CHILD HEALTH NURSING

GROWTH AND DEVELOPMENT

GROWTH: is refered as increase in number and size of cells resulting in increased size and weight of the
whole or any of its body parts. It is a quantitative change

DEVELOPMENT: It is the gradual change and expansion of the individuals capacities though growth,
maturation and learning. It is a a qualitative change

MATURATION: it is referred as an increase in competence and adaptability, usually describing a

qualitative change. It makes a particular organ to function at a maximum level.

PRINCIPLES OF GROWTH AND DEVELOPMENT

Growth and development is a continuous, orderly, and progressive process, with definite and
predictable patterns which are universal and basic to all human being

1. Growth and devt progress in a cephalocaudal or head to tail direction. Eg: infant achieve head
control before having control of trunk and extremities
2. It occurs in proximo-distal or midline to peripheral concept, that is in early embryonic
development limb buds develop before the rudimentary fingers and toes.
3. The third trend, differentiation refers development from simple operations to more complex
activites
4. Generalized development precedes specific and specialized deveopement
5. There is a definite, predictable sequence in growth and devt with each child passing through
every stage. Eg: children stand before they start to walk
6. Early foundations of trust are important in personality devt in later stage
7. There are periods of accelerated and decelerated growth periods in both total body growth and
subsystems
8. There are sensitive periods during the process of growth when the organism interacts with a
particular environment in a specific manner. They are termed as critical, sensitive, vulnerable
and optimal . these periods influence positive or negative growth in a child
9. Each child grows in a unique way. Though the sequence of events are predictable, the exact
time of achievement is not

FACTORS AFFECTING GROWTH AND DEVELOPEMNT

The main factors affecting growth and development are hereditary, genetic and environment factors.

1.HEREDITORY AND GENETIC FACTORS

 Characteristics of parents eg: parents with high IQ tend to have children with high IQ
 Race – growth potential of children of different racial group is different
 Sex- boys are heavier and taller than girls, prepupertal growth spurt occurs earlier in girls
  Biorhythm and maturation (girls attain menarche at similar age of their mother)
 Genetic factors- certain genetic disorders causes growth retardation

2. ENVIRONMENTAL FACTORS

 Physical surrounding and social factor

 Prenatal environment- maternal nutritional deficiencies, metabolic endocrine distrubances,
infectious diseases, malposition of fetus, smoking, alcohol and intake of certain drugs
 Postnatal environment- nutrition, infections, trauma, socioeconomic status, climate, cultural
beliefs, attitudes, emotional factors, ordinal position in the family etc

BIOLOGICAL DETERMINANTS OF GROWTH AND DEVELOPMENT

The most prominent feature of childhood and adolescence is physical growth. Linear growth or
height is considered as a stable measurement of growth, bone age determinants and the state of
dentition are indicators of development

1. SKELETAL GROWTH AND MATURATION

Bone age is the most accurate measurement of general development, active growth takes place
in epiphyseal growth plate. Prenatally he first centres of ossification appears at 2 months of
gestation, postnatally the earliest centres appear by 5 to 6months of age at capitate and humate
bones of wrist, hence radiographs of the hand and wrist are the most useful areas to determine
the skeletal age. Any trauma or infection in the growth plate results in deformity

2. NUROLOGIC MATURATION
Prenatally, a rapid growth in nervous system takes place between 15 to 20wks of gestation and
also by 30 weeks of gestation witch continues until 1year of age. Rapid growth occurs in early
childhood and continues at gradual rate in later childhood. Neurophysiological changes provide
the basis for language, learning and behavior development

3. LYMPHOID TISSUE
Lymphoid tissues are well developed at birth. They reach adult dimension by 6 yrs of age and
continues to grow until 10-12 yrs of age to reach a maximum level of twice the adult size. Later
it declines rapidly to stable adult dimension

4. DEVELOPMENT OF ORGAN SYSTEMS

All tissues and organ systems undergo changes during development, some will have significant
changes while others have very subtle changes. It varies with age.

PHYSIOLOGICAL CHANGES
Physiological changes takes place in all organs and systems. Other changes such as pulse, respiratory
rate and blood pressure are integral part of physical assessment. In addition, changes in basic functions
including metabolism, temperature, and patterns of sleep and rest.

METABOLISM

Changes in BMR occurs through out life. BMR is slightly higher in boys than girls. It determines the
caloric requirements. The basal energy requirement in infants is about 108kcal/kg of body weight and
decreases to 40-45 kcal/ kg at maturity.

TEMPERATURE

Thermoregulation is one of the most important adaptation response of infants during the transition
from intrauterine life to etrauterine life. Heat production steadily declines as the infant grows into
childhood. By 12 yrs of age the temperature remains relatively stable, girls maintain slightly higher
temperature than boys.

SLEEP AND REST

It is a protective function in all organisms, allows for repair and recovery of tissues after activity. An
infant spend much of the time in sleep, as children mature, the total time they spent in sleep gradually
decreases. It is also affected by social, activity and academic schdules.

NUTRITION

It is the single most important factor of growth. During infancy protein and caloric requirements are
higher, later it reduces as the rate of metabolism slows down. The need for nutrition changes according
to the growth patten

TEMPERAMENT

It refers to the way in which a person deals with life. Most children can be placed in one of the 3
patterns of temperamental attributes.

The easy child: they are even tempered and regular and predictable in their habits and have a positive
approach to new stimuli.

The difficult child: highly active, irritable and irregular in their habits. These children adapt slowly to new
situations

The slow to warm up child: they are inactive and moody, show moderate irregulariy in fucntions. they
react negatively with mild intensity to new stimuli.

The difficult and slow to warm up children have tendencies to develop behavioral problems later in life
NURSING CARE OF HIGH RISK NEWBORN AND FAMILY

Def

A newborn regardless of GA or birthweight who has higher chance of mortality and morbidity due to
conditions and circumstances associated with birth and adjustment to extrauterine life.

Classification of high risk newborns

1.Classification according to size

a)Low birthweight infant: an infant with birthweight less than 2.5kg regardless of GA

b)Very low birth weight infant: an infant with birthweight less than 1.5kg

c)Extremely low birth weight : an infant with birthweight less than 1000g

d)Appropriate for GA : an infant whose birthweight falls between 10 th and 90th percentile

e)Small for GA / small for date : an infant whose birthweight falls below 10 th percentile on growth chart

f)Intrauterine growth restriction: an infant whose intrauterine growth is restrited

g)Large for GA: an infant whose birthweight falls above the 90 th percentile

2. Classification according to GA

a) preterm infant: an infant born before completion of 37 wks of GA regardless of weight

b)full term infant: an infant born between 38 to 42 wks of GA regardless of birthweight

c) late preterm infant: an infant born between 34 0/7 to 36 6/7 wks of GA regardless of birthweight

d)post term infant : an infant born after 42 weeks of GA regardless of birthweight

3. Classification according to mortality

a) live birth: birth in which the neonate manifest any heartbeat, breathes and displays voluntary
movement regardless GA

b)fetal death: death of fetus after 20 wks of GA and before delivey

c)neonatal death: death that occurs in 27 days of neonatal life, early neonate death occurs during the 1 st
week of life and late neonatal death occur from 7-27 days

d)perinatal mortality: total no of fetal and early neonatal deaths per 1000 live births

ASSESSMENT OF HIGH RISK INFANT:

A thorough systematic assessment of high risk infant is an essential component of nursing care. Subtle
changes in feeding behavior, activity, color, o2 saturation and other vital signs often indicate an
underlying problem, low birth weight and preterm babies are ill equipped to withstand prolonged
physiological stress and may die with in minutes of exhibiting abnormal symptoms. Therefore nurses
caring for these babies must be aware of subtle changes and react promptly to implement appropriate
interventions

PHYSICAL ASSESSMENT

a) General assessment includes weight, height, head circumference, posture at rest, ease of
breathing, and presence of deformities, edema, occurrence of apnea etc
b) Respiratory assessment includes respiratory rate, regularity, retractions, nasal flaring, abnormal
breath sounds , cyanosis, cry etc
c) Cardiovascular assessment includes heart rate, rhythm, blood pressure, color, quality of pulses
etc
d) Gastrointestinal assessment includes abdominal distention, visible peristalsis, bowel sounds, any
regurgitation, stool pattern etc
e) Gentitourinary assessment includes genital abnormalities and the characteristics of urine
f) Neurological and musculoskeletal assessment includes assessment of newborn reflexes, level of
activity, changes in head circumference, fontenelles pupillary responses etc
g) Skin assessment includes color, presence of lesions, texture and skin turgor ect
h) Temperature : determine the axillary temperature and its relationship with environment

MONITORING OF PHYSIOLOGICAL DATA

Includes vital signs, urine output and biochemical tests such as blood glucose, bilirubin, serum
electrolytes and blood gas, hematocrit etc

OBJECTIVES OF NURSING CARE

1. Respiratory support

2. Thermoregulation

3. Protection from infection

4. Hydration

5. Nutrition

6. Breast feeding

7. Energy conservation

8. Skin care

9. Administration of medications
10.Family support and involvement

11. discharge planning

MANAGEMENT

- When a delivery of an high risk newborn is anticipated, the unit must be kept ready to early
resuscitation and other therapeutic interventions
- Infant who do not require resuscitation are immediately transferred to NICU in an incubator

1. RESPIRATORY SUPPORT
The primary objective is to establish and maintain adequate respiration.
Baby should be nursed in appropriate position to maximize oxygenation and ventilation
Oxygen therapy
Supplemental oxygen should be given if the baby exhibits signs of respiratory distress and
cyanosis
Assisted ventilation if apnea present

2. THERMOREGUALATION
Maintaining a neutral thermal environment is crucial in newborn care It permits to maintain a
optimum core temperature with minimum oxygen consumption and caloric expenditure. Less
subcutaneous fat and low brown fat for heat production in neonates put them at high risk for
hypothermia. In addition to that heat loss from radiation and evaporation is greater in very low
y birth neonates. hypothermia is associated with increase in mortality.
 It can be achieved by use of incubator, radiant warmer and cotton blankets. if the
infant is well kangaroo mother care can be provided.

3. PROTECTION FROM INFECTION

It is an integral part of all newborn care. But preterm and sick neonates are particulary
susceptible to infections. The following measures will reduce the risk of infections in these
babies
 Regular cleaning of protective environment such as incubator, changing of bed linen etc
 Meticulous and frequent hand washing by health care workers and visitors
 Personnel with any infection should not be allowed to care for the baby
 Standard precaution must be followed
 Equipments used in care of infants such as cribs, mattresses, monitors, warmers etc.
must be cleansed on regular basis

4. HYDRATION
Adequate hydration is particularly important in preterm infants due to higher extracellular
water content. Infants who are extreme low birth weight, receiving phototherapy have
increased insensible fluid loss. Therefore nurses must monitor the fluid status by
  Daily weight
 Accurate intake output including medications and blood products
 Serum electrolytes should be monitored
 Monitor for tremors or seizures, it may be a sign of hyponatremia or hypernatremia
 Parental fluid may be given via peripheral veins, umblical venous catherters when
indicated

5.NUTRITION:

Optimum nutrition is critical in the management of lowbirth weight and preterm infants due to
underdeveloped mechanisms for ingestion and digestion of foods and also poor sucking and swallowing
coordination.

 If the infant is medically stable, feeding with breast milk or preterm formula should be
started immediately following birth
 If the baby cannot tolerate entral feeding, parentral nutrition should be given to prevent
hypoglyciemia and dehydration

6.BREAST FEEDING

Small preterm infants maybe breastfed if they have adequate sucking and swallowing reflexes

Milk produced by mothers of preterm babies contain higher concentration of protein, immunoglobulin
IgA

Breastmilk also contains growth factors, harmones, prolactin, calcitonin, thyroxine, steroids, taurine an
essential amino acid etc

Breastfeeding is associated with lower incidence of desaturation, bradycardia, hypothermia and apnea

Mothers should be taught about the proper method of expressing breast milk and storage

Preterm babies who cannot take oral feeds due to poor sucking and swallowing ability, nasogastric
tubefeeding may be provided, however they must be assessed frequently for readiness of feeding

ENERGY CONSERVATION

Disturbing the infant as little as possible

Maintain a neutral thermal environment

Plan the care in such way that baby gets enough rest periods

Prone position is better for preterm infants because it results in better tolerated feedings and more
sleep- rest patterns

SKIN CARE
Preterm babies skin is highly sensitive and fragile hence usage of skin products should be avaoided

Use minimal adhesive tapes backing up with cotton

Use cleansing agents with neutral PH

Use standard precautions

Do not make attempts to remove vernix completely

Daily cleansing of eye, umbilicus, oral and diaper areas

Avoid rubbing the skin during bathing or drying

Skin breakdown around mouth, buttocks, fingers and toes in preterm infants may indicate zinc
deficiency

ADMINISTRATION OF MEDICATIONS

Medications that contains preservatives should be avoided in infants

Hyperosmolar solutions are danger to infants, it should be sufficiently diluted before use

Nurses must be vigilant enough to prevent medication errors

FAMILY INVOLVEMENT

Parents must be involved in the care of high risk neonates as much as possible

Parents should be encouraged to visit the baby before transferring to a special unit or other hospital

Parents should interact with the baby during care giving activities

DISCHARE PLANNING AND HOME CARE

Advise the parents on

 regular follow up
 immunization
 breast feeding etc

NURSING PROCESS

Ineffective breathing pattern related to pulmonary and neuromuscular immaturity

Ineffective thermoregulation related to immature temperature control and decreased subcutaneous

fat

Imbalanced nutrition, less than body requirement related to poor intake

 Risk for infection related to inadequate immunity, exposure to environmental pathogens etc

Risk for impaired skin integrity related to immature skin structure, invasive procedures etc

Delayed growth and development related to disease condition

Interrupted family process related to situational crisis

Catheter toes: presence of umblical venous or arterial catheter infants precipitate microthrombi in the
vascular bed. It is manifested by sudden bluish discoloration in the toes, refered as catheter toes. If
observed it should be promptly reported to the physician and rectified immediately. Failure to do this may
result in loss of toe/ foot or even leg