near the
child and family. This action puts the nurse at eye level. If a chair is
not accessible, the nurse may stoop or squat. The important part is to
be at eye level while remaining at a comfortable distance for the child
and family (Figure 3-2).
The nurse should not overlook privacy or underestimate its impor-
tance. A room should be available for conducting private conversations
away from roommates or family members and visitors. Privacy is par-
ticularly critical in working with adolescents, who typically will not
discuss sensitive topics with parents present. The nurse’s skill and ease
with parents of adolescents will increase the adolescents’ trust in the
nurse. Nurses need to avoid hallway conversations, particularly outside
a child’s room, because children and parents may overhear only some FIG 3-2  For effective communication, the nurse needs to be at the
words or phrases and misinterpret the meaning. Overhearing may lead child’s eye level. (Courtesy Pat Spier, RN-C. In Leifer, G. [2011]:
to unnecessary stress and mistrust between the health care providers Introduction to maternity & pediatric nursing, [6th ed.], St. Louis:
and the child or family. Elsevier.)

Messages given must be received for communication to be complete. and eliminate potential distractions (e.g., TV, computer, video games,
Therefore, listening is an essential component of the communication smartphones).
process. By practicing active listening skills, nurses can be effective
listeners. Active listening skills are as follows. Clarification through Reflection
Using similar words, the nurse expresses to the speaker what was heard
Attentiveness and understood about the content of the message. For example, when
The nurse should be intentional about giving the speaker undivided the child or family member says, “I hate the food that comes on my
attention. Eliminating distractions whenever possible is important. For tray,” a reflective response would be, “When you say you are unhappy
example, the nurse should maintain eye contact, close the room door, with the food you’ve been given, what can we do to change that?” As
CHAPTER 3â•… Communicating with Children and Families 39

the conversation progresses, the nurse can move the child through a immediately explained, children might immediately assume they are
dialogue that identifies those nutritional foods the child would eat. about to receive an injection.
Some children, and some adults, are visual learners. They learn best
Empathy when they can see or read instructions, demonstrations, diagrams, or
The nurse identifies and acknowledges feelings expressed in the information. Using various methods of presenting and sharing infor-
message. For example, if a child is crying after a procedure, the nurse mation will increase comprehension for such children.
might say, “I know it is uncomfortable to have this procedure. It is okay Concepts can be presented more vividly by using photographs,
to cry. You did a great job holding still.” videotapes, dolls, computer programs, charts, or graphs than by using
written or spoken words alone. The nurse needs to select teaching tools
Impartiality and materials that appropriately match the child’s growth and devel-
To understand and avoid prejudicing what is heard with personal bias, opmental level.
the nurse listens with an open mind. For example, if a young adolescent
shares that she is sexually active and is mainly concerned about sexually Tone of Voice
transmissible infections, the nurse remains a supportive listener. The The spoken word comes to mind most often when communication is
nurse can then provide her with educational materials and resources as the topic. Communication, however, consists of not only what is said
well as discuss the possible outcomes of her actions in a manner that is but also the way it is said. The tone and quality of voice often com-
open and not judgmental, regardless of the nurse’s personal values and municate more than the words themselves.
beliefs. Because infants’ cognitive understanding of words is limited, their
During shift report, descriptions of family must be shared objec- understanding is based on tone and quality of voice. A soft, smooth
tively and impartially. Otherwise, perceptions of families may nega- voice is more comforting and soothing to infants than a loud, startling,
tively affect how colleagues approach and interact with families. harsh voice. Infants can sense from the tone of voice whether the
To enhance the effectiveness of communication and maximize caregiver is angry or happy, frustrated or calm. The nurse can assess
normal language patterns that contribute to language development, how aware of and sensitive to these messages infants are by observing
the nurse focuses on talking with children rather than to them and their body language. Infants are relaxed when they hear a calm, happy
develops conversations with children. caregiver and tense and rigid when they hear an angry, frustrated
The nurse must be prepared to listen with the eyes as well as the caregiver.
ears. Information will not always be audible, so the nurse must be alert Children can detect anger, frustration, joy, and other feelings that
to subtle cues in body language and physical closeness. Only then can voices convey, even when the accompanying words are incongruent.
one fully understand the messages of children. For example, when the This incongruity can be very confusing for children. The nurse should
nurse enters the room to complete an initial assessment of a 4-year-old strive to make words and their intended meanings match.
child and observes the child turning away and beginning to suck her Verbal communication extends beyond actual words. All audible
thumb, the child is communicating about her basic security and sounds convey meaning. An infant’s primary mode of audible commu-
comfort level, although she has not said a word. nication is crying. Crying is a cue to check basic needs, including hunger,
pain, discomfort (e.g., wet diaper), and temperature. Cooing and bab-
╇ NURSING QUALITY ALERT bling, also heard during the first year of life, generally convey messages
of comfort and contentment. As children develop and mature, they have
Tips to Enhance Listening and larger vocabularies to express their ideas, thoughts, and feelings.
Communication Skills The choice of words is critical in verbal communication. The nurse
• Children understand more clearly than they can speak. needs to avoid talking down to children but should not expect them to
• To develop conversations with children, ask open-ended questions rather understand adult words and phrases. Technical health care terms
than questions requiring yes-or-no responses. should be used selectively, and jargon should be avoided (see Table 3-4).
• Comprehension is increased when the nurse uses different methods to
present and share information.
Body Language
• Use “people-first” language (e.g., “Sally in 428 has cystic fibrosis” instead From the gentle caress of holding an infant to sitting and listening
of “The CF patient in 428 is Sally.”) intently to an adolescent’s story, body language is a factor in commu-
nication. An open body stance and positioning invite communication
and interaction, whereas a closed body stance and positioning impede
Visual Communication communication and interaction.
Eye contact is a communication connector. Making eye contact helps Using an open body posture improves the nurse’s understanding of
confirm attention and interest between the individuals communicat- children and the children’s understanding of the nurse. Nurses need to
ing. Direct eye contact may be uncomfortable, however, for people in learn to read children’s body language and should become more aware
some cultures, so the nurse needs to be sensitive to responses when of their own body language. Table 3-1 compares open and closed body
making eye contact. postures.
Clothing, physical appearance, and objects being held are visual
communicators. Children may react to an individual’s presence on the Timing
basis of a white lab coat, a bushy beard, or a syringe or video game in Recognizing the appropriate time to communicate information is a
the hand. The nurse needs to think ahead and anticipate visual stimuli developed skill. A distraught child whose parents have just left for work
a child may find startling and those that may be pleasing and to make is not ready for a diabetic teaching session. The session will be much
appropriate adjustments when possible. For example, it is a routine more productive and the information better understood if the child
practice for nurses to bring a medication in a syringe for insertion has a chance to make the transition. The convenience of a schedule
into an intravenous (IV) line. Unless the purpose of the syringe is should be secondary to meeting a child’s needs.
40 CHAPTER 3â•… Communicating with Children and Families

with grandparents parenting; blended families with stepparents and

stepsiblings; gay or lesbian parents; foster parents; group homes; and
Any discussion about effective ways to communicate with children homeless children. The nurse should be prepared to identify the foun-
must also include a discussion of effective communication with fami- dational strengths in all family structures (see Chapter 2). Family-
lies. Family-centered care emphasizes that the family is intimately centered care also means that the nurse truly believes that the child’s
involved in the care of the child. Parents need to be supported while care and recovery are greatly enhanced when the family fully partici-
sustaining their parental role during their child’s hospitalization pates in the child’s care (Figure 3-3).
(Sanjari, Shirazi, Heidari, et╯al., 2009). Family-centered care is achieved
when health care professionals can create partnerships with families, ╇ NURSING QUALITY ALERT
recognizing that the family is essential to the child and that the family Communicating with Families
has the right to participate fully in planning, implementing, and evalu-
ating the child’s plan of care. • Include all involved family members. One essential step toward achieving
Commitment to family-centered care means that the nurse respects a family-centered care environment is to develop open lines of
the family’s diversity. Children and parents live in a variety of family communication with the family.
structures. An expanded definition of family is required in the twenty- • Encourage families to write down their questions.
first century, because the term no longer refers to only the intact, • Remain nonjudgmental.
nuclear family in which parents raise their biologic children. Contem- • Give families both verbal and nonverbal signals that send a message of
porary family structures include adolescent parents; extended families availability and openness.
with aunts, uncles, or cousins parenting; multigenerational families • Respect and encourage feedback from families.
• Families come in various shapes, sizes, colors, and generations.
• Avoid assumptions about core family beliefs and values.
• Respect family diversity.
POSTURES Establishing Rapport
OPEN CLOSED Critical to establishing rapport with families is the nurse’s ability to
Leaning toward other person Leaning away from other person convey genuine respect and concern during the first encounter. A non-
Arms loose at sides Arms folded across chest judgmental approach and a willingness to assist family members in
Frequent eye contact No eye contact effectively caring for their child demonstrate the nurse’s interest in
Hands moving freely Hands on hips their well-being.
Soft stance, body swaying slightly Rigid stance
Availability and Openness to Questions
Head up Head bowed
Calm, slow movements Constant motion, squirming A nurse who does not take time to see how a child and family
Smiling, friendly facial cues Frowning, negative facial cues are doing—such as a nurse who leaves a room immediately after a
Conversing at eye level Conversing at a level that requires treatment or administration of a medication—will not encourage or
the child to move to listen invite families to ask questions. Families want and need unrushed and
uninterrupted time with the nurse. Sometimes this time can be made

The nurse explains a child’s test results to his mother and grandmother.
Including all important family members in the child’s health care reflects
commitment to family-centered care. (Courtesy University of Texas at
Arlington College of Nursing.)

This nurse practitioner has learned Spanish to communicate better with her
many Spanish-speaking clients. Speaking with family members in their own
language encourages the family to remain in the health care system. The
nurse is also using eye contact and has positioned herself at the mother’s
eye level. (Courtesy Parkland Health and Hospital System Community
Oriented Primary Care Clinic, Dallas.)
FIG 3-3  The child’s continuing health care, both preventive and during illness, is enhanced by partici-
pation of the family.
CHAPTER 3â•… Communicating with Children and Families 41

available only by purposefully scheduling it into the day. Encouraging

families to write down their questions will enable them to take full Spirituality
advantage of their time with the nurse. Children have rich spiritual lives, although they do not use the same
The nurse might encourage effective use of time by saying, “I know vocabulary as adults to describe them. Spiritual care is a vital coping
you have a lot of questions and are very anxious to learn more about resource for many children. In order to provide holistic care to chil-
your son’s condition. I have another patient who has an immediate dren, it is important to assess the child’s beliefs and faith (Neuman,
need, but I will be available in 10 minutes to meet with you. In the 2011). Supporting children’s existing faith and spiritual practices is
meantime, here is a parent handbook that gives general information recommended. Children can be assisted in maintaining their rituals,
about seizures. Please feel free to review it and write down any ques- whether they are bedtime prayers, songs, or blessings at meals. Nurses
tions that we can discuss when I return.” can provide spiritual care in ways that offer hope, encouragement,
comfort, and respect. A resource to pursue in many hospital or health
Family Education and Empowerment care settings is the pastoral care or chaplain’s department.
Educating parents about their child’s condition, ensuring their contin-
ued involvement in planning and evaluating the plan of care, and
teaching them the skills to participate empower the family. Families
need support as they gain confidence in their skills, and they need BOX 3-1â•… STRATEGIES FOR MANAGING
guidance to assist them as they navigate through the health care experi- CONFLICT
ence. Communication is enhanced when families feel competent and
confident in their abilities. • Understand the parents’ perspective (walk in their shoes). Imagine yourself
as the parent of a child in a hospital where your values and beliefs are
Effective Management of Conflict exposed and scrutinized. Try to understand the parents’ perspective better
When conflict occurs, it should be addressed in an expedient manner by encouraging them to share it.
to prevent further breakdown in communication. Box 3-1 suggests • Determine a common goal and stay focused on it. Determine the agreed-on
strategies for managing conflict, and Table 3-2 highlights the impor- result, and work toward it. By staying focused on a common goal, the
tance of choosing words carefully to make families feel welcome and parties involved are more likely to find workable strategies to achieve the
to further facilitate family-centered care. identified goal.
• Seek win-win solutions. Conflict should not be about who is right and who
Feedback from Children and Families is wrong. Effective conflict management focuses on finding a solution
The nurse needs to be alert for both verbal and nonverbal cues. Rou- whereby both parties “win.” By establishing a common goal, both parties
tinely checking with family members about their experiences, satisfac- win when this goal is achieved.
tion with communications, teaching sessions, and health care goals is • Listen actively. Critical to resolving situations of conflict is the ability to
an effective way to ensure that health care providers obtain appropriate listen and understand what the other person is saying and feeling. In active
feedback. To enhance the delivery of care, the nurse should explain listening, the receiver actively and empathically listens to gain a better
how this feedback will be used. The nurse should listen and observe understanding of the actual and the implied message.
carefully to make sure that what family members are saying is truly • Openly express your feelings. Talking about feelings is much more con-
what they are feeling. structive than acting them out. The nurse might say, “I am very concerned
Transparent communication between parents and nurses is integral about Jamie’s safety when you leave his side rails down.”
to providing family-centered care (McCann, Young, Watson, et╯al, 2008). • Avoid blaming. Each party owns part of the problem. Pointing fingers and
For example, while one nurse was teaching the mother of a 2-year- blaming others will not solve the problem. Instead, identify the part of the
old child who was recently diagnosed with type 1 diabetes mellitus, the problem that each party owns and work together to resolve it. Seek win-
mother reported that, although she was her child’s primary caregiver, win solutions.
the child’s grandmother frequently cared for the child while the mother • Summarize the decision. At the end of any discussion, summarize what has
was at work. The nurse therefore notified the other team members and been decided and identify who is responsible for follow-up. This process
altered the teaching plan for diabetes care to include the child’s ensures that everyone is clear about the decision and facilitates account-
grandmother. ability for implementing solutions.


Policies allowed or not permitted Convey attitude that hospital personnel Guidelines, working together, Convey openness and appreciation
have authority over parents in matters welcome for position and importance of
concerning their children families
Noncompliant, uncooperative, Imply that health care providers make Partners, colleagues, joint decision Acknowledge that families bring
difficult (when referring to decisions and give instructions that makers, experts about their child important information and insight
parents and other family families must follow without input and that families and professionals
members) form a team
Dysfunctional, in denial, Pronounce judgment that may not Coping (describing family’s reactions Remain open to reaching a more
overprotective, uninvolved, incorporate full understanding of with care and respect) complete and appreciative
uncaring (labeling families) family’s situation, reactions, or understanding of families over time
42 CHAPTER 3â•… Communicating with Children and Families


Conflict can arise when the nurse comes from a cultural background • Buying gifts for individual children or families
that is different from that of the child and family. Such differences • Giving out one’s home phone number
could influence the approach to care. As the demographics in the • Competing with other staff for the child’s or family’s affection
United States continue to change, health care professionals will be • Inviting the child or family to social gatherings
challenged to become more transcultural in their approach to clients • Accepting invitations to family gatherings (e.g., birthday parties,
if the professionals want to continue to be effective in their relation- weddings)
ships with children and families. Health care professionals need to be • Visiting or spending time with the child or family during off-duty time
aware of their own values and beliefs and need to recognize how these • Revealing personal information
influence their interactions with others. They also need to be aware of • Lending or borrowing money
and respect the child’s and family’s values and beliefs. In working with • Making decisions for the family about the child’s care
children and families, the initial nursing assessment should address
values, beliefs, and traditions. The nurse can then consider ways in
which culture might affect communication style, methods of decision
making, cultural adaptations for nursing intervention, and other BOX 3-3â•… WARNING SIGNS OF
behaviors related to health care practices. UNDERINVOLVEMENT
During the initial interview, the nurse ascertains the following
• Avoiding the child or family
information related to the child and family:
• Calling in sick so as not to take assignment of a specific child
Decision-making practices: Are decisions made by individuals or
• Asking to trade assignments for a specific child
collectively as a group?
• Spending less time with a particular child
Child-rearing practices: Who are the primary caregivers? What are
their disciplinary practices?
Family support: What is the family structure? To whom do the
patient and family turn for support? important in working with these families is to promote the parents’
Communication practices: How is the information communicated feelings of competence through education and empowerment. The
to the rest of the family? nurse keeps parents well informed of the child’s care through frequent
Health and illness practices: Do family members seek professional phone calls and actively involves them in decision making. Teaching
help or rely on other resources for treatment and advice? parents skills necessary to care for their child promotes confidence,
Once this information is obtained, the nurse can use it to individual- enhances self-esteem, and fosters independence.
ize the treatment plan and approach for the child’s and family’s needs. Nurses must be able to recognize their own personal and profes-
For example, if the parents of a child with an Orthodox Jewish religious sional needs. Being aware of the motives for one’s own actions will
background request a kosher diet, the nurse facilitates the routine greatly enhance the nurse’s ability to understand the needs of children
delivery of kosher meals and communicates the family’s wishes to the and families and to give families the tools to manage care effectively.
rest of the team members so that they can also respect the family’s
customs. If the family of a child who has a severe brain injury requests
the services of a healer, the nurse enables the family to arrange the visit.
Coordinating the child’s daily schedule to provide an uninterrupted Maintaining a Therapeutic Relationship
visit with the healer is one aspect of family-centered care. When the
Maintaining professional boundaries requires that the nurse constantly be
nurse communicates the family’s cultural preferences to other members
aware of the fine line between empathy and overinvolvement.
of the health care team, communication and holistic care are enhanced.


Trust is important in establishing and maintaining therapeutic rela- Assessment
tionships with families. Trust promotes a sense of partnership between A comprehensive needs assessment of the child and family elicits infor-
nurses and families. Becoming overly involved with the child or family mation about problem-solving skills, cultural needs, coping behaviors,
can inhibit a healthy relationship. Because nurses are caring, nurturing and the child’s routines. Any assessment requires the nurse to obtain
people and the profession demands that nurses sometimes become information from the child and the family.
intimately involved in other people’s lives, maintaining the balance The nurse might say, “Mrs. Jiminez, I value your input as well as
between appropriate involvement and professional separation is quite your child’s. Hearing Ramon explain his understanding of his diabetic
challenging. Box 3-2 delineates behaviors that may indicate overinvolve- dietary restrictions in his own words will help us gain better insight
ment. Box 3-3 identifies behaviors that may indicate professional sepa- into how best to manage his care. Let’s take a few minutes to hear from
ration or underinvolvement. Whether nurses become too emotionally Ramon, and then we can talk about your perspective.”
involved or find themselves at the other end of the spectrum, being Assessment enables the nurse to develop better insight by gathering
underinvolved, they lose effectiveness as objective professional resources. information from multiple perspectives and facilitates the develop-
Family members may display feelings of incompetence, fear, and ment of a more comprehensive plan of care. A thorough assessment
loss of control by expressing anger, withdrawal, or dissatisfaction. Most of the child’s communication skills presumes that the nurse
CHAPTER 3â•… Communicating with Children and Families 43

understands developmental milestones and can relate comprehension understand a different language appropriately communicate through
and communication skills to the child’s cognitive and emotional devel- an interpreter.
opment and language abilities. During the initial assessment of the
child and family, the nurse should also describe routines and provide ? ╇ CRITICAL THINKING EXERCISE 3-1
information about what the child and family can expect during their
visit. The nurse caring for an 8-year-old boy observes him lying in his bed with his
The family’s level of health literacy is an important component of back facing the door. He is crying, although he quickly wipes his eyes when
a communication assessment. Because of language, educational, or he sees the nurse at the door. He has been hospitalized because of leukemia.
other barriers, some family members may not understand medical or He lives in a small community 350 miles from the hospital. His parents visit
health terminology in ways nurses might expect. Consequences, such on the weekends.
as not adhering to medication or recommended treatment routines, 1. Identify two things that might be upsetting the child.
can result from miscommunication related to low health literacy 2. What strategies could you use to encourage the child to talk about his
(Jones & Sanchez-Jones, 2008). Assessment data that might suggest feelings related to the problems you have identified?
poor health literacy in family members include avoidance of reading
or filling out hospital forms, providing incorrect information about
the child, and not appearing curious about the child’s health status Interventions
(Jones & Sanchez-Jones, 2008). Providing instructions and explana- Nurses working with children should determine the best communica-
tions in language the caregiver understands as well as having the tion approach for each child individually on the basis of the child’s age
caregiver repeat or demonstrate back the instructions can increase and developmental abilities. Table 3-3 presents an overview of devel-
understanding and adherence (Colby, 2009). In addition, health care opmental milestones related to communication skills in children and
professionals should use only trained translators to help explain pro- some approaches to facilitate successful interactions. Other interven-
cedures, treatments, and other health-related information to patients tions that facilitate communication between the nurse and children
and families with limited English competency. In these instances, the include play, storytelling, and strategies for enhancing self-esteem.
use of untrained translators, such as children or other family members, Play.╇ Play can greatly facilitate communicating with children.
is unacceptable (Levetown & Committee on Bioethics, 2008). Approaching children at their developmental level with familiar forms
of play increases their comfort and allows the nurse to be seen in a
Nursing Diagnosis and Planning more positive, less threatening role.
The nursing assessment may suggest diagnoses that affect communica- Because play is an everyday part of children’s lives and a method they
tion but that arise from the child’s encounter with the health care use to communicate, they are less likely to be inhibited when participat-
system. Other diagnoses are related to the child’s and family’s com- ing in play interactions. Through play, children may express thoughts
munication abilities. and feelings they may be unable to verbalize (see Chapters 5 through 8
• Anxiety related to potential or actual separation from parents (e.g., for normal play activities and Chapter 11 for therapeutic play).
a 4-year-old girl who becomes withdrawn and unable to cooperate Storytelling.╇ Storytelling is an innovative and creative communica-
with an office hearing test when separated from her mother). tion strategy. It is also a skill that can be acquired and refined through
Expected Outcomes.╇ The child verbalizes the cause of the anxiety and practice. Familiarity with stories and frequent practice in storytelling
more readily communicates with the health care professional. The increase a nurse’s confidence and competence as a storyteller. Storytell-
child exhibits posture, facial expressions, and gestures that reflect ing can be a routine part of a nurse’s day. Its purposes range from
decreased distress. establishing rapport to approaching uncomfortable topics, such as loss,
• Fear related to a perceived threat to the child’s well-being and death, fear, grief, and anger. In storytelling, there is a teller and a lis-
inadequate understanding of procedures or treatments (e.g., a tener. In individual situations, the child may be the teller or the listener,
7-year-old boy scheduled for tonsillectomy who wonders where his although in a shared story, adult and child may each take a turn in both
throat will be cut to remove his tonsils). roles (Box 3-4).
Expected Outcomes.╇ The child talks about fears and accurately Explaining Procedures and Treatments.╇ Preparation before a proce-
describes the procedure or treatment. dure, which includes explaining the reasons for the procedure and the
• Hopelessness related to a deteriorating health status (e.g., an expected sequence of events and outcomes, can greatly reduce a child’s
11-year-old child in isolation with prolonged illness and uncertain fears and anxieties. Preparation enables the child to experience some
Expected Outcomes.╇ The child verbalizes feelings and participates in
care. The child makes positive statements, maintains eye contact BOX 3-4â•… STORYTELLING STRATEGIES
during interactions, and has appetite and sleep patterns that are appro- • Capture a story on paper or on videotape as told by a child or group of
priate for the child’s age and physical health. children.
• Powerlessness related to limits to autonomy (e.g., a 3-year-old child • Tell a “yarn story” with two or more people. A long piece of yarn with knots
with a C6 spinal fracture as a result of a motor vehicle trauma). tied at varied intervals is slid loosely through the hands of the teller until
Expected Outcomes.╇ The child expresses frustrations and anger and a knot is felt, at which time the yarn is passed to the next person, who
begins to make choices in areas that are controllable. The child asks continues the story.
appropriate questions about care and treatment. • Initiate a game of sentence completion, either oral or written, with sen-
• Impaired verbal communication related to physiologic barriers or tences beginning “If I were in charge of the hospital … ,” “I wish … ,”
cultural and language differences (e.g., a 17-year-old adolescent who “When I get home I will … ,” or “My family …”
has had her jaw wired subsequent to orthodontic surgery). • Read stories with themes related to issues a child is facing. The children’s
Expected Outcomes.╇ The adolescent effectively uses alternative section of the local public library is an excellent resource.
communication methods. The child and family who speak and
44 CHAPTER 3â•… Communicating with Children and Families


Infants (0-12╯mo)
Infants experience world Crying, babbling, cooing. Dependent on others; high Interactions largely reflexive. Use calm, soft, soothing voice.
through senses of hearing, Single-word production. need for cuddling and Beginning to see repetition of Be responsive to cries.
seeing, smelling, tasting, Able to name some simple security. activities and movements. Engage in turn-taking
and touching. objects. Responsive to environment Beginning to initiate vocalizations (adult imitates
(e.g., sounds, visual interactions intentionally. baby sounds).
stimuli). Short attention span Talk and read regularly to
Distinguish between happy (1-2╯min). infants.
and angry voices and Prepare infant as you are about
between familiar and to perform care; talk to infant
strange voices. about what you are about to
Beginning to experience do.
separation anxiety. Use slow approach and allow
child time to get to know you.

Toddlers (1-2╯yr)
Toddlers experience world Two-word combinations Strong need for security Experiment with objects. Learn toddler’s words for
through senses of hearing, emerge. objects. Participate in active common items, and use them
seeing, smelling, tasting, Participate in turn taking in Separation/stranger anxiety exploration. in conversations.
and touching. communication (speaker/ heightened. Begin to experiment with Describe activities and
listener). Participate in parallel play. variations on activities. procedures as they are about
“No” becomes favorite word. Thrive on routines. Begin to identify cause-and- to be done.
Able to use gestures and Beginning development of effect relationships. Use picture books.
verbalize simple wants and independence: “Want to do Short attention span Use play for demonstrations.
needs. myself.” (3-5╯min). Be responsive to child’s
Still very dependent on receptivity toward you and
significant adults. approach cautiously.
Preparation should occur
immediately before event.

Preschool Children (3-5╯yr)

Preschool children use words Further development and Like to imitate activities and Begin developing concepts of Seek opportunities to offer
they do not fully expansion of word make choices. time, space, and quantity. choices.
understand; they also do combination (able to speak Strive for independence but Magical thinking prominent. Use play to explain procedures
not accurately understand in full sentences). need adult support and World seen only from child’s and activities.
many words used by Growth in correct encouragement. perspective. Speak in simple sentences, and
others. grammatical usage. Demonstrate purposeful Short attention span explore relative concepts.
Use pronouns. attention-seeking (5-10╯min). Use picture and story books,
Clearer articulation of behaviors. puppets.
sounds. Learn cooperation and turn Describe activities and
Vocabulary rapidly expanding; taking in game playing. procedures as they are about
may know words without Need clearly set limits and to be done.
understanding meaning. boundaries. Be concise; limit length of
explanations (5╯min). Engage
in preparatory activities 1-3╯hr
before the event.
CHAPTER 3â•… Communicating with Children and Families 45


School-Age Children (6-11╯yr)
School-age children Expanding vocabulary Interact well with others. Able to grasp concepts of Use photographs, books,
communicate thoughts and enables child to describe Understand rules to games. classification, conversation. diagrams, charts, videos to
appreciate viewpoints of concepts, thoughts, and Very interested in learning. Concrete thinking emerges. explain. Make explanations
others. feelings. Build close friendships. Become very oriented to sequential.
Words with multiple Development of Beginning to accept “rules.” Engage in conversations that
meanings and words conversational skills. responsibility for own Able to process information encourage critical thinking.
describing things they have actions. in serial format. Establish limits and set
not experienced are not Competition emerges. Lengthened attention span consequences.
thoroughly understood. Still dependent on adults to (10-30╯min). Use medical play techniques.
meet needs. Introduce preparatory materials
1-5 days in advance of the

Adolescents (12╯yr and older)

Adolescents are able to Able to verbalize and Beginning to accept Able to think logically and Engage in conversations about
create theories and comprehend most adult responsibility for own abstractly. adolescent’s interests.
generate many concepts. actions. Attention span up to 60╯min. Use photographs, books,
explanations for situations. Perception of “imaginary diagrams, charts, and videos
They are beginning to audiences.” (see Chapter 8) to explain.
communicate like adults. Need independence. Use collaborative approach, and
Competitive drive. foster and support
Strong need for group independence.
identification. Introduce preparatory materials
Frequently have small group up to 1╯wk in advance of the
of very close friends. event.
Question authority. Respect privacy needs.
Strong need for privacy.

mastery over events, gives the child time to develop effective coping • Provide sensory information. Inviting children to see, hear, feel,
behaviors, and fosters trust in those caring for the child. Adequate taste, smell, and experience similar sensations during the prepa-
preparation is the key to helping a child have a successful, positive ration will greatly enhance their preparedness and diminish
health care experience. their anxieties. For example, in preparing a child for an IV line
In general, the younger the child, the closer in time to the event the insertion, the nurse can show the child the catheter or explain
child should be prepared for it. For example, a 3-year-old child will the purpose of the tourniquet and allow the child to put it on
generally be very anxious and therefore should be prepared immedi- or to put it on the arm of a doll, if the child so desires. The nurse
ately before, whereas teenagers would benefit from a longer prepara- should let the child smell an alcohol swab and feel its coolness
tion time so that they can develop strategies for dealing with the when applied to the skin. Showing the child the treatment room
situation. Table 3-3 gives age-related attention span guidelines. and inviting the child to sit on the treatment table where the
Key elements for communicating complete and accurate informa- procedure will be performed are effective ways to convey
tion are as follows (Gaynard, Wolfer, Goldberger, et╯al., 1998): information.
• Learn the procedure. To explain a procedure adequately, • Explain the sequence of events. Preparation includes a descrip-
the nurse must understand what is involved. What pieces of tion of the sequence in which events will occur. Recognizing the
equipment will be used? Where will the procedure take place? procedure as a series of sequential steps allows children to antic-
Essentially, the nurse needs to learn what the child can expect ipate appropriately and gives them a sense of control and a
to happen during the procedure. better understanding of the number of steps to expect before
• Determine what information to share with the child and family. the procedure is over.
The preparation should include information only about what • Explain how long the procedure will last. Whenever possible, the
the child will experience or perceive directly. Consultation with nurse should invite the child to have simulated play experiences.
the family will allow the nurse to learn words and terminology Inviting the child to perform the procedure on a doll or stuffed
used by the child. Table 3-4 offers other concrete suggestions animal is often effective and gives the child a real sense of time
of appropriate language for nurses to use in working with and firsthand experience with the sequence of events. If a con-
children. crete demonstration is not possible, the nurse should explain
46 CHAPTER 3â•… Communicating with Children and Families


“The doctor will give you some dye.” “The doctor will put some medicine in the tube that will help her see your
â•… To make me die? _______ more clearly.”
Dressing, dressing change Bandages; clean, new bandages.
â•… Why are they going to undress me?
â•… Do I have to change my clothes?
Stool collection Use child’s familiar term, such as “poop,” “BM,” or “doody.”
â•… Why do they want to collect little chairs?
Urine Use child’s familiar term, such as “pee.”
â•… You’re in?
Shot Describe giving medicine through a (small, tiny) needle.
â•… When people get shot, they’re really badly hurt.
CAT scan Describe in simple terms, and explain what the letters of the common name
â•… Will there be cats? stand for.
PICU Explain as above.
â•… Pick you?
ICU Explain as above.
â•… I see you?
IV Explain as above.
â•… Ivy?
Stretcher Bed on wheels.
â•… Stretch her? Stretch whom?
Special; funny (words that are usually positive descriptors) Odd, different, unusual, strange.
â•… It doesn’t look/feel special to me.
Gas, sleeping gas “A medicine, called an anesthetic, is a kind of air you will breathe through a
â•… Is someone going to pour gasoline into the mask? mask like this to help you sleep during your operation so you won’t feel
anything. It is a different kind of sleep.” (Explain differences.)
“The doctor will put you to sleep.” “The doctor will give you medicine that will help you go into a very deep sleep.
â•… Like my cat was put to sleep? It never came back. You won’t feel anything until the operation is over. Then the doctor will stop
giving you the medicine, so you can wake up.”
“Move you to the floor.” Unit, ward.
â•… Why are they going to put me on the ground? â•… (Explain why the child is being transferred, and where.)
OR (or treatment room) table A narrow bed.
â•… People aren’t supposed to get up on tables.
“Take a picture.” “A picture of your insides.” (Describe appearance, sounds, and movement of the
â•… (X-ray, CT, and MRI machines are far larger than a familiar camera, equipment.)
move differently, and do not yield a familiar end product.)
“Flush your IV.” Explain.
â•… Flush it down the toilet?

Words can be experienced as “hard” or “soft” according to how much they increase the perceived threat of a situation. For example,
consider the following word choices:

“This part will hurt.” “It (you) may feel (or feel very) sore, achy, scratchy, tight, snug, full, or (other
manageable, descriptive term).”
“The medicine will burn.” (Words such as scratch, poke, or sting might be familiar for some children and
frightening to others.)
“The room will be very cold.” “Some children say they feel very warm.”
“Some children say they feel very cold.”
“The medicine will taste (or smell) bad.” “The medicine may taste (or smell) different from anything you have tasted
before. After you take it, will you tell me how it was for you?”
“Cut,” “open you up,” “slice,” “make a hole.” “The doctor will make an opening.”
“As big as _____” (e.g., size of an incision or of a catheter). (Use concrete comparisons, such as “your little finger” or “a paper clip” if the
opening will indeed be small.)
“Smaller than _______.”
“As long as _______” (e.g., for duration of a procedure). “For less time than it takes you to _______.”

NOTE: Words or phrases that are helpful to one child may be threatening for another. Health care providers must listen carefully and be sensitive
to the child’s use of and response to language.
Modified with permission of The Child Life Council, Inc., 11820 Parklawn Dr., Rockville, MD 20852-2529; from Gaynard, L., Wolfer, J.,
Goldberger, J., et╯al. (1998). Psychosocial care of children in hospitals: A clinical practice manual from ACCH Child Life Research Project.
Rockville, Md.: The Child Life Council, Inc.
CHAPTER 3â•… Communicating with Children and Families 47


“As much as _______.” “Less than _______.”
â•… (These are open-ended and “extending” expressions.) (These expressions help confine, familiarize, and imply the manageability of an
event or of equipment.)

The unfamiliar usage or complexity of some common medical words or expressions can be confusing and frightening.


“Take your vitals” (or “your vital signs”) “Measure your temperature,” “see how warm your body is,” “see how fast and
strongly your heart is working.”
(Nothing is “taken” from the child.)
Electrodes, leads “Sticky like a Band-Aid, with a small wet spot in the center, and small strings
that attach to the snap (monitor electrodes); paste like wet sand, with strings
with tiny metal cups that stick to the paste (electroencephalogram [EEG]
electrodes). The paste washes off easily afterward; the strings go into a box
that will make a picture of how your heart (or brain) is working.”
(Show child electrodes and leads before using. Let child handle them and apply
them to a doll or to self.)
“Hang your (IV) medication.” “We will bring in a new medicine in a bag and attach it to the little tube already
in your arm. The needle goes into the tube, not into your arm, so you won’t
feel it.”
N.P.O. “Nothing to eat. Your stomach needs to be empty.” (Explain why.) “You can eat
and drink again as soon as _______.”
(Explain with concrete descriptions.)
Anesthesia “The doctor will give you medicine—you may hear it called ‘anesthesia.’ It will
help you go into a very deep sleep. You will not feel anything at all. The doctor
knows just the right amount of medicine to give you so you will stay asleep
through your operation. When the operation is over, the doctor stops giving you
that medicine and helps you wake up.”

the timing in terms that the child can understand; for example, To enhance the child’s self-esteem, adults should strive for positive
the nurse might say, “The procedure will last as long as it takes language.
to sing your favorite song.” Providing children with developmentally appropriate information
• Monitor accuracy of information (feedback). Feedback can be about their condition and any treatments they may be receiving
used to modify or reinforce future preparation sessions. Feed- enhances their control over the hospitalization experience and increases
back also allows the nurse to correct any misunderstandings the feelings of self-esteem (Marshall, 2008). If adolescents are to “have a
child may have and provides an opportunity for the child to voice” in decision making about their care, they must receive informa-
process verbally and express feelings about the experience. tion that is thorough, developmentally appropriate, and understand-
Open, honest communication about treatments and procedures able (Levetown & Committee on Bioethics, 2008).
and attentiveness to the learning needs of the child will greatly facilitate
achievement of the treatment goals. Evaluation
Because nonadherence to treatment protocols can be a problem in Although evaluation is traditionally thought of as a closure activity,
some families, it is essential that the nurse ensure that children and evaluation should be a continuous activity throughout the nursing
family members can describe the treatment plan. Using a variety of process. Keep expected outcomes visible, and assess whether they are
written, verbal, interactive, and visual materials can improve compre- being realized. Are the outcomes attainable? Could the wrong nursing
hension and adherence. For psychomotor skill development, return diagnosis have been made? Adjust the plan of care as needed.
demonstration is important. Reinforcement with written materials in
the family’s chosen language or at the family’s assessed literacy level
provides a ready reference for the family after the child’s discharge COMMUNICATING WITH CHILDREN WITH
(Jones & Sanchez-Jones, 2008).
Strategies for Enhancing Self-Esteem.╇ Communication practices
play an important role in the development of children’s self-esteem The opportunity to interact with children who have special commu-
and confidence. Nurses are in an excellent position to model commu- nication needs presents an exciting challenge for nurses. To identify
nication practices that enhance self-esteem. Table 3-5 compares helpful successful alternative methods of communication, the nurse needs to
and harmful communication practices. learn particular techniques for working with children and families.
The words adults choose, their tone of voice, and the place and Alternative methods of communicating are critical. Children need to
timing of message delivery all influence the child’s interpretation of express their wants and needs accurately. Through adequate prepara-
the message. The interpretation may be positive, negative, or neutral. tion and reassurance, the nurse can offer the child comfort
48 CHAPTER 3â•… Communicating with Children and Families


COMMUNICATION PRACTICES Communicating with Children with
ENHANCE SELF-ESTEEM SELF-ESTEEM In working with children with special needs, the nurse must carefully assess
Praise efforts and Criticize efforts and each child’s physical, mental, and developmental abilities and determine the
accomplishments. accomplishments. most effective methods of communication.
Use active listening skills. Be too busy to listen.
Encourage expression of feelings. Tell children how they should feel.
The Child with a Hearing Impairment
Acknowledge feelings. Give no support for dealing with
feelings. For the child with a hearing impairment, the nurse can do the
Use developmentally based Use physical punishment. following:
discipline. • Thoroughly assess the child’s self-help skills and abilities.
Use “I” statements. Use “you” statements. • Identify the family’s method of communication and, if possible,
Be nonjudgmental. Judge the child. adopt it.
Set clearly defined limits, and Set no known limits or boundaries. • Encourage a family member to stay with the child at all
reinforce them. times to decrease the stress of hospitalization and facilitate
Share quality time together. Give time grudgingly. communication.
Be honest. Be dishonest. • If sign language is used, learn the most frequently used signs
Describe behaviors observed when Use coercion and power as and use them whenever able. Keep a chart of signs near the
praising and disciplining. discipline. child’s bed.
Compliment the child. Belittle, blame, or shame the child. • Develop a communication board with pictures of most com-
Smile. Use sarcastic, caustic, or cruel monly used items or needs (e.g., television, cup, toothbrush,
“humor.” toilet, shower).
Touch and hug the child. Avoid coming near the child, even • Determine whether the child uses a hearing aid. If so, make sure
when the child is open to touching, that the batteries are working and that the hearing aid is clean
holding, or hugging. Touch and hold and intact.
only when performing a task. • When entering the room, do so cautiously and gently touch the
Rock the child. Avoid comforting through rocking. child before speaking.
• Always face the child when speaking. If the child is a lip reader,
face-to-face visibility will greatly enhance the child’s ability to
• Do not shout or exaggerate speech. This behavior distorts the
face and can be very confusing. Rather, speak in a normal tone
and understanding. Successfully meeting this challenge is a rewarding and at a regular pace.
experience for the nurse and a positive, supportive experience for the • Remember that nonverbal communication can speak as loud as,
child and family. if not louder than, speech (e.g., a frown or worried face can say
more than words).
The Child with a Visual Impairment • When performing a procedure that requires standing behind the
For the child with a visual impairment, the nurse can do the child, such as when giving an enema or assisting with a spinal
following: tap, have another person stand in front of the child and explain
• Obtain a thorough assessment of the child’s self-help skills and the procedure as it is being performed.
abilities (i.e., toileting, bathing, dressing, feeding, mobility). • Whenever possible, use play strategies to help communicate and
• Orient the child to the surroundings. Walk the child around the demonstrate procedures (see Table 3-3).
room and unit several times, indicating landmarks (e.g., doors,
closets, bedside tables, windows) while guiding the child by the The Child Who Speaks Another Language
hand or by the way the child prefers. Explain sounds that the For the child who speaks another language, the nurse can do the
child may frequently hear (e.g., monitors, alarms, nurse call following:
bells). • Thoroughly assess the child’s abilities in speaking and under-
• Encourage a family member to stay with the child. This person standing both languages.
can facilitate communication and greatly enhance the child’s • Identify an interpreter, perhaps another adult family member,
comfort in this unfamiliar environment. friend of the family, or other individual with proficiency in both
• Keep furniture and other items in the same, consistent place. languages to be used for communication not related to health
Consistency aids in the child’s orientation to the room, fosters care. Other children should not be used as interpreters.
independence, and promotes safety. • Use an interpreter whenever possible but always when explain-
• Keep the nurse call bell in the same place and within the child’s ing procedures, determining understanding, teaching new skills,
reach. and assessing needs.
• Identify yourself when entering the room, and tell the child • Use a communication board with the names of items printed in
when you are departing. both languages.
• Carefully and fully explain all procedures. • Learn the words and names of commonly used items in the
• Allow the child to handle equipment as the procedure is child’s language, and use them whenever possible. Using the
explained. familiar language not only aids in communication but also
CHAPTER 3â•… Communicating with Children and Families 49

demonstrates sincere interest in learning the language and respect should be used. For the child with a profound neurologic
respect for the culture. impairment, the nurse can do the following:
• Learn as much about the child’s culture as possible and develop • Address the child when entering and exiting the room. Gently touch
plans of care that demonstrate respect for the culture. Sincere the child while saying the child’s name.
attempts to learn to communicate with the child and family • Speak softly, calmly, and slowly to allow the child time to process
demonstrate the nurse’s concern for their well-being. what you are saying.
• Use play strategies whenever possible. Play seems to be a uni- • While in the room with the child, talk to the child. Do not talk as
versal language. if the child were not there.
The nurse might say, “Jenny, I am going to wash your arm now,” or
The Child with Other Communication Issues “Jenny, now I am going to take your temperature by putting the ther-
For the child who has more severe communication issues, the nurse mometer under your arm.” Identifying an assistant, the nurse might
can do the following: say, “Jenny, Kristi, another nurse, is here to help me lift you into your
• Thoroughly assess the child’s self-help skills and abilities. Deter- chair.”
mine the child’s and family’s methods of communicating and • Talk to the child about activities and objects in the room, things
adopt them as much as possible. that the child might see, hear, smell, touch, taste, or sense.
• Encourage parents to stay with the child to decrease anxiety and For example, the nurse might say, “It is a sunny day today; can you
foster communication. feel the warm sun shining on you through the window?”
• Determine whether the child uses sign language or augmented • When asking the child questions, allow the child adequate time to
communication devices. Use a communication board if respond. Be careful to ask questions only of children who are
appropriate. capable of responding.
• Be attentive to and maximize the child’s nonverbal communica- • Ascertain the child’s ability to respond to simple questions. Some
tion. Facial grimaces, frowns, smiles, and nods are effective means children can respond to yes-or-no questions by squeezing a hand
of communicating responses and expressing likes and dislikes. or blinking their eyes (once for yes and twice for no).
• If appropriate, encourage the child to use writing boards (dry • Be extremely attentive to any signs or gestures (e.g., facial grimaces,
erase or chalk; or pads of paper) to write needs, wants, ques- smiling, eye movements) that may convey responses to likes or
tions, and concerns. dislikes. Signs or gestures may be the child’s only means of
The Child with a Profound Neurologic Impairment • As with all children with special communication needs, thoroughly
Because hearing, vision, and language abilities are often hard to deter- document and communicate to others who interact with the child
mine in the child who is profoundly neurologically impaired, the nurse any special techniques that work. Providing information will greatly
should assume that the child can hear, see, and comprehend something enhance continuity and more fully facilitate the child’s ability to
of what is said. A friendly tone of voice that conveys warmth and communicate.

• Components of effective communication with children involve a problem, can lead to a breakdown in the relationship between the
verbal and nonverbal interactions. Essential components include nurse and the child and family.
touch, physical proximity, environment, listening, eye contact, • Family-centered communication strategies include establishing
visual cues, pace of speech and tone of voice, and overall body rapport, identifying needs, establishing expectations, being avail-
language. able and open to questions, family education, empowerment,
• The best communication approach for an individual child should obtaining feedback from children and families, promoting effective
be determined on the basis of the child’s age, developmental abili- conflict management, learning techniques for transcultural com-
ties, and cultural preferences. Strategies include play and storytell- munication, and maintaining professional boundaries.
ing, explaining procedures and treatments, and modeling • In working with children with special needs, the nurse should
communication practices that enhance self-esteem. carefully assess each child’s physical, mental, and develop-
• Communication pitfalls, such as using jargon, talking down to chil- mental abilities and determine the most effective methods of
dren or beyond their developmental level, and avoiding or denying communication.

Colby, B. (2009). Repeat back to me: A program to improve Levetown, M. & Committee on Bioethics (2008). Commu- Neuman, M. (2011). Addressing children’s beliefs through
understanding. Journal of Pediatric Nursing, 24(2), e6. nicating with children and families: From everyday Fowler’s Stages of Faith. Journal of Pediatric Nursing, 26,
Retrieved from interactions to skill in conveying distressing informa- 44-50.
Fisher, M., & Broome, M. (2011). Parent-provider com- tion. Pediatrics, 121, e1441-e1460. Retrieved from Sanjari, M., Shirazi, F., Heidari, S., et al. (2009). Nursing
munication during hospitalization. Journal of Pediatric support for parents of hospitalized children. Issues in
Nursing, 26, 58-69. Marshall, L. (2008). Communicating with children. In C. Comprehensive Pediatric Nursing, 32, 120-130.
Gaynard, L., Wolfer, J., Goldberger, J., et al. (1998). Psycho- Williams (Ed.), Therapeutic intervention in nursing. Topper, E. F. (2004). Working knowledge: It’s not what you
social care of children in hospitals: A clinical practice Boston: Jones & Bartlett. say, but how you say it. American Libraries, 35, 76.
manual from ACCH Child Life Research Project. Rock- McCann, D., Young, J., Watson, K., et al. (2008). Effective-
ville, MD: The Child Life Council, Inc. ness of a tool to improve role negotiation and commu-
Jones, J., & Sanchez-Jones, T. (2008). Health literacy nication between parents and nurses. Paediatric Nursing,
and communication. In C. Williams (Ed.), Therapeutic 20, 14-19.
interaction in nursing. Boston: Jones & Bartlett.
e4 Nursing Care of Children


Communicating with Children: Age-Related Techniques
Communicating with the child is essential for promoting effective coping and Nursing Diagnoses
facilitating nursing care. Special sensitivity to the child’s developmental needs Impaired Verbal Communication related to developmental level, language, physi-
and cognitive ability is necessary. Children are highly sensitive to both verbal ologic or cultural barriers; and Fear or Anxiety related to unmet informational
and nonverbal means of communication and internalize their personal interpreta- needs about or changes in health status, or threat to self-concept
tions of communicated messages. They are normally not as likely to share their
interpretations unless prompted by an adult, thus placing the bulk of the respon-
sibility for effective communication on the nurse.

Related Text
• Chapter 3, Communicating with Children and Families

1. Identify nature of the child’s diagnosis and prognosis. This information provides a basis for predicting feelings the child may be
experiencing and the type of information that needs to be communicated.
2. Determine the child’s age and developmental level (see Age-Related Age and developmental level influence factors such as word selection,
Communication Needs, below). complexity, and approach. Younger children are more concrete in their
communication, whereas adolescents can think abstractly.
3. Determine presence of developmental or perceptual disorders (e.g., Developmental or perceptual disorders may influence or alter the communication
developmental delay, deafness). process.
4. Assess family’s basic value system and other culturally prescribed The more the family’s value orientation is understood, the greater the probability
determinants of communication. that communication will be appropriate and responsive to the family’s and
child’s needs. Culture can affect communication patterns and word meanings.
For example, in Native American and some Asian cultures, direct eye contact is
considered disrespectful.
5. Determine need for an interpreter. When the nurse and child or family speak different languages, an interpreter
facilitates communication.
6. Consider readiness for communication (e.g., the ability to focus In a crisis situation or when in a state of fear or denial, the child may not be
thoughts). able to listen.
7. Determine past medical events and experiences with professionals. Children’s experiences with medical professionals may have an effect (either
positive or negative) on communication.
8. Determine purpose of communication (e.g., to elicit information, to Communication with the child is an ongoing process. Determining the purpose of
provide information, to offer psychosocial support, to prepare the child each communicative encounter guides selection of techniques and choice of
for an event, or to build rapport). communication setting.
9. Assess personal feelings and attitudes about the child and family. Feelings and attitudes are easily communicated to the child and family
nonverbally. The appropriate person to interact with the child is someone who
is capable of communicating positive feelings and attitudes. If this is not
possible for the caregiver, reassignment should be strongly considered.


1. Choose where communication will occur. Much communication occurs during the routine course of the day. However, if
the purpose of the communication demands privacy, a quiet room may be more
Special Considerations: If play materials are to be used, the playroom may be
the most appropriate setting.
Pediatric Nursing Skill e5


Communicating with Children: Age-Related Techniques—cont’d
2. Select an appropriate time, considering factors such as timing, A consideration of such factors offers the greatest possibility for successful
readiness, and the child’s schedule. communication.
3. Develop nursing goals of care:
To engage in an accurate and communicative exchange
To establish open communication
To establish a therapeutic relationship

1. Communicate a caring attitude toward the child. Providing communication with a caring attitude establishes a safe emotional
environment in which trust can develop.
Nonverbally, a statement is made that this child is lovable and that all children
are worthy of being loved regardless of appearance, behavior, or life situation.
If there is a conflict between verbal and nonverbal communication, the
nonverbal communication will commonly be believed above the verbal.
a. When speaking to the child, use his or her name. Using a child’s name demonstrates value for and appreciation of individual
b. Speak directly to the child at eye level. Special Considerations: Avoid extended eye contact, which can be
uncomfortable to some children. Also a child may be distrustful of a new face
with a too broad smile, or of an overly friendly manner.
e6 Nursing Care of Children


Communicating with Children: Age-Related Techniques—cont’d
c. Touch the child (e.g., pat the child on the arm or hand, touch his or Special Considerations: Touch must be used judiciously, considering readiness
her shoulder, or hold the infant). and cultural factors.

d. Handle the child and speak in a gentle and loving manner.

e. Attend to the child’s responses, especially when performing
procedures. Allow enough time for the child to complete a statement
or ask a question.
f. Convey the recognition of the uniqueness and individuality of the
child (e.g., refer to a special endearing characteristic of the child).
2. Be an empathetic listener. Empathetic listening facilitates establishment of a trusting relationship.
a. Use active listening (e.g., “It sounds like you are concerned that you An active listener demonstrates interest in and concern about what the listener
won’t be able to use your hand after the surgery”). perceives is important to the person.
b. Use reflective listening (e.g., “Are you saying you think your blood A reflective listener rephrases what was said for clarification.
might all come out if you have an IV?”).
3. Provide opportunity for ventilation of feelings, and acknowledge feelings When the child ventilates feelings, he or she is able to cope more effectively.
expressed. If the child is unable to express feelings verbally, use play to Young children especially have difficulty expressing feelings and need an adult
encourage self-expression (see Skill: Therapeutic Play). to help name their feelings. A child learns it is acceptable to feel and express
emotions when an adult acknowledges the feelings.
4. Use silence when appropriate. A quiet presence can communicate caring and concern. A common misconception
is that something needs to be said to be therapeutic.
5. Communicate as honestly and as accurately as possible. Honest, accurate communication facilitates trust and establishes safe parameters
a. Give accurate information. Tell the child if the information is a guess. in which concerns and questions can be aired.
b. Offer to get answers; locate information when necessary.
c. Use terms the child understands; explain medical terms when used.
d. Use visual aids (e.g., charts, drawings, or models) to promote
accurate understanding.
6. Observe for blocks to communication. Blocks have an adverse effect on the communication process.
7. Allow time for questions, both at the time and later. Provide paper and Absorbing information is a process. Additional questions may surface after the
pen or pencil. passage of time and the opportunity for reflection. With paper and pen or
pencil, the child or family can write down questions so they can remember to
ask them at a later time.
Pediatric Nursing Skill e7


Communicating with Children: Age-Related Techniques—cont’d
8. Convey sincerity. Phrases such as “I understand” are of no value unless the person saying it has
a. When choosing phrases of comfort or support truly been in that situation. Furthermore, most situations are viewed as unique,
and such a statement may provoke well-deserved anger.
Special Considerations: Use of the third person could be more effective (e.g.,
“Other children in your situation have told me they felt very helpless. Is that
how you’re feeling right now?”).
b. When sharing private information about self Traditionally, personal disclosure was discouraged. A more open approach is
advocated today. However, relating private information should have a purpose.
Validation of feelings through personal experience can prove very supportive to
the child.
9. Use humor when appropriate. Sharing humor invites those present to come a little closer. Humor provides a
common ground to soften cultural and economic barriers.
10. Use a variety of communication methods. Using a variety of communication techniques may elicit a more effective


1. Communication is effective. Techniques of therapeutic communication are employed. The child communicates
and interacts in a comfortable manner. Needed information is exchanged.
2. The child communicates needs and fears. The child asks questions and expresses fears in a developmentally appropriate

• Document significant conversations with the child on his or her chart.
• Use direct quotes as much as possible.
• Describe the child’s response to the use of specific techniques.

Age-Related Communication Needs

Infants Infants communicate primarily nonverbally and by vocalizing (e.g., crying).
Parents are best able to discriminate differences in meaning of their infant’s cry.
Sounds that were familiar in utero tend to calm the infant (e.g., music or singing).
Gentle touching, cuddling, patting, and light bouncing are comforting to the infant, as is a soft, low, calm voice.
Smile at the infant and respond to his or her cues.
Approach the infant slowly because sudden movements may be frightening.
Play pat-a-cake, peek-a-boo, or “this little piggy” with the child.
Duplicate the parental style of holding the child. If style is unknown, hold the child in an upright manner.
Keep the mother in the infant’s view.
Toddler to 5 years Preschoolers have limited verbal communication; therefore they continue to rely heavily on nonverbal
Kneel to look at the child at eye level when speaking.
Touch the child gently on the shoulder to gain attention.
Introduce yourself in terms the child can understand.
Show interest in the child (e.g., ask about a toy in the child’s hand or comment on his or her appearance).
Speak to the child in familiar terms (e.g., use the family term for urination).
Provide positive reinforcement through words and tangible objects (e.g., say “I like the way you are sitting in
that chair,” or “Your mommy and I are talking right now. If you continue to play quietly until we are finished,
you can play with my favorite puppet.”)
Use short, concrete descriptions and terms.
If it is essential to communicate more than one statement at a time, pause briefly between sentences or at the
end of phrases to allow time for the child to grasp the information.
Avoid words or phrases with literal and figurative meaning (e.g., “coughing your head off” or “a little stick in
the arm”).
Respect the child’s ability to animate inanimate objects, taking care not to dehumanize toys. Use play to project
feelings and gain information.
Use communication techniques of third person, therapeutic responding, storytelling, bibliotherapy, “what if”
questions, and three wishes.

From Smith D et╯al: Comprehensive child and family nursing skills, St Louis, 1991, Mosby. Modified from Wong D, Whaley L: Clinical manual of
pediatric nursing, ed 8, St Louis, 2011, Mosby.
e8 Nursing Care of Children


Communicating with Children: Age-Related Techniques—cont’d
Allow the child to sit on the lap of the parent or nurse or beside him or her, if the child desires. Repeat
explanations several times if the child has not grasped the content. When possible, couple explanations of
objects with a child-sized replica of the object or with simple fantasy play.
Answer persistent “why” questions with pleasant but short answers.
Explain how things might feel in simple terms. Give the child a name for what he or she seems to be feeling
(e.g., “You look upset right now”).
Use humor. Laugh when the child sees humor in a situation; make funny faces, imitate, or tickle the child in an
appropriate manner.
Set limits firmly, but gently, in a nonaccusatory manner. Reward acceptable behavior (e.g., “The toys are not to
be thrown. Sit here beside me right now. When you are calm, you may play with the toys again.”).
6 to 12 years Younger school-age children desire explanations. They are better able to grasp the information they seek.
When providing answers to questions, give the how, when, where, and why as the child requests.
Use humor by laughing at things the child finds humorous, telling simple jokes and riddles, making funny faces,
and using dramatizations.
Use simple role play, therapeutic play, three wishes, “what if” questions, bibliotherapy, and storytelling.
Allow fearful children to sit with parents.
If the parents desire, ask them to perform the activity or provide the explanation.
Allow the child to participate at his or her own pace.
Adolescents Adolescents communicate most often in verbal form and develop a “language” that is shared by their peers;
ask for clarification of terms, if needed. Use adolescent terms in moderation.
Because of the adolescent’s fluctuating emotions and behavior, communication may be adultlike one moment
and childlike the next. Anticipate shifts in communication by using a variety of techniques: third person
technique, bibliotherapy, storytelling, “what if” questions, three wishes, rating game, word association
game, sentence completion, pros and cons, writing, and drawing.
Use humor by taking advantage of funny events that happen, telling jokes and riddles, listening to the
adolescent’s jokes, or watching a funny video.
Play a board game or card game with an adolescent to facilitate discussion.
Express a nonjudgmental attitude by not reacting to issues that differ with personal values.
Adolescents may at one time reveal feelings and at another be silent.
Attend to conversations without interruption and avoid comments that are value laden.
Remain aware of developmental issues that the adolescent may wish to talk about (e.g., peer relationships,
sexuality, parental relationships, and identity concerns).
Decide whether to talk with the adolescent and parents together or separately; when possible, communicate
directly with the adolescent and retain confidentiality.
Inform the adolescent of limits to confidentiality (e.g., if the adolescent would have suicidal or homicidal
Assist with resolution of conflicts with parents by role playing assertive communication, arbitrating a family
meeting, or brainstorming solutions.

Health Promotion for
the Developing Child

After studying this chapter, you should be able to:
• Define terms related to growth and development. • Describe the classifications and social aspects of play.
• Discuss principles of growth and development. • Explain how play enhances growth and development.
• Describe various factors, including genetics and genomics, • Identify health-promoting activities that are essential
that affect growth and development. for the normal growth and development of infants and
• Discuss the following theorists’ ideas about growth and children.
development: Piaget, Freud, Erikson, and Kohlberg. • Discuss recommendations for scheduled vaccines.
• Discuss theories of language development. • Discuss the components of a nutritional assessment.
• Identify methods used to assess growth and development. • Discuss the etiology and prevention of childhood injuries.

Humans grow and change dramatically during childhood and adoles- or any of its parts or an increase in the number and size of cells. Growth
cence. Normal growth and development proceed in an orderly, predict- can be measured easily and accurately. For example, any observer can
able pattern that establishes a basis for assessing an individual’s abilities see that an infant grows rapidly during the first year of life. This growth
and potential. Nurses provide health care teaching and anticipatory can be measured readily by determining changes in weight and length.
guidance about the growth and development of children in many set- The difference in size between a newborn and a 12-month-old infant
tings, such as newborn nurseries, emergency departments, community is an obvious sign of the remarkable growth that occurs during the
clinics and health centers, and pediatric inpatient units. first year of life.
Development is a more complex and subtle concept. Development
is generally considered to be a continuous, orderly series of conditions
OVERVIEW OF GROWTH AND DEVELOPMENT leading to activities, new motives for activities, and patterns of
Nurses are frequently the members of the health care team whom behavior.
parents approach. Parents are often concerned that their children are Another definition of development is an increase in function and
not progressing normally. Nurses can reassure parents about normal complexity that occurs through growth, maturation, and learning—in
variations in development and can also identify problems early so that other words, an increase in capabilities. The process of language acqui-
developmental delays can be addressed as soon as possible. Nurses who sition provides an example of development. The use of language
work with ill children must have a clear understanding of how children becomes increasingly complex as the child matures. At 10 to 12 months
differ from adults and from each other at various stages. This aware- of age, a child uses single words to communicate simple desires and
ness is essential to allow nurses to create developmentally appropriate needs. By age 4 to 5 years, complete and complex sentences are used
plans of care to meet the needs of their young clients. to relate elaborate tales. Language development can be measured by
determining vocabulary, articulation skill, and word use.
Definition of Terms Maturity and learning also affect development. Maturation is the
Although the terms growth and development often are used together physical change in the complexity of body structures that enables a
and interchangeably, they have distinct definitions and meanings. child to function at increasingly higher levels. Maturity is programmed
Growth generally refers to an increase in the physical size of a whole genetically and may occur as a result of several changes. For example,

CHAPTER 4â•… Health Promotion for the Developing Child 51

maturation of the central nervous system depends on changes that cognitive, emotional, language, and motor development specific to
occur throughout the body, such as an increase in the number of each stage.
neurons, myelinization of nerve fibers, lengthening of muscles, and
overall weight gain. Parameters of Growth
Learning involves changes in behavior that occur as a result of both Statistical data derived from research studies of large groups of chil-
maturation and experience with the environment. Predictable patterns dren provide health care professionals with information about how
are observed in learning, and these patterns are sequential, orderly, and children normally grow. Throughout infancy, childhood, and adoles-
progressive. For example, when learning to walk, babies first learn to cence, growth occurs in bursts separated by periods when growth is
control their heads, then to roll over, next to sit, then to crawl, and stable or consistent.
finally to walk. The child’s muscle mass and nervous system must grow Weight, length (or height), and head circumference are parameters
and mature as well. that are used to monitor growth. They should be measured at regular
These examples show how complex and interrelated the processes intervals during infancy and childhood. The weight of the average term
of growth, development, maturation, and learning are. Children must newborn infant is approximately 7 1 2 pounds (3.4╯kg). Male infants are
be monitored carefully to ensure that these complicated events and usually slightly heavier than female infants. Usually, the birth weight
activities unfold normally. Wide variations occur as children grow and doubles by 6 months of age and triples by 1 year of age. Between 2 and
develop. Each child has a unique rate and pattern of development, 3 years of age, the birth weight quadruples. Slow, steady weight gain
although parameters are used to identify abnormalities. Nurses must during childhood is followed by a growth spurt during adolescence.
be familiar with normal parameters so that delays can be detected early. The average newborn infant is approximately 20 inches (50╯cm)
The earlier that delays are discovered and intervention initiated, the long, with an average increase of approximately 1 inch (2.5╯cm) per
less dramatic their effect will be. month for the first 6 months, followed by an increase of approximately
1 inch (1.2╯cm) per month for the remainder of the first year. The
Stages of Growth and Development child gains 3 inches (7.6╯cm) per year from age 1 through 7 years and
To simplify analysis and discussion of the complex processes and theo- then 2 inches (5╯cm) per year from age 8 through 15 years. Boys gener-
ries related to growth and development, researchers and theorists have ally add more height during adolescence than do girls. Body propor-
identified stages or age-groupings. These stages serve as reference tion changes are shown in Figure 4-1.
points in describing various features of growth and development Head circumference indicates brain growth. The normal occipital-
(Table 4-1). Chapters 5 through 8 discuss the physical growth and frontal circumference of the term newborn head is 13 to 15 inches (32
to 38╯cm). Average head growth occurs according to the following
pattern: 4.8 inches (12╯cm) during the first year, 1 inch (2.54╯cm)
TABLE 4-1╅ STAGES OF GROWTH AND during the second year; 1 2 inch (1.27╯cm) per year from 3 to 5 years,
DEVELOPMENT and 1 2 inch (1.2╯cm) per year from 5 years until puberty. The average
The following stages and age-groupings refer to stages of childhood growth adult head circumference is approximately 21 inches (53╯cm).
and development: Dentition, the eruption of teeth, also follows a sequential pattern.
Newborn Birth to 1 month Primary dentition usually begins to emerge at approximately 6 to 8
Infancy 1 month to 1 year months. Most children have 20 teeth by age 2 1 2 years. Permanent teeth,
Toddlerhood 1 to 3 years 32 in all, erupt beginning at approximately age 6 years, accompanied
Preschool age 3 to 6 years by the loss of primary teeth (see Chapter 9). Although some parents
School age 6 to 11 or 12 years place importance on eruption of the teeth as a sign of maturation,
dentition is not related to the level or rate of development.

2 Months 5 Months Newborn 2 Years 6 Years 12 Years 25 Years

(fetal) (fetal)

FIG 4-1  Changes in body proportions with growth.

52 CHAPTER 4â•… Health Promotion for the Developing Child

PRINCIPLES OF GROWTH AND DEVELOPMENT from the midline to the periphery. The growth and branching
pattern of the respiratory tract illustrates this concept. The trachea,
Patterns of Growth and Development which is the central structure of the respiratory tree, forms in the
Growth and development are directional and follow predictable pat- embryo by 24 days of gestation. Branching and growth outward occur
terns (Box 4-1 and Box 4-2). The first direction of growth is cephalo- in the bronchi, bronchioles, and alveoli throughout fetal life and
caudal, or proceeding from head to tail (or toe). This means that infancy. Alveoli, which are the most distal structures of the system,
structures and functions originating in the head develop before those continue to grow and develop in number and function until middle
in the lower parts of the body. At birth the head is large, a full one childhood.
fourth of the entire body length, the trunk is long, and the arms are Growth and development follow patterns, one of which is general
longer than the legs. As the child matures, the body proportions gradu- to specific. As a child matures, activities become less generalized and
ally change; by adulthood the legs have increased in size from approxi- more focused. For example, a neonate’s response to pain is usually a
mately 38% to 50% of the total body length (see Figure 4-1). whole-body response, with flailing of the arms and legs even if the pain
Directional growth and development are illustrated further by is in the abdomen. As the child matures, the pain response becomes
myelinization of the nerves, which begins in the brain and spreads more localized to the stimulus. An older child with abdominal pain
downward as the child matures (see Box 4-1). Growth of the myelin guards the abdomen.
sheath and other nerve structures contributes to cephalocaudal devel- Another pattern is the progression of functions from simple to
opment, which is illustrated by an infant’s ability to raise the head complex. This pattern is easily observed in language development. A
before being able to sit and to sit before being able to stand. toddler’s first sentences are formed simply, using only a noun and a
A second directional aspect of growth and development is proxi- verb. By age 5 years, the child constructs detailed stories using many
modistal, which means progression from the center outward, or complex modifiers.
The rate of growth is not constant as the child matures. Growth
spurts, alternating with periods of slow or stagnant growth, are
BOX 4-1â•… PATTERNS OF GROWTH AND observed throughout childhood. Spurts are frequently seen as the child
prepares to master a significant developmental task, such as walking.
An increase in growth around a child’s first birthday may promote the
Although heredity determines each individual’s growth rate, the normal pace neuromuscular maturation needed for taking the first steps.
of growth for all children falls into four distinct patterns: All facets of development (cognitive, motor, social/emotional, lan-
1. A rapid pace from birth to 2 years guage) normally proceed according to these patterns. Knowledge of
2. A slower pace from 2 years to puberty these concepts is useful when determining how a child’s development
3. A rapid pace from puberty to approximately 15 years is progressing and when comparing a child’s development with normal
4. A sharp decline from 16 years to approximately 24 years, when full adult patterns.
size is reached Mastery of developmental tasks is not static or permanent, and
developmental stages do not always correlate with chronologic age.
Children progress through developmental stages at varying rates
within normal limits and may master developmental tasks only to
BOX 4-2â•… DIRECTIONAL PATTERNS OF regress to earlier levels when ill or stressed. Also, people can struggle
GROWTH AND DEVELOPMENT repeatedly with particular developmental tasks throughout life,
although they have achieved more advanced levels of development.
Cephalocaudal Pattern (Head to Toe)
Examples Critical Periods
Head initially grows fastest (fetus), then trunk (infant), and then legs (child).
After birth, critical or sensitive periods exist for optimal growth and
Infant can raise the head before sitting and can sit before standing.
development. Similar to times during embryologic and fetal life, in
Cephalocaudal (head to toe) which certain organs are formed and are particularly vulnerable to
injury, critical periods are blocks of time during which children are
ready to master specific developmental tasks. Children can master tasks
outside these critical periods, but some tasks are learned more easily
during particular periods.
Many factors affect a child’s sensitive learning periods, such as
injury, illness, and malnutrition. For example, the sensitive period for
learning to walk seems to be during the latter part of the first year and
the beginning of the second year. Children seem to be driven by an
irresistible urge to practice walking and display great pride as they
Proximodistal (from the center outward) succeed. If a child is immobilized, for instance, for the treatment of an
Proximodistal Pattern (from the Center Outward) orthopedic condition from age 10 months to 18 months, the child may
Examples have difficulty learning to walk. The child can learn to walk, but the
In the respiratory system, the trachea develops first in the embryo, followed task may be more difficult than for other children.
by branching and growth outward of the bronchi, bronchioles, and
alveoli in the fetus and infant.
Factors Influencing Growth and Development
Motor control of the arms comes before control of the hands, and hand Genetics
control comes before finger control. One factor that greatly influences a child’s growth and development is
genetics. Genetic potential is affected by many factors. Environment
CHAPTER 4â•… Health Promotion for the Developing Child 53

influences how and to what extent particular genetic traits are mani- • Developmental behaviors, such as mouthing or playing out-
fested. Genetics is discussed in greater depth later in this chapter. doors, increase the risk for hazardous ingestion from hand-to-
mouth transfer.
Environment • Environmental toxins can be passed to an infant through breast
The environment, both physical and psychosocial, is a significant milk.
determinant of growth and developmental outcomes before and after Nurses can assist parents in preventing environmental injury by
birth. Prenatal exposures, which include maternal smoking, alcohol teaching them how to avoid the most common sources of environmen-
intake, chemical exposures, and disease such as diabetes, can adversely tal exposure. Anticipatory guidance about avoiding sun exposure, sec-
affect the developing fetus. Socioeconomic status, mainly poverty, also ondhand smoke or other air pollutants, lead in the home environment
has a significant effect on the developing child. Imported toys and and in toys, mercury in foods, use of pesticides in gardens and play-
other equipment for children can pose environmental hazards, par- ground equipment, pet insecticides (e.g., flea and tick collars), and
ticularly if they have multiple small pieces or components with high radon will provide parents with the information they need to reduce
concentrations of lead or leaded paint. risk. As with communicable disease, teaching about the importance of
Scientists suggest that factors in children’s physical environment hand hygiene is paramount.
increasingly influence their health status (AAP, 2011). Children are During well visits, nurses can perform a brief or expanded environ-
vulnerable to environmental exposures for the following reasons (AAP, mental health screening. Figure 4-2 provides an example of an envi-
2011; United States Environmental Protection Agency [EPA], 2006; ronmental history. There are thousands of synthetic chemicals to
Veal, Lowry, & Belmont, 2007): which children are exposed, with very few having federal guidelines for
• Immature and rapidly developing tissue in multiple body exposure limits (Veal et╯al., 2007). The American Academy of Pediat-
systems increases the risk for injury from exposure to lower- rics (2011) has expressed heightened concern that toxic chemicals in
level environmental toxins. the environment are not being regulated to the extent needed to
• Increased metabolic rate and growth, which necessitate a higher protect children and pregnant women, and this position has been sup-
intake in relation to body mass of food and liquids, result in a ported by the American Nurses’ Association, the American Medical
higher concentration of ingested toxins. Association, and the American Public Health Association. The AAP
• More rapid respirations increase inhalation of air pollutants. (2011) recommends revisions to the Toxic Substances Control Act that

FIG 4-2  Pediatric environmental history (0-18 years of age). (Reprinted with permission from The
National Environmental Education and Training Foundation:
54 CHAPTER 4â•… Health Promotion for the Developing Child

would base decisions about toxic chemical exposures on a “reasonable whole family and requires skill in dealing with both adults and
concern” for harm, especially their potential for harm to children and children.
pregnant women (p. 988), Among other recommendations, the AAP Nurses might reduce parental anxiety about an ill child by saying,
(2011) recommends increased funding for evidence-based research to “Your child is in the best place possible here at the hospital. You
examine the effects of chemicals exposures on children. brought him in at just the right time so that we can help him.”
Nurses can access, and can refer parents to, several online resources, Family structures are in a constant state of change, and these
including the Environmental Protection Agency ( dynamic states influence how children develop. Within the family,
children), Pediatric Environmental Health Specialty Units (PEHU) relationships change because of marriage, birth, divorce, death, and
(, Tools for Schools program (, new roles and responsibilities. Societal forces outside the family, such
and Tox Town (, among others. Nurses can as economics, population shifts, and migration, change how children
advise parents to be aware of toy and equipment recalls and to suggest are raised. These forces cause changes in family structures and the
that parents examine toys carefully before purchasing them. outcomes of child rearing, which must be considered when planning
nursing care for children. The family is discussed in Chapter 2.
Culture Parental Attitudes.╇ Parental attitudes affect growth and develop-
Culture is the way of life of a people, including their habits, beliefs, ment. Growth and development continue throughout life, and parents
language, and values. It is a significant factor influencing children as have stage-related needs and tasks that affect their children. Superim-
they grow toward adulthood. posed on these developmental issues are other factors influencing
When gathering data, nurses need to recognize how the common parental attitudes: educational level, childhood experiences, financial
family structures and traditional values of various groups affect chil- pressures, marital status, and available support systems. Parental atti-
dren’s performance on assessment tests. The child’s cultural and ethnic tudes are also affected by the child’s temperament, or the child’s unique
background must be considered when assessing growth and develop- way of relating to the world. Different temperaments affect parenting
ment. Standard growth curves and developmental tests do not neces- practices and have a bearing on whether a child’s unique personality
sarily reflect the normal growth and development of children of traits develop into assets or problems.
different cultural groups. Growth curves for children of various racial Child-Rearing Philosophies.╇ Child-rearing philosophies, shaped
and cultural backgrounds are increasingly available. Nurse researchers by myriad life events, influence how children grow and develop. For
and others conduct studies to determine the effectiveness of measure- example, well-educated, well-read parents often provide their children
ment tools for culturally diverse populations. In addition, culturally with extra stimulation and opportunities for learning beginning at a
sensitive instruments are being developed to gather data to determine young age. This enrichment includes extra parental attention and
appropriate nursing interventions. To provide quality care to all chil- interaction—not necessarily expensive toys. Generally, development
dren, nurses must consider the effect of culture on children and fami- progresses best when children have access to enriched opportunities
lies (see Chapter 2). for learning.
Other parents may not recognize the value of providing a rich
Nutrition learning environment at home, may not have time, or may not appreci-
Because children are growing constantly and need a continuous supply ate this type of parenting. Children of these parents may not progress
of nutrients, nutrition plays an important role throughout childhood. at the same rate as those raised in a more enriching atmosphere.
Children need more nutritious food in proportion to size than adults A significant point for parents to remember is that children must
do. Children’s food patterns have changed over the years. Children are be ready to learn. If motor and neurologic structures are not mature,
drinking more low fat or skim milk; however, children over the age of an overzealous approach for accomplishing a task related to those
3 years consistently do not drink enough milk. Instead, they consume structures can be frustrating for both child and parent. For example, a
juices or other drinks that contain sugar (Peckenpaugh, 2010). Today’s child who is 6 months old will not be able to walk alone no matter
children often eat meals outside the home, with 10% of young children how much time and effort the parent expends. However, at 12 to 14
having one or more meals in a daycare setting, away from parental months, a child usually is ready to begin walking and will do so with
supervision (Peckenpaugh, 2010). Nutrition is discussed in more depth ease if given opportunities to practice.
later in this chapter.

Health Status
Overall health status plays an important part in the growth and devel-
opment of children. At the cellular level, inherited or acquired disease Many theorists have attempted to organize and classify the complex
can affect the delivery of nutrients, hormones, or oxygen to organs and phenomena of growth and development. No single theory can ade-
also can affect organ growth and function. Disease states that affect quately explain the wondrous journey from infancy to adulthood.
growth and development include digestive or malabsorptive disorders, However, each theorist contributes a piece of the puzzle. Theories
heart defects, and metabolic diseases. are not facts but merely attempts to explain human behavior.
Table 4-2 compares and contrasts theories discussed in the text. The
Family chapters on each age-group provide further discussion of these
A child is an inseparable part of a family. Family relationships and theories.
influences substantially determine how children grow and progress.
Because of the special bond and influence of the family on the child, Piaget’s Theory of Cognitive Development
there can be no separation of child from family in the health care Jean Piaget (1896–1980), a Swiss theorist, made major contributions
setting. For example, to diminish anxiety in a child, nurses sometimes to the study of how children learn. His complex theory provides a
attempt to reduce parental anxiety, which may then reduce the stress framework for understanding how thinking during childhood pro-
on the child. Nursing care of children involves nursing care of the gresses and differs from adult thinking. Like other developmental
CHAPTER 4â•… Health Promotion for the Developing Child 55


Premorality or Preconventional
Period 1 (Birth-2╯yr): Morality, Stage 0 (0-2╯yr): Naivete
Infancy Sensorimotor Period Oral Stage Trust vs. Mistrust and Egocentrism
Reflexive behavior is used to Mouth is a sensory organ; Development of a sense that No moral sensitivity; decisions are made on
adapt to the environment; infant takes in and explores the self is good and the the basis of what pleases the child; infants
egocentric view of the during oral passive world is good when like or love what helps them and dislike
world; development of substage (first half of consistent, predictable, what hurts them; no awareness of the
object permanence. infancy); infant strikes out reliable care is received; effect of their actions on others. “Good is
with teeth during oral characterized by hope. what I like and want.”
aggressive substage (latter
half of infancy).
Premorality or Preconventional Morality,
Period 2 (2-7╯yr): Autonomy vs. Shame and Stage 1 (2-3╯yr): Punishment-
Toddlerhood Preoperational Thought Anal Stage Doubt Obedience Orientation
Thinking remains egocentric, Major focus of sexual Development of sense of Right or wrong is determined by physical
becomes magical, and is interest is anus; control of control over the self and consequences: “If I get caught and
dominated by perception. body functions is major body functions; exerts self; punished for doing it, it is wrong. If I am
feature. characterized by will. not caught or punished, then it must be
Premorality or Preconventional Morality,
Phallic or Oedipal/Electra Stage 2 (4-7╯yr): Instrumental Hedonism
Preschool Age Stage Initiative vs. Guilt and Concrete Reciprocity
Genitals become focus of Development of a can-do Child conforms to rules out of self-interest:
sexual curiosity; superego attitude about the self; “I’ll do this for you if you do this for me”;
(conscience) develops; behavior becomes behavior is guided by an “eye for an eye”
feelings of guilt emerge. goal-directed, competitive, orientation. “If you do something bad to
and imaginative; initiation me, then it’s OK if I do something bad to
into gender role; you.”
characterized by purpose.
Morality of Conventional Role
Period 3 (7-11╯yr): Conformity, Stage 3 (7-10╯yr): Good-Boy
School Age Concrete Operations Latency Stage Industry vs. Inferiority or Good-Girl Orientation
Thinking becomes more Sexual feelings are firmly Mastering of useful skills and Morality is based on avoiding disapproval
systematic and logical, but repressed by the superego; tools of the culture; or disturbing the conscience; child is
concrete objects and period of relative calm. learning how to play and becoming socially sensitive.
activities are needed. work with peers;
characterized by
Morality of Conventional Role
Conformity, Stage 4 (begins at about
10-12╯yr): Law and Order Orientation
Right takes on a religious or metaphysical
quality. Child wants to show respect for
authority, and maintain social order; obeys
rules for their own sake.
Morality of Self-Accepted Moral
Period 4 (11╯yr-Adulthood): Principles, Stage 5: Social Contract
Adolescence Formal Operations Puberty or Genital Stage Identity vs. Role Confusion Orientation
New ideas can be created; Stimulated by increasing Begins to develop a sense of Right is determined by what is best for the
situations can be analyzed; hormone levels; sexual “I”; this process is lifelong; majority; exceptions to rules can be made
use of abstract and energy wells up in full peers become of if a person’s welfare is violated; the end no
futuristic thinking; force, resulting in personal paramount importance; longer justifies the means; laws are for
understands logical and family turmoil. child gains independence mutual good and mutual cooperation.
consequences of behavior. from parents; characterized
by faith in self.

56 CHAPTER 4â•… Health Promotion for the Developing Child


Adulthood Intimacy vs. Isolation
Development of the ability to
lose the self in genuine
mutuality with another;
characterized by love.
Morality of Self-Accepted Moral
Generativity vs. Principles, Stage 6: Personal Principle
Stagnation Orientation
Production of ideas and Achieved only by the morally mature
materials through work; individual; few people reach this level;
creation of children; these people do what they think is right,
characterized by care. regardless of others’ opinions, legal
sanctions, or personal sacrifice; actions are
guided by internal standards; integrity is of
utmost importance; may be willing to die
for their beliefs.
Morality of Self-Accepted Moral
Principles, Stage 7: Universal
Ego Integrity vs. Despair Principle Orientation
Realization that there is order This stage is achieved by only a rare few;
and purpose to life; Mother Teresa, Gandhi, and Socrates are
characterized by wisdom. examples; these individuals transcend the
teachings of organized religion and
perceive themselves as part of the cosmic
order, understand the reason for their
existence, and live for their beliefs.

theorists, Piaget postulated that, as children develop intellectually, they future events remain obscure. Although reasoning powers increase
pass through progressive stages (Piaget, 1962, 1967). The ages assigned rapidly during this stage, the child cannot deal with abstractions or
to these periods are only averages. with socialized thinking.
During the sensorimotor period of development, infant thinking Normally, adolescents progress to the period of formal operations.
seems to involve the entire body. Reflexive behavior is gradually In this period the adolescent proceeds from concrete to abstract and
replaced by more complex activities. The world becomes increasingly symbolic and from self-centered to other centered. Adolescents can
solid through the development of the concept of object permanence, develop hypotheses and then systematically deduce the best strategies
which is the awareness that objects continue to exist even when they for solving a particular problem because they use a formal operations
disappear from sight. By the end of this stage, the infant shows some cognitive style. Not all adolescents, however, reach this landmark at a
evidence of reasoning. consistent age, and at any given time, an adolescent may or may not
During the period of preoperational thought, language becomes exhibit characteristics of formal operations (Kuhn, 2008).
increasingly useful. Judgments are dominated by perception and are
illogical, and thinking is characterized, especially during the early part Nursing Implications of Piaget’s Theory
of this stage, by egocentrism. In other words, children are unable to Although other developmental theorists have disputed Piaget’s theo-
think about another person’s viewpoint and believe that everyone per- ries, especially the ages at which cognitive changes occur, his work
ceives situations as they do. Magical thinking (the belief that events provides a basis for learning about and understanding cognitive devel-
occur because of wishing) and animism (the perception that all objects opment. Piaget’s theory is especially significant to nurses as they
have life and feeling) characterize this period. develop teaching plans of care for children. Piaget believed that learn-
At the end of the preoperational stage, the child shifts from ego- ing should be geared to the child’s level of understanding and that the
centric thinking and begins to be able to look at the world from child should be an active participant in the learning process. For health
another person’s view. This shifting enables the child to move into the teaching to be effective, nurses must understand the different cognitive
period of concrete operations, where the child is no longer bound by abilities of children at various ages. Nurses also must know how to
perceptions and can distinguish fact from fantasy. The concept of time engage children in the learning process with developmentally
becomes increasingly clear during this stage, although far past and far appropriate activities. Because illness and hospitalization are often
CHAPTER 4â•… Health Promotion for the Developing Child 57

frightening to children, especially toddlers and preschoolers, nurses Nursing Implications of Freud’s Theory
must understand the cognitive basis of fears related to treatment and Both children and parents may have questions and concerns about
be able to intervene appropriately (see Chapter 11). normal sexual development and sex education. Nurses need to under-
Understanding cognitive development that occurs at various stand normal sexual growth and development to help parents and
ages and developmental levels also has implications for children’s children form healthy attitudes about sex and create an accepting
health literacy (Borzekowski, 2009). With health related messages climate in which adolescents may talk about sexual concerns.
so obvious in the media and so accessible on the Internet, it is impor-
tant that children begin to think about health, evaluate health messages Erikson’s Psychosocial Theory
and become involved in their own health promotion (Borzekowski, Erik H. Erikson (1902–1994), inspired by the work of Sigmund Freud,
2009). proposed a popular theory about child development. He viewed devel-
opment as a lifelong series of conflicts affected by social and cultural
Freud’s Theory of Psychosexual Development factors. Each conflict must be resolved for the child and adult to prog-
Sigmund Freud (1856–1939) developed theories to explain psycho- ress emotionally. How individuals address the conflicts varies widely.
sexual development. His theories were in vogue for many years According to Erikson, however, unsuccessful resolution leaves the indi-
and provided a basis for other theories. Freud postulated that early vidual emotionally disabled (Erikson, 1963).
childhood experiences provide unconscious motivation for actions Each of eight stages of development has a specific central conflict
later in life (Freud, 1960). According to Freudian theory, certain or developmental task. These eight tasks are described in terms of a
parts of the body assume psychological significance as foci of sexual positive or negative resolution. The actual resolution of a specific con-
energy. These areas shift from one part of the body to another as the flict lies somewhere along a continuum between a perfect positive and
child moves through different stages of development. Freud’s work a perfect negative.
may help to explain normal behavior that parents may confuse with The first developmental task is the establishment of trust. The basic
abnormal behavior, and it also may provide a good foundation for sex quality of trust provides a foundation for the personality. If an infant’s
education. physical and emotional needs are met in a timely manner through
Freud believed that during infancy sexual behavior seems to focus warm and nurturing interactions with a consistent caregiver, the infant
around the mouth, the most erogenous area of the infant body (oral begins to sense that the world is trustworthy. The infant begins to
stage). Infants derive pleasure from sucking and exploring objects by develop trust in others and a sense of being worthy of love. Through
placing them in their mouths. During early childhood, when toilet successful achievement of a sense of trust, the infant can move on to
training becomes a major developmental task, sensations seem to shift subsequent developmental stages.
away from the mouth and toward the anus (anal stage). Psychoanalysts According to Erikson, unsuccessful resolution of this first develop-
see this period as a time of holding on and letting go. A sense of control mental task results in a sense of mistrust. If needs are consistently
or autonomy develops as the child masters body functions. unmet, acute tension begins to appear in children. During infancy,
During the preschool years, interest in the genitalia begins (phallic signs of unmet needs include restlessness, fretfulness, whining, crying,
stage). Children are curious about anatomic differences, childbirth, clinging, physical tenseness, and physical dysfunctions such as vomit-
and sexuality. Children at this age often ask many questions, freely ing, diarrhea, and sleep disturbances. All children exhibit these signs
exhibit their own sexual organs, and want to peek at those of others. at times. If these behaviors become personality characteristics, however,
Children often masturbate, sometimes causing parents great concern. unsuccessful resolution of this stage is suspected.
Although it is not universal, a phenomenon described by Freud as the The toddler’s developmental task is to acquire a sense of autonomy
Oedipus complex in boys and the Electra complex in girls is seen in rather than a sense of shame and doubt. A positive resolution of this
preschool children. This possessiveness of the child for the opposite- task is accomplished by the ability to control the body and body func-
sex parent, marked by aggressiveness toward the same-sex parent, tions, especially elimination. Success at this stage does not mean that
is considered normal behavior, as is a heightened interest in sex. To the toddler, even as an adult, will exhibit autonomous behavior in all
resolve these disturbing sexual feelings, the preschooler identifies with life situations. In certain circumstances, feelings of shame and self-
or becomes more like the same-sex parent. The superego (an inner doubt are normal and may be adaptive.
voice that reprimands and evokes guilt) also develops. The superego is Erikson’s theory describes each developmental stage, with crises
similar to a conscience (Freud, 1960). related to individual stages emerging at specific times and in a par�
Freud describes the school-age period as the latency stage, when ticular order. Likewise, each stage is built on the resolution of
sexuality plays a less prominent role in the everyday life of the child. previous developmental tasks. During each conflict, however, the child
Best friends and same-sex peer groups are influential in the school-age spends some energy and time resolving earlier conflicts (Erikson,
child’s life. Younger school-age children often refuse to play with chil- 1963).
dren of the opposite sex, whereas prepubertal children begin to desire
the companionship of opposite-sex friends. Nursing Implications of Erikson’s Theory
During adolescence, interest in sex again flourishes as children In stressful situations, such as hospitalization, children, even those with
search for identity (genital stage). Under the influence of fluctuating healthy personalities, evoke defense mechanisms that protect them
hormone levels, dramatic physical changes, and shifting social relation- against undue anxiety. Regression, a behavior used frequently by
ships, the adolescent develops a more adult view of sexuality. Cognitive children, is a reactivation of behavior more appropriate to an earlier
skills, particularly in young adolescents, are not fully developed, stage of development. This defense mechanism is illustrated by a
however, and decisions are made often based on the adolescent’s emo- 6-year-old boy who reverts to sucking his thumb and wetting his pants
tional state, rather than on critical reasoning (Cromer, 2011). This can under increased stress, such as illness or the birth of a sibling. Nurses
lead to questionable judgments about sexual matters and questions or can educate parents about regression and encourage them to offer
confusion about sexual feelings and behaviors (A. Freud, 1974). their children support, not ridicule. They can provide constructive
58 CHAPTER 4â•… Health Promotion for the Developing Child

suggestions for stress management and reassure parents that regression from their own viewpoint to consider what rights and values must be
normally subsides as anxiety decreases. upheld for the good of all. Some individuals never reach this point.
Erikson’s main contribution to the study of human development Within this level is stage 5, in which conformity occurs because indi-
lies in his outline of a universal sequence of phases of psychosocial viduals have basic rights and society needs to be improved. The ado-
development. His work is especially relevant to nursing because it lescent in this stage gives as well as takes and does not expect to get
provides a theoretic basis for much of the emotional care that is given something without paying for it. In stage 6, conformity is based on
to children. The stages are further discussed in the chapters on each universal principles of justice and occurs to avoid self-condemnation
age-group. (Colby, Kohlberg, & Kauffman, 1987; Kohlberg, 1964).
Only a few morally mature individuals achieve stage 6. These
Kohlberg’s Theory of Moral Development people, committed to a moral ideal, live and die for their principles.
Lawrence Kohlberg (1927–1987), a psychologist and philosopher, Kohlberg believes that children proceed from one stage to the next
described a stage theory of moral development that closely parallels in a sequence that does not vary, although some people may never
Piaget’s stages of cognitive development. He discussed moral develop- reach the highest levels. Even though children are raised in different
ment as a complicated process involving the acceptance of the values cultures and with different experiences, he believes that all children
and rules of society in a way that shapes behavior. This cognitive- progress according to his description.
developmental theory postulates that, although knowing what behav-
iors are right and wrong is important, it is much less important than Nursing Implications of Kohlberg’s Theory
understanding and appreciating why the behaviors should or should To provide anticipatory guidance to parents about expectations and
not be exhibited (Kohlberg, 1964). discipline of their children, nurses must be aware of how moral devel-
Guilt, an internal expression of self-criticism and a feeling of opment progresses. Parents are often distraught because their young
remorse, is an emotion closely tied to moral reasoning. Most children children apparently do not understand right and wrong. For example,
12 years old or older react to misbehavior with guilt. Guilt helps them a 6-year-old girl who takes money from her mother’s purse does not
realize when their moral judgment fails. show remorse or seem to recognize that stealing is wrong. In fact, she
Building on Piaget’s work, Kohlberg studied boys and girls is more concerned about her punishment than about her misdeed.
from middle- and lower-class families in the United States and With an understanding of normal moral development, the nurse can
other countries. He interviewed them by presenting scenarios with reassure the concerned parents that the child is showing age-appropriate
moral dilemmas and asking them to make a judgment. His focus behavior.
was not on the answer but on the reasoning behind the judgment
(Kohlberg, 1964). He then classified the responses into a series of levels
and stages.
During the Premorality (preconventional morality) level, which has
three substages (see Table 4-2), the child demonstrates acceptable Human language has a number of characteristics that are not shared
behavior because of fear of punishment from a superior force, such as with other species of animals that communicate with each other.
a parent. At this stage of cognitive and moral development, children Human language has meaning, provides a mechanism for thought, and
cannot reason as mature members of society. They view the world in permits tremendous creativity.
a selfish, egocentric way, with no real understanding of right or wrong. Because language is such a complex process and involves such a vast
They view morality as external to themselves, and their behavior number of neuromuscular structures, brain growth and differentiation
reflects what others tell them to do, rather than an internal drive to do must reach a certain level of maturity before a child can speak. Lan-
what is right. In other words, they have an external locus of control. A guage development, which closely parallels cognitive development, is
child who thinks “I will not steal money from my sister because my discussed by most cognitive theorists as they explain the maturation
mother will spank me” illustrates premorality. of thinking abilities. The process of how language develops remains a
During the Morality of Conventional Role Conformity (conventional mystery, however.
morality) level, which is primarily during the school-age years, the Passive, or receptive, language is the ability to understand the spoken
child conforms to rules to please others. The child still has an external word. Expressive language is the ability to produce meaningful vocal-
locus of control, but a concern for social order begins to emerge and izations. In most people, the areas in the brain responsible for expres-
replace the more egocentric thinking of the earlier stage. The child has sive language are close to motor centers in the left cerebral area that
an increased awareness of others’ feelings. In the child’s view, good control muscle movement of the mouth, tongue, and hands. Humans
behavior is that which those in authority will approve. If behavior is use a variety of facial and hand movements as well as words to convey
not acceptable, the child feels guilty. ideas.
Two stages, stage 3 and stage 4, characterize this level (see Table Crying is the infant’s first method of communication. These vocal-
4-2). This level of moral reasoning develops as the child shifts the focus izations quickly become distinct and individual and accurately convey
of living from the family to peer groups and society as a whole. As the such states as hunger, diaper discomfort, pain, loneliness, and boredom.
child’s cognitive capacities increase, an internal sense of right and Vowel sounds appear first, as early as 2 weeks of age, followed by con-
wrong emerges and the individual is said to have developed an internal sonants at approximately 5 months of age.
locus of control. Along with this internal locus of control comes the By age 2 years, children have a vocabulary of roughly 300 words
ability to consider circumstances when judging behavior. and can construct simple sentences. By age 4 years, children have
Level 3, Morality of Self-Accepted Moral Principles (postconven- gained a sense of correct grammar and articulation, but several con-
tional morality), begins in adolescence, when abstract thinking abilities sonants, including “l” and “r,” remain difficult to pronounce. For
develop. The person focuses on individual rights and principles of example, the sentence “The red and blue bird flew up to the tree” might
conscience during this stage. There is an internal locus of control. be pronounced by the preschooler as “The wed and boo bud fwew up
Concern about what is best for all is uppermost, and persons step back to the twee!”
CHAPTER 4â•… Health Promotion for the Developing Child 59

The language of school-age children is less concrete and much more Structure of Genes and Chromosomes
articulate than that of the preschooler. School-age children learn and The transmission of traits from parents to their children is a complex
understand language construction, use more sophisticated terminol- process involving basic structures called DNA, genes, and chromosomes.
ogy, use varied meanings for words, and can write and express ideas in DNA is a long molecule that resembles a spiral ladder, or double helix.
paragraphs and essays (Feigelman, 2011). A pair of nitrogen bases forms each rung of the spiral ladder with
Infants learn much of their language from their parents. Children alternating sugar (deoxyribose) and phosphate groups forming the
who are raised in homes where verbalization is encouraged and sides. Each nitrogen base attaches one of its “ends” to a sugar group. It
modeled tend to display advanced language skills. Also, in infancy, pairs with another nitrogen base at the other “end” by means of weak
receptive ability (the understanding of language) is more developed hydrogen bonds. There are four nitrogen bases in DNA, which always
than expressive skill (the actual articulation of words). This tendency, pair in the following manner: adenine with thymine and guanine with
which persists throughout life, is important to realize when caring for cytosine. Genes are specific sequences of base pairs within a DNA
children. In clinical situations, nurses must communicate what is hap- molecule.
pening to their young clients by use of simple, age-appropriate words, Genes.╇ A gene is a segment of DNA that directs (codes for) the
although the child may not verbalize understanding. production of a specific protein needed for body structure or function.
Nurses and other health providers need to assess a young child’s Genes may also code for regulatory molecules that control the process
language development at each well visit. Parent concern or positive of translating the genetic code into a protein. Humans probably have
family history of language problems, combined with clinical assess- between 20,000 and 25,000 genes (Clamp et╯al., 2007; Jorde, 2010).
ment of language development, can identify children who may be at Genes often have two or more alternate forms (alleles). Wild-type
risk for disorders associated with altered expressive or receptive lan- alleles are those gene versions that occur most commonly in the popu-
guage (Schum, 2007). Language development is discussed in more lation. A polymorphism is a place (locus) on the DNA molecule where
depth in chapters on each age-group and in Chapter 31. the sequence of base pairs is different from the expected sequence.
Polymorphisms are relatively common. All humans have polymor-
phisms in their genomes. If it occurs in a gene or a regulatory sequence,
GENETIC AND GENOMIC INFLUENCES ON a polymorphism may result in production of a protein that is dysfunc-
tional or deficient. On the other hand, it may have no effect or it might
Heredity, the transmission of genetic characteristics from parent to There are different types of polymorphisms. The most common
offspring, is a significant determinant of growth and development. At polymorphisms are single nucleotide polymorphisms or SNPs (pro-
the completion of the Human Genome Project in 2003, the entire nounced “snip”). A SNP happens when a single base is deleted, inserted,
sequence of the 3 billion chemical base pairs in human DNA was or changed in the DNA sequence. The mutation that causes sickle cell
determined and 20,000-25,000 genes had been identified. Since then, disease is a SNP. In the beta globin gene, substitution of an adenine for
thousands of disease-associated genetic variants have been identified. a thymine at the 17th base position results in producing an altered
These discoveries have opened a frontier in biomedical research that version of hemoglobin, which causes red blood cells to assume a rigid,
is being pioneered today. Advances in genetics and genomics have sickled shape under certain kinds of stress.
moved forward so rapidly that personalized medicine, individualized Chromosomes.╇ Usually DNA exists as threadlike structures floating
treatment based on a person’s genotype, is becoming a reality. This in an unorganized manner within the nucleus of the cell. At certain
means that pediatric nurses must master a set of genetic/genomic stages of cell reproduction DNA becomes highly condensed and orga-
competencies that has expanded to be more relevant to the rapidly nized into structures called chromosomes (Figure 4-3). Chromosomes
changing options that patients will now have.
Nurses need a working knowledge of how genetic traits are trans-
mitted, how common chromosomal abnormalities occur, how genetic
factors influence complex conditions, and how genotype affects
response to drugs. Pediatric nurses are particularly likely to care for
individuals with monogenic disorders and must understand the impact Chromosome
of these conditions on children and families. Alert and skilled nurses
can provide early assessment, identification, and referral to appropriate
professionals for genetic evaluation and counseling. A significant DNA
nursing role is offering families support in coping with known genetic
abnormalities. Informed nurses can act as advocates, helping children
and families maneuver through the complexities of the health care
system. Finally, nurses are in an excellent position to educate families
and communities about the causes of birth defects and the prevention
of environmentally induced disorders.

Genetics and Genomics

Genetics is the study of how inherited characteristics, or traits, are
transmitted through single genes and how genetic material, deoxyribo-
nucleic acid (DNA), affects the physiology of cells. The focus of genetics
is single genes studied one at a time. Genomics is the study of the entire FIG 4-3  Diagrammatic representation of the deoxyribonucleic
set of genetic instructions (the genome) in an organism, including the acid (DNA) helix, which is the building block of genes and
interactions of genes with each other and with the environment. chromosomes.
60 CHAPTER 4â•… Health Promotion for the Developing Child

can be seen distinctly under the microscope during the metaphase chemicals. Although mutations are often perceived as harmful, they are
period of cell division. Technicians photograph or use computer an important source of human variation.
imaging to organize and display the chromosomes from largest to
smallest pairs in an image known as a karyotype. The karyotype is then Principles of Mendelian Inheritance
analyzed by inspection. The fundamental principles of inheritance were discovered by an
There are normally 46 chromosomes in the nucleus of somatic cells. Augustinian monk, Gregor Mendel, in the mid-19th century. By
During cell division chromosomes physically pair. Twenty-two chro- means of observations of pea plants, Mendel discovered how single
mosome pairs are called autosomes and are the same in everyone. The traits are inherited. Although advances in contemporary genetics have
23rd pair makes up the sex chromosomes. Normal females have two X demonstrated non-Mendelian inheritance patterns, the patterns
sex chromosomes and normal males have an X and a Y chromosome. described by Mendel, termed Mendelian inheritance, remain the
Mature sperm or egg cells have half the chromosomes (23) of somatic major determinants of genetic diseases in children. Mendel’s greatest
cells. During germ cell division, one chromosome from each chromo- contributions include the principles of segregation, which refers to
some pair is distributed randomly in daughter cells, resulting in the separation of paired genes during cell division, and independent
random combinations of maternal and paternal chromosomes. This assortment, which refers to the random distribution of alleles into
process of random assortment is one of the primary mechanisms gametes during cell division. The characteristic of dominance, in
through which human variation occurs. When the ovum and sperm which one allele masks the expression of the other, was also described
unite at conception, the total number of nuclear chromosomes is by Mendel.
restored to 46.
Added or missing chromosomes or structurally abnormal chromo- Dominant and Recessive Alleles
somes are usually harmful. Extra chromosomal material means that All humans share the same genes, and each human normally has two
extra DNA and, therefore, probably extra genes are present, which may copies of each gene. However, all humans do not share the same ver-
result in an “overdose” of the proteins that the extra genes encode. In sions of each gene. Genes have different versions, known as alleles, and
a similar fashion, missing or abnormal chromosomal material implies some alleles are dominant to others. In the case of a dominant allele,
that DNA, and therefore probably some genes that affect function, is one copy is enough to cause the trait it encodes to be expressed. When
missing. This results in an insufficient dose of the proteins that the an allele is expressed, the trait it encodes becomes observable. It
missing genes encode. becomes a phenotype.
Chromosome analysis is a common procedure during diagnostic For example, in the ABO blood system, alleles for group A and
evaluation for fetuses, infants, or children with congenital anomalies group B blood types are dominant. Therefore, a single copy of either
or intellectual impairment. Cells for chromosomal analysis must be of these alleles is enough to be expressed in the person’s blood type. If
nucleated and alive. Specimens must be obtained and preserved care- a person’s two copies of the gene for blood type contain an allele for
fully to provide enough living cells for chromosomal analysis. Tem- blood group A and another allele for blood group O, then the pheno-
perature extremes, blood clotting, or improper preservatives can kill type (the observable trait) will be blood group A because the A allele
cells and render them useless for analysis. Common cell types used for is dominant to the O allele.
chromosome analysis include white blood cells, skin fibroblasts, bone Recessive alleles will only be expressed if two identical copies of the
marrow cells, and fetal cells from chorionic villi (future placenta) or recessive allele are present. The gene for blood group O is recessive.
amniotic fluid. Only if a person receives an allele for blood group O from both parents
Alleles.╇ Chromosomes that physically pair during cell division are will laboratory testing identify his or her blood group as O. Some
called homologous chromosomes. Homologous chromosomes have alleles are equally dominant. The person who receives an allele for
one allele at the same location on each member of the chromosome blood group A from one parent and group B from the other will have
pair. The paired alleles may be identical (homozygous) or different type AB blood because both alleles are equally dominant and both are
(heterozygous). expressed in blood typing.
Some alleles occur more frequently in certain groups than they do Dominance and recessiveness are not absolute for all alleles. Some
in the population as a whole. For example, the allele that causes Tay- people with a single copy of an abnormal recessive allele (carriers) may
Sachs disease is carried by about 1 of every 27 Ashkenazi Jews, whose have a slightly abnormal level of the gene product (e.g., an enzyme)
families have their roots in Eastern Europe. Some non-Jewish French- that can be detected by laboratory methods. These people usually do
Canadians and Cajun people from Louisiana also have a higher inci- not have the disease because the normal copy of the allele directs pro-
dence of the disorder. However, an estimated 1 of every 300 people duction of enough of the required product to allow normal or near-
outside these groups carries the mutated allele (Martin, Mark, Triggs- normal function.
Raine, & Natowicz, 2007). Other disorders that are prevalent in certain
ethnic groups are cystic fibrosis (primarily whites of northern Euro- Gene Location
pean descent) and sickle cell disease (primarily people of African, Genes located on autosomes are either autosomal dominant or auto-
Mediterranean, Indian, or Middle Eastern descent). The increased fre- somal recessive, depending on whether one or two identical copies of
quency of some disease-associated allelic variants in certain racial/ the allele are needed to produce the trait. Genes located on the X
ethnic groups is the basis for including race/ethnicity in the health chromosome are paired only in females because males have one X and
history. one Y chromosome. A female with an abnormal recessive gene on one
Mutations.╇ Mutations are inheritable changes in the DNA nucleo- of her X chromosomes usually has a normal gene on the other X
tide sequence or in the structure of chromosomes. Mutations can affect chromosome that compensates and maintains relatively normal func-
whole chunks of DNA resulting in chromosome abnormalities, or a tion. However, the male is at a disadvantage if his only X chromosome
single base resulting in a SNP, as well as other variations. Mutations has an abnormal gene. He has no compensating normal gene because
occur spontaneously in humans due to errors in DNA replication his other sex chromosome is a Y. The abnormal gene will be expressed
or exposure to environmental factors, such as radiation or toxic in the male because it is unopposed by a normal gene.
CHAPTER 4â•… Health Promotion for the Developing Child 61

Autosomal Dominant Inheritance Pattern

dD dd Each child has:

• 50% chance of having the disease
• 50% chance of being normal

No carrier state

No relationship to sex of the child

Examples: Neurofibromatosis
dd dD dd dD Blood groups A and B

Key: d  normal gene; D  abnormal, dominant gene

Autosomal Recessive Inheritance Pattern

Pp Pp Each child has:

• 25% chance of having the disease
• 50% chance of being a carrier
• 25% chance of being normal

No relationship to sex of the child

Examples: Sickle cell disease

Cystic fibrosis
PP Pp Pp pp

Key: P  normal gene; p  abnormal, recessive gene

X-Linked Recessive Inheritance Pattern

xy xxr
Each female child has:
• 50% chance of being a carrier
• 50% chance of being normal

Each male child has:

• 50% chance of having the disease
• 50% chance of being normal

Females do not usually have X-linked

xy xry xx xxr recessive disorders

Males are not usually carriers

Key: xy  normal male sex chromosome pattern;
xx  normal female sex chromosome pattern;
Examples: Hemophilia
r  sex-linked recessive gene
Duchenne muscular dystrophy
FIG 4-4  Inheritance pattern and risk.

Mendelian Inheritance Patterns BOX 4-3â•… SINGLE-GENE ABNORMALITIES

Three important patterns of inheritance of single alleles are (1) auto- • A person affected with an autosomal dominant disorder has a 50% risk of
somal dominant, (2) autosomal recessive, and (3) X-linked. Figure 4-4 transmitting the disorder to each of his or her children.
summarizes characteristics and transmission of each pattern. Single- • Two healthy parents who carry the same abnormal autosomal recessive
gene traits are traits that are determined by only one gene. Complex gene have a 25% risk at each conception of having a child affected with
traits are determined by multiple interacting genes or interactions the disorder caused by this gene.
between genes and the environment. Complex traits include complex • Parental consanguinity (blood relationship) increases the risk for having a
chronic diseases, such as asthma, heart disease, and non-insulin child with an autosomal recessive disorder.
dependent diabetes. Complex, multifactorial diseases are common in • One copy of an abnormal X-linked recessive gene is enough to produce the
adults. In children, the single-gene disorders are of great concern disorder in a boy.
because their manifestations are typically observed in infancy or early • Abnormal genes can arise as new mutations that are then transmitted to
childhood and they account for significant allocation of health care future generations.
resources (Box 4-3).
62 CHAPTER 4â•… Health Promotion for the Developing Child

Single-gene disorders have mathematically predictable rates of

occurrence. For example, if a couple has a child with an autosomal
recessive disorder, the risk that future children from the same couple NUMERIC STRUCTURAL
will have the disorder is 1â•›:â•›4 (25%) at every conception. Single chromosome Part of a chromosome missing or added
added (trisomy)
Autosomal Dominant Traits Single chromosome DNA rearrangements within chromosome(s)
An autosomal dominant trait is produced by a dominant allele on a missing (monosomy)
non-sex chromosome. The expression of abnormal autosomal domi- One or more added sets Part of a chromosome breaks off and becomes
nant alleles may result in multiple and seemingly unrelated effects in of chromosomes attached to another (translocation)
the affected person. The gene’s effects may vary substantially in sever- (polyploidy) Fragility of a specific site on a chromosome
ity, leading a family to think that a trait skips a generation. A careful
physical examination may reveal subtle evidence of the trait in each
generation. Some people may carry the dominant gene but may have
no apparent expression of it in their physical makeup.
In some autosomal dominant disorders, such as Huntington’s their only X chromosome has the abnormal gene on it. Females can
disease, the disease does not manifest until adulthood. The person show the full disorder when:
having the defective gene for Huntington’s disease will always have the • A female has a single X chromosome (Turner syndrome)
disease if he or she lives long enough. In other disorders, only a portion • A female child is born to an affected father and a carrier mother
of those carrying the gene will ever exhibit the disease. New mutations X-linked recessive disorders can be relatively mild, such as color
often account for the introduction of autosomal dominant traits into blindness, or they may be severe, such as hemophilia. The disorders
a family that has no history of the disorder. may occur with varying degrees of severity.
The person who is affected with an autosomal dominant disorder
is usually heterozygous for the gene—that is, the person has a normal
gene on one paired chromosome but has an abnormal gene on the Chromosomal Abnormalities
other chromosome in the pair, which overrides the influence of the Chromosomal abnormalities are common (50% or more) in embryos
normal gene. Occasionally, a person is homozygous for the gene, which or fetuses that are spontaneously aborted. Chromosomal abnormali-
means that he or she receives two copies of the same abnormal auto- ties often cause major defects because they involve many added or
somal dominant gene. Such an individual is usually much more missing genes (Box 4-4).
severely affected than someone with only one copy.

Numerical Abnormalities
Autosomal Recessive Traits Numerical chromosomal abnormalities involve added or missing
An autosomal recessive trait occurs when a person receives two copies single chromosomes and multiple sets of chromosomes. Trisomy refers
of a recessive gene carried on an autosome. Most people carry a few to an additional single chromosome and monosomy indicates deletion
abnormal autosomal recessive genes without problems because a com- of a single chromosome. Polyploidy describes abnormalities involving
pensating normal gene produces enough of the gene’s product entire sets of chromosomes.
for normal function. Because the probability that two unrelated Trisomy.╇ A trisomy exists when each body cell contains an extra
people will share even one of the same abnormal genes is low, the copy of one chromosome, bringing the total number to 47. Each chro-
incidence of autosomal recessive diseases is relatively low in the general mosome is normal, but there is an extra one in every cell. The most
population. common trisomy is Down syndrome, or trisomy 21 (see Chapter 30).
Situations that increase the likelihood that two parents will share In Down syndrome, each body cell has three copies of chromosome
the same abnormal autosomal recessive gene are: 21. Trisomies of chromosomes 13 and 18 are less common and have
• Consanguinity (blood relationship of the parents) more severe effects. The incidence of trisomies increases with maternal
• Membership in groups that are isolated by culture, geography, age, so most women who are 35 years old or older at conception are
religion, or other factors offered prenatal diagnosis to determine whether the fetus may have
Many autosomal recessive disorders are severe, and affected persons Down syndrome or another trisomy.
may not live long enough to reproduce. Two exceptions are phenylke- Monosomy.╇ A monosomy occurs when each body cell has a missing
tonuria and cystic fibrosis. Improved care of people with these disor- chromosome, with a total number of 45. The only monosomy that is
ders has allowed them to live into their reproductive years. If one compatible with extended postnatal life is Turner’s syndrome, or mono-
member of a couple is affected by the autosomal recessive disorder, all somy X. People with Turner’s syndrome have a single X chromosome
their children will be carriers. Their risk for having similarly affected and the female phenotype. Complete absence of an X chromosome is
children is higher as well, depending on the prevalence of the abnormal always lethal.
gene in the general population. Live-born infants with Turner’s syndrome have excess skin around
the neck and edema that is most noticeable in the hands and feet. If
Turner’s syndrome is not identified and treated during infancy or
X-Linked Traits childhood, an affected girl will remain very short and will not have
X-linked recessive traits are more common than X-linked dominant menstrual periods nor will secondary sex characteristics develop. Heart
ones. Sex differences in the occurrence of X-linked recessive traits and and aortic defects are common. Severe defects are surgically repaired.
the relationship of affected males to one another distinguish these Children with Turner’s syndrome usually have normal intelligence,
disorders from autosomal dominant or recessive disorders. Males although they may have difficulty with spatial relationships or solving
usually show the full effects of an X-linked recessive disorder because visual problems, such as reading a map.
CHAPTER 4â•… Health Promotion for the Developing Child 63

Polyploidy.╇ Polyploidy occurs when gametes do not halve their

chromosome number during meiosis or when two sperm fertilize an
ovum simultaneously. The result is an embryo with one or more extra • Multifactorial defects are some of the most common birth defects encoun-
sets of chromosomes. The total number of chromosomes is a multiple tered in pediatric nursing practice. They result from interactions between
of the haploid number of 23 (69 or 92 total chromosomes). Polyploidy genetic susceptibility and environmental factors during prenatal
usually results in an early spontaneous abortion but is occasionally development.
seen in a live-born infant. • These are usually single, isolated defects, although the primary defect may
cause secondary defects.
Structural Abnormalities • Some occur more often in certain geographic areas.
The structure of one or more chromosomes may be abnormal. Part of • A greater risk for occurrence exists for any of the following:
a chromosome may be missing or added, or DNA within the chromo- • Several close relatives have the defect, whether mild or severe
some may be rearranged. Some of these rearrangements are harmless. • One close relative has a severe form of the defect
Others are harmful because important genetic material is lost or dupli- • The defect occurs in a child of the less frequently affected gender
cated in the structural abnormality, or the position of the genes in • Infants who have several major or minor defects, or both, that are not
relation to other genes is altered so that normal function is not directly related to each other, probably do not have a multifactorial defect
possible. but have another syndrome, such as a chromosomal abnormality.
Another structural abnormality occurs when all or part of a chro-
mosome breaks off and becomes attached to another (translocation).
Many people with a chromosomal translocation are clinically normal
because their total genetic material is normal, or balanced. If a parent
has a balanced translocation, offspring may have normal chromosomes Exposure to an Adverse Prenatal Environment
or may have a balanced translocation, too. However, offspring may Avoiding exposure to harmful influences begins before conception
receive too much or too little chromosomal material and may be spon- because major organ systems develop early in pregnancy, often before
taneously aborted or suffer birth defects. Balanced or unbalanced a woman realizes that she is pregnant. Alcohol, substance, or cigarette
chromosomal translocations may occur spontaneously in the child use requires major lifestyle changes to avoid fetal or infant exposure.
of parents who have no translocation. Teratogens are agents in the fetal environment that either cause or
Fragile X syndrome is a structural chromosome abnormality that increase the likelihood that a birth defect will occur. Teratogens include
often causes intellectual impairment among males. With this abnor- certain medications, infectious agents, chemicals or pollutants, and
mality, a site on the X chromosome is more fragile than normal. ionizing radiation. Some maternal conditions, such as type I diabetes
Although females can also be affected with fragile X syndrome, males mellitus, can increase the risk of adverse effects on the fetus.
are more severely affected because the female has a second X chromo-
some that is usually normal. The fragile X syndrome is inherited in an Genetic Counseling
X-linked dominant pattern, with males being most severely affected. Genetic counseling provides services to help people understand genetic
disorders and the risk that a disorder will occur in their families.
Multifactorial Birth Defects Genetic counseling is often available through facilities that provide
Multifactorial birth defects result from the interaction of genetic maternal-fetal medicine services. State departments of mental health
and environmental factors. Gene-environment interactions may and intellectual impairment or rehabilitation services also may provide
influence prenatal and postnatal development positively or nega- counseling services. The National Society of Genetic Counselors
tively. For example, two embryos may have an equal genetic suscep- maintains a database of genetic counselors in the United States,
tibility for development of a disorder such as spina bifida (open which is searchable by zip code. It is accessible at
spine), but the disorder will not occur unless an environment favor- resourcelink.cfm.
ing its development, such as deficient maternal intake of folic acid, Genetic counseling focuses on the family rather than on an indi-
also exists. vidual. One family member may have a genetic disorder, but study of
Multifactorial birth defects have two characteristics that distinguish the entire family is usually needed for accurate counseling. Genetic
them from other types of birth defects. They are typically (1) present counselors construct a pictorial representation of the family health
and detectable at birth and (2) isolated defects rather than ones that history (pedigree), which requires as much information about the
occur with other unrelated abnormalities. A multifactorial defect may health status of family members as possible. This may involve obtain-
cause a secondary defect, however. For example, infants with spina ing medical records, including the mother’s prenatal and perinatal
bifida often have hydrocephalus because abnormal development of the history, or performing physical examinations or laboratory and other
spine and spinal cord disrupts spinal fluid circulation, allowing it to diagnostic studies on numerous family members. Examining photo-
build up in the brain’s ventricular system. graphs, particularly of deceased or unavailable family members, may
Multifactorial defects represent some of the most common birth be helpful. Counseling is impaired if family members are unwilling to
defects that a pediatric nurse encounters (Box 4-5). Examples include provide their medical records or agree to examinations or laboratory
many heart defects; neural tube defects, such as spina bifida; cleft lip studies. Moreover, those who seek counseling may be unwilling to
and palate; and developmental dysplasia of the hip. Unlike single-gene request cooperation from other family members or to share the genetic
traits, multifactorial disorders are not usually associated with one information they acquire.
causal gene mutation, nor are they associated with a fixed risk of occur- Genetic counseling is nondirective; that is, the counselor does not
rence or recurrence in a family. Factors that may affect the degree of tell the individual or parents what decision to make but educates them
risk are number of affected close relatives, severity of the disorder in about options for dealing with the disorder. Families often interpret
affected family members, sex of the affected child, geographic location, the counseling subjectively, however. Some parents may regard a 50%
and seasonal variations. risk of occurrence or recurrence as low, whereas others may think that
64 CHAPTER 4â•… Health Promotion for the Developing Child

a 1% risk is unacceptably high. The family’s values and beliefs influence • Genetic information has implications for others in the affected
whether they seek counseling and what they do with the information person’s family, raising privacy issues.
that is provided. • Identification of genetic problems could lead to poor self-
Genetic counseling is often a slow process, and despite a compre- esteem, guilt, and excessive caution, or, conversely, a reckless
hensive evaluation, a diagnosis may never be established. Nevertheless, lifestyle.
counseling provides families with the best information concerning • Presymptomatic identification of a genetically influenced illness
what is known about the cause and natural course of the disorder, could be a source of long-term anxiety.
options for caring for an affected child, the likelihood that the disorder • Genetic knowledge could affect one’s choice of a partner.
will occur in others, the availability of treatment and services (includ- • Although federal legislation exists that prohibits discrimination
ing prenatal diagnosis for future pregnancies), and how to minimize in employment and insurance based on genetics, stigma or
future risk. other forms of discrimination based on genetic information
Nurses who participate on a genetic counseling team usually are may occur.
educated in the specifics of genetic disorders and in counseling tech- • Ownership of genes through gene patents may affect patient
niques. These nurses assist women or couples through the process of access to specific gene tests and genetic therapies.
prenatal diagnosis and support parents as they make decisions after
receiving abnormal prenatal diagnostic results. They also help the
family deal with the emotional impact of having a child with a birth
defect and assist them to access needed services and support.
╇ Because growth is an excellent indicator of physical well-being,

Expected Genetic Competencies of the Pediatric Nurse accurate assessments must be made at regular intervals so that patterns

╇ Appendix—Growth Charts, CDC and WHO Growth Curves for Children Ages 0 to 2 Years
Essential genetic and genomic competencies were established for all of growth can be determined. Trained individuals using reliably cali-
registered nurses by 2005 and were endorsed by the Society of Pediatric brated equipment and proper techniques should perform growth mea-
Nurses. As professionals, all nurses are expected to recognize when surement. Methods of obtaining accurate measurements in children
personal attitudes toward genetic/genomic science and technologies are described in Chapter 9. To minimize the chance of error, data
may affect care that is provided to clients. All nurses are also expected should be collected on children under consistent conditions on a
to advocate for client access to desired genetic services and resources. routine basis, and values should be recorded and plotted on growth
In the practice setting, nurses are expected to identify clients who charts immediately.
might benefit from genetic services, facilitate appropriate referrals to Standardized growth charts allow an individual child’s growth
genetic specialists, recognize genetic contributions to response to med- (length/height, weight, head circumference, body mass index [BMI])
ications, and identify resources for clients seeking genetic information. to be compared with statistical norms. The most commonly used
All nurses should be able to elicit a complete three-generation family growth charts for boys and girls ages 2 years to 20 years are those
health history and construct a pedigree using appropriate symbols and developed by the National Center for Health Statistics. The World
terminology, as well as identify family health history tools that can be Health Organization growth charts are recommended for infants and
used by clients. Nurses are expected to assess client perspectives on children younger than 2 years old (see Evolve website).
genetic issues when relevant and use effective communication skills to Because height and weight are the best indicators of growth,
enable clients to express their views and wishes in regards to genetic these parameters are measured, plotted on growth charts, and
testing or procedures. A complete list of the genetic/genomic compe- monitored over time at each well visit. Brain growth can also be
tencies established by consensus panel for all registered nurses (Con- monitored by measuring infant frontal-occipital circumference at
sensus Panel on Genetic/Genomic Nursing Competencies, 2009) is intervals and plotting the values on growth charts. It is important
available online. to relate head size to weight because larger babies have bigger heads.
The full sequence of human genes was completed in April 2003 These measurements are routinely performed during the first 2 years
when the Human Genome Project was completed. That event opened of life.
the door to an explosion in new genetic/genomic knowledge. It is criti- BMI, which is a function of both height and weight, is an important
cal that pediatric nurses understand basic principles of genetics and be measure of growth and overall nutritional status in children older than
aware of advances in genetic/genomic science relevant to human health age 2 years. Because childhood overweight and obesity can contribute
in order to communicate information to patients. Information gained to health problems later in life, the American Academy of Pediatrics
from continued progress in genetic/genomic science will allow advances (Barlow, 2007) recommends beginning obesity prevention at birth.
such as: Infants and children younger than two-years-old can be screened for
• Easier, quicker, and less costly types of genetic testing to deter- overweight using the weight to length measurement; concern is gener-
mine risk for disorders or the actual presence of disorders. ated when that percentile exceeds the 95th. BMI charts are included in
• The ability to base reproductive decisions on more accurate and the most recent versions of charts available from the National Center
specific information than has previously been available. for Health Statistics.
• Early identification of genetic susceptibility to a disorder so that Growth rate is measured in percentiles. The area between any two
interventions to reduce risk can be instituted. percentiles is referred to as a growth channel. Childhood growth nor-
• Safe use of gene therapy to modify a defective gene. mally progresses according to a pattern along a particular growth
• Choosing pharmacotherapy and other treatments on the basis channel. Deviations from normal growth patterns may suggest prob-
of an individual’s genetic code or the genetic makeup of tumor lems. Any change of more than two growth channels indicates a need
cells. for more in-depth assessment.
The explosion of knowledge about the genetic basis for disease Recognition of abnormal growth patterns is an important nursing
raises legal and ethical issues for which we do not yet have answers. function. The earlier that growth disorders are detected, diagnosed,
For instance: and treated, the better the long-term prognosis.
CHAPTER 4â•… Health Promotion for the Developing Child 65

most important reason for assessment is that abnormal development

must be discovered early to facilitate optimal outcomes through early
Assessment of development is a more complex process than assess- intervention.
ment of growth. To assess developmental progress accurately, nurses
and health providers need to gather data from many sources, includ- Denver Developmental Screening Test II (DDST-II)
ing observations and interviews, physical examinations, interactions ╇ One, more in-depth, screening tool used for infants and young

with the child and parents, and various standardized assessment children is the Denver Developmental Screening Test II (DDST-II).

╇ Appendix—Denver Developmental Screening Test II

tools. The DDST-II provides a clinical impression of a child’s overall devel-
The American Academy of Pediatrics issued a policy statement in opment and alerts the user to potential developmental difficulties. It
2006 (reaffirmed in 2010), which calls for providers to do a combina- requires training to learn how to administer it properly.
tion of developmental surveillance and developmental screening The DDST-II, designed to be used with children between birth and
throughout a child’s infancy and early childhood (AAP, 2006/2010). 6 years of age, assesses development on the basis of performance of a
Developmental surveillance is performed at every well visit and series of age-appropriate tasks. There are 125 tasks or items arranged
includes eliciting and paying attention to parent concerns, keeping in four functional areas (Frankenburg & Dodds, 1992):
a documented developmental history, identifying protective and 1. Personal-social (getting along with others, caring for personal
risk factors, and direct observation of the child’s development (AAP, needs)
2006, p. 419). If surveillance raises a concern, the provider refers the 2. Fine motor (eye-hand coordination, problem-solving skills)
child for more formalized screening. The AAP recommends that pro- 3. Language (hearing, using, and understanding language)
viders conduct a formal developmental screening with a sensitive and 4. Gross motor (sitting, jumping)
specific screening instrument when the child is 9 months, 18 months, Items for rating the child’s behavior are also included at the end of
and 24 to 30 months of age (AAP, 2006/2010). Using formalized the test.
screening in addition to routine surveillance can increase appropriate The test form is arranged with age scales across the top and
referrals for early intervention (Hix-Small, Marks, Squires, & Nickel, bottom (see the Evolve website for a sample test form). After calculat-
2007). Although the AAP recommendations were issued initially in ing the child’s chronologic age (age in years), the test administrator
2006, recent mixed (quantitative and qualitative) research using a draws an age line on the form. Each of the 125 tasks or items is
national sample of 17 pediatric practices found that the percentage of arranged on a shaded bar depicting at which ages 25%, 50%,
children screened at the appropriate ages is approximately 85% of 75%, and 90% of the children in the research sample completed that
children, however, the rate of referral for follow-up is far less (King particular item. The examiner assesses the child using the items clus-
et╯al., 2010). tered around the age line. The directions must be followed exactly
Observation is a valuable method most often used to obtain infor- during administration of the test. A score for performance on each
mation about a child’s developmental age (level of functioning). By item is recorded according to the following scale: pass (P), fail (F),
watching a child during daily activities, such as eating, playing, toilet- no opportunity (NO), and refusal (R). At the completion of the test,
ing, and dressing, nurses gather a great deal of assessment data. Obser- the screener scores test behavior ratings (located at the bottom left of
vation of the child’s problem-solving abilities, communication patterns, the form).
interaction skills, and emotional responses can yield valuable informa- Interpretation of the test is based first on individual items and
tion about the child’s level of development. Similarly, interviews and then on the test as a whole. Individual items are considered as
physical examinations can provide much information about how the “advanced, normal, caution, delayed, or no opportunity.” Reliability
child functions. and validity of the test can be altered if the child is not feeling well or
In addition to these sources of data, many standardized assess- is under the influence of medications. Parental presence and input as
ment tools are available for nurses and other health care professionals to whether the child is behaving as usual is desired (Frankenburg &
to use for developmental assessment. Standardized developmental Dodds, 1992).
tools should be both sensitive (accurately identifies developmental The results of the test can be used to identify a child’s developmen-
problems) and specific (accurately identifies those who do not have tal age and how a child compares with others of the same chronologic
developmental problems). Additionally, they should be relatively easy age. This information can be used to alert health care providers to
to administer or to have the parent complete in a reasonable amount potential problems. To ensure that the results are accurate, only indi-
of time. General assessment screening instruments that meet these viduals who are trained to administer the test in a standardized manner
criteria include the Ages and Stages Questionnaire, the Infant Devel- should perform testing. Training is obtained through study of the
opment Inventory, and the Parents’ Evaluations of Developmental testing manual, review of the accompanying videotape, and supervised
Status (PEDS), among others (AAP, 2006/2010). In general, screening practice with children of various ages.
tools are organized around major developmental areas (language, Although the DDST-II is widely used, it is a screening test only, not
cognitive, social, behavioral, and motor). Many are given to parents an intelligence quotient (IQ) test. It is not a definitive predictor of
to complete in the office setting or before the child’s appointment. future abilities, and it should not be used to determine diagnostic
Domain-specific instruments for identifying delays in language/ labels. It is, however, a useful tool for noting problems, validating
cognitive areas or for screening for autism also are available (Wallis hunches, monitoring development, and providing referrals.
& Smith, 2008).
Developmental assessment should be part of a newborn infant’s
assessment and of every well-child examination for several reasons. NURSE’S ROLE IN PROMOTING OPTIMAL GROWTH
One reason is that parents want to know how their child compares with
others and whether development is normal, especially if they had a
difficult pregnancy or have other children who are developmentally Nurses are particularly concerned with preventing disease and pro-
delayed. Developmental assessment tends to allay fears. Probably the moting health. One aspect of preventive care is providing anticipatory
66 CHAPTER 4â•… Health Promotion for the Developing Child

guidance or basic information for parents about normal growth and Play
development as their child approaches different ages and developmen- Although play is not work in the traditional sense, it is children’s work.
tal levels. Play is those tasks, done to amuse oneself, that have behavioral, social,
or psychomotor rewards. To adult observers, children’s play may
Developmental Assessment appear unorganized, meaningless, and even chaotic. Anyone who
Nursing care for children is not complete without addressing the devel- watches carefully, however, quickly discovers that play is a rich activity,
opmental issues that are unique to each child. Because children grow intricately woven with meaning and purpose. In adulthood, work is
and change rapidly, the nurse must use knowledge of theories of any activity during which one uses time and energy to create a product
growth and development to create plans of care for both healthy and or achieve a goal. Play in childhood is similar to adult work in that it
ill children. Assessment data are collected from a variety of sources, is undertaken by the child to accomplish developmental tasks and
categorized, and analyzed with a theoretic knowledge base and clinical master the environment.
experience. A list of strengths and problems related to growth and Play is also an important part of the developmental process. Play is
development is generated. Nursing diagnoses are formulated with indi- how children learn about shape, color, cause and effect, and themselves.
vidualized goals, interventions, and evaluation to address specific In addition to cognitive thinking, play helps the child learn social
problems that are related to, but differ from, physiologic and psycho- interaction and psychomotor skills. It is a way of communicating joy,
social needs. fear, sorrow, and anxiety.

Interview Classifications of Play

During the initial interview, the nurse asks questions about the child’s Piaget (1962) described the following three types of play that relate to
cognitive, language, motor, and emotional development. The parents’ periods of sensorimotor, preoperational, and concrete operational
emotional state, level of education, and culture must be considered functioning. These three types of play are overlapping and are linked
when information is gathered. For example, the nurse might use the to stages of cognitive development.
following questions and statements when interviewing the parents of Sensorimotor, which is also known as functional or practice play,
a 4-year-old child: involves repetitive muscle movements and the introduction of a delib-
• What does your child like to do at home? erate complication into the way of doing something. In this type of
• Does your child know the days of the week? play the infant plays with objects, making use of their properties
• Describe your child’s typical day. (falling, making noises) to produce pleasurable effects (Pellegrini &
• Does your child attend preschool? If so, how often? Smith, 2005).
• Can your child throw a ball, ride a tricycle, climb? Symbolic play, as its name suggests, uses games and interactions
• Can your child draw pictures, color them? that represent an issue or concern to be addressed. Garvey (1979)
• How effective is your child’s use of language? identified three elements of symbolic play: one or more objects, a theme
• How did your child’s development progress during infancy and or plan, and roles. As children play, they incorporate some object (a
toddlerhood? toy syringe), use a theme (getting an injection), and then play the roles
The nurse also assesses the child’s ability to think through situations each player will have (child, nurse). Because there are no rules in sym-
and to communicate verbally. In addition, how the child interacts with bolic play, the child can use this play not only to reinforce or learn the
other children and adults can be a measure of cognitive abilities. The good things in life but also to alter those things that are painful.
number, type, length, appropriateness, and correct use of words and Games include rules and usually are played by more than one
sentences are also noted. Carefully observing the child in a variety of person, although some games can be played by oneself. For example,
situations, including play, provides valuable information about cogni- the card game solitaire is played by one person, as are many video
tive development. games. Children younger than 4 years of age rarely play games with
A child’s stage of emotional development can be assessed in a rules; games are most commonly seen in the school-age child (Piaget,
number of ways. From Erikson’s theory, it is expected that a 4-year-old 1962). Games continue throughout life as adults play board games,
child’s major conflict would be developing a sense of initiative rather cards, and sports.
than a sense of guilt. If the child is hospitalized, however, regressive Through games, children learn to play by the rules and to take
behaviors might be exhibited if the anxiety of hospitalization becomes turns. Board games facilitate this accomplishment. Young children
overwhelming. Questions directed to the parents, such as those that often make up games with unique sets of rules, which may change each
follow, could help validate inferences about the child’s psychosocial time the game is played. Older children have games with specific rules;
development: younger children tend to change the rules.
• What types of play activities does your child like best?
• How does your child get along with other children? With Social Aspects of Play
adults? As the child develops, increased interaction with people occurs. Certain
• How does your child usually handle stressful situations? types of play are associated with, but not limited to, specific
• What do you do to help your child cope with problems? age-groups.
• How does your child’s ability to cope compare with that of your Solitary Play.╇ Solitary play is characterized by independent
other children? play (Figure 4-5). The child plays alone with toys that are very
• Is the behavior exhibited your child’s usual behavior? different from those chosen by other children in the area. This
The nurse can also obtain valuable information from careful type of play begins in infancy and is common in toddlers because
observation of a child who is hospitalized. The nurse should note of their limited social, cognitive, and physical skills. It is important
how the child deals with pain, intrusive procedures, and separation for children in all age-groups, however, to have some time to play
from parents. by themselves.
CHAPTER 4â•… Health Promotion for the Developing Child 67

When engaging in solitary play, the

child is playing apart from other chil-
dren and with different types of toys.
(Courtesy University of Texas at
Arlington School of Nursing.)

The little girl at right demonstrates onlooker play. She is inter-

ested in what is going on and observes another girl playing on
the slide, but she makes no attempt to join the youngster on the

Playing safely with medical equipment

(familiarization play) lessens its unfamiliar-
ity to the child and can allay fears. A less
fearful child is likely to be more cooperative
and less traumatized by necessary care.
(Courtesy University of Texas at Arlington
School of Nursing.)
Games with rules, such as board games, help children learn
boundaries, teamwork, taking turns, and competition. (Courtesy
Cook Children’s Medical Center, Fort Worth, TX.)
FIG 4-5  Types of play.

Parallel Play.╇ Parallel play is usually associated with toddlers, spontaneous or guided, and it often includes medical or nursing equip-
although it can be found in any age-group. Children play side by side ment. It is especially valuable for children who have had or will have
with similar toys, but there is a lack of interactive activity. multiple procedures or hospitalizations.
Associative Play.╇ Associative play is characterized by group play Hospitals and clinics with child life specialists on staff usually have
without group goals. Children in this type of play do not set group a medical play area as part of the activity room. Nurses may provide
rules, and although they may all be playing with the same types of toys opportunities for spontaneous and guided dramatic play. The nurse
and may even trade toys, there is a lack of formal organization. This may choose to observe spontaneous play or be an active participant
type of play can begin during toddlerhood and continue into the with the child. Occasionally nurses will want to structure the dramatic
preschool age. play to review a specific treatment or procedure. In guided play situa-
Cooperative Play.╇ Cooperative play begins in the late preschool tions, the nurse directs the focus of the play. Specialized play kits may
years. This type of play is organized and has group goals. There is usually be developed for specific procedures, such as central line care, casting,
at least one leader, and children are definitely in or out of the group. bone marrow aspirations, lumbar punctures, and surgery, using sup-
Onlooker Play.╇ Onlooker play is present when the child observes plies related to the hospital or clinic setting.
others playing. Although the child may ask questions of the players, Familiarization Play.╇ Familiarization play allows children to
the child does not attempt to join the play (see Figure 4-5). Onlooker handle and explore health care materials in nonthreatening and fun
play is usually during the toddler years but can be observed at any age. ways (see Figure 4-5). This type of play is especially helpful for but not
limited to preparing children for procedures and the whole experience
Types of Play of hospitalization.
Dramatic Play.╇ Dramatic play allows children to act out roles and Examples of familiarization activities include using sponge mouth
experiences that may have happened to them, that they fear will swabs as painting and gluing tools; making jewelry from bandages,
happen, or that they have observed in others. This type of play can be tape, gauze, and lid tops; creating mobiles and collages with health care
68 CHAPTER 4â•… Health Promotion for the Developing Child

supplies; making finger puppets with plaster casting material; filling a others and soon initiates behavior that involves others. Infants discover
basin with water and using tubing, syringes without needles, medicine that when they coo, their mothers coo back. Children will soon expect
cups, and bulb syringes for water play; decorating beds, wheelchairs, this response and make a game of playing with their mothers.
and intravenous poles with health care supplies; and using syringes for Playing make-believe allows the child to try on different roles.
painting activities. When children play “restaurant” or “hospital,” they experiment with
rules that govern these settings.
Functions of Play Of course, most games, from board games to sports, involve inter-
Play enhances the child’s growth and development. Play contributes to action with others. The child learns boundaries, taking turns, team-
physical, cognitive, emotional, and social development. work, and competition. Children also learn how to negotiate with
Physical Development and Play.╇ Play aids in the development of different personalities and the feelings associated with winning and
both fine and gross motor activity. Children repeat certain body move- losing. They learn to share and to take turns (see Figure 4-5).
ments purely for pleasure, and these movements in turn aid in the Moral Development.╇ When children engage in play with their peers
development of body control. For example, an infant will first hit at a and their families, they begin to learn which behaviors are acceptable
rattle, then will attempt to grasp it, and eventually will be able to pick and which are not. Quickly they learn that taking turns is rewarded
up that same rattle. Next the infant will shake the rattle or perhaps and cheating is not. Group play assists the child in recognizing the
bring it to the mouth. importance of teamwork, sharing, and being aware of the feelings of
The parent and child may make a game of repeating sounds others.
such as “ma ma” or “da da,” which increases the child’s language
ability. Repeating rhymes and songs can be a fun way for children to HEALTH PROMOTION
increase their vocabulary. Children love to color on a paper with a
crayon and will scribble before being able to draw pictures and to color. Immunizations
This assists the child with eventually learning how to write letters and Immunizations are effective in decreasing and, in some cases, eliminat-
numerals. ing childhood infectious diseases. Naturally occurring smallpox has
Cognitive Development.╇ Play is a key element in the cognitive been virtually eliminated, and the incidence of diphtheria, tetanus,
development of children. Once a child has learned a general concept, measles, mumps, rubella, varicella, and poliomyelitis has greatly
further experiences with that concept expand from that beginning declined in the United States since vaccines against these diseases were
knowledge. Piaget gave the example of an infant learning to swing an introduced. In accordance with recommendations from the Centers for
object and then subsequently swinging other objects (Piaget, 1962). Disease Control and Prevention (CDC) and the American Academy of
This could apply, for example, to things to be eaten, read, or ridden. Pediatrics, children are immunized against 14 communicable diseases
Progression takes place as the child begins to have certain experiences, before they reach 2 years of age (CDC, 2011d).
test beliefs, and understand the surrounding world. Since the introduction of the hepatitis B vaccine, the childhood
Children can increase their problem-solving abilities through prevalence of hepatitis B in the United States has decreased 98% (AAP
games and puzzles. Pretend play can stimulate several types of learning. Committee on Infectious Diseases, 2009b). Much of this reduction is
Language abilities are strengthened as the child models significant due to the decrease in perinatal and household transmission from
others in role playing. The child must organize thoughts and be able adults to children.
to communicate with others involved in the play scenario. Children The incidence of diseases caused by Haemophilus influenzae type b
who play “house” create elaborate details of what the characters do (Hib), which can cause meningitis in infants and young children, has
and say. been reduced by 99% since the vaccine was introduced in the United
Children also increase their understanding of size, shape, and States in the late 1980s. The World Health Association reports that Hib
texture through play. They begin to understand relationships as they infection is virtually nonexistent in industrialized nations. In develop-
attempt to put a square peg into a round hole, for example. Books and ing countries, however, Hib is still a leading cause of respiratory deaths
videos increase a child’s vocabulary while increasing understanding of in children (World Health Organization, 2011).
the world. Immunization with pneumococcal conjugate vaccine introduced in
Emotional Development.╇ Children in an anxiety-producing situa- 2000 has substantially reduced the number of cases of severe disease
tion are often helped by role playing. Play can be a way of coping with caused by the bacteria Streptococcus pneumoniae. Until recently, infants
emotional conflict. Play can be a way to determine what is real and and children have been vaccinated with PCV7 (Pneumococcal conju-
what is not. Children may escape through play into a world of fantasy gate vaccine, which provides protection from seven different strains of
and make-believe to make sense out of a sometimes senseless world. Streptococcus pneumonia); PCV13 (protection against six additional
Play can also increase a child’s self-awareness as an event or situation strains) became available in 2010 (CDC, 2010).
is explored through role playing or symbolic play. In response to an increasing incidence of pertussis (whooping
As significant others in children’s lives respond to their initiation cough), particularly among the adolescent population, an adult
of play, children begin to learn that they are important and cared for. tetanus, diphtheria, and pertussis vaccine (Tdap) was approved in 2005
Whether the child initiates the play or the adult does, when a signifi- (Hall-Baker et╯al., 2011). Pertussis (whooping cough) has been increas-
cant person plays a board game with a child, shares a bike ride, plays ing in incidence in the United States, with nearly 50% of new cases
baseball, or reads a story, the child gets the message, “You are more occurring among adolescents (Hall-Baker et╯al., 2011). The major con-
important than anything else at this time.” This increases the child’s tributing factor to this phenomenon is presumed to be waning of
self-esteem. immunity during midadolescence. Because pertussis can be a serious
Social Development.╇ The newborn infant cannot distinguish self problem resulting in school absences and health consequences, includ-
from others and therefore is narcissistic. As the infant begins to play ing possible exposure of underimmunized infants, the CDC (2011a)
with others and things, a realization of self and others begins to recommends one dose of Tdap vaccine for children and adolescents.
develop. The infant begins to experience the joy of interacting with The dose would be administered to 11- and 12-year-old children, so
CHAPTER 4â•… Health Promotion for the Developing Child 69

long as they have had the primary diphtheria-tetanus-acellular pertus- Live or attenuated vaccines have had their virulence (potency)
sis (DTaP) series and have not previously received the tetanus- diminished so as not to produce a full-blown clinical illness. In response
diphtheria (Td) booster, and to older adolescents who have not to vaccination, the body produces antibodies and causes immunity to
received the Td booster or for whom 5 years has elapsed since their be established (e.g., measles vaccine). Killed or inactivated vaccines
last Td booster (CDC, 2011a). contain pathogens made inactive by either chemicals or heat. These
Hepatitis A vaccine is recommended for all children at age 1 year vaccines also allow the body to produce antibodies but do not cause
(12 to 23 months). The two doses in the series should be administered clinical disease. Inactivated vaccines tend to elicit a limited immune
at least 6 months apart. Children who are not vaccinated by age 2 years response from the body; therefore, several doses are required (e.g.,
can be vaccinated at subsequent visits (CDC, 2011a). polio and pertussis).
Influenza vaccine is recommended annually prior to the beginning Toxoids are bacterial toxins that have been made inactive by either
of the flu season for all healthy children. Household contacts of chil- chemicals or heat. The toxins cause the body to produce antibodies
dren in these groups, including siblings and caregivers, should also (e.g., diphtheria and tetanus vaccines).
receive the vaccine. If not given previously, any child younger than 9 Immune globulin is made from the pooled blood of many people.
years needs to receive two doses initially, each dose being 1 month Large numbers of donors are used to ensure a broad spectrum of non-
apart (AAP Committee on Infectious Diseases, 2009b). specific antibodies. Disease-specific immune globulin vaccines are also
Meningococcal conjugate vaccine (MCV4) should be administered available and are obtained from donors known to have high blood
to all children at age 11 to 12 years, as well as to unvaccinated adoles- titers of the desired antibody (hepatitis B immune globulin [HBIG],
cents at high school entry (15 years). All college freshmen living in rabies immune globulin [RIG]). The disadvantage of human immune
dormitories should also be vaccinated. In addition, infants and chil- globulin is that it offers only temporary passive immunity. Live vac-
dren between the ages of 9 months to 10 years of age who are consid- cines must be given on the same day as immune globulin or the two
ered to be at risk for meningococcal disease (e.g., immunosuppressed, must be separated by 30 days to ensure appropriate immune response
complement deficiency, asplenia) should be immunized (Advisory from both.
Committee on Immunization Practices [ACIP], 2011b). Antitoxins are made from the serum of animals and are used to
The U.S. Food and Drug Administration has licensed a rotavirus stimulate production of antibodies in humans. Examples of antitoxins
vaccine for use among infants. Depending on the particular vaccine include rabies, snake bite, and spider bite. Animal serums have the
used, the dosage recommendation is for three doses at given to infants disadvantage of being foreign substances, which may cause hypersen-
at 2, 4, and 6 months of age (RV5), or two doses given at 2 and 4 months sitivity reactions; thus a history (including questions about asthma,
of age (RV1) (AAP, 2009a). Rotavirus vaccine is an oral vaccine allergic rhinitis, urticaria, and previous injections of animal serums)
and should not be given to children older than 8 months of age (AAP, and skin sensitivity testing should always precede the administration
2009a). of an antitoxin.
Human papillomavirus (HPV) vaccine is available in both bivalent As all vaccines have the potential to cause anaphylaxis, it is impera-
and quadrivalent forms. The vaccine prevents infection with certain tive that the nurse ask about allergies and previous reactions before
strains of HPV that are known to be associated with later development administering any vaccine.
of cervical cancer. Occasionally, HPV infection can be transmitted
perinatally. The Advisory Committee on Immunization Practices Obstacles to Immunizations
(ACIP) recommends immunizing girls at ages 11 to 12 years (ACIP, Major reasons identified for low immunization rates during health care
2009) with either of the two vaccines. Three doses of the vaccine are visits are presented in Box 4-6. In the 1980s the safety of the pertussis
given—the second dose 4 weeks after the first, and the third dose 12 portion of the diphtheria-tetanus-pertussis vaccine was questioned.
weeks or more after the second. The ACIP also recommends routinely Some parents elected not to immunize their children, which resulted
vaccinating boys age 11 to 12 years with the quadrivalent vaccine in an increase in pertussis cases. Medical concern has led to the use in
(ACIP, 2011a).
The threat of bioterrorism has generated interest in reintroducing
smallpox vaccine. Because children have a high risk for adverse effects
from the existing smallpox vaccine, nonemergency vaccination of chil- BOX 4-6â•… BARRIERS TO IMMUNIZATION
dren younger than 18 years of age is not recommended (CDC, 2007). • Complexity of the health care system, which may lead to a delay in vac-
It is important that adults who have been vaccinated against smallpox cinating children when parents become confused or frustrated with the
be cautious that children not come in contact with the vaccination site health care system; special barriers include the following:
until it is completely healed (usually 21 days). • Appointment-only clinics
• Excessively long waiting periods
Active and Passive Immunity
• Inconvenient scheduling
Immunizations are effective in preventing illness due to their activa- • Inaccessible clinic sites
tion of the body’s immune response. Active immunity occurs when the • The need for formal referral from a primary health care provider
body has been exposed to an antigen, either through illness or through • Language and cultural barriers
immunization, and the immune system creates antibodies against the • Expense of immunization services
particular antigen. Active immunity generally confers long-term, and • Parental misconceptions about disease severity, vaccine efficiency and
in some cases lifelong, protection against disease. A child acquires safety, complications, and contraindications
passive immunity when a serum that contains a disease-specific anti- • Inaccurate record keeping by parents and health care workers
body is transferred to the child via parenteral administration (e.g., • Reluctance of the health care worker to give more than two vaccines during
intravenous immune globulin) or, in some cases, through placental the same visit
transfer from mother to infant. Protection from passive immunity is • Lack of public awareness of the need for immunizations
relatively short.
70 CHAPTER 4â•… Health Promotion for the Developing Child

the United States of the acellular pertussis vaccine, which has fewer vaccine, or hepatitis B vaccine to someone who is immune has no
side effects. harmful effects. For children older than 7 years, depending on age, the
The media play an important part in the immunization status of Td vaccine or Tdap vaccine, rather than the DTaP vaccine, should be
children. News programs that highlight the side effects of vaccines, administered (CDC, 2011a).
rather than their individual and collective protective effect, create fear International adoptees, refugees, and exchange students should be
and misunderstanding in the public. Health care providers need to immunized according to recommended schedules for healthy infants
address this issue when recommending various immunizations to and children. If written records of prior immunization are not avail-
parents. It is important for nurses to be aware of vaccine controversies able, the child begins the schedule for children not immunized during
and to know how to access appropriate, research-based information. infancy. Refer to for rec-
The National Network for Immunization Information, an initiative of ommendations for immunizing children who were not immunized
the Infectious Diseases Society of America, the Pediatric Infectious during infancy.
Diseases Society, the AAP, and the American Nurses Association, pro- When taking an immunization history, the nurse should avoid
vides up-to-date information about immunization research. It can be asking the question, “Are your child’s immunizations up to date?” This
accessed on-line at question will frequently be answered with “yes,” but that does not give
the nurse sufficient information. The nurse may gain more informa-
Informed Consent tion by asking, “Can you tell me when and what was the last immuniza-
The National Childhood Vaccine Injury Act of 1986 requires that the tion your child had?”
benefits and risks associated with immunizations be discussed with
parents before immunizations. The act also requires that families Administration of Vaccines
receive vaccine information statements (VISs) before immunization. The manufacturer’s packaging insert for each vaccine includes recom-
All health care providers who administer immunizations are mendations for handling, storage, administration site, dosage, and
required by federal law to provide general information about immu- route. Nurses responsible for handling vaccines should be familiar with
nizations to the child and parents, preferably in the family’s native storage requirements to minimize the risk of vaccine failures. When
language. This information describes why the vaccine is being given, multidose vials are used, sterile technique should be used to prevent
the benefits and risks, and common side effects. Before providers contamination. To ensure safe administration, the vaccines should be
administer a vaccine, parents should read the federally required infor- given by the recommended route. The deltoid muscle can be used in
mation about that vaccine (the VIS) and have the opportunity to ask children ages 18 months and older; for younger children and infants,
questions (AAP Committee on Infectious Diseases, 2009b). It is neces- the anterolateral thigh is used. Vaccines given intramuscularly need to
sary that the parents feel comfortable with the information and with be injected deep into the muscle mass to avoid irritation and possible
the answers to any questions. It has been shown that VISs do increase necrosis.
the parents’ knowledge level and are beneficial. Providing the informa- More than one immunization may be administered at the same age
tion before scheduled vaccinations allows parents the time to read all or time. Some vaccines may be given as combined vaccine; several
the information. Providers are encouraged to obtain written informed combination vaccines have been approved for use in the United States.
consent for each vaccine administered. If signatures are not obtained, When more than one injection is to be given, vaccines should be
the client’s medical record should document that the vaccine informa- administered with separate syringes, not mixed into one, unless using
tion was reviewed. a manufactured and approved combined vaccine. They should be given
at different sites (preferably in different thighs), and the site used for
Immunization Schedule each vaccine should be recorded to identify possible reactions. For
Each January, recommendations regarding vaccinations in the United infants and young children, to minimize the stress of vaccine admin-
States are made by the Advisory Committee on Immunization Prac- istration, two nurses can give the vaccines simultaneously at different
tices (ACIP) of the CDC, the AAP Committee on Infectious Diseases, sites. The nurse should also record the lot number for each vaccine
and the American Academy of Family Physicians (AAFP) (CDC, given. Box 4-7 lists nursing responsibilities associated with administer-
2011c). All states require immunizations for children enrolled in ing vaccines.
licensed child-care programs and school. Some states further require
immunizations in the upper grades and at the time of college entrance. Precautions and Contraindications
One group who may be overlooked includes children who receive The main purpose of vaccination is to achieve immunity with the
home schooling. It is of utmost importance therefore that immuniza- fewest possible side effects (Box 4-8). Most vaccines have no side
tion records be traced and that vaccinations be given over the course effects; when side effects occur, they are usually mild. Fever and local
of the fewest visits possible. State requirements can be obtained from irritation are not uncommon after administration of the DTaP vaccine,
each state health department. Refer to and fever and rash can occur 1 to 2 weeks after administration of live-
izschedule.html to access the current recommendations for immuniza- virus vaccine.
tion of healthy children in the United States. Some severe side effects have been reported, however. These events
are usually not predictable. Because cases have been reported of devel-
Children with an Uncertain History of Immunization opment of paralytic polio in healthy children after administration of
When a lapse in immunization occurs, the entire series does not have oral polio vaccine, the AAP and the CDC now recommend a full
to be restarted. Children’s charts should be flagged to remind health schedule of inactivated polio vaccine. Reactions to the MMR vaccine
care providers of these children’s immunization status. For children of have included anaphylactic reactions, both in children with and in
unknown or uncertain immunization status, appropriate immuniza- those without a history of egg allergy. This has prompted consideration
tion should be administered. Readministration of measles, mumps, of other possible causative agents. For instance, the MMR vaccine
and rubella (MMR) vaccine, Hib vaccine, inactivated poliovirus contains neomycin, which may be the cause of the sensitivity.
CHAPTER 4â•… Health Promotion for the Developing Child 71


• Know the recommended immunization schedule and the recommended SAFETY OF VACCINES
alternative schedule for those with lapsed immunizations or unknown The following conditions or circumstances are not contraindications to the
immunization history. administration of vaccines:
• Acquire up-to-date information because recommendations are revised • Mild acute illness with low-grade fever or mild diarrhea in an otherwise
frequently. healthy child.
• Assess the family’s beliefs and values to assist in the education of the • A reaction to a previous dose of DTaP vaccine with only soreness,
family as to the rationale for immunizations, the risks and side effects, and redness, or swelling in the immediate vicinity of the injection site.
the risks of nonimmunization.
• Take a careful history to determine possible contraindications or precau-
tions and report any pertinent information to the practitioner. Educate the
family as to the rationale for any contraindications.
• Some vaccines are combination vaccines (e.g., Pediarix—diphtheria, Before a second dose of any vaccine is given, the nurse needs to
tetanus, pertussis, hepatitis B, and polio). Other vaccines should not be ascertain and record whether any side effects or possible reactions
mixed. Check manufacturer’s recommendations. occurred after the previous dose of that vaccine. The National Child-
• Administer vaccines according to the manufacturer’s recommended sites. hood Vaccine Injury Act of 1986 requires health care providers who
• Use hand hygiene before vaccine administration and between children. administer vaccines to maintain permanent vaccination records and to
• Review with the parents common side effects and the signs of potentially report occurrences of certain adverse events stipulated in the act
severe reactions that warrant contacting the practitioner. (Vaccine Adverse Event Reporting System [VAERS]). Anaphylaxis or
• Instruct the parents that they may administer age-appropriate doses of anaphylactic shock and encephalopathy are examples of two reportable
acetaminophen every 6 hours for 24 hours if the child has discomfort events associated with the tetanus and pertussis vaccines. Providers
related to vaccine administration. administering immunizations must be aware of reportable events and
• For painful or red injection sites, advise the parents to apply cold com- comply with the provisions of the act.
presses for the first 24 hours; then use warm or cold compresses as long
as needed. Immunocompromised Children
• Give multiple administrations in different sites and record those sites in In general, children who are immunologically compromised should
the medical record. not receive live bacterial or viral vaccines (e.g., MMR, varicella vaccine).
• Document parental consent in the medical record. Documentation should There are some exceptions related to children with human immuno-
also include the type of vaccine, date of administration, manufacturer and deficiency virus infection and in some specific instances of children
lot number, expiration date, administration site, any data pertinent to risks in remission from cancer. Children with human immunodeficiency
and side effects, and the signature and title of the person administering virus infection who are not severely compromised should receive
the immunization. MMR; varicella vaccine can be given, depending on the CD4+ count
(see Chapter 18).

Immunization is a critical component of a child’s health care. Knowl-
edge of immunization schedules and an awareness of potential delays
will aid the health care provider in identifying children who have not
been fully immunized. Health care providers must provide parents
Special Considerations Related to Immunizations with accurate information regarding immunizations because immuni-
• The preferred site for intramuscular administration of vaccines to infants zations are the primary and safest means of managing preventable
and children is the anterolateral thigh; the deltoid can be used in older infectious diseases. All children in the United States should have access
children. Subcutaneous injections can be given in the thigh or upper arm. to appropriate immunization. The State Children’s Health Insurance
• For intramuscular (IM) administration, use a needle of sufficient length to Program (see Chapter 1) and the Vaccines for Children program
penetrate the muscle. ensure that there are no financial barriers. Nevertheless, health provid-
• When giving DTaP, Hib, and hepatitis B vaccines simultaneously, it is ers need to be aware that, although immunization rates are increasing
advisable to administer the most reactive vaccine (DTaP) in one leg and to through efforts of the federal and state governments, disparities in
inject the others, which cause less reaction, into the other leg. immunization access for the poor and certain racial or ethnic minori-
• Live bacterial or virus vaccines should not be given to immunocompromised ties still exist (CDC, Office of Minority Health, 2007).
children, except under special circumstances.
Nutrition and Activity
• Live measles vaccine is produced by chick embryo cell culture, so there is
a remote possibility of anaphylactic hypersensitivity in children with egg To provide care for infants and children, the nurse must understand
allergies. Most reactions from the MMR are reactions to other components the body’s nutritional needs. The body is nourished by food. Carbo-
of the vaccine, so MMR is not usually contraindicated for children with egg hydrates, fats, proteins, water, vitamins, and minerals are the basic
hypersensitivity (AAP Committee on Infectious Diseases, 2009b). nutrients in food. Carbohydrates, fats, and proteins provide energy,
• Any immunization may cause an anaphylactic reaction. All offices and which is required by the cells of the body to transport all substances
clinics must have epinephrine 1â•›:â•›1000 available. across the cell membrane, to synthesize substances within the cell, and
to dispose of waste products.
72 CHAPTER 4â•… Health Promotion for the Developing Child

Carbohydrates provide most of the energy needed to maintain a
healthy body. They exist in two forms, simple and complex. Complex
carbohydrates should make up the majority of calories consumed. TO CHILDREN AND
Most complex carbohydrates are found in starch from cereal grains, ADOLESCENTS
roots, vegetables, and legumes. The more mature the vegetable, the • Breastfeed infants for a minimum of 4 months; avoid introducing solid
higher the starch content. Foods that are good sources of complex foods until 4 to 6 months of age.
carbohydrates are relatively inexpensive and easily obtained. Insuffi- • Consume whole-grain products often; at least half the grains should be
cient calorie intake causes the body to break down protein and fat whole grains.
for energy and glucose production. Carbohydrates are a food source • Children 1 to 8 years should consume 2 cups per day of milk; use fat-free
for many of the essential nutrients, including fiber, vitamins C and E, or low-fat milk or equivalent milk products for children older than 2 years.
the majority of B vitamins, potassium, and the majority of trace • Children 9 years of age and older should consume 3 cups per day of fat-free
elements. or low-fat milk or equivalent milk products.
• Limit juice, but provide several servings of fruits and vegetables each day.
Fats Use 100% fruit juice and not juice drinks, which contain added sugar.
Fats serve as the secondary source of energy by providing 30% or less • Total daily fat intake should not exceed 30% to 35% of calories for children
of daily calorie intake. The Food and Drug Administration requires 2 to 3 years of age and 25% to 35% of calories for children and adolescents
food manufacturers to list trans fat (i.e., trans fatty acids) on Nutrition 4 to 18 years of age. Polyunsaturated and monounsaturated fatty acids,
Facts and some Supplement Facts panels. Trans fat, like saturated fat such as fish, nuts, and vegetable oils, should be the primary source of fats.
and dietary cholesterol, raises the low-density lipoprotein cholesterol. • Elementary school age children can be taught to read food labels
Trans fat can be found in processed foods made with partially hydro-
genated vegetable oils such as vegetable shortenings, some margarines, Data from American Heart Association. (2011). Dietary
recommendations for healthy children. Retrieved from
crackers, candies, cookies, snack foods, fried foods, and baked goods.
Dietary fat allows the absorption of the fat-soluble vitamins (A, D, E,
and K) and adds flavor to foods. The layer of fat beneath the skin plays
a role in regulating body temperature. Fat is a component of cell mem-
branes and acts as a protective padding for the internal organs. When Dietary Guidelines
excess calories are consumed, dietary fats are stored as excess body fat. The U.S. Department of Health and Human Services and the U.S.
The monounsaturated and polyunsaturated fats can raise high-density Department of Agriculture regularly publishes and updates dietary
lipoprotein and decrease low-density lipoprotein cholesterol. For this guidelines, which are used as the basis for a federal nutrition policy.
reason, emphasis should be placed on replacing saturated fats with The guidelines recommend that a variety of nutrient-dense foods and
these fats whenever possible. Most whole grains, breads, pastas, and beverages within and among the basic food groups be consumed, but
cereals are naturally low in fat. Families should be taught to choose foods that contain saturated and trans fats, cholesterol, added sugars,
lean meats, beans, and low-fat dairy products and to limit their intake salt, and alcohol should be limited (Box 4-9).
of processed foods such as crackers, cookies, cakes, and higher-fat The MyPyramid Food Guidance System was developed to provide
snacks. food-based guidance to help implement the recommendations of the
guidelines. Although the food choice and amount recommendations
Proteins have not changed, the United States Department of Agriculture
Dietary protein is necessary for building and maintaining body tissues. (USDA) issued the MyPlate system in 2010 (USDA Center for Nutri-
Proteins are involved in homeostasis by working with other elements tion Policy and Promotion, 2010) (Figure 4-6). The MyPlate image
in the blood to maintain fluid balance. Many vitamins and minerals illustrates the recommended portion of daily nutrients in a way that
are bound to protein carriers for transport. Proteins, as antibodies, aid children, as well as adults, can easily understand. The MyPlate focuses
in the regulation of the body’s immune system. on eating a variety of foods to get the required nutrients and adequate
energy. The dietary guidelines suggest consuming half of the daily
Water requirements as fruits and vegetables, limiting saturated fats and
Water is essential for life. It transports nutrients to cells and waste sugars, using only lean meats, increasing other sources of protein, such
products away from cells. It assists in the regulation of body tempera- as beans, and using low fat or skim dairy products (USDA & USDHHS,
ture and in chemical reactions. Water lubricates joints and provides 2011). Other web-based interactive tools and print materials can be
form and structure to the cells and the medium for body fluids. Water accessed at
is found in most foods, including solids. Water requirements can be
estimated by a variety of methods. The child’s activity level and Energy, Calories, and Servings
ambient temperature influence the amount of water needed. Energy is measured in calories. Energy or calorie needs depend on the
person’s age, sex, height, weight, and level of physical activity. Calorie
Vitamins and Minerals needs vary during childhood. Infants need sufficient calories to support
Vitamins and minerals are necessary in the regulation of metabolic rapid growth; therefore fat is not restricted in children younger than 2
processes. They are present in a wide variety of foods. Vitamins and years. Fat intake should be between 30% and 35% of calories for chil-
minerals are added to processed formulas and to other foods such dren 2 to 3 years of age and between 25% and 35% of calories for
as cereals. Except for Vitamin D supplementation, it is generally children and adolescents 4 to 18 years of age, with most fats coming
not necessary for children to receive supplementation after infancy from sources of polyunsaturated and monounsaturated fatty acids,
unless they are at nutritional risk (e.g., have anorexia or a chronic such as fish, nuts, and vegetable oils (American Heart Association
disease). [AHA], 2011).
CHAPTER 4â•… Health Promotion for the Developing Child 73

• Aerobic exercise should comprise the major component of chil-

dren’s daily exercise, but physical activity should also include
muscle-strengthening and bone-strengthening activities.
• Make exercise fun and a habitual activity.
• Encourage students to participate fully in any physical educa-
tion classes.
Appendix—Growth Charts, CDC and WHO Growth Curves for Children Ages 0 to 2 Years

• Encourage parents to investigate their community’s physical

activity programs. City recreation centers, parks, and commu-
nity YMCAs can provide fun places to engage in physical

Cultural and Religious Influences on Diet

Dietary intake is profoundly affected by both cultural and religious
beliefs. An understanding of these patterns will assist the nurse in both
the assessment and implementation of nutrition-related behaviors.
Hospitalized children who become stressed by being in a new and
strange environment do not need the added stress of unfamiliar foods.
Information regarding a child’s food preferences can be obtained
during a dietary history.
A child’s religious beliefs may also have an effect on the types of
foods eaten and the way in which they are served. Within religious
FIG 4-6  MyPlate. MyPlate advocates building a healthy plate by groups there may be a variety of dietary observances. The nurse should
making half of your plate fruits and vegetables and the other half assist and encourage the child and the child’s family in communicating
grains and protein. Avoiding oversized portions, making half your specific dietary needs.
grains whole grains, and drinking fat-free or low-fat (1%) milk are
additional recommendations for a healthy diet. (From U.S. Depart- Assessment of Nutritional Status
ment of Agriculture: MyPlate, Washington, DC, June 2011, The A nutritional assessment is an essential component of the health exam-
Service, available online at ination of infants and children. This assessment should include
anthropometric data, biochemical data, clinical examination, and
dietary history. From these data, a plan of care can be developed. In
addition, children at risk can be identified and areas of prevention
pursued through teaching and further evaluation and follow-up.
Physical Activity Anthropometric Data.╇ Height and head circumference reflect past
╇ Over the past several decades, children of all ages have become less nutrition or chronic nutritional problems. Weight, skinfold thickness,
active and more sedentary. The prevalence of overweight children ages midarm circumference, and BMI better reflect current nutritional
6 to 11 years has nearly tripled in the past 30 years, going from 7% in status. The nurse should always be aware of the roles of birth weight
1980 to 20% in 2008 (National Center for Health Statistics, 2010). The and ethnic, familial, and environmental factors when evaluating
rate among adolescents ages 12 to 19 years more than tripled, increas- anthropometric measurements. Infants and children should have
ing from 5% to 18% (National Center for Health Statistics, 2010). anthropometric measurements done during each preventive health
Physical activity, dietary behavior, and genetics affect weight across all care visit.
age-groups. Boys who are Mexican American and non-Hispanic black Clinical Evaluation.╇ The clinical evaluation includes a physical
girls have the highest prevalence of obesity (National Center for Health examination and complete history. Special attention is paid to the areas
Statistics, 2010). where signs of nutritional deficiencies appear: the skin, hair, teeth,
A person’s BMI provides an indication of relative obesity, gums, lips, tongue, and eyes. Clinical symptoms usually are not by
and this number (a function of weight and height) is being used themselves diagnostic but may suggest conditions, which are then con-
more frequently to assess for obesity. For children, the BMI per� firmed by biochemical tests and diet histories. More than one defi-
centile for age is a more accurate measurement of overweight ciency may be present.
and obesity than the adult BMI measurement of >25. The Evolve Dietary History.╇ Obtaining an accurate history of dietary intake is
website contains information about the BMI for children of various difficult. The knowledge that what the child is eating is being recorded
ages. can influence what the parent feeds the child or what the child eats.
Any health promotion counseling during childhood and adoles- Children often cannot remember what they have eaten. If the child or
cence needs to include an emphasis on increasing the child’s and parent is not committed to the process, incomplete information may
parents’ daily physical activity. Children particularly enjoy an activity be obtained. It is still a useful assessment process, however, and should
if it is associated with fun and group involvement, and they are more be used. Client teaching includes an understanding of the importance
likely to participate in physical exercise if they see their parents exercis- of recording the child’s dietary intake and the need for accuracy.
ing as well. Common methods of assessing dietary intake include 24-hour recall,
When counseling parents and children about increasing physical a food frequency questionnaire, and a food diary.
activity, the nurse can emphasize the following points (CDC, 2011b Twenty-four-hour recall.╇ With the 24-hour recall method, the
& c): child or parent is asked to recall everything the child has eaten in the
• Children and adolescents should be physically active for at least past 24 hours. A questionnaire may be used, or the nurse may conduct
one hour daily. an interview asking the pertinent questions.
74 CHAPTER 4â•… Health Promotion for the Developing Child

The child or parent may have difficulty remembering the kinds

and amounts of food eaten, or the family may have had an atypical
day on the previous day or may not feel comfortable relating what
was eaten the day being evaluated. How the child or parents see the INJURIES
nurse may influence the response; they may say what they think • Model safety practices in the home, workplace, and community.
the interviewer wants to hear. Asking for information in relation to • Educate parents and children through anticipatory safety guidance to help
meals eaten as opposed to food groups may increase the accuracy of reduce needless injuries.
the assessment. • Support legislative efforts that advocate prevention measures.
Food-frequency questionnaire.╇ The food-frequency question- • Collaborate with other health care providers to promote safety and injury
naire elicits information on the intake of particular foods or food prevention.
groups on a daily, weekly, or monthly basis. This tool can be used to
validate the 24-hour recall data. As for all methods of assessment, this
requires the interviewer to be nonjudgmental and objective. Putting
the information into a questionnaire may be less threatening to the
child and family and will save time. development. Knowledge of growth and development also helps the
Food diary.╇ When keeping a food diary, the child or parent records nurse understand the risks associated with each age-group and choose
everything consumed during a specified period. Various sources rec- the educational strategy appropriate to a child’s developmental level.
ommend different lengths of time for keeping the diary; 3-day to 7-day Early in their parenting experience, parents need to know how to
records may be used. As in all nursing care, the nurse must evaluate provide a safe environment for their children and what behaviors they
what is a reasonable time to expect the family or child to keep the can expect at various developmental levels. Anticipatory guidance
records. The time, place, and people present when the food was eaten builds on the safety principles of the previous stage. Awareness of a
may also be recorded. This provides the nurse with additional informa- child’s changing capabilities allows the parent to be more alert and
tion, which may identify trends and other information related to the reactive to safety hazards that the child is likely to encounter. This
child’s eating behaviors. awareness is especially important for first-time parents.
Simply telling parents to “watch your children” or to “child-proof ”
Safety the home or telling a child to “be careful” has little educational impact.
Unintentional injury is the most significant but underrecognized Educational efforts are much more likely to be effective if they focus
public health threat facing children today. Unintentional injury is the on specific problems with specific solutions rather than providing
leading cause of death in children. Across age-groups, motor vehicle broad or vague advice.
traffic injuries are the major causes of injury in children and adoles-
cents (Forum on Child and Family Statistics, 2011). (See Chapter 10
for a more detailed discussion of the causes of injury in childhood.) ╇ SAFETY ALERT
The number of childhood deaths is staggering, but it is only a frac-
tion of the number of children who are hospitalized and require emer- Relationship Between Safety and
gency treatment and who have a permanent disability as a result of Childhood Development
injury. The economic burden to society is equally astounding, reaching Developmentally, children are vulnerable to injury for the following reasons:
billions of dollars yearly. What cannot be quantified is the emotional • Children are naturally curious and enjoy exploring their surroundings.
loss, suffering, and pain the child and family must endure once an • Children are driven to test and master new skills.
injury has occurred. • Children frequently attempt activities before they have developed the cog-
All children are at risk for injury because of their normal curiosity, nitive and physical skills required to accomplish the task safely.
impulsiveness, and impatience. Everywhere they venture, they are • Children often assert themselves and challenge rules.
exposed to potentially hazardous situations. • Children develop a strong desire for peer approval as they grow older.

Injury Prevention
Injury prevention is a relatively new focus of health promotion. The
term accident, with its implied meaning of random chance or lack of Teaching Strategies
responsibility, has been replaced with injury, with its implication that Teaching can be formal or informal, simple or elaborate, as long as it
injuries have causes that can be modified to prevent or lessen their provides relevant safety information and coincides with the child’s or
frequency and severity. Safety education is a critical component of parents’ cognitive abilities.For children younger than 5 or 6 years, it is
injury prevention. It increases awareness, it attempts to modify human advisable to incorporate the parents into the teaching process so that
behavior, and it reinforces changes implemented through legal mandates the parents can assist with reinforcement or questions the child later
(e.g., seatbelt laws) or product modification (e.g., crib design, airbags). has about the safety issue. With younger children, who are easily dis-
Nurses need to become proactive in childhood injury prevention tracted, the information should be presented in short sessions.
by increasing children’s and adults’ awareness of safety issues (Box Many local and national organizations have safety information
4-10). Nurses who care for children are acutely aware of the devastating available for distribution. This information can be used to supplement
effects and complex problems injuries cause. From their experiences, the teaching process. Prepared materials range from pamphlets, book-
they become well-informed advocates for childhood safety. lets, posters, and audiovisual materials to entire teaching programs that
can assist in providing injury prevention education to all age-groups.
Anticipatory Guidance Some programs offer the materials free of cost. Internet information,
To be most effective in providing anticipatory safety guidance, nurses such as that obtained at, can be extremely helpful to
must gear educational strategies to the child’s level of growth and parents.
CHAPTER 4â•… Health Promotion for the Developing Child 75

• Growth, development, maturation, language, and learning are • Inherited predisposition to disease can occur through Mendelian
complex, interrelated processes that produce complicated series of inheritance patterns, chromosomal abnormalities, or multifactorial
changes in individuals from conception to death; they are influ- influences.
enced by genetics, the environment, access to care, culture, nutri- • Pediatric nurses must obtain competencies in genetics and genom-
tion, health status, and family structure. ics in order to provide appropriate counseling to parents and
• Developmental theories, such as those developed by Piaget, Erikson, children.
Freud, and Kohlberg, form a basis for understanding the many • Play enhances the child’s growth and development through physi-
facets of development. cal, cognitive, emotional, and social interactions with others.
• A variety of physical and developmental screening tools, adminis- • Personnel who administer immunizations must be aware of recom-
tered at regular intervals during infancy and early childhood, pro- mendations for scheduling, handling, storing, and administering
vides an overall picture of a child’s growth and developmental the vaccines. Special attention should be given to the site of admin-
progress and alerts the nurse to potential growth and developmen- istration, dosage, route and previous adverse reactions.
tal delays. • Components of a nutritional assessment include anthropometric
• The 46 human chromosomes are long strands of DNA, each con- data, biochemical data, clinical examination, and dietary history.
taining up to several thousand individual genes. • Many childhood injuries and deaths are predictable and prevent-
• With the exception of those genes located on the X and Y chromo- able; understanding the developmental milestones of each age-
somes in males, genes are inherited in pairs that may be identical group is important for promoting safety awareness for parents,
or different. Some genes are considered to be dominant and others, caregivers, and children.

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Health Promotion
for the Infant

After studying this chapter, you should be able to:
• Describe the physiologic changes that occur during infancy. • Discuss the importance of immunizations and recommended
• Describe the infant’s motor, psychosocial, language, and cognitive immunization schedules for infants.
development. • Provide parents with anticipatory guidance for common concerns
• Discuss common problems of infancy, such as separation anxiety, during infancy, such as immunizations, nutrition, elimination,
sleep problems, irritability, and colic. dental care, sleep, hygiene, safety, and play.

During no time after birth does a human being grow and change as States has declined markedly over the past 30 years (see Chapter 1),
dramatically as during infancy. Beginning with the newborn period and many infants still die before the first birthday (6.8 per 1000 live births).
ending at 1 year, the infancy period, a child grows and develops from The leading cause of death in infants younger than 1 year of age is
a tiny bundle of physiologic needs to a dynamo, capable of locomotion congenital anomalies, followed by conditions related to prematurity or
and language and ready to embark on the adventures of the toddler years. low birth weight (National Center for Health Statistics [NCHS], 2011).
Sudden infant death syndrome (SIDS), which for a long time was the
second leading cause of infant deaths, is now the third leading cause
GROWTH AND DEVELOPMENT OF THE INFANT of death (NCHS, 2011), primarily because of international efforts, such
Although historically adults have considered infants unable to do as the Back to Sleep campaign. Unintentional injuries rank seventh in
much more than eat and sleep, it is now well documented that even this age-group and contribute to mortality and morbidity rates in the
young infants can organize their experiences in meaningful ways and infant population (NCHS, 2011). Nurses provide anticipatory guid-
adapt to changes in the environment. Evidence shows that infants form ance for families with infants to reduce morbidity and mortality rates.
strong bonds with their caregivers, communicate their needs and During the first year after birth, the infant’s development is dra-
wants, and interact socially. By the end of the first year of life, infants matic as the child grows toward independence. Knowledge of devel-
can move about independently, elicit responses from adults, commu- opmental milestones helps caregivers determine whether the baby is
nicate through the use of rudimentary language, and solve simple growing and maturing as expected. The nurse needs to remember that
problems. these markers are averages and that healthy infants often vary. Some
Infancy is characterized by the need to establish harmony between infants reach each milestone later than most. Knowledge of normal
the self and the world. To achieve this harmony, the infant needs food, growth and development helps the nurse promote the safety of chil-
warmth, comfort, oral satisfaction, environmental stimulation, and dren. Nurses teach parents to prepare for the child’s safety before the
opportunities for self-exploration and self-expression. Competent child reaches each milestone.
caregivers satisfy the needs of helpless infants, providing a warm, nur- Providing parents with information about immunizations, feeding,
turing relationship so that the children have a sense of trust in the sleep, hygiene, safety, and other common concerns is an important
world and in themselves. These challenges make infancy an exciting nursing responsibility. Appropriate anticipatory guidance can assist
yet demanding period for both child and parents. with achieving some of the goals and objectives determined by the U.S.
Nurses play an important role in promoting and maintaining government to be important in improving the overall health of infants.
health in infants. Although the infant mortality rate in the United Nurses are in a good position to offer anticipatory guidance on the

78 CHAPTER 5â•… Health Promotion for the Infant

basis of the infant’s growth and achievement of developmental mile-

stones. Table 5-1 summarizes growth and development during infancy.
Healthy People 2020 Objectives for Infants
Physical Growth and Maturation of Body Systems
MICH-20 Increase the proportion of infants who are put to sleep on their
Growth is an excellent indicator of overall health during infancy. back.
Although growth rates are variable, infants usually double their birth MICH-21 Increase the percentage of infants who are breastfed, especially
weight by 6 months and triple it by 1 year of age. From an average those exclusively breastfed.
birth weight of 7 1 2 to 8 pounds (3.4 to 3.6╯kg), neonates lose 10% of MICH-29 Increase the percentage of infants and children who are
their body weight shortly after birth but regain birth weight by 2 weeks. screened appropriately and referred for autism spectrum
During the first 5 to 6 months, the average weight gain is 1 1 2 pounds disorder and other developmental delays.
(0.68╯kg) per month. Throughout the next 6 months, the weight AHS-5 Increase the percentage of infants and children who have an
increase is approximately 1 pound (0.45╯kg) per month. Weight gain ongoing source of medical care.
in formula-fed infants is slightly greater than in breastfed infants. EH-8 Reduce blood lead levels in infants and children
During the first 6 months, infants increase their birth length by IID-7 Achieve and maintain effective vaccination coverage levels for
approximately 1 inch (2.54╯cm) per month, slowing to 1 2 inch (1.27╯cm) universally recommended vaccines among young children.
per month over the next 6 months. By 1 year of age, most infants have IVP-11 Reduce deaths caused by unintentional injuries.
increased their birth length by 50%. IVP-15 Increase use of age-appropriate vehicle restraint systems.
The head circumference growth rate during the first year is approxi- ENT-VSL-1 Increase the proportion of newborns who are screened for
mately 4 10 inch (1╯cm) per month. Usually the posterior fontanel closes hearing loss by no later than age 1 month, have audiologic
by 2 to 3 months of age, whereas the larger anterior fontanel may evaluation by age 3 months, and are enrolled in appropriate
remain open until 18 months. Head circumference and fontanel mea- intervention services no later than age 6 months.
surements indicate brain growth and are obtained, along with height
and weight, at each well-baby visit. Chapter 9 discusses growth-rate Modified from U.S. Department of Health and Human Services.
monitoring throughout infancy. (2010). Healthy People 2020. Retrieved from


1-2 Months
Fast growth; weight gain of Gross Erikson’s stage of trust vs. Piaget’s sensorimotor phase. Strong cry.
1 12 lb (0.68╯kg) per month May lift head when held mistrust. 1 month: Notes bright Throaty sounds.
and height gain of 1 inch against shoulder. Infant learns that world is objects if in line of vision. Responds to human faces.
(2.54╯cm) per month during Head lag. good and “I am good.” Vision 20/100. 6-8 weeks: Begins to smile
first 6 months. Fine This stage is the foundation Reflexes dominate behavior. in response to stimuli.
Upper limbs and head grow Palmar grasp. for other stages. 2 months: Begins to follow
faster. 1 month: Immediately drops Child is entirely dependent objects.
Primitive reflexes present; object placed in hand. on parents and other
strong suck and gag reflex. Fist usually clenched (grasp caregivers.
Obligate nose breather. reflex). Needs should be met in a
Posterior fontanel closes by 2 months: Holds objects timely fashion.
2-3 months. momentarily. Touch is important.
Hands often open (grasp
reflex fading).

3 Months
Primitive reflexes fading. Gross Smiles in response to others. Follows an object with eyes. Babbles, coos.
Can get hand to mouth. Uses sucking to soothe self. Plays with fingers. Enjoys making sounds.
Can lift head off bed when in Responds to voices, watches
prone position. speaker.
Head lag still present but
Holds objects placed in
Grasp reflex absent.
CHAPTER 5â•… Health Promotion for the Infant 79


4-5 Months
Can breathe when nose is Gross Mouth is a sensory organ 4 months: Brings hands Crying becomes
obstructed. Plays with feet; puts foot in used to explore together at midline. Vision differentiated.
Growth rate declines. mouth. environment. 20/80. Babbling is common.
Drooling begins in Bears weight when held in a Attachment is continuing Begins to play with objects. 4 months: Begins consonant
preparation for teething. standing position. process throughout infancy. Recognizes familiar faces. sounds: H, N, G, K, P, B.
Moro, tonic neck, and rooting Turns from abdomen to back. Has increased interest in Turns head to locate sounds. 5 months: Makes vowel
reflexes have disappeared. Fine parent, shows trust, knows Shows anticipation and sounds: ee, ah, ooh.
Begins reaching and grasping parent. excitement.
with palm. Shows emotions of fear and Memory span is 5-7 minutes.
Hits at object, misses. anger. Plays with favorite toys.

6-7 Months
Weight gain slows to 1 Gross Smiles at self in mirror. Can fixate on small objects. Produces vowel sounds and
pound (0.45╯kg) per month. Sits, leaning forward on both Plays peek-a-boo. Adjusts posture to see. chained syllables.
Length gain of 12 inch hands; when supine, lifts Begins to show stranger Responds to name. Begins to imitate sounds.
(1.27╯cm) per month. Birth head off table. anxiety. Exhibits beginning sense of Belly laughs.
weight doubles; tooth Turns from back to abdomen. object permanence. Babbles (one syllable) with
eruption begins; chewing Fine Recognizes parent in other pleasure.
and biting occur. Transfers objects from one clothes, places. Calls for help.
Maternal iron stores are hand to the other. Is alert for 1 12 -2 hours. “Talks” to toys and image in
depleted. Picks up object well with the mirror.
whole hand.

8-9 Months
Continues to gain weight, Gross Stranger anxiety is at its Beginning development of Stringing together of vowels
length. Sits steadily unsupported. height. depth perception. and consonants begins.
Patterns of bladder and Can crawl and pull up. Separation anxiety is Object permanence continues First few words begin to
bowel elimination begin to Fine increasing. to develop. have meaning (Mama,
become more regular. Pincer grasp develops. Follows parent around the Uses hands to learn concepts Dada, bye-bye, baby).
Reaches for toys. house. of in and out. Begins to understand and
Rakes for objects and obey simple commands,
releases objects. such as, “Wave bye-bye.”
Responds to “No!”
Shouts for attention.

10-12 Months
12 months: Birth weight Gross Has mood changes. Vision 20/40. Can say two or more words.
triples; birth length Can stand alone. Quiets self. Searches for hidden toy. Says “Mama” or “Dada”
increases by 50%. Can walk with one hand held Is quieted by music. Explores boxes, inserts specifically.
Head and chest but crawls to get places Tenderly cuddles toy. objects in container. Waves bye-bye.
circumference equal. quickly. Symbol recognition is Begins to differentiate
Babinski reflex disappears. Fine developing (enjoys books). between words.
Releases hold on cup. Enjoys jabbering.
10 months: Finger-feeds self. Vocalization decreases when
12 months: Feeds self with walking.
spoon. Knows own name.
Holds crayon to mark on
12 months: Pincer grasp is
80 CHAPTER 5â•… Health Promotion for the Infant

In addition to height and weight, organ systems grow and mature foreign bodies. The eustachian tube is short and relatively horizontal,
rapidly in the infant. Although body systems are developing rapidly, increasing the risk for middle ear infections.
the infant’s organs differ from those of older children and adults in
both structure and function. These differences place the infant at risk Cardiovascular System
for problems that might not be expected in older individuals. For The cardiovascular system undergoes dramatic changes in the transi-
example, immature respiratory and immune systems place the infant tion from fetal to extrauterine circulation. Fetal shunts close, and pul-
at risk for a variety of infections, whereas an immature renal system monary circulation increases drastically (see Chapter 22). During
increases risk for fluid and electrolyte imbalances. Knowledge of these infancy, the heart doubles in size and weight, the heart rate gradually
differences provides the nurse with important rationales on which to slows, and blood pressure increases.
base anticipatory guidance and specific nursing interventions.
Immune System
Neurologic System Transplacental transfer of maternal antibodies supplements the infant’s
Brain growth and differentiation occur rapidly during the first year of weak response to infection until approximately 3 to 4 months of age.
life, and they depend on nutrition and the function of the other organ Although the infant begins to produce immunoglobulins (Ig) soon
systems. At birth, the brain accounts for approximately 10% to 12% of after birth, by 1 year of age the infant has only approximately 60% of
body weight. By 1 year of age, the brain has doubled its weight, with a the adult IgG level, 75% of the adult IgM level, and 20% of the adult
major growth spurt occurring between 15 and 20 weeks of age and IgA level. Breast milk transmits additional IgA protection. The activity
another between 30 weeks and 1 year of age. Increases in the number of T lymphocytes also increases after birth. Although the immune
of synapses and expanded myelinization of nerves contribute to matu- system matures during infancy, maximum protection against infection
ration of the neurologic system during infancy. Primitive reflexes dis- is not achieved until early childhood. This immaturity places the infant
appear as the cerebral cortex thickens and motor areas of the brain at risk for infection.
continue to develop, proceeding in a cephalocaudal pattern: arms first,
and then legs (Box 5-1). Gastrointestinal System
The stomach capacity of a neonate is approximately 10 to 20╯mL, but
Respiratory System with feedings the capacity increases rapidly to approximately 200╯mL
In the first year of life, the lungs increase to three times their weight at 1 year of age. In the gastrointestinal system, enzymes needed for the
and six times their volume at birth. In the newborn infant, alveoli digestion and absorption of proteins, fats, and carbohydrates mature
number approximately 20 million, increasing to the adult number of and increase in concentration. Although the newborn infant’s gastro-
300 million by age 8 years. During infancy, the trachea remains small, intestinal system is capable of digesting protein and lactase, the ability
supported only by soft cartilage. to digest and absorb fat does not reach adult levels until approximately
The diameter and length of the trachea, bronchi, and bronchioles 6 to 9 months of age.
increase with age. These tiny, collapsible air passages, however, leave
infants vulnerable to respiratory difficulties caused by infection or Renal System
Kidney mass increases threefold during the first year of life. Although
the glomeruli enlarge considerably during the first few months, the
glomerular filtration rate remains low. Thus the kidney is not effective
as a filtration organ or efficient in concentrating urine until after the
BOX 5-1â•… INFANT REFLEXES first year of life. Because of the functional immaturity of the renal
Rooting: Stroke or touch the infant’s cheek or mouth; the infant should system, the infant is at great risk for fluid and electrolyte imbalance.
respond by searching for and attempting to suck the examiner’s finger.
Sucking: If a nipple or finger is placed in the mouth so that it touches the
hard palate, the infant should suck vigorously. This reflex is also indicative
of functional gag and swallowing reflexes. Intake and Output in the Newborn Infant
Ciliary: Stroking the eyelashes results in closure of one or both of the eyes. First 2 days of life
Doll’s eyes: If the infant is placed in a supine position and the head is turned • Intake: 65╯mL/kg (30╯mL/pound) a day
from side to side, the eyes should move to the opposite side. • Output: 2 to 6 voids
Moro: Holding the infant in a supine position then displacing the body down- After the first 2 days
ward a few centimeters causes the infant to extend, then abduct the • Intake: 100 to 150╯mL/kg (45 to 68╯mL/pound) a day
extremities, with fingers spread in a symmetrical fashion. This may also • Output: 5 to 25 voids
elicit a cry.
Tonic neck: When the infant is placed in a supine position, the head is turned
to one side with the opposite arm and leg extended and the arm and leg
Motor Development
on the same side are flexed. If the head is turned to the other direction,
the positioning of the extremities is reversed. This reflex may or may not During the first few months after birth, muscle growth and weight gain
be present at birth, and its absence is not considered abnormal. This is allow for increased control of reflexes and more purposeful movement.
sometimes called the fencing reflex. At 1 month, movement occurs in a random fashion, with the fists
Palmar: If a finger is placed in the palm, the infant should respond by grasping tightly clenched. Because the neck musculature is weak and the head
the examiner’s finger. The grasp should be symmetrical. If pressure is put is large, infants can lift their heads only briefly. By 2 to 3 months,
on the balls of the feet, the infant should grasp with the toes. infants can lift their heads 90 degrees from a prone position and can
hold them steadily erect in a sitting position. During this time, active
CHAPTER 5â•… Health Promotion for the Infant 81

grasping gradually replaces reflexive grasping and increases in fre- The nurse might, for instance, explain, “Infants grow and mature
quency as eye-hand coordination improves (see Table 5-1). very rapidly, and you will be very busy with a new baby. Now is the
The Moro, tonic neck, and rooting reflexes disappear at approxi- time to ‘baby-proof ’ your home before Mary turns over and begins
mately 3 to 4 months. These primitive reflexes, which are controlled crawling and reaching for objects. By doing this now, you can prevent
by the midbrain, probably disappear because they are suppressed by later injuries and worries.”
growing cortical layers. Head control steadily increases during the third During the fifth and sixth months, motor development accelerates
month. By the fourth month, the head remains in a straight line with rapidly. Infants of this age readily reach for and grasp objects. They
the body when the infant is pulled to a sitting position. Most infants can bear weight when held in a standing position and can turn from
play with their feet by 4 to 5 months, drawing them up to suck on their abdomen to back. By 5 months, some infants rock back and forth as a
toes. Parents need anticipatory guidance about ways to prevent unin- precursor to crawling.
tentional injury by “baby-proofing” their homes before each motor Six-month-old infants can sit alone, leaning forward on their hands
development milestone is reached. (tripod sitting). This ability provides them with a wider view of the
world and creates new ways to play. Infants of this age can roll from
back to abdomen and can raise their heads from the table when supine.
At 6 to 7 months, they transfer objects from one hand to the other. In
addition, they can grab small objects with the whole hand and insert
them into their mouths with lightning speed.
At 6 to 9 months, infants begin to explore the world by crawling.
How to “Baby-Proof” the Home By 9 months, most infants have enough muscle strength and coordina-
By the time babies reach 6 months of age, they begin to become much more tion to pull themselves up and cruise around furniture. These new
active, curious, and mobile. Although your baby might not be creeping or methods of mobility enable the infant to follow a parent or caregiver
crawling yet, it is difficult to predict when that will happen. For this reason, around the house.
you need to be prepared by making sure your house and the toys with which By 6 to 7 months, infants become increasingly adept at pointing to
the baby plays are safe. Babies learn through exploring and participating in make their demands known. Six-month-old infants grasp objects with
many different types of experiences. By keeping the baby’s environment safe, all their fingers in a raking motion, but 9-month-olds use their thumbs
you can encourage these experiences for your baby. and forefingers in a fine motor skill called the pincer grasp. This grasp
Be sure to check the following: provides infants with a useful yet potentially dangerous ability to grab,
• All small or sharp objects or dangerous substances should be out of the hold, and insert tiny objects into their mouths.
baby’s reach. Get down to the baby’s eye level to be sure. This includes Nine-month-old infants can wave bye-bye and clap their hands
plants and paint chips, which can be poisonous. Be sure to check that together. They can pick up objects but have difficulty releasing them
any bedside table near the baby’s crib is kept clear of ointments, creams, on request. By 1 year of age, they can extend an object and release it
pins, or any other small objects. Be sure to check that small pieces from into an offered hand. Most 1-year-old children can balance well enough
older siblings’ toys are put away. Keep money put away. to walk when holding another person’s hand. They often resort to
• Put plastic fillers in all plugs, and put cabinet and drawer locks on all crawling, however, as a more rapid and efficient way to move about.
cabinets and drawers. Doorknob covers are also available that prevent An increased ability to move about, reach objects, and explore their
the infant from opening the door. world places infants at great risk for accidents and injury. Nurses
• Remove front knobs from the stove. Be sure to keep all pot and pan provide information to parents about how quickly infant motor skills
handles turned away from the edge of the stove. develop.
• Remove from lower cabinets and lock away all dangerous or poisonous
Cognitive Development
substances, including such items as pet food, household cleaning
agents, cosmetic aids, pesticides, plant fertilizers, paints, matches, Many factors contribute to the way in which infants learn about their
medicines, and plastic bags. Be sure to store these products in their world. Besides innate intellectual aptitude and motivation, infants’
original containers. Never give a small child a latex balloon. sensory capabilities, neuromuscular control, and perceptual skills all
• Place a gate on the top and bottom of stairways. Be sure the gate does affect how their cognitive processes unfold during infancy and
not have openings that can trap the baby’s head, hands, or fingers. throughout life. In addition, variables such as the quality and quantity
• Remove heavy containers from table tops covered with a tablecloth. Do of parental interaction and environmental stimulation contribute to
not hold the baby on your lap while drinking or eating any kind of hot cognitive development.
foods. Cognitive development during the first 2 years of life begins with a
• Pad furniture with sharp edges. Be sure all windows have screens. profound state of egocentrism. Egocentrism is the child’s complete self-
• Keep household hot water temperature at less than 120° F; always test absorption and the inability to view the world from anyone else’s vantage
water temperature before bathing the baby. Never leave a baby unat- point (Piaget, 1952). As infants’ cognitive capacities expand, they become
tended near water (toilet, bathtub, swimming pool, hot tub). Keep increasingly aware of the outside world and their separateness from it.
water containers or tubs empty when not in use. Be sure there is no Gradually, with maturation and experience, they become capable of
direct entrance to a backyard swimming pool through the house. differentiating themselves from others and their surroundings.
• Shorten all hanging cords (appliance, window cords, telephone) so they According to Piaget’s theory (1952), cognitive development occurs
are out of the baby’s reach. Be sure pull-toy cords are shorter than 12 in stages or periods (see Chapter 4). Infancy is included in the senso-
inches. rimotor stage (birth to 2 years), during which infants experience the
• Have your house tested for sources of lead. world through their senses and their attempts to control the environ-
• Never leave your baby unattended or in the care of a young sibling. ment. Learning activities progress from simple reflex behavior to trial-
and-error experiments.
82 CHAPTER 5â•… Health Promotion for the Infant

During the first month of life, infants are in the first substage, reflex Sensory Development
activity, of the sensorimotor period. In this substage, behavior such as Vision
grasping, sucking, or looking is dominated by reflexes. Piaget believed The size of the eye at birth is approximately one half to three fourths
that infants organize their activity, survive, and adapt to their world by the size of the adult eye. Growth of the eye, including its internal
the use of reflexes. structures, is rapid during the first year. As infants grow and become
Primary circular reactions dominate the second substage, occur- more interested in the environment, their eyes remain open for longer
ring from age 1 to 4 months. During this substage, reflexes become periods. They show a preference for familiar faces and are increasingly
more organized and new schemata are acquired, usually centering able to fixate on objects. Visual acuity is estimated at approximately
on the infant’s body. Sensual activities such as sucking and kicking 20/100 to 20/150 at birth but improves rapidly during infancy and
become less reflexive and more controlled and are repeated because toddlerhood. Infants show a preference for high-contrast colors, such
of the stimulation they provide. The baby also begins to recognize as black and white and primary colors. Pastel colors are not easily
objects, especially those that bring pleasure, such as the breast or distinguished until about 6 months of age.
bottle. Young infants may lack coordination of eye movements and extra-
During the third substage, or the stage of secondary circular reac- ocular muscle alignment but should achieve proper coordination by
tions, infants perform actions that are more oriented toward the world age 4 to 6 months. A persistent lack of eye muscle control beyond age
outside their own bodies. The 4- to 8-month-old infant in this substage 4 to 6 months needs further evaluation. Depth perception appears to
begins to play with objects in the external environment, such as a rattle begin at approximately 7 to 9 months and contributes to the infant’s
or stuffed toy. The infant’s actions are labeled secondary because they new ability to move about independently (see Chapter 31).
are intentional (repeated because of the response that is elicited). For
example, a baby in this substage intentionally shakes a rattle to hear Hearing
the sound. Hearing seems to be relatively acute, even at birth, as shown by reflexive
By age 8 to 12 months, infants in the fourth substage, coordination generalized reactions to noise. With myelinization of the auditory
of secondary schemata, begin to relate to objects as if they realize that nerve tracts during the first year, responses to sound become increas-
the objects exist even when they are out of sight. This awareness is ingly more specialized. By 4 months, infants should turn their eyes and
referred to as object permanence and is illustrated by a 9-month-old heads toward a sound coming from behind, and by 10 months infants
infant seeking a toy after it is hidden under a pillow. In contrast, should respond to the sound of their names. The American Academy
6-month-olds can follow the path of a toy that is dropped in front of of Pediatrics (AAP), Joint Committee on Infant Hearing (2007) has
them; however, they will not look for the dropped toy or protest its recommended that all newborn infants be screened for hearing impair-
disappearance until they are older and have developed the concept of ment either as neonates or before 1 month of age and that those infants
object permanence. who fail newborn screening have an audiologic examination to verify
Infants in the fourth substage solve problems differently from how hearing loss before age 3 months. The AAP also suggests that infants
they solve problems in earlier substages. Rather than randomly select- who demonstrate confirmed hearing loss be eligible for early interven-
ing approaches to problems, they choose actions that were successful tion services and specialized hearing and language services as early as
in the past. This tendency suggests that they remember and can possible, but no later than 6 months of age (AAP, Joint Committee on
perform some mental processing. They seem to be able to identify Infant Hearing, 2007). Newborn hearing screening generally is done
simple causal relationships, and they show definite intentionality. For before hospital discharge. Rescreening of both ears within 1 month of
example, when an 11-month-old child sees a toy that is beyond reach, discharge is recommended for those newborns with questionable
the child uses the blanket that it is resting on to pull it closer (Flavell, results. Additionally, screening should be available to those infants
1964; Piaget, 1952). born at home or in an out-of-hospital birthing center (AAP, Joint
Cognitive development in the infant parallels motor development. Committee on Infant Hearing, 2007).
It appears that motor activity is necessary for cognitive development Health providers should assess the risk for hearing deficits at every
and that cognitive development is based on interaction with the envi- well-child visit; any child who manifests one or more risks should have
ronment, not simply maturation. Infancy is the period when the child diagnostic audiology testing by age 24 to 30 months (Harlor, Bower, &
lays the foundation for later cognitive functioning. Nurses can promote Committee on Practice and Ambulatory Medicine, 2009). Risk factors
the cognitive development of infants by encouraging parents to inter- include, but are not limited to, structural abnormalities of the ear,
act with their infants and provide them with novel, interesting stimuli. family history of hearing loss, prenatal or postnatal infections known
At the same time, parents should maintain familiar, routine experi- to contribute to hearing deficit, trauma, persistent otitis media, devel-
ences through which their infants can develop a sense of security about opmental delay, and parental concern (AAP, Joint Committee on Infant
the world. Within this type of environment, infants will thrive and Hearing, 2007). Harlor, Bower, & Committee on Practice and Ambula-
learn. tory Medicine, (2009) further recommend that referral for more com-
plete testing and intervention be made for any child who fails an
objective hearing screening, or whose parent expresses concerns about
possible hearing loss.
╇ NURSING QUALITY ALERT Language Development
Possible Signs of Developmental Delays The acquisition of language has its roots in infancy as the child becomes
Lack of eye muscle control after 4 to 6 months suggests a vision impairment increasingly intrigued with sound, begins to realize that words have
and the need for further evaluation. meaning, and eventually uses simple sounds to communicate (Box
Lack of a social smile by 8 to 12 weeks requires further evaluation and close 5-2). Although young infants probably understand tones and inflec-
follow-up. tions of voice rather than words themselves, it is not long before repe�
tition and practice of sounds enable them to understand and
CHAPTER 5â•… Health Promotion for the Infant 83


1 to 3 Months
Reflexive smile at first, and then smile becomes more voluntary; sets up a
reciprocal smiling cycle with parent. Cooing.

3 to 4 Months
Crying becomes more differentiated. Babbling is common.

4 to 6 Months
Plays with sound, repeating sounds to self. Can identify mother’s voice. May
squeal in excitement.

6 to 8 Months
FIG 5-1╇ This 6-month-old infant responds delightedly to her mother
Single-consonant babbling occurs. Increasing interest in sound.
with a true social smile. Such interactive responses between parent
and child promote communication and emotional development.
8 to 9 Months
Stringing of vowels and consonants together begins. First few words begin to
have meaning (Mama, Daddy, bye-bye, baby). Begins to understand and obey
simple commands such as “Wave bye-bye.” According to Erikson’s theory of psychosocial development (1963),
infants struggle to establish a sense of basic trust rather than a sense of
9 to 12 Months basic mistrust in their world, their caregivers, and themselves. If pro-
Vocabulary of two or three words. Gestures are used to communicate. Speech vided with consistent, satisfying experiences delivered in a timely
development may slow temporarily when walking begins. manner, infants come to rely on the fact that their needs will be met and
that, in turn, they will be able to tolerate some degree of frustration and
discomfort until those needs are met. This sense of confidence is an early
form of trust and provides the foundation for a healthy personality.
communicate with words. Infants can understand more than they can On the other hand, if infants’ needs are ignored or met in a consis-
express. tently haphazard, inadequate manner, they have no reason to believe
The social smile develops early in the infant, usually by 3 to 5 weeks that their needs will be met or that their environment is a safe, secure
of age (Figure 5-1). This powerful communication tool helps to foster place. According to Erikson, without consistent satisfaction of needs,
attachment and demonstrates that the infant can differentiate between the individual develops a basic sense of suspicion or mistrust (Erikson,
people and objects within the environment. The infant who does not 1963).
display a social smile by 8 to 12 weeks of age needs further evaluation Parallel to this viewpoint is Freudian theory, which regards infancy
and close follow-up because of the possibility of developmental delay. as the oral stage (Freud, 1974). The mouth is the major focus during
During infancy, connections form within the central nervous this stage. Observation of infants for a few minutes shows that most
system, providing fine motor control of the numerous muscles required of their behavior centers on their mouths. Sensory stimulation and
for speech. Maturation of the mouth, jaw, and larynx; bone growth; pleasure, as well as nourishment, are experienced through their
and development of the face help prepare the infant to speak. mouths. Sucking is an adaptive behavior that provides comfort and
Vocalization, or speech, does not appear to be reflexive but satisfaction while enabling infants to experience and explore their
rather is a relatively high-level activity similar to conversation. Parents world. Later in infancy, as teething progresses, the mouth becomes an
usually elicit vocalization in infants better than other adults can. effective tool for aggressive behavior (see Chapter 6).
Language includes understanding word meanings, how to combine
words into meaningful sentences and phrases, and social use of con- Parent-Infant Attachment
versation. The development of both speech and language can be influ- One of the most important aspects of infant psychosocial development
enced by environmental cues, such as structures unique to a native is parent-infant attachment. Attachment is a sense of belonging to or
language, physical disorders, hearing loss, cognitive impairment, connection with each other. This significant bond between infant and
autism spectrum disorders, or learning disabilities such as dyslexia parent is critical to normal development and even survival. Initiated
(Schum, 2007). immediately after birth, attachment is strengthened by many mutually
Although there is great variability, most children begin to make satisfying interactions between the parents and the infant throughout
nonmeaningful sounds, such as “ma,” “da,” or “ah,” by 4 to 6 months. the first months of life.
The sounds become more meaningful and specific by 9 to 15 months, For example, noisy distress in infants signals a need, such as hunger.
and by age 1 year the child usually has a vocabulary of several words, Parents respond by providing food. In turn, infants respond by quiet-
such as “mama,” “dada,” and “bye-bye.” Infants who have older siblings ing and accepting nourishment. The infants derive pleasure from
or who are raised in verbally rich environments sometimes meet these having their hunger satiated and the parents from successfully caring
developmental milestones earlier than other infants. for their children. A basic reciprocal cycle is set in motion in which
parents learn to regulate infant feeding, sleep, and activity through a
Psychosocial Development series of interactions. These interactions include rocking, touching,
Most experts agree that infancy is a crucial period during which children talking, smiling, and singing. The infants respond by quieting, eating,
develop the foundation of their personalities and their sense of self. watching, smiling, or sleeping.
84 CHAPTER 5â•… Health Promotion for the Infant

Conversely, continuing inability or unwillingness of parents to meet

the dependency needs of their infants fosters insecurity and dissatisfac-
tion in the infants. A cycle of dissatisfaction is established in which
parents become frustrated as caregivers and have further difficulty • Nutrition: How much is your child eating, how often, what kinds of foods?
providing for the infant’s needs. • Elimination: How many wet diapers, stools? Consistency of stools?
If parents can adapt to their infant, meet the infant’s needs, and • Safety: Use of car restraints? Gun violence? Smoking in the home?
provide nurturance, attachment is secure. Psychosocial development • Hearing/vision: Any concerns?
can proceed on the basis of a strong foundation of attachment. On the • Can you tell me about the times you would feel it necessary to call your
other hand, if parents’ personalities and abilities to cope with infant doctor?
care do not match their infant’s needs, the relationship is considered • How is the family adjusting to the baby?
at risk. • Are you getting enough time alone and time together?
Although the establishment of trust depends heavily on the quality • Has there been any change in the household or family’s lifestyle?
of the parental interaction, the infant also needs consistent, satisfying • Are there any financial concerns?
social interactions within a family structure. Family routines can help • Are there any other questions or concerns?
to provide this consistency. Touch is an important tool that can be used
by all family members to convey a sense of caring.

Stranger Anxiety
Another important aspect of psychosocial development is stranger Immunization
anxiety. By 6 to 7 months, expanding cognitive capacities and strong The importance of childhood immunization against disease cannot be
feelings of attachment enable infants to differentiate between caregiv- overemphasized. Infants are especially vulnerable to infectious disease
ers and strangers and to be wary of the latter. Infants display an obvious because their immune systems are immature. Term neonates are pro-
preference for parents over other caregivers and other unfamiliar tected from certain infections by transplacental passive immunity from
people. Anxiety, demonstrated by crying, clinging, and turning away their mothers. Breastfed infants receive additional immunoglobulins
from the stranger, is manifested when separation occurs. This behavior against many types of viruses and bacteria. Transplacental immunity
peaks at approximately 7 to 9 months and again during toddlerhood, is effective only for approximately 3 months, however, and for a variety
when separation may be difficult (see Chapter 6). of reasons many mothers choose not to breastfeed. In any case, this
Although stressful for parents, stranger anxiety is a normal sign of passive immunity does not cover all diseases, and infection in the
healthy attachment and occurs because of cognitive development infant can be devastating. Immunization offers protection that all
(object permanence). Nurses can reassure parents that, although their infants need.
infants seem distressed, leaving the infant for short periods does no Nurses play an important role in health promotion and disease
harm. Separations should be accomplished swiftly, yet with care, love, prevention related to immunization. Nursing responsibilities include
and emphasis on the parents’ return. assessing current immunization status, removing barriers to receiving
immunizations, tracking immunization records, providing parent edu-
HEALTH PROMOTION FOR THE INFANT cation, and recognizing contraindications to the receipt of vaccines.
Chapter 4 provides detailed information regarding immunizations and
AND FAMILY their schedule.
Parents, particularly new parents, often need guidance in caring for
their infant. Nurses can provide valuable information about health Skin Care
promotion for the infant. Specific guidance about everyday concerns, Cord care with topical antiseptics prevents umbilical cord infection
such as sleeping, crying, and feeding, can be offered, as well as anticipa- better than leaving the cord to air dry (Zupan, Garner, & Omari, 2004).
tory guidance about injury prevention. An important nursing respon- Many maternity facilities recommend that routine cord care be per-
sibility is to provide parents with information about immunizations formed after each bath and each diaper change. The umbilical stump
and dental care. Nurses can offer support to new parents by identifying and the area where it attaches to the abdomen are cleaned with rubbing
strategies for coping with the first few months with an infant. The or isopropyl alcohol; in some instances chlorhexidine powder may be
schedule of well visits corresponds with the schedule recommended by used. The umbilical cord usually falls off about 10 days after birth.
the AAP (see Chapter 4). At each well visit the nurse assesses develop- Some slight bleeding may be noted. Parents should be taught to rec-
ment, administers appropriate immunizations, and provides anticipa- ognize the signs and symptoms of umbilical infection (see Patient-
tory guidance. The nurse asks the parent a series of general assessment Centered Teaching: Care of the Umbilical Cord box).
questions (Box 5-3) and then focuses the assessment on the individual Seborrheic dermatitis, or cradle cap, is seen in some infants. It
infant. appears as thick, yellow, scaly patches that are found on the scalp (most
often over the anterior fontanel) but it may also appear on the eye-
brows or eyelid. The scales may be removed by warming a small
? ╇ CRITICAL THINKING EXERCISE 5-1 amount of baby oil, applying it to the patches, and allowing it to pen-
Mary Brown and her 4-week-old daughter, Tonja, are being seen for a well- etrate the crust. The crusts may then be washed away with baby
baby checkup. Tonja is Mrs. Brown’s first child. Mrs. Brown looks very tired shampoo. It is important to reassure parents that the condition is
and begins to cry when you ask her how she is doing. temporary and usually disappears by 12 months.
1. What are some of the possible causes the nurse should explore? Some infants have acne neonatorum, an acne-like condition prob-
2. How will you approach exploring these possible causes? ably caused by hormonal changes. It generally appears when the infant
3. What are some of the appropriate nursing measures? is approximately 2 to 4 weeks old, and it is self-limiting, disappearing
in several weeks to months.
CHAPTER 5â•… Health Promotion for the Infant 85


Care of the Umbilical Cord FOR THE INFANT FOR THE MOTHER
• Call your health provider if you observe: Allergies are less likely to develop. Oxytocin release enhances involution
• Bleeding Immunologic properties help of uterus.
• Bad odor prevent infections. May have Mother loses less blood because of
• Redness fewer respiratory, ear, and delayed return of menses.
• Drainage gastrointestinal infections and Mother more likely to rest while
• The cord does not fall off after 2 weeks less risk for SIDS. feeding.
• Do the following: Composition meets infant’s specific Mother likely to eat balanced diet
• Fold the diaper back below the cord to expose it to the air nutritional needs. that improves healing.
• Change diapers frequently to avoid excessive moisture in the cord area Nutritional and immunologic Frequent, close contact may enhance
• Don’t: properties change according to bonding.
• Give tub baths until the cord falls off infant’s needs. Convenient: always available, no
Breast milk easily digested. bottles to prepare, no formula to
Protein, fat, and carbohydrate in buy or heat.
most suitable proportions. Economical: eliminates cost of
No possibility of improper (and formula and bottles.
The diaper area, including the gluteal folds, should be cleaned and potentially dangerous) dilution. Traveling easier: no bottles to
thoroughly dried with each diaper change. Either warm water or baby Breast milk unlikely to be prepare, carry, refrigerate, or warm.
wipes can be used. Parents should be cautioned not to use commercial contaminated; not affected by May reduce the risk of some cancers.
baby wipes if any diaper rash is noted. It is important to teach parents water supply.
to wipe females from front to back and to clean under the scrotum of Less likely to result in overfeeding.
males. Infant unlikely to have constipation.

Feeding and Nutrition

Because infancy is a period of rapid growth, nutritional needs are of
special significance. During infancy, eating progresses from a princi- nutrition for infants, and evidence suggests that breastfed infants are
pally reflex activity to relatively sophisticated, yet messy, attempts less likely to be at risk for later overweight or obesity (Huh, Rifas-
at self-feeding. Because the infant’s gastrointestinal system continues Shiman, Taveras et╯al., 2011). A recent meta-analysis of 18 case
to mature throughout the first year, changes in diet, the introduction control studies provides high level evidence that the odds of a breast-
of new foods, and even upsets in routines can result in feeding fed infant dying of sudden infant death syndrome (SIDS) are far
problems. lower than those of infants never given breast milk, and that the pro-
Parents often have many questions and concerns about nutrition. tection is even stronger for infants who are exclusively breastfed
They are influenced by a variety of sources, including relatives and (Hauck, Thompson, Tanabe, et╯al., 2011). Mothers who breastfeed
friends who may not be aware of current scientific practices regarding need instruction and support as they begin. They are more likely to
infant feeding. To provide anticipatory guidance, the nurse must have succeed if they are given practical information (Table 5-2). Many
a clear understanding of gastrointestinal maturation and knowledge facilities provide lactation consultants or home visits, or nursing staff
about breastfeeding and various infant formulas and foods. Families may call to assess the mother’s needs. Significant others are included
and cultures vary widely in food preferences and infant feeding prac- in teaching to provide a support system for the mother.
tices. The nurse must remain cognizant of these differences when Increasing the percentage of infants who are exclusively breastfed
providing anticipatory guidance related to infant nutrition. is a goal of Healthy People 2020. Although 74% of infants in the United
States are breastfed at birth, the rate drops to 43.5% for infants in the
United States who are breastfed for 6 months, and the percentage goes
╇ NURSING QUALITY ALERT down to 22% for those who are breastfed for 1 year (United States
Department of Health and Human Services [USDHHS], 2010). The
Essential Information for Infant Nutrition percentage of infants who are exclusively breastfed for 6 months is only
╇ Pediatric Skills—Infant Feeding

Breast milk or commercially prepared iron-fortified formula provides optimal 14.1%. The goal is to increase the percentage of infants who are breast-
nutrition throughout infancy. fed for 6 months to over 60%, and those who are exclusively breastfed
Formula must be prepared according to instructions, and leftover formula for 6 months to 25.5% (USDHHS, 2010). To promote breastfeeding,
should be stored or discarded according to the manufacturer’s directions. the United Nations Children’s Fund (UNICEF) and the World Health
Some health care providers discourage the use of powdered formula until Organization (WHO) advocate that birth facilities become certified as
the infant is older than 6 weeks. “baby-friendly” hospitals, with policies to actively encourage mothers
to breastfeed. Guidelines to becoming certified as a baby-friendly hos-
pital emphasize educating staff and parents about breastfeeding;
encouraging early initiation of breastfeeding, demand feedings, and
Factors Influencing Choice of Feeding Method rooming-in; and avoiding use of formula and pacifiers. More informa-
╇ The AAP strongly recommends exclusive breastfeeding for the tion is available at The AAP has also
first 6 months of life for all infants, including premature and sick recently updated its website on breastfeeding and has information for
newborns, with rare exceptions (Gartner, Morton, Lawrence, and AAP parents and professionals ( In 2011,
Section on Breastfeeding, 2005). Breast milk provides complete the Surgeon General issued a Call to Action to Support Breastfeeding;
86 CHAPTER 5â•… Health Promotion for the Infant

╇ See Evolve for Inspection and Evaluation videos of the neonate.

╇ The Newborn to 1-Month-Old Infant

Focused Assessment
Ask the parent the following:
• How have you been feeling? Have you made your postpartum checkup
• How have you and your partner been adjusting to the baby? Do you have
other children? How are they adjusting?
• Have you discussed child-rearing philosophies?
• Does anyone in your household smoke cigarettes?
• Does anyone in your household use substances?
• Have you recently been exposed to or had any sexually transmissible disease?
• Have you experienced any periods of sadness or feeling “down”?
• Do you have any concerns about the costs of the baby’s care?
• Do you feel that you and the baby are safe?

Developmental Milestones
Personal/social: Looks at parent’s face; fixates, tracks, follows to midline; smiles
responsively; prefers brightly colored objects
Fine motor: Newborn reflexes present
Language/cognitive: Prefers human female voice: responds to sounds; begins to
Vitamin D supplement 400╯IU/day for breastfed infants and for formula-fed
Gross motor: Equal movements; lifts head; lifts head and chin (by 1 month)
infants if taking less than 1 liter (33 ounces) of formula a day
Place on right side after feeding
Health Maintenance
Physical Measurements Elimination
Weight: 7.5 to 8 pounds (3.4 to 3.6╯kg) average. Loses 10% of body weight after Six wet diapers
birth but gains it back by 2 weeks. Stools related to feeding method
Gains 12 ounce a day on average.
Length: Average 20 inches (50╯cm). Gains 1 inch (2.5╯cm) a month for the first Dental
several months. Continue prenatal vitamins and calcium if breastfeeding
Head Circumference: 13 to 14 inches (33 to 35.5╯cm). Gains average of 12 inch
(1.2╯cm) per month until 6 months of age. Posterior fontanel closes by 2 to 3 Sleep
months; anterior by 12 to 18 months. Place on back to sleep in parent’s room in a separate crib/cradle/bas-
sinet. Keep loose or soft bedding and toys out of the crib, offer pacifier
Immunizations for nap and bedtime if not breastfeeding.
Thimerosal-free hepatitis B #1 at birth and #2 at 1 to 2 months. Be sure to discuss 16 or more hours
side effects. Give the parent information about upcoming immunizations. By 1 month begin to establish nighttime routine
If planning to use a combination vaccine that contains hepatitis B, wait until 2
months for second hepatitis B.
Sponge bathe until cord falls off
Circumcision care, if applicable
Health Screening
Phenylketonuria and other metabolic diseases; cystic fibrosis Safety
Hearing screening Be sure crib is safe: Slats <2 3 8 inches apart, firm mattress that fits the crib
Visual inspection for congenital defects Eliminate all environmental smoke
Rear-facing approved infant car seat
Anticipatory Guidance Fire prevention: Smoke detectors, fire extinguishers
Nutrition Water temperature <120° F
Breast milk on demand at least every 2 to 3 hours Cardiopulmonary resuscitation and first aid classes; emergency phone numbers
Iron-fortified formula 2 to 3 ounces every 3 to 4 hours if not breastfeeding Violence: Discuss shaking, guns in the home
CHAPTER 5â•… Health Promotion for the Infant 87

information can be obtained at are expected to breastfeed and formula is not available in birth houses
breastfeeding/calltoactiontosupportbreastfeeding.pdf. (Callister, Getmanenko, Garvrish, et╯al., 2007). However, immigrants
Some parents prefer a combination of breastfeeding and bottle from countries where breastfeeding is the norm may breastfeed for
feeding. It is best to delay giving formula until lactation has been well shorter durations or not at all because they lack the support system
established at 3 to 4 weeks of age. Giving breastfeeding infants formula they had in their own country. Some of these women may think that
leads to a decrease in breastfeeding frequency and milk production, because formula is available in the hospital and they see American
making successful breastfeeding less likely (Committee on Health Care women using formula, it is the preferred method of feeding. They may
for Underserved Women, American College of Obstetricians and believe breastfeeding is inferior to formula feeding and that formula
Gynecologists [ACOG], 2007). However, if the mother chooses to feed will make their infants big and healthy (Hernandez, 2006). Nurses
both breast milk and formula, the nurse should educate and support must emphasize the superiority of breastfeeding and encourage these
her so the infant receives the benefits of breast milk at least part of the women to continue their cultural tradition of breastfeeding and cul-
time. tural practices that facilitate it. Nurses should be particularly watchful
Some mothers choose to give a bottle daily or only occasionally, for ways to help mothers from other cultures who might wish to
such as when a babysitter is caring for the infant. These mothers feel breastfeed but fail to do so because of lack of support.
this allows them to be away from the infant for longer periods of time Employment.  Women should be encouraged to continue breast-
yet allows the enjoyable closeness with the infant, as well as the physical feeding when they return to work. Because of the decreased incidence
advantages of breastfeeding, to continue. Mothers may choose to use of illness in breastfed infants, the mother is less likely to miss work to
breast milk or formula for occasional bottle feedings. take care of a sick infant. This is an advantage for the employer as well
Support from Others.  The influence of family members is often an as the breastfeeding family.
important determinant of whether mothers breastfeed. Some women Unfortunately, returning to work or school is a major cause of
choose not to breastfeed because their partner objects. The opinion of discontinuation of breastfeeding. The mother may choose formula
a woman’s mother or mother-in-law may also be important. The from the beginning, plan a short period of breastfeeding before
woman with little support or with active discouragement from her weaning the infant to formula, or use a combination of breastfeeding
family will probably have a difficult time nursing. Advice from friends and bottle feeding with breast milk or formula. Nurses who provide
who have breastfed may also influence the mother’s decision. practical information about options, breastfeeding and working,
Involvement of the fathers in infant care is important for some breast pumps, and storage of breast milk help a mother continue
families and some may feel it is only possible with feedings. Nurses breastfeeding for a longer period. Referral to a lactation consultant
can suggest other infant care measures, such as holding, rocking, can provide a mother with continued education and support after she
and bathing, that fathers can enjoy (AAP, 2011a). Educating family goes home.
members about the advantages of breastfeeding and how to deal with Other Factors.  Other factors may also influence a woman’s deci-
problems may lead to their encouragement of the breastfeeding sion. Her knowledge and past experience with infant feeding are
mother. Educating fathers about the benefits of breastfeeding as well important. Women who are most likely to breastfeed are Asian or
as techniques for coping with any difficulties that might occur is Hispanic and live in the western mountain or Pacific coast regions of
important. When fathers are knowledgeable and supportive, full the United States. Those with the lowest breastfeeding rates include
breastfeeding is more likely to continue longer (AAP, 2011a). Prenatal African-American women who live in the southern region of the
classes that include breastfeeding information have been shown to help United States (Centers for Disease Control and Prevention [CDC],
a woman decide to breastfeed and to successfully persist (Rosen, 2011a & 2011b).
Krueger, Carney, & Graham, 2008). This can lead to a higher rate of
exclusive breastfeeding with less use of formula. It can also increase a Normal Breastfeeding
woman’s satisfaction with the breastfeeding experience. Fathers should The pediatric nurse may encounter mothers of newborn infants on the
also attend the classes so they can provide increased support based on pediatric unit and therefore should have current knowledge of both
their knowledge (AAP, 2011a). advantages of breastfeeding and proper breastfeeding techniques.
Encouragement from the woman’s health care provider may be a Advantages.  Breast milk contains a more complete protein than
powerful influence in the woman choosing to breastfeed (Newton, cow’s milk–based formulas, is more easily digested, and results in more
2007). The support the mother receives from the nursing staff plays a rapid gastric emptying time. For this reason, infants who breastfeed
significant part in whether she feels comfortable with her chosen need to eat more frequently than do formula-fed infants. Breastfeeding
feeding method. Those who do not feel confident in their ability to is convenient, economical, and enhances mother-infant attachment
breastfeed before they leave the birth facility are less likely to continue and interaction.
breastfeeding if they encounter difficulties at home. Human milk changes to meet the changing nutrient needs of the
Peer support also may be important. Trained peer counselors have infant. Human milk and colostrum contain immunologic and antibac-
been effective in helping mothers breastfeed for longer periods without terial components not available in formula. Human milk is higher in
using formula. Peer counseling groups can be particularly helpful lactose, which is converted to monosaccharide galactose, essential for
because there is a social aspect to them that benefits new mothers as central nervous system development and growth.
they learn more and become confident about breastfeeding (“Peer The fat content of breast milk is higher in monounsaturated fat,
counselors,” 2011). which is more easily digested and absorbed than fat in formulas. The
Culture.  Cultural influences may dictate decisions about how and fat content varies during the feeding and the time of day. The milk
when a mother feeds her infant. For example, many Mormon women produced at the end of a feeding (hindmilk) and in the middle of the
believe that breastfeeding is an important part of motherhood. Muslim day has a higher fat content. Because the milk at the beginning of a
women often breastfeed for the infant’s first 2 years. feeding (foremilk) has less fat content than at the end, it is important
Immigrants to the United States often would breastfeed infants if that the length of feeding time be sufficient for the infant to derive
they were still in their own countries. For example, in Russia women benefits from the higher-fat hindmilk.
88 CHAPTER 5â•… Health Promotion for the Infant

Breast milk does not provide an adequate amount of vitamin D to hormone responsible for milk production), the more frequently the
prevent rickets and other vitamin D–associated conditions. Infants infant feeds, the better the mother’s milk supply.
who are exclusively breastfed need vitamin D supplementation to Breastfeeding Concerns.  Because they cannot visually observe the
prevent rickets. The AAP (Greer, Sicherer, Burks, & Section on Breast- amount of milk the infant is receiving, many mothers become con-
feeding & Committee on Nutrition, 2008) recommends vitamin D cerned that the infant is not receiving enough. The nurse assists the
supplementation of 400 International Units/day for all breastfed mother to observe the infant swallow during feeding. An infant who
infants and for formula-fed infants who consume less than 32╯ounces is receiving adequate milk will be gaining weight, appear satisfied after
of vitamin D–fortified formula a day. In addition to an insufficiency feedings, have at least six wet diapers a day (after the first week), and
of vitamin D in breast milk, breast milk also lacks iron and zinc. There have loose, golden (mustard color and texture) stools.
is some evidence that some infants use up maternal stores of iron Although infants are sleepier the few first days after birth, some
before the commonly accepted 6-month benchmark; this increases infants continue this pattern and need some gentle stimulus either to
their risk for iron deficiency (Baker, Greer, & AAP Committee on wake for a feeding or to wake up during a feeding. It is best to com-
Nutrition, 2010). The AAP now recommends supplementing the diet pletely remove the breast from an infant who has fallen asleep while
of exclusively or partially breastfed infants with 1╯mg/kg/day iron, nursing rather than jiggling the breast in the infant’s mouth. Excessive
beginning at 4 months of age and ending when the infant is able to sleepiness during feeding in an infant younger than 6 weeks may be
take complementary solid foods high in iron (e.g., iron-fortified cause for further evaluation.
cereals) (Baker, Greer, & AAP Committee on Nutrition, 2010). Because movement of the tongue is different between bottle feeding
Breastfeeding Techniques.  A breastfeeding mother can use one of and breastfeeding, it is best to avoid bottle feeding until the mother’s
several positions for feeding (see Patient-Centered Teaching: Guidelines milk supply is fully established. Some lactation specialists advise
for Breastfeeding). It is important for the infant’s head and body to be mothers to avoid pacifier use as well. The AAP Task Force on Sudden
directly facing the breast in a “tummy to tummy” position at a height Infant Death Syndrome (2005), states that evidence suggests that
that prevents pulling or tension on the nipple. Hand position for feeding giving an infant a pacifier for nap or night sleep may be protective
is important. Either a “C” position or a “V” position is acceptable. In against SIDS. It recommends that pacifiers be offered to all bottle-fed
the “V” position, the mother uses both forefinger and middle finger to infants and to breastfed infants older than 1 month (AAP, Task Force
lift and support the breast. Because suckling releases prolactin (the on Sudden Infant Death Syndrome, 2005).

The Case for Vitamin D
The American Academy of Pediatrics recommends that all breastfed infants give vitamin D supplements if strongly recommended by a pediatric provider and
should receive a daily supplement of 400╯IU of vitamin D. Infants, children, and significantly less likely to give the supplements if they believe that breast milk
adolescents who consume fewer than 32╯ounces of vitamin D–fortified infant provides complete nutrition to their child.
formula or whole milk (children older than age 1 year) also should receive supple- Evidence from multiple sources, as described in an in-depth systematic litera-
mental vitamin D because they are at risk for vitamin D insufficiency (Misra, ture review (Level V) by Misra et╯al. (2008), suggests that vitamin D insufficiency
Pacaud, Teryk, et╯al., 2008). The impetus for these recommendations, which are is related to two general issues: (1) the primary natural source of vitamin D is
updated from initial recommendations in 2003, was a near-doubling of the in ultraviolet light from the sun, and (2) infants and children consume inadequate
reported incidence and prevalence of children diagnosed with rickets in the nutritional sources of vitamin D. Use of sunscreen and other protective measures
United States between 1975 and 2003 (Misra et╯al., 2008). Rickets is a disease to reduce skin cancer risk from UV rays, along with decreased sun exposure from
that causes malformations in growing bone as a result of decreased bone outdoor play, can decrease the natural synthesis of vitamin D that occurs through
mineralization; vitamin D is one factor that affects the absorption and use of the skin. In addition, infants and children with dark skin are more at risk for
calcium for bone formation. Because of public health efforts to decrease the vitamin D insufficiency if they do not have appropriate vitamin D supplementa-
prevalence of vitamin D deficiency (e.g., fortifying foods) the prevalence of tion because of the UV protection from increased melanin (Misra et╯al., 2008).
rickets had markedly decreased; however, the more recent increase in identified Breast milk is the most nutritionally complete source of nutrition for infants,
cases of rickets has been a matter of concern to health professionals who care and exclusive breastfeeding for a minimum of the first 6 to 12 months is recom-
for children (Misra et╯al.). In addition, evidence is increasing that sufficient mended by the American Academy of Pediatrics. However, breast milk does not
vitamin D plays a role in the health of other body systems, as demonstrated by provide a sufficient amount of vitamin D to prevent rickets in exclusively breast-
the presence of vitamin D receptors in organs of the gastrointestinal, neurologic, fed infants or in infants, children, and adolescents receiving less than 32╯ounces
endocrine, and immune systems (Misra et╯al., 2008). of fortified formula or milk a day (Misra et╯al., 2008). Other nutritional sources
Several studies have suggested that parents of infants and children in the of vitamin D include oily fish, cod liver oil, and an assortment of fortified dairy
United States have low adherence to vitamin D supplementation recommenda- and cereal products, most of which are not appealing to children or adolescents
tions (Misra et╯al., 2008; Perrine, Sharma, Jefferds, et╯al., 2010; Taylor, Geyer, or are consumed in less than recommended amounts.
& Feldman, 2009). A recent observational (Level VI) study of providers and Because parents rely on health care professionals to provide evidence-based
parents in a northwest American city (Taylor et╯al., 2009) revealed that overall, information, think about the following: If a breastfeeding mother were to ask
parents are not giving breastfed infants vitamin D supplements. This study your advice about giving vitamin D supplements to her infant, how might you
demonstrated that parents of breastfed infants are significantly more likely to respond? What is your knowledge about vitamin D?

Misra, M., Pacaud, D., Teryk, A., et╯al., & Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. (2008). Vitamin
D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics, 122(2), 398-417; Perrine, C., Sharma,
A., Jefferds, M., et╯al. (2010). Adherence to vitamin D recommendations among U.S. infants. Pediatrics, 125, 627-632; Taylor, J., Geyer, L., &
Feldman, K. (2009). Use of supplemental vitamin D among infants breastfed for prolonged periods. Pediatrics, 125(1), 105-111.
CHAPTER 5â•… Health Promotion for the Infant 89

Guidelines for Breastfeeding
• Wash hands. Wash nipples with warm water, no soap. • Lying-down position: Lie on your side in bed with your infant lying on the
• There are three basic positions: side facing you.
• Cradle position: Cradle your infant in one arm, with the head resting in the
bend of your elbows. The infant’s mouth is close to the breast. You can
be sitting up straight in bed, with pillows supporting your back, or sitting
in a chair. Sometimes a pillow may be needed on your lap to elevate the
infant to the nipple level.

• Hold the breast so the nipple brushes the center of the infant’s lips and wait
for the infant to open the mouth.
• Your infant’s mouth should be opened wide, as with a yawn, and should cover
the entire areola, or a large amount of the areola. If necessary, apply pressure
• Football hold: A pillow is needed to be successful with this position. Sit to your infant’s chin with your index finger to open the infant’s mouth wider.
in a chair and place a pillow next to you on the nursing side. The pillow Your breast needs to be placed far back into the infant’s mouth to drain the
supports the elbow and your infant’s buttocks and should bring your breast adequately. Your hand position is important: Hold your hand in a “C”
infant’s head up to the level of your breast. position around your breast with the thumb on top behind the areola and the
fingers against the chest wall and supporting the underside of the breast.

• Both breasts are used in each feeding, usually 10 to 15 minutes on the first
side, followed by burping before beginning the second side. The length of
time on the second side is related to the quality of the infant’s suckling. At
the next feeding, your infant starts to feed on the breast used to finish the
preceding feeding.
• Break suction by placing your finger in the corner of your infant’s mouth and
quickly remove your breast.
• The neonate is nursed shortly after birth and approximately every 2 to 3 hours
thereafter for a total of 8 to 12 feedings a day.
• Infants should be burped after each breast and at the end of the feeding.
• Nipples often become tender during the first week of nursing but should not
become sore. Soreness and prolonged feedings are most often the result of
an infant who is not latched onto the breast properly.
90 CHAPTER 5â•… Health Promotion for the Infant

for their infant. A variety of bottles and nipples are available; the type
chosen is based on parent preference.
MILK Ready-to-use.╇ Ready-to-use formula is available in bottles to which
• Milk may be stored for 24 hours in the refrigerator (colder than 39° F [4° a nipple is added or in cans to be poured directly into a bottle. It should
C]), up to 1 month in a freezer compartment that has a separate door from not be diluted. Although expensive, it is practical for traveling, when
the refrigerator, or up to 6 months in a deep freezer (AAP, 2010). there is difficulty mixing the formula, or the water supply is in question.
• Containers, either glass or plastic, used to store breast milk should have a An open can should be refrigerated and used within 48 hours.
tight cap and should be sterile. Concentrated liquid.╇ Explain to the parents how to dilute concen-
• Freeze in amounts that are likely to be used for one feeding and discard trated liquid formula. Equal parts of formula and water are mixed
any unused portion. Be sure to mark each container with the date and use together in a bottle to provide the amount desired for each feeding.
the oldest first. Opened cans should be stored in the refrigerator and used within 48
• To thaw breast milk, either thaw in the refrigerator or by holding under hours (Janke, 2008).
cool, running water. Breast milk remains safe if kept in the refrigerator and Powdered formula.╇ Powdered formula is more economical and is
used within 24 hours of thawing. particularly useful when a breastfeeding mother plans to give an occa-
sional bottle of formula. Usually one scoop of powder is added to each
2 ounces of warm water in a bottle. Single-portion packets of powder
are available for travel. Formula should be well mixed to dissolve the
Milk Storage.  Many mothers choose to pump and store breast powder and make the solution uniform. New formula should be pre-
milk, either because they have returned to work or want to keep a pared for each feeding.
supply on hand so others may feed the infant. Expressed breast milk Although commercially prepared formulas have many similarities,
is relatively free from bacterial contamination, but it can become con- there are also differences. Some commonly used brands are Enfamil,
taminated when artificially collected and stored. Hands and collection SMA, Similac, Gerber, and Good Start. There are formulas specifically
equipment should be clean and the expressed milk stored appropri- designed for infants older than 6 months, but it is not necessary to
ately (Box 5-4). Expressed milk not used within 24 hours should be change to a different formula when a child reaches that age. Some
frozen; thawed milk should not be refrozen. formulas are designed for feeding low-birth-weight or ill infants. These
include high-calorie formulas and predigested formulas (e.g., Pre-
Formula Feeding gestimil, Neutramagen).
Formula given by bottle is a choice selected by many women in the Many different types of bottles and nipples are available. Mothers
United States. This method is often easier for the mother who must may use glass or plastic bottles or a plastic liner that fits into a rigid
return to work soon after her infant’s birth, and it has the advantage container. Some nipples are designed to simulate the human nipple to
of allowing other members of the family to participate in the infant’s promote jaw development. Selection of the type of bottles and nipples
feeding. Infant formula does not have the immunologic properties and depends on individual preference.
digestibility of human milk, but it does meet the energy and nutrient Formula Preparation.  The parent can prepare a single bottle or a
requirements of infants. If bottle-feeding is chosen as the preferred 24-hour supply. If the water supply is safe, sterilization is not necessary.
feeding method, the formula should be iron fortified. The Infant If there is any possibility that the water supply is not safe, water should
Formula Act of 1980, which was revised in 1986, establishes the stan- be boiled or sterile, bottled water should be used. Bottles and nipples
dards for infant formulas. It also requires that the label show the can be washed in hot, sudsy water using a brush to clean well and then
quantity of each nutrient contained in the formula. Special formulas rinsed and allowed to air-dry. Bottles may be washed in a dishwasher,
are available for low-birth-weight infants, infants with congenital but nipples tend to deteriorate quickly unless washed by hand. Instruct
cardiac disease, and for infants allergic to cow’s milk–based formulas. the mother to wash her hands, as well as the top of the can and the
There are some physiologic reasons why some mothers choose to use can opener. The formula and water are poured into the bottles, which
formula. Infants with galactosemia or whose mothers use illegal drugs, are then capped. Emphasize that the proportion of water and liquid or
are taking certain prescribed drugs (e.g., antiretrovirals, certain chemo- powdered formula must be adhered to exactly to prevent illness in the
therapeutic agents), or have untreated active tuberculosis should not be infant.
breastfed (CDC, 2009). In the United States and other countries where Explain that if safety of the water supply is questionable, steriliza-
safe water is available and breastfeeding is culturally acceptable, women tion, by aseptic or terminal method, is required. In both methods, all
who are infected with HIV should avoid breastfeeding (AAP, 2009). equipment is washed and rinsed well before beginning.
Cow’s Milk.  Cow’s milk (whole, skim, 1%, 2%) is not recom- In the aseptic method, equipment needed for the procedure is
mended in the first 12 months. Cow’s milk contains too little iron, boiled for 5 minutes in a sterilizer or deep pan. Water for diluting the
and its high renal solute load and unmodified derivatives can put formula is boiled separately. The bottles are then assembled, using
small infants at risk for dehydration. The tough, hard curd is difficult sterilized tongs to avoid contamination by the hands. The formula and
for infants to digest. In addition, skim milk and reduced-fat milk boiled water are added, and the bottles are capped and refrigerated
deprive the infant of needed calories and essential fatty acids. The until needed.
incidences of allergy and iron deficiency anemia are higher in infants In the terminal sterilization method, the formula is placed in clean,
who are given cow’s milk than in those who receive breast milk or loosely capped bottles. The bottles are then placed in the sterilizer or
formula. pan of water and boiled for 25 minutes. After the bottles cool, the caps
Types of Formula.  Formula can be purchased in three different are tightened and the bottles refrigerated.
forms—ready-to-use, concentrated liquid, and powdered. With the Formula-Feeding Techniques.  It should not be assumed that
exception of the ready-to-use formula, all need to have water added to parents know how to bottle feed an infant. The nurse may need to teach
obtain the appropriate concentration for feeding. Storage instructions them how often and how much to feed, how to hold and cuddle while
differ, so nurses need to strongly encourage parents to carefully follow feeding, when and how to burp, and how to prepare formula. The
the directions for storage of the specific type of formula they are using nurse demonstrates to the mother how to position the infant in a
CHAPTER 5â•… Health Promotion for the Infant 91

Behaviors that might indicate a readiness to begin weaning include

the following:
• Throwing the bottle down