Current Trends in Child Health Care

Introduction:

Historically, the concept of pediatrics was limited to the curative aspects of diseases
peculiar to the children. Hippocrates (460-370 BC) made many significant observations on
disease found in children and devoted a great part of his treatise to children. The first printed
book on pediatrics was in Italian (1472) by Bagallarder’s “Little Book on disease in
children”. The first English book on children’s diseases was “Book of Children” written by
Thomas Phaer.

The world’s first pediatricians were two Indians, Kashyapa and Jeevaka, of sixth
century BC. Their pioneering works on child care and childhood diseases are as relevant
today as many of the modern concepts of child health. Sushruta, also wrote many aspects
of child rearing and Charaka wrote about care and management of newborn. This is all
about the trends in child health care in the ancient time. But in the recent hears child
health care has changed dramatically due to advances in medical knowledge and
understanding of emotional responses of children.

Current trends in Child Health Care:

Modern concept of child health emphasizes on continuous care of “Whole Child”.

According to UNICEF, assistance for meeting the needs of children should no longer be
broad based and geared to their long-term personal development ensuring holistic health
care of children.

At present, in child health care more emphasis given on preventive approach rather
than curative care only. Primary health care concept with team approach and
multidisciplinary collaboration are adopted for child care. The challenge of this time is to
study child health in relation to community, to social values and social policy. Increased
public awareness, consumerism and family participation in child care are newer trends.

Family health, a new concept is accepted for the care of children in their families and
families in society. Need based, problem oriented, risk approach care is practiced for
better child health.

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 In developed countries child health care extended up to adolescent, whereas in
developing countries and in India, child care is extended up to 10 to 12 years of age.
Recently special emphasis is given on adolescent health through RCH packages services
in our country. Special attention is given on the children at-risk like, orphans, destitute,
disastrous, pavement dwellers, slum dwellers, child labors and handicapped children.
Movement against gender bias, female feticide, child abuse and neglect and maltreatment
are in highlight at present.

Interest of the political leaders and understanding the importance of child health,
construction of national health policy for children and implementation of various health
programs for improvement of child health are great achievements for children. Population
control and family welfare approach, improvement of educational status specially women
education and women empowerment, involvement of Govt. and Non-Govt. organizations,
political commitment and special budgetary allocation for child health activities,
international guidance by WHO, UNICEF and other child welfare organizations for
improvement of child health are promising aspects towards survival, health and well
being of children.

Growth of sub-specialties for the super-specialized care of children is recent trend.

The sub-areas are neonatology, peri-natology, pediatric surgery, pediatric cardiology,
pediatric neurology, pediatric hematology, pediatric nephrology, preventive pediatrics,
child psychology, child psychiatry, pediatric intensive care units, neonatal intensive care
units etc.

Provision of care

1. Self care: Self responsibility concept for maintaining high-level wellness is of

prime importance in the role of the nurse.

According to Orem (1980), self care are the those activities an individual initiates and
carries out for self to maintain life, well-being and health. The human being has an innate
ability for self-care and is capable of natural behaviour designed to maintain or promote
health. The nurse then monitors and supports their self care efforts and helps them to
become responsible for their own lives.

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 2. Child initiated care: In the past, pediatric care was essentially parented especially
mother centred and the child assumed a passive role in that care. The children who have a
health problem, the newer approach has been proposed by Lewis (1974) a former school
nurse, she believes that children of elementary age and older not only can help to decide
what their health problems but also can participate in deciding what should be done for
them.

3. Support or Self help group for parents and children: Families are more mobile
than in the past years and parents find themselves isolated from their own parents and
family members.

Parent groups may be highly or loosely organized. They may have professional
assistance; parents who are emotionally distressed over a problem relating to their child
may have a telephone support service. Groups of parents who share problems also have
been organized with in the hospital setting. The purpose of these groups is to recognize
the crisis of illness the family is experiencing and to provide reassurance and emotional
support for family members. These groups are generally coordinated by a nurse.

4. Home Health Care: Early discharge of maturity patients, neonates and children
from hospital units as a result of diagnostic related grouping, care of the children
following surgical or other procedures in ambulatory settings and the children are not all
enough to be admitted to a hospital necessitate “Home care”. Because consumers are
demanding the better and less expensive health care and increased participation in
decision making process.

Nurses from home health care and public health nursing agencies also visit the home
to assist parents in nursing care of their child and to teach the use of special equipment
that may be necessary.

Changing Role of Pediatric Nurse

Present concept of pediatric nursing is within the framework of the definition of

nursing. Nursing is committed to serving the patient and helping him to meet his health
needs. There has been shift from traditional role to process oriented role.

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 The changing focus of the pediatric nursing or current trends in pediatric nursing
today is,

Shift From Focus On

a) Disease centred care a) Child centred care

b) That of discouraging the families b) Taking special care of the female

on neglect of the female child child as she is the future mother.
Immunization of all girls for tetanus
and rubella before marriage

c) Starting care for the woman after c) Health education on planned

she become pregnant parenthood and guarding the maternal
health before conception

d) Special care during the last d) Early identification and family

trimester and the postnatal period to counseling based on biochemical
the child born with congenital screening and chromosomal studies to
anomalies and hereditary disorders prevent congenital anomalies and
hereditary disorders in children.

e) Only caring for the child after the e) Guarding the health of the child from
birth of the child the day of conception.

f) Only care to the sick children in the f) The participation in prevention of

hospital illness, health promotion activities.

g) Caring of the physical condition of g) Comprehensive care of the child in

the child in isolation. relation to his home and community in
which he lives and providing emotional
support to the family.

h) Not allowing the parents to be with h) Ensuring that children must have one
the child in the hospital and rigid parent stay with them in the hospital
visiting hours. and participate in the care. Flexible
visiting hours in children wards.

i) One of illness oriented i) One that is health oriented.

j) Only cleanliness and treatment j) Warmth and love oriented providing

oriented. (rocking, cuddling) tactile stimulation
to the infants.

k) Only curative and rehabilitative to k) Health promotion activities

the children in the hospital. including environmental stimulation,
intelligent manipulation of the
environment, play activities, services
related to fertility, sex education and

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 counseling.
l) The concept of pediatrics as infant
feeding and care of a few diseases of l) The comprehensive care of the child
children. from conception to maturity.

m) Adapting indifferent attitude to

child neglect and abuse by family and m) Safeguarding and protecting the
society. children’s rights by healthy cultural
practices and encouraging laws.

Conclusion:

Medical science is advancing in every moments. So child health will also progress by
various movements towards the aims to improve the survival and well being of all
children, as per one of the WHO theme, “Healthy mothers and healthy children.”

TRENDS IN PEDIATRICS & PEDIATRIC NURSING

INTRODUCTION:-
Pediatric has the greatest scope of prevention of diseases and promotion of health.
Unfortunately this component has not received adequate emphasis it deserves. Today every
nurse in basic nursing training programme should receive training in preventive and
promoting health.

TRENDS OR MILESTONES OF THE PEDIATRIC DEPARTMENT

1958 : Foundation of the Department of Pediatrics.

1958- Normal neonates were looked after by Obstetric department. Sick
1968 : Neonates were looked after by Pediatric department.
1968 : Pediatric department took charge of normal neonates.
1970 : Establishment of separate neonatal care unit next to post-natal ward.
1977-
High risk newborn OPD services started for follow up of nursery graduates.
1978 :
1985 : Dr. S. F. Irani - Professor of Pediatrics took charge of Neonatology division
1990 : Level II Neonatal Care Unit established on the 10th floor of New
M.S.Building at K.E.M Hospital.
1992 : Level III Neonatal Intensive Care Unit (NICU) established.
1994 : Division of Neonatology was separated from parent Department of Pediatrics

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 and started functioning as full - fledged Neonatology department.
Recognition of the department for DM (Neonatology) degree course by
University of Mumbai.
Dr. R.H. Udani - Prof. of Neonatology took charge of the Dept. of
1995 :
Neonatology
Mothers allowed to enter into NICU and Humane Neonatal Care approach
2000 :
initiated.
2001 : Creation of Mothers' resting place 'Vatsalya' (Donation received from
BidadaSarvodaya Trust, Mumbai) Initiation of Kangaroo Mother Care for
LBW infants
2002 : Creation of Seminar room 'Gyandeep' (Donation received from
MatushriJekuvarbaDoshi Trust, Rajkot)
2004 : Dr.Ruchi N. Nanavati, Prof of Neonatology took charge of the Dept. of
Neonatology
2005 : Establishment of Human Milk Bank (Donation received from Inner Wheel
Club of Bombay)
2005 : Establishment of Ambulatory Kangaroo Mother Care Center (Donation
received from 'Saving Newborn Lives', an initiative led by 'Save The
Children- (USA)' with support of the Bill & Melinda Gates Foundation

Major causes of global under-five mortality WHO world health statistics, 2007:-

Chart Title
11% Pneumonia
19%
Diarrheal disease
Measles
Malaria
HIV/AIDS
Injuries
17% Neonatal diseases
36%
Others

3%
8%
3% 3%

TRENDS IN PAEDIATRIC NURSING OR SPECIALIZED FIELD OF NURSING:-

Neonatology:-

It may be interesting to note that 40 years back, there were no specialised units for the
care of low birth weight babies or special care units of the new born, with the result that even
in some of the best private hospitals the nurses were not trained in simple procedure like
gavage feeding for low birth weight babies or neonates who were ill. It was with this idea that
the special care units for the new born were started at institute of child health J.J Hospital,

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Bombay in 1961 in spite of tremendous constraints resources. However, once the special care
unit was stated, it improved gradually to build up the necessary care to the neonates, low
birth weight babies as well as proper training to large number of nursing and other personnel.
Today all the nurses are posted in such a special neonatal units so that universal training care
of the low birth weight babies and procedure like gavage feeding is done. This is an example
of unit in a developing country where one starts with tremendously adverse conditions but in
course of time with hard work something can be developed for the good of the low birth
weight babies. However, one should be satisfies at the general care of the newborn but today
we have specialised intensive unit for high risk babies.

Neonatal Intensive Care Unit:-

Though neonatal intensive care unit (NICU) have a role of continuous monitoring and
care of the high risk new born. In NICU, a baby resuscitative room is part and parcel of the
unit. This room is equipped with as suction pump, oxygen cylinders, artificial respiration,
radiant heaters, and special equipment of the immediate care of the new born. Close
collaboration of obstetrician. Paediatrician, highly trained nursing personnel and specialist
from various disciplines are necessary for specialised training of nurses in this vital field of
perinatal medicine. Improved special care will lead to lowering of maternal and perinatal
mortality, better start and quality of life for children and greater receptivity of family
planning methods.

Neonatal Intensive Care Unit (NICU) of the future:-

A NEW "LEARNING" MODEL FOR NEONATES COMBINING FAMILY-CENTRIC

CARE AND CUTTING-EDGE TECHNOLOGY, NON-INVASIVE MONITORING, AND
TESTING

The NICU of the Future project goals will design a NICU that incorporates the following:

 Family-centered care
 Developmentally-appropriate care for vulnerable newborns
 Smart workplaces
o Operationally efficient

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 o User-friendly for medical/hospital staff
o Ability to adapt to evolving health care practices
 Minimally-invasive, state-of-the-art technology
 A data-based "living laboratory' for translational research
 Telemedicine enabled for local, national and international consultation and education

Intensive Respiratory and Cardiac Care Unit:-

These should be two separate sections for such unit; one width is infectious and
second for non-infectious diseases.

Air pollution exacerbates the condition of people with respiratory and cardiovascular
diseases and causes measurable increases in the rates of hospitalization for these
diseases.Cardiovascular and respiratory diseases are among the leading causes of death.

Intensive Respiratory Care Unit:-

There are number of children with respiratory paralysis due to paralytic poliomyelitis.
Large number of infant with bronchiolitis and respiratory failure require intensive care.
Though the incidence of diphtheria has come down in the recent past. There are a significant
number of cases of laryngeal diphtheria with respiratory obstruction and often mortality in
such children was high. However, still, infection of the respiratory tract particularly acute
laryngo-tracheo bronchitis that may need intensive respiratory care. It is in such intensive
respiratory or cardiac care units that special students on blood gases, serum electrolytes and
other studies to assess the respiratory or cardiac function may be required periodically. Also
monitoring of blood pressure, cardiac function or biochemical changes required frequently
can be done in such unit. Through trained doctors in the intensive care units are necessary, it
is equally important if not more so, to have specially trained nurses in paediatric who can
carry out this work under supervision. A good intensive respiratory or cardiac care can be
provided by nursing personnel. However, they are required to be given adequate training both
in theoretical as well as practical aspect in such critical care units.

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* Respiratory disease classifications according to the International Classification of
Diseases, Ninth Revision, Clinical Modification codes 460--519.

In 2005, approximately one fourth of the 2.4 million hospitalizations for children aged
<15 years were for respiratory diseases, the largest category of hospitalization diagnoses in
this age group. Of these, 31% were for pneumonia, 25% for asthma, 25% for acute bronchitis
and bronchiolitis, and 19% for other respiratory diseases, including croup and chronic disease
of tonsils and adenoids.

Intensive cardiac care unit:-

Today most of the children with congenital heart disease can at the large number of
centres in our country. It may be desirable to have special paediatric training to look after
these newborns, infants or children who have undergone cardiac surgery. It is irony of fate
that often major heart operation is done on a baby by an expert surgeon and child because of
lack adequate intensive cardiac care. Both the export surgical and nursing care is equally
important components for successful result.

Comprehensive Care Team: -

Our team includes medical, surgical, and support staff--specialists who are highly
skilled in caring for children with serious heart disease. Paediatric cardiac intensive care team
members include:

 Cardiac intensivists (doctors who specialize in paediatric cardiac critical care)

 Cardiac surgeons
 Cardiologists
 Cardiac anesthesiologists
 Critical care and cardiac nurses
 Respiratory therapists
 Pharmacologists
 Nutritionists
 Child life specialists

In most cases, there is a one-to-one ratio of nurses to patients. In some very critical
cases, two nurses will care for one patient.
Key Services and Features:-

When we designed our paediatric cardiac intensive care unit, we planned for the latest
technology while being mindful of a child's need to stay in a comfortable, child-centered
environment. The unit is conveniently located close to the paediatric cardiac surgery
operating room and catheterization suite, ensuring smooth transport to and from procedures.

Intensive Labour Care Unit (ILCU):-

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 Evidently training of nursing in such a unit is of vital importance because by
improving care during labour will bring down the rate of maternal complication and mortality
as well as morbidity and mortality of the new born. Moreover proper care will prevent the
damage to brain which lead to prevention will of late effect which may result in behaviour
disorders and learning disability.

However training in such a unit has to be done at the tertiary care level where
sophisticated equipment and highly skilled personnel are available like obstetricians,
paediatricians, anaesthetists, and those trained in diagnostic and prognostic tool like foetal
monitoring and ultrasonography. One trained, nursing personnel by experience and training
may be able to help the medical personnel at second level care.

Care in such a unit is specially targeted at those groups of mothers in whom strenuous
and prolonged labour can be harmful to the mother or the child. Moreover ILCU finds its
specific uses in cases of deficiencies that have gone uncorrected during the pregnancy period
such as severe anaemia, diabetes or heart problems, severe bleeding or in case of complicated
labour which carry the risk of either uterine rupture or very high risk baby. Almost 20%
pregnant women in India fall in the high risk rate of category. In Wadia hospital in Bombay,
7% of cases in the labour room have been referred as emergency admissions. Moreover, the
ILCU will be very useful in reducing maternal and infant death. For example, maternal
morbidity rate is 1 per 100 deliveries and 1/3 rd of total death in infant occur at the time of
labour or delivery. In such a unit, close monitoring of the high risk mother can be carried out
during labour and delivery and special care instituted in time. This can be done by the use of
foetal monitor, ultrasound machine etc. The nurses can be trained to assess, help and study
such monitoring.

Pediatric Intensive Care Units:-

Over and above care for very high risk neonates, it is essential to develop various
intensive paediatric care units to improve the services and training of nursing and other
personnel and medical students. In paediatrics, emergencies are most commonly encountered
and have to be treated. If adequate treatment cannot be given in time. The mortality is very
high. If the little child is given help in the time there is high and rapid recovery.

Services Offered & Conditions Treated

 Congenital anomalies   
 Respiratory system  
 Injury and poisoning  
 Nervous system     
 Circulatory system   
 Perinatal conditions   
 Endocrine, nutritional and metabolic conditions
 Infectious and parasitic diseases
 Digestive system    

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  Neoplasms    
 Blood and blood-forming organs 
 Musculoskeletal system  
 Genitourinary system   
 Residual codes    
 Skin and subcutaneous tissue  
 Ill-defined conditions  
 Mental disorders

Fetal surgery

While most prenatally diagnosed malformation is best managed by appropriate

medical and surgical therapy after birth, a few require or benefit from correction before birth.
Extensive experimental works in animals and innovative technologic developments have
made fetal surgery a viable approach to perinatal care. At present, only a few life-threating
malformations have been successfully corrected. Additional research into the abnormal
function of some malformations, the development of less interventional techniques, and fetal
stem cell transplantation should lead to successful treatment of more fetal disorders.

Although only few fetal defects are amenable to surgical treatment at present, the
enterprise of fetal surgery has produced some unexpected spin-offs that have interest beyond
this narrow therapeutic field. More recently the development of video endoscopic techniques
allows fetal manipulation without hysterotomy, greatly extending the indications for fetal
surgery. Many innovative techniques developed for fetal surgery – radiotelemetric
monitoring of the fetal elecrocardigram and uterine contractions, for instance – may prove
useful in managing other high-risk pregnancies.

Maternal outcome with open fetal surgery

Variable Medium Range
Maternal age year 26 18-43
Gestational age of fetus, wk 24.2 17-28
Operative time, total, min 127.4 69.182
Operative time, fetal repair, 34 10-92
mim
Blood loss, ml 455 150-1,400

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Fetal malformations that interfere with development and may be surgical ameliorated before Birth
Fetal defects Effect on development (rationate for treatment) Treatment
Effect Likely result
Life threatening
Urinary obstruction Hydonephrosis lung Renal failure pulmonary Percutaneous catheter
hypoplasia failure placement,
videofetoscopicvesicostomy,
open vesicostomy
Cystic adenomatoid Lung hypoplasia or Hydrops and death Open pulmonary lobectomy
malformation hydrops
Diaphragmatic hernia Lung hypoplasia Pulmonary failure Open repair; temporary
tracheal occlusion
Sacrococcygealteratoma High-output failure Hydrops and death Rescenttrumor,
videofetoscopic vascular
occlusion
Twin-twin transfusion Vascular steal through Hydrops and death Open fetectomy;
syndrome placenta videofetoscopic division of
placenta
Complete heart block Low-output failure Hydrops and death Percutaneous pacemaker;
open pacemaker
Aqueductal stenosis Hydrocephalus Brain damage Ventriculoamniotic shunt;
open ventriculopritoneal
shunt.
Pulmonary artery or Ventricular hypertrophy Heart failure Percutaneous valvuloplasty;
aortic obstruction open valvuloplasty
Tracheal atresia or Overdistension by lung Hydrops and death Videofetoscopic
stenosis fluid tracheostomy, open
tracheostomy
Not life threateninh
Myelomeningocele Spinal cord damage Paralysis, neurogenic Videofetoscopiccoverage;
bladder open repair
Cleft lip and palate Facial defect Persistent deformity Videofetoscopic repair;
 open repair
Metabolic or cellular
Stem cell or enzyme Hemoglobinopathy Anemi, hydrops infection Fetal stem cell transplant; or
defects immunodeficiency retardation gene therapy using fetal
storage disease stem cells
Predictable organ failure Hypoplastic heart, Neonatal heart, kidney, or Induce tolerance for
kidneys, or lung lung failure. postnatal organ transplant
using fetal stem cells
Family – Centered Care:-

All health care professionals recognize that quality health care of children must extend to
the entire family. Thus the focus of paediatric nursing must be on the child as well as the family.
The term family-centered care describes a philosophy of care that recognizes the centrally of the
family in the child’s life and inclusion of the family’s contribution and involvement in the plan
for care and its delivery. It is a healthy care delivery model that seeks to fully involve families in
the care of children. Family-centerd care evolved in response to the critical need to maintain the
relationship between hospitalized child and their families. Previously this relationship has been
neglected or disrupted because of forced separation by the health care system.

The elements of family-centered care are based on principles that are designed to
promote greater family self-determination, decision-making capabilities, control, and self-
efficiency. Collectively, these attributes are said to reflect a sense of empowerment. In contrast,
the medical model directs health care professionals to assume the role of evaluator and controller
of treatment interventions. This approach results in child and caregiver dependence on the health
care providers. This position is in direct conflict with conditions necessary for more active
involvement of caregivers in the care of their health-impaired children. Many health care
provider respect and support the idea of family-centered care.

Atraumatic Care:-

A traumatic care as a philosophy of providing care that minimizes of eliminates physical

and psychological distress for children and families in the health care environment. In paediatric
care, many interventions are traumatic, stressful, and painful; therefore, it is important for nurses
to be cognizant of these situations and provide care that minimize distress.

Three principles provide the basis for traumatic care:

1. Identifying stressors for the child and family.

2. Minimizing separation of the child from caregivers, and
3. Minimizing or preventing pain.

Home Health Care:-

Early discharge of maternity patients, neonates and children from hospital units as a
result of diagnostic related grouping the care of children following surgical or other procedures
in ambulatory setting and the care of children who are not ill enough to be admitted to a hospital
necessitate home care. Because consumers are demanding better and less expensive health care
and increased participation in the decision making processes that accompany it, home care
system.

Nursing personnel in maternity, pediatric, and ambulatory care units, as well as those in
hospital based home care departments and home health care and public health agencies, are
assuming responsibility for teaching the parents or child how to provide this care. Nursing in
hospitals are also obtaining the information and skills required to teach long term care in the
home.

Nurses from home health care and public health nursing agencies also visit the home to
assist parents in nursing care of their child and to teach the use of special equipment that may be
necessary. During home visit, informal assessment can be made and interactions between the
child and parents and be observed. In rural areas nurses may use mobile units to provide an
easily accessible place for screening and evaluating children and a convenient setting in which
groups of parents can meet and share experiences.

The Nurse Parent Support Tool Manual:-

The Nurse-Parent Support Tool (NPST), which was designed to measure parents’
perception of nursing support during their child’s hospitalization.

Focus of the Instrument

The nursing staffs, both individually and as a group, provides an important environmental
context for the parents of children who are hospitalized for an illness. During the period of acute
illness and hospitalization, the environment created by the nursing staff defines a large part of
the reality for parents. Nurses control contact with and interaction with the sick child, provide an
important channel of information, and have ongoing interactions with parents

Conceptual Model for the Instrument

Thus, the nursing perspective behind the development of the NPST is that pediatric
nurses caring for sick children should have as a primary goal that of providing a supportive
relationship with parents that helps them cope with their child’s illness and hospitalization. The
NPST was developed from a nursing support model based on House’s conceptual definitions of
social support (1981). Social support, which has been a focus of research for decades, generally
focuses on the assistance provided by individuals who are part of one’s ongoing social network;
professional interventions are not usually conceptualized as part of one’s support network
(Hupcey& Morse, 1997). However, the concepts used to define social support have relevance to
professional intervention. More specifically, the all-encompassing aspects of social support
identified by House (1981) incorporate many areas of interpersonal support that are provided by
nurses to patients and families. Thus, a Nurse Parent Support Model was developed based on
House’s conceptualizations of support. This nursing support model, however, does not
conceptualize nursing support as similar to or a replacement for social support (Hupcey& Morse,
1997). Rather, nursing support is conceptualized as professional support and the Nurse Parent
Support Model views the professional support provided by nurses to parents during a child’s
hospitalization as a vital component of nursing practice.

Another advantage is the diversity of functions a group can serve. The Parent Support
Groups module developed by the California State Department of Education lists the following
functions of a Parent Support Group:

 Provide on-going support

 Help in time of crisis
 Reinforce positive coping behaviors
 Help focus anger and use its energy in positive ways
 Share information, ideas and resources
 Provide training for parents to increase skills
 Help in dealing with educational, medical and other service agencies
 Give an opportunity to relieve loneliness and form new friendships.

Pediatric Genetic Counselling

Genetics clinics serve children, adults and their families with known or suspected genetic
conditions and birth defects. Some clinics serve both children and adults whereas others serve
primarily children (pediatric genetics clinics) or adults (adult genetics clinics). A team of
physicians and genetic counselors are available to assist in finding a diagnosis and providing
support and help for those with any genetic condition. Some families start out in a general
genetics clinic and, if a diagnosis can be made, they then may be referred to a specialty clinic.
Some general genetics clinics provide outreach services to rural areas. If you are far from
a major medical center, contact your nearest center and ask about outreach programs. Some
outreach programs also specialize in prenatal services, in addition to the same genetic
consultation services provided in a general clinic.

Play therapy:-

The purpose of Play Therapy TM, a quarterly professional publication produced by the
Association for Play Therapy (APT), is to publish and disseminate clinical articles, critical
reviews, and other news and information to the general public and mental health professionals.
Critical reviews of play therapy books, audio/video programs, and games are included not to
market a particular product but to help play therapists select those materials that increase their
play therapy knowledge or practice.
The process of play therapy

Given the opportunity, children will play out their feelings and needs in a manner or
process of expression that is similar to that for adults. Although the dynamics of expression and
the vehicle for communication are different for children, the expressions (fear, satisfaction,
anger, happiness, frustration, contentment) are similar to those of adults. Children may have
considerable difficulty trying to tell what they feel or how their experiences have affected them.
If permitted, however, in the presence of a caring, sensitive, and empathetic adult, they will
reveal inner feelings through the toys and materials they choose, what they do with and to the
materials, and the stories they act out. The play therapy process can be viewed as a relationship
between the therapist and the child in which the child utilizes play to explore his or her personal
world and also to make contact with the therapist in a way that is safe for the child. Play therapy
provides an opportunity for children to live out, during play, experiences and associated feelings.
This process allows the therapist to experience, in a personal and interactive way, the inner
dimensions of the child's world. This therapeutic relationship is what provides dynamic growth
and healing for the child. 

Because the child's world is a world of action and activity, play therapy provides the
therapist with an opportunity to enter the child's world. The child is not restricted to discussing
what happened; rather, the child lives out at the moment of play the past experience and
associated feelings. If the reason the child was referred to the therapist is aggressive behavior,
the medium of play gives the therapist an opportunity to experience the aggression firsthand as
the child bangs on the Bobo or attempts to shoot the therapist with a gun and also to help the
child learn self-control by responding with appropriate therapeutic limit-setting procedures. 

Without the presence of play materials, the therapist could only talk with the child about
the aggressive behavior the child exhibited yesterday or last week. In play therapy, whatever the
reason for referral, the therapist has the opportunity to experience and actively deal with that
problem in the immediacy of the child's experiencing. Axline (1947) viewed this process as one
in which the child plays out feelings, bringing them to the surface, getting them out in the open,
facing them, and either learning to control them or abandon them. 

Play therapy research and results

Play therapy is not an approach based on guess, trial and error, or whims of the play
therapist at the moment. Play therapy is a well-thought-out, philosophically conceived,
developmentally based, and research-supported approach to helping children cope with and
overcome the problems they experience in the process of living their lives. Play therapy has been
demonstrated to be an effective therapeutic approach for a variety of children's problems
including, but not limited to, the following areas: 

 Abuse and Neglect

  Aggression and acting out
 Attachment difficulties
 Autism
 Burn victims
 Chronic illness
 Deaf and physically challenged children
 Dissociation and schizophrenia
 Emotionally disturbed children
 Enuresis and encopresis problems
 Fear and Anxiety
 Grief
 Hospitalization
 Learning disabilities
 Mentally challenged children
 Reading difficulties
 Selective mutism
 Self-concept and self-esteem
 Social adjustment problems
 Speech difficulties
 Traumatisation
 Withdrawn children
 
The popular myth that play therapy requires a long-term commitment for many months is
unfounded as is shown in case studies and research reports reported by Landreth, Homeyer,
Glover, and Sweeney (1996) in their book, Play Therapy Interventions with Children's
Problems. 

Future trends in play therapy

The field of play therapy is growing and is now represented by the Association for Play
Therapy, an international professional organization. A national Center for Play Therapy has been
established at the University of North Texas. Increasing numbers of elementary school
counselors and therapists in private practice and agencies are incorporating play therapy into
their work with children. There is a trend in family therapy to address social and emotional
values of developmental as well as family group session issues. In filial therapy, parents are
trained to use play therapy procedures with their children. This method is well researched and
has proven to be effective in ameliorating children's problems through enhancing the parent-
child relationship

Anticipatory Guidance:-
Tips for Providing Anticipatory Guidance
 Respect for the caregiver as an adult with knowledge, life experience, viewpoints and
values.
 Use multiple learning methods including discussion, pamphlets, demonstrations, and
active participation (let the caregiver practice brushing the child’s teeth while you watch).
 Ask both open and closed ended questions. Examples would be “Have you started
cleaning your child’s teeth yet?” and “Can you think of a good way to work daily
brushing with fluoride toothpaste into your daily routine?”
 Listen to the caregiver and ask the caregiver for ideas about what he/she thinks might
work on issues like weaning, daily brushing, and diet modification.
 Use culturally and linguistically appropriate methods of communication in working
with patients of diverse ethnic, linguistic, cultural, and socio-economic backgrounds and
abilities when addressing their oral health needs and behaviours.
 If you remain non-judgemental and friendly towards both the child and the caregiver,
they will be more likely to trust you and listen to your advice.
 Small steps involve choosing 1-2 changes that you want the family to focus on.
 Positive reinforcement lets the caregiver know that you are on their side. Keep in mind
that health behaviour change is a process, not a single event. It usually takes many
triggers over time to change health behaviour. Try not to get discouraged, but consider
each counselling visit as getting one step closer to change.

The most important tool you have is your own genuine concern and caring for the children and
their families.

Pain Control in Children:-

Key Factors In the Assessment of a Child in Pain

 Pain Assessment
 Self Report Physical
 Examination
 Behavioural Observation
 Physiologic Measures & Diagnostic Results

Pain scales

Which scale for which child?

• Depends on age
• Cognitive functioning of child

Examples of scales
Children under 3 years
• FLACC scale
• TVP scale
Children over 3 years
• Wong-Baker faces
• CAPS: Children’s
Anxiety and Pain Scale
Children over 7 years
• Colour rating scale
• Visual analogue scale
• Numerical rating scale
• Verbal descriptor

Comfort Measures
 Quiet presence: - Sitting quietly and displaying a sense of calmness.
 Massage: - Includes stroking, rubbing or deep manipulation of muscles.
 Music: - Can help to provide the child with a familiar environment; children often come
to the hospital or hospice with their own music.
 Heat: - Warm compress or use of a heating pad, to the painful site (moist or dry heat).
 Cold/Ice: - Cold compress or ice pack. Precaution: assure ice pack is wrapped allowing
comfortable sensation of cold without damaging the skin by freezing tissue. Limit ice
application to 10 minutes, then rotate site. If skin becomes blanched, discontinue cold
treatment. Baths Warm soak; can include whirlpool/Jacuzzi.
 Vibration: - Over the counter massage devise. May be used to stimulate skin and
muscle tissue.
 Menthol Product (e.g., Ben-Gay) Apply to skin, however caution must be used to avoid
areas of open wounds or irritated skin. Product selection is important as some contain
salicylates which may be contraindicated insome patients.

Advances and changes in medical care:-

The care of children has changed dramatically for both physician and nurses during
recent decades of advances in medical knowledge and understanding of the emotional responses
of children, such as the discovery of various immunizations, antibiotics and other drugs that have
curative values in many illness; computed tomographic (CT) scans and ultrasound techniques
that make early diagnosis possible; and public health measures and public education that can
prevent or shorten periods of hospitalization. Children who required hospitalization are less often
isolated for prolonged periods for infectious diseases, have opportunities for early ambulation
and shorter convalescences than in the past. Today some children may still require long
hospitalization for complicated diagnostic or therapeutic measures, some of which have been
discovered only during recent years.
 Nurses can now understand from the foregoing discussion that they have an important
role in organized community action by collaborating with other members of the health team. In
addition nurses have the responsibility of providing nursing intervention in the hospital, clinic,
school, home, or the community where children or parents have health or counselling needed.
The ability of nurses who care for children as health educators, teachers, counsellors,
researchers, case finders, and compassionate, skills care providers are urgently needed by today’s
society.

Health policy and the pediatric nurse clinician:-

As directed by the department of health and human services, a reimbursement plan will
be forthcoming for the provision of children’s services. The pediatric nurse’s clinician who has a
commitment to the care of children and their families will be a valuable resource in researching
the diagnosis related groups for use in caring for children.

As may be expected, services for children are more costly than for adults with
comparable health problems. Since cost containment is a current concern of nurses as well as
consumers it is essential that innovations be developed that utilize all available resources to
provide quality nursing care for children.

Child’s right to health care:-

Human right, which are essential to total personal development, belong to everyone-
children and adults, men and women, well and illness, and individual of all races. In young
people, these are frequently moral rights instead of legal right. Children have right in the areas
specific to knowledge of their state of health or illness, decisions regarding treatment modalities,
and counselling.

The concepts of human rights, as in the Declaration of the right of the child, are derived
from human need, not wants, Examples of physical need are nutrition and the maintenance of
body integrity, examples of intellectual need are the rights to question and to learn. The ill child
is more vulnerable and less able to cope than when well therefore the nurse fulfils the child’s
need or helps the child fulfil them through self-care so that individual identify and integrity can
be maintained. The right of each child to health care is without question.

Child and family advocacy:-

Child and family advocacy has increased in importance in recent year. The national
center for child advocacy, established in the office of child development in 1971 is based on the
idea of advocacy as an organizing principle for constructive action for children.

The goal of family advocacy is to assist families and individual members to develop and
to function at their optimal level of ability. The advocate nurse becomes a coordinator, not
relying on a single method or technique of intervention but tailoring an approach to the problem
at hand. In this kind of approach the family’s access to and use of information and of other
services are important.

Human Milk Bank

In 1985, the Human Milk Banking Association of North America (HMBANA) was
established.

At the dawn of the twentieth century, nearly all children were human milk fed - either
maternally breastfed or provided with donated human milk. Over the next one hundred years, a
number of dramatic changes took place including the replacement of human milk by artificial
feeding products. By the beginning of the twenty-first century, human milk feeding was once
again the recommended method of infant feeding. Experts recommend breastfeeding exclusively
for six months and the introduction of age appropriate foods with breast milk to remain in the
diet for two years and beyond. When maternal milk is inadequate or lacking particularly for high
risk or premature infants pasteurized donor milk is the next best option. Donor milk banking
plays an important role in meeting these recommendations.

The functional role of the nurse:-

Nurses who care for children view their role in terns are their relation with the patients,
the child and the family group as a whole. The nurse may be described broadly not as a parent
substitute but as “father’s or mother’s friend”. In this role the nurse may plan and actually
provide comprehensive care to children, as in primary nursing, or may function as a member of a
nursing team.