INTRODUCTION

What is Paediatrics?
Paediatrics is a branch of Medicine that deals with development, diagnosis and
treatment of child health problems.
What is Paediatric Nursing?
This is a specialized field of Nursing that deals with the diagnosis, treatment,
prevention and management of children’s response to actual or potential problems.
It is also defined as a specialized field of nursing that deals with the identification,
management and prevention of neonates, infants and children responses to actual or
potential health problems

Why focus on paediatric Nursing?

1. We were all kids including you, we were all children once we have lived
through it.
2. The population of Sierra Leone has a large percentage of children.
3. As nurses pediatric course will not only be applicable to patients, but
also to your family member- siblings, children, cousins etc.
4. Sierra Leone still has a high rate of under 5 morbidity and mortality
rate.
5. Many of the top killer diseases can be prevented.
6. Children are special gift from GOD, therefore, they must be cared for.

Right of the Child

United Nations Declaration.
1. To be free from discrimination.
2. To develop physically and mentally in freedom and dignity.
3. To have a name and Nationality.
4. To have adequate nutrition, housing recreation and medical services
5. To receive special treatment if handicapped.
6. To receive love, understanding and material security.
7. To receive education and develop his/her abilities.
8. To be the first to receive protection in disaster.
9. To be protected from neglect cruelty and exploitation.

GROWTH AND DEVELOPMENT IN CHILDREN

Growth Refers to Increase in Physical Size
Development is Increase in capability or function.
Principles of Growth and Development

1. Development proceeds from the head downward. This is called the

cephalocaudal principle. This principle describes the direction of growth and
development. According to this principle, the child gains control of the head
first, then the arms, and then the legs.
2. Development proceeds from the centre of the body outward. This is the
principle of proximodistal development that also describes the direction of
development. This means that the spinal cord develops before outer parts of
the body. The child’s arms develop before the hands and the hands and feet
develop before the fingers and toes. Finger and toe muscles (used in fine
motor dexterity) are the last to develop in physical development.
3. Development depends on maturation and learning. Maturation refers to the
sequential characteristic of biological growth and development. The biological
changes occur in sequential order and give children new abilities.
4. Development proceeds from the simple (concrete) to the more complex.
Children use their cognitive and language skills to reason and solve problems.
5. Growth and development is a continuous process. As a child develops, he or
she adds to the skills already acquired and the new skills become the basis
for further achievement and mastery of skills.
6. Growth and development proceed from the general to specific. In motor
development, the infant will be able to grasp an object with the whole hand
before using only the thumb and forefinger.
7. There are individual rates of growth and development. Each child is different
and the rates at which individual children grow is different.

Differences between growth and development

Factors Impact Growth
• Sex
• Parental traits
• Genetic disorders i.e. Down syndrome
• Nutrition
• Infections
• Socio-economic level
• Position in the family
• Environmental
• Chronic illness
What Measurements are put on Growth Charts in Sierra Leone?
• In Sierra Leone, up to age 5 years, weight for age is measured on the Child Health
Records.
• MUAC is measured from 6 months up to 5 years.
• Weight and length (for children<2yrs).
• Head Circumference is measured up to 36 months in some places.
• With older children (for children> 2yrs), weight, body mass index (BMI) are
measured.
Assignment
Each group to explain the various growth measurements

Measures to Minimize Errors during Growth Assessment

To minimize chances of error:
• Only trained individuals should perform growth measurements.
• Use proper techniques and calibrated equipment.
• Data should be collected on children under consistent conditions on a routine basis.
• Values should be recorded and plotted on growth charts immediately.

Some “Rules Of Thumb” In Assessing Growth

• 10% of birth weight lost after birth. Regained by 2 weeks.
• 25g per day for first 5 months.
• 15g per day in the first year.
• 2.5kg in 2nd year of life
• 2kg per year up to 5 years.
• Birth weight doubled by 5-6 months
• Tripled by 1 year.
DEVELOPMENTAL ASSESSMENT
GOAL: To identify children whose developmental level is below normal for
their age.
WHY?
To identify early and take proper interventions
To maximize their potential
What are options here?
What tools are available in Sierra Leone?
FACTORS THAT INFLUENCE DEVELOPMENT
1. Heredity and environment
2. Gender difference vs cultural expectations
3. Parental influence.
4. Socio economic/ educational status
5. Interpersonal relationships
6. Stress
7. Televisions and mass media
8. Severe abuse or maltreatment
9. Social interaction
10. Nutrition
11. Physical activity (play)
12. Maternal health
13. Medical conditions/infections
Assess various forms/areas of development:
– Physical
–Neurological
– Emotional/Social development
– Cognitive development
IMPORTANT TO KNOW and ASSESS
MILESTONES IN ALL 4 AREAS!!!

Domains of Growth and Development

1. Physical/Physiological Domain:
• Body size, body proportions, appearance, brain development, motor development,
perception capacities, physical health – gross motor and fine motor
2. Cognitive Domain:
• Thought processes and intellectual abilities including attention, memory, problem
solving, imagination, creativity, academic and everyday knowledge, metacognition
and language – simple to complex thought
3. Social/Emotional Domain:
• Self-knowledge (self-esteem, metacognition, sexual identity, ethnic identity), moral
reasoning, understanding and expression of emotions, self-regulation, temperament,
understanding others, interpersonal skills and friendships – social & emotional
development.
ASSIGNMENT
Key G&D Theorist: Activity
• There are many theories of Growth and Development. This can include Cognitive,
Physical and Psychosocial theories.
• In groups, search for the key points for the stage you are assigned.
• Identify and present 3 key messages of the theory to present to the larger group.

Developmental mile stones

The five stages of child development and milestones
The previous section explained the characteristics of child development. Each
characteristic has its own milestone indicators that help us to determine if a child is
developing at the right pace. The milestones contain different actions or targets that
a child should be able to accomplish at different stages of their childhood.
1. Newborn
During the first month of life, newborns exhibit automatic responses to external
stimuli. In other words, a newborn will turn her head toward your hand when you
stroke her cheek or grab your finger when you place it in her hand. A newborn is
able to see close-up objects, recognize certain smells, smile or cry to indicate a
need, and move her head from side to side. Newborns may show signs of
developmental disabilities, such as spina bifida, genetic disorders and fetal alcohol
syndrome.
2. Infant
Infants develop new abilities quickly in the first year of life. At three to six months, an
infant can control his head movements and bring his hands together. By six to nine
months old, an infant can sit without support, babble and respond to his name.
Between nine and twelve months old, a baby can pick up objects, crawl and even
stand with support. Slow development in infants may be signs of Down’s syndrome
and other developmental disabilities.
3. Toddler
As children reach the ages between one and three years, toddlers learn to walk
without help, climb stairs and jump in place. They can hold a crayon, draw a circle,
stack one block on top of another, use short sentences and even follow simple
instructions. The Centers for Disease Control and Prevention (CDC) recommends
screening for autism at 18 to 24 months, or whenever a parent or health care
professional has a concern.
4. Preschool
Between the ages of three and five years, children refine their motor skills. They can
throw a ball overhand, skip and hop, stand on one foot for ten seconds or longer,
dress themselves, and draw a person with features. Signs of developmental
disabilities, such as cerebral palsy, may appear during this stage of development.
5. School Age
School age children are six to 12 years old. They are capable, confident,
independent and responsible. Peer relationships, particularly relationships with
friends of the same gender, are important to school age children. The older school
age child begins to develop sexual characteristics. Signs of ADHD, such as trouble
staying focused and being easily distracted, may appear in school age children. If
you worry that your child is falling behind, contact RISE, innovative human services
network originally established in 1987. RISE offers a variety of helpful services for
people with disabilities, including day programs, employment assistance, managed
care, residential settings, and home and community based services. The
developmental specialists at RISE provide early intervention services, such as
occupational therapy, speech therapy, physical therapy for children with
developmental disabilities.
ADOLESCENT
Adolescent developmental domains are intertwined and strongly influenced by
experiences and environments.
Physical development
In early adolescence, the body undergoes more developmental change than at any
other time, apart from birth to two years old. The rate of growth is rapid and uneven,
with a different pace and rate of change for each individual. Physical changes
include increases in height, weight, and internal organ size as well as changes in
skeletal and muscular systems.
Puberty occurs in early adolescence, triggered by the release of hormones which
lead to the development of primary sex characteristics (genitalia) and secondary sex
characteristics (eg breast development in girls; facial hair in boys). The increased
hormone production affects skeletal growth, hair production, and skin changes.
Physical changes are visible to all and highlight the range and pace of change. This
sometimes leads to adolescents feeling more or less mature than others. Physical
development growth spurts occur about two years earlier in girls than boys.
Social development
Adolescent social development is often described as the process of establishing a
sense of identity and establishing a role and purpose. It is an outwards sense of
oneself. Body image is a key factor in developing a sense of self and identity,
especially for girls, and the family and increasingly peers play an important role
assisting and supporting the adolescent to achieve adult roles. Risk-taking is a
natural part of the adolescent journey. Social development and emotional
development are closely intertwined as young people search for a sense of self and
personal identity.

Emotional development
The way a person thinks and feels about themselves and others, their inward
thoughts, is key to their emotional development. Developing and demonstrating
individual emotional assets such as resilience, self-esteem and coping skills is
heightened during adolescence because of the rapid changes being experienced.
Schools are important sites for social and emotional learning and have developed
policies and programs around student wellness, often with a focus on a strengths-
based approach.
Cognitive development
Cognition is the process involving thought, rationale and perception. The physical
changes of the brain that occur during adolescence follow typical patterns of
cognitive development. They are characterized by the development of higher-level
cognitive functioning that aligns with the changes in brain structure and function,
particularly in the prefrontal cortex region.
The structural and functional brain changes affect the opportunity for increased
memory and processing. They may also contribute to vulnerability, such as risk
taking and increased sensitivity to mental illness.
When Things Don’t Go as Planned… (Class Discussion)
• What are “Red Flags” in development across the age groups in relation to
milestones?
• How are these signs of delayed or abnormal growth and development determined?
• What are the key child/family-related factors to consider?
• How would you counsel a parent whose child is showing signs of developmental
delay?

Stages of Acceptance
A diagnosis of developmental delay can be devastating for families.
– Initial support is provided during a time of uncertainty before an official diagnosis
has been made.
– Subsequent support is required as parents/families work through the six stages of
adjustment.
Counselling Parents
• Choose a time and place where you can talk alone.
• Use compassion and an appropriate degree of hope for the child and parents.
• Be prepared for strong emotions.
• Ask parents how much and what types of communication they find helpful.
• Build rapport with honesty and caring. Be caring, supportive, and respectful.
• Ask if parents have concerns or questions about how the child seems to be
developing.
• Share own observations and concerns.
• Choose words carefully.
• Avoid using labels or technical terms.
• Be ready to offer information and resources. Know the resources available.
• Try to determine the parents’ level of adjustment.
• Assess understanding of previous information you have discussed.
• Reinforce parental participation in helping their child learn and develop.
• Readily admit to unknowns and seek answers to parents' inquiries.
• Understand and accept the stages of adjustment as being a normal process.

PHYSICAL AND DEVELOPMENTAL ASSESSMENT OF THE CHILD AND

FAMILY
Kids are different than adults, sequence of assessment is often different.
Head to toe for Adults.
Need to accommodate for developmental level in paediatrics
Age appropriate techniques

GOAL OF ASSESSMENT
Minimize anxiety and stress
Maximize accuracy of physical examination.
Foster a trusting nurse - child – parent relationship

PHYSICAL EXAM
GROWTH MEASUREMENTS
Length versus height
Head circumference until 2 years of age
Weight, MUAC (Mid upper arm circumference) if indicated.
Plot on appropriate growth chart
Gender, age, corrected for prematurity.

PHYSIOLOGICAL MEASUREMENT
VITAL SIGNS - HR, RR, BP after three years of age appropriate size,
temperature, pain
Learn the normal values for a given group and compare your patient’s vitals.
Find the trend for your patient and track it.
PHYSICAL EXAM
Chest, heart, lungs, Abdomen, Genitalia, Back and extremity, Neurologic
assessment

TIPS FOR PHYSIOLOGICAL ASSESSMENT

Order of assessment matters
Respiration first
Heart rate second
Blood pressure third
Temperature last.

NEONATES ASSESSMENT
A neonates is a body between 0 - 28 days

Heart rate: 120 -160 beats per minute.

Respiratory Rate: 40 - 60 breaths per minute.
Blood pressure: systolic > 60

PHYSICAL ASSESSMENT TIPS

Keep in parents lap.
Listen to heart beat and lung sounds while sleeping or Feeding.
Start with least invasive and finish with most.
Start with heart and lung sounds; finish with pupils place infant on family’s
shoulder to assist pupils.
SCENARIO
Your 12 day old patient has a HR of 190. Is this normal, if not what
could be the cause.

TACHYCARDIA
Increased HR can be the result of: crying, fever, pain.
Cardiac arrhythmic and malformations, electrolyte imbalance
Hyperthyroidism, dehydration
What could you do to treat each cause?

INFANTS
12 months of age
Heart rate: 100 – 120 beats per minute.
Respiratory rate: 25 – 50 beats per minute.
Blood pressure: systolic 70 - 95.

CHILDREN - [1- 8 years]

HR: 80- 100 beats per minute
RR: 15- 30 breaths per minute
BP: 80 - 100/ 40 - 60.

ADOLESENTS AND ADUILTS

HR: 60 - 100 bpm
RR: 12- 20 BPM
BP: 90 - /130/70- 90

PHYSICAL ASSESSMENT TIPS

Provide privacy if possible
Start with least personal
 TERM AND PREMATURE INFANTS
•Term infants:
–The goal of a healthy pregnancy is to deliver a baby at 40 weeks.
–A term infant is an infant born between the 38th week and the 42nd week of
gestation regardless of birth weight.
–Staying pregnant full term is one of the best ways to give the baby the time needed
to grow and develop.
•Premature infant:
–A premature infant is a baby born before 37weeks of gestation (more than 3 weeks
before the due date).
–Classified in two categories:
•Early preterm –born < 35 weeks of gestation (High risk group and requires
admission to the NICU)
•Late preterm –born between 35 and 37 weeks of gestation (May not look
premature)

Other Classifications of Infants to Consider

•A post term (post mature) is one born after complete 42-week gestation regardless
of birth weight.
•Low birth weight is a birth weight < 2.0kg.
•Small-For-Date Babies (or small for gestational age babies) are infants born small
compared to other babies carried in the womb for the same amount of time.
Premature infants

Discussion
•What are some of the pregnancy-related problems that could have increased the
risk of preterm labour?

Characteristics of Premature Infants

•Skin: May be reddened and thin so blood vessels are easily seen
•Lanugo: There is a lot of fine hair all over the baby’s body.
•Limbs: The limbs are thin and may be poorly flexed or floppy due to poor muscle
tone.
•Head size: Appears large in proportion to the body. The fontanelles are smooth
and flat.
•Chest: No breast tissue before 34 weeks of pregnancy.
•Sucking ability: Weak or absent.
•Genitals: In boys the testes may not be descended and the scrotum may be small;
in girls the clitoris and labia minora may be large.
•Soles of feet: Creases are located only in the anterior of the sole, not all over, as
in the term baby.

Challenges and Treatment for Preterm Infant

•Respiratory problems
•Digestive problems
•Poor thermal stability
•Renal problem
•Nervous problems
•Exposed to infections
•Liver functioning issues
•Skin problems
•Eye infections

Management
•Ensure adequate warmth at all times
•Monitor for apnea and intervene
•Nutrition
•Infection prevention
•Medicinal support –Caffeine or artificial surfactant

Complications of Prematurity
•Bronchopulmonary dysplasia (BPD): This is a chronic lung disease as a result of
immature lungs.
•Delayed growth and development
•Mental or physical disability
•Retinopathy of prematurity, vision loss or blindness

Low-Birth-Weight Babies

Management of Low-Birth-Weight Babies

•Keep baby warm.
•Support breathing and oxygenation.
•Protect from infection.
•Support fluid and nutritional needs.
–Monitor blood glucose to ensure episodes of hypoglycemia do not occur.
–Provide nutritional supplements.
Discharge And Follow-up Of Low-Birth-Weight Infants
•Low-birth-weight infants can be discharged when:
–They have no danger signs or signs of serious infection.
–They are gaining weight on breastfeeding alone.
–They can maintain their temperature in the normal range (36 -37°C) in an open cot.
–The mother is confident and able to care for the infant.
•Low-birth-weight infants should be given all the scheduled vaccines at the time of
birth and any second doses that are due by the time of discharge.

Other Considerations
•Support Groups
–The nurse can help establish support groups for parents of premature babies.
–The social worker can be involved in this process. To establish this in Sierra
Leone.
•Outlook (Prognosis)
–Prematurity is still a major cause of infant deaths.
–In low-income settings, half of the babies born at or below 32 weeks gestation die.
–However, improved medical and nursing techniques have increased the survival of
premature infants. Such as, preventing and treating infection, providing respiratory
support, and supporting mothers with breastfeeding
–The longer the pregnancy, the greater the chance of the baby's survival.

Neonatal Infections
Neonatal Sepsis
•Neonatal sepsis is any infection involving the infant during the first 28 days of life.
Neonatal sepsis is also known as sepsis neonatorum.
•The infection may involve many organs or be limited to just one.
–Example: The lungs with pneumonia
•Neonatal infections maybe acquired prior to birth (intrauterine sepsis) or after birth
(extra uterine sepsis).
Incidence
•In Africa alone, infectious disease accounts for over 76% of under five deaths.
•An estimated 36% of neonatal death cases stem from possible severe bacterial
infection in neonates in sub-Saharan Africa, Asia and Latin America in 2012.
•This underscores the potential for excess morbidity and mortality due to antibiotic
resistance.
Why Are Neonates Susceptible to Sepsis?
•Immature immune system
•Immature skin and mucosal surfaces
•Umbilical cord
•Risk is higher with prematurity, low birth weight, underlying illness
•During delivery new-borns may be infected by microbes in the birth canal.
•Neonatal infections can be acquired from health care.
•Generally slow progress in improving IPC practices

MENINGITIS
•Meningitis is the inflammation of the membranes that surround the brain and spinal
cord.
•These membranes are called the “meninges.” They help protect the brain from
injury and infection.
•Occasionally, bacteria overcome the body’s defences, such as physical barriers,
local immunity, phagocytes or macrophages, and cause infection.
•In this process the bacteria may spread through the bloodstream to the meninges
and cause meningitis.
What is Neonatal Meningitis?
•Neonatal meningitis is the term used to describe meningitis that occurs in the first
28 days of life.
•Many different organisms can cause neonatal meningitis, broadly grouped as
bacteria, viruses and fungi.
•The most common causes are bacteria; in particular Group B Streptococcus (GBS)
and Escherichia coli (E. coli).
•Group B Streptococcus bacteria live harmlessly in the vagina and intestinal tract of
approximately 10 to 30% of women.
•These bacteria can sometimes be passed to the baby during delivery.
Signs and Symptoms of Meningitis
•Fever (with cold hands and feet)
•Reluctance to feed
•Vomiting and/or diarrhoea
•Irritability/dislikes being handled
•Difficulty waking/unresponsive (lethargic)
•Difficulties breathing or grunting
Faster or slower than normal breathing rate
•Pale/blotchy skin
•Red/purple spots/rash does not fade under pressure
•High-pitched cry/moaning/whimpering
•Bulging fontanelle (soft spot)
•Convulsions/seizures
•Arched back (opisthononus)

Diagnosis
•Physical assessment of the infant (head to toe), measure vital signs, perform lumbar
puncture
•Laboratory investigation includes:
–Blood sample for full blood count
–Differential and platelet count
–Urine sample for urinalysis
–Complete evaluation of cerebrospinal fluid (CSF)
–Culture and sensitivity
Priority Nursing Care
•Baby will need admission to NICU/SCBU (Neonatal Intensive Care Unit/ Special
Care Baby Unit).
•Assess and monitor frequently for signs of deterioration.
•Control fever with exposure and Paracetamol.
•Keep baby warm to reduce the risk of stress from cold.
•Observe strict infection control –e.g., wash hands with soap and clean water, wear
face mask, gowns and gloves.
•Monitor and maintain fluid balance.
•Support family with diagnosis and care.
•Feeding support provided through NG tube until improvement.
•Administer IV antibiotics as ordered.
Complications
•Many babies will make a good recovery.
•Up to 50% of babies who have neonatal meningitis may be left with aftereffects.
•Aftereffects of meningitis are usually the result of damage to various areas of the
brain, including the nerves responsible for hearing and sight.
•Serious and disabling aftereffects are well recognized and include:
–Hearing loss or deafness
–Loss of vision or blindness.
 Neonatal Cord Sepsis (Omphalitis)
•Omphalitis is defined as infection and inflammation of the umbilicus –in particular,
the umbilical stump in the newborn.
•It primarily affects neonates, in whom the combination of the umbilical stump and
decreased immunity presents an opportunity for infection.
•It is rarely reported outside the neonatal period.
•This is mostly attributed to bacterial infection.
Incidence
•The incidence in developing countries has been quoted to be between 2 and 7 in
every 100 live births.
•The incidence is even higher in communities that practice application of non-sterile
home remedies to the cord.
•In one study of neonates admitted to an African general paediatric ward, omphalitis
accounted for 28% of neonatal admissions.
What Causes Omphalitis?
•The umbilical cord lacks the normal barrier of skin defenses at the stump.
•Cord area becomes colonized with potential bacterial pathogens intrapartum or
immediately postnatal.
•The infection can spread along the umbilical artery, umbilical veins, abdominal wall,
liver and kidneys resulting in hepatitis and herpes, and by direct spread to
contagious areas.
Signs and Symptoms
•Purulent or foul-smelling discharge
•Fever (temperature ≥ 38⁰C)
•Tachycardia (heart rate > 180bpm)
•Tachypneoa (respiratory rate > 60cpm)
•Poor suckling
•Skin redness
•Irritability
•Abdominal distention

Diagnosis
•Perform head-to-toe examination to help diagnosis.
•Measure and record vital signs.
•Umbilical swab for culture and sensitivity
•Blood sample for full blood count
•Differential count
•Abdominal ultra-sonography
Nursing Priorities/Interventions
•Monitor and record vital signs.
•Maintain fluid balance and adequate hydration.
•Use chlorhexidine for cord care
•For newborns with any signs of serious bacterial infection or sepsis give:
–ampicillin (or penicillin) and gentamicin as first-line antibiotic treatment.
•If at greater risk of staphylococcus infection (extensive skin pustules, abscess or
omphalitis in addition to signs of sepsis) give:
–IV cloxacillin and gentamicin.
The most serious bacterial infections in newborns should be treated with antibiotics
for at least 7 -10 days.
•Ensure adequate nutrition.
•Ensure strict infection prevention practices.
•Provide cord care.
•Support family to be involved in care and provide teaching for proper cord care.
Umbilical Infections -Complications
•Fasciitis
–Inflammation of the fascia
•Cellulitis
–Diffuse and especially subcutaneous inflammation of connective tissue
•Septicemia
–Invasion of the bloodstream by virulent microorganisms, especially bacteria, along
with their toxins

Neonatal Tetanus
•Tetanus is acquired through exposure to the spores of the bacterium Clostridium
tetani which are universally present in the soil, dust and manure.
•The disease is caused by the action of a potent neurotoxin produced during the
growth of the bacteria in dead tissues, e.g., in dirty wounds or in the umbilicus
following un-sterile delivery.
•People of all ages can get tetanus, but the disease is particularly common and
serious in newborn babies.
•Most infants who get the disease die.
•Neonatal tetanus is particularly common in rural areas where most deliveries are at
home without adequate sterile procedures.
Pathophysiology of Tetanus
•Tetanus toxin, the product of Clostridium tetani, is the cause of tetanus symptoms.
•Tetanus toxin is taken up into terminals of lower motor neurons and transported
axonally to the spinal cord and/or brain stem.
•Muscle rigidity and spasms ensue, often manifesting as trismus/lockjaw, dysphagia,
opistotonus, or rigidity and spasms of respiratory, laryngeal and abdominal muscles,
which may cause respiratory failure.
Predisposing Causes
•Unimmunized pregnant woman (Tetanus vaccine). Should receive vaccine 2 times
before delivery
•Cutting the umbilical cord with dirty unsterilized instrument, e.g., infected old blade
or knife
•Tying the umbilical cord with old piece of cloth
•Dressing the umbilical cord with unhygienic materials.

Signs and Symptoms

•Umbilicus may be affected.
•Muscle rigidity
•Irritability/Restlessness
•Locked jaw
•Dysphagia: Difficulty swallowing
•Facial grimacing/Sardonic smile
•Asphyxia
•Opisthotonus (stiff arched back)
•Rigid abdomen
•Convulsion or muscle spasm
•Fever

Management
•Reassurance for family –this is a medical emergency.
•Monitor vital signs and occurrence of any seizures.
•Immediate treatment with human Tetanus Immune Globulin (TIG) agents to control
muscle spasm, aggressive wound care, antibiotics and a tetanus toxoid booster.
•If TIG is unavailable, Immune Globulin Intravenous (IGIV) can be used
•Airway maintenance: Suction apparatus, laryngoscope and endotracheal tubes
should be available + oxygen if necessary.
•Regular sedation, muscle relaxants to control pain and discomfort related to muscle
spasms.
•Local and systemic treatment of infection.
Complications of Tetanus
•Laryngospasms
•Fractures
•Hypertension
•Nosocomial infections
•Pulmonary embolism
•Aspiration pneumonia
•Death

Neonatal Jaundice
Case Study
•Baby Jamila is 2 days old and is on admission on the paediatric ward of a district
hospital on account of severe discoloration of the skin, conjunctiva, palms and soles
of the feet.
•She has a temperature of 38 degrees Celsius and a high-pitched cry and is irritable.
–Upon assessment, what is your impression of baby Jamila?
What is Neonatal Jaundice?
•Yellow discolouration of the skin, and/or conjunctivae and other mucous
membranes
•Caused by increased bilirubin deposits in the tissues
•Progresses in a head-to-toe direction.
•Babies become clinically jaundiced when the bilirubin level reaches about 85mmol/L
(5mg/dl)
•About 50% of term neonates and 80% of premature infants get mild to moderate
jaundice
•Jaundice is not always pathologic and can be caused by normal neonatal changes
in bilirubin metabolism.
Types of Jaundice in Newborns
Normal (physiological)
•Occurs 2 days to 2 weeks of age
•Skin and eyes yellow but none of the signs of abnormal jaundice
Abnormal (non-physiological)
•Starts on the first day of life
•Lasts > 14 days in term and > 21 days in preterm infants
•With fever
•Deep jaundice: Palms and soles of the infant deep yellow.

Causes of Non-Physiological Jaundice

•Non-physiological jaundice may be caused by:
–Serious bacterial infection
–Haemolytic disease due to blood group incompatibility or glucose 6-phosphate
–Dehydrogenase deficiency
–Congenital syphilis or other intrauterine infection
–Liver disease such as hepatitis or biliary atresia (stools pale and urine dark)
–Hypothyroidism
Maternal Risk Factors for Hyperbilirubinemia in Newborns
•Blood group incompatibility or other known haemolytic disease (such as G6PD
deficiency)
•Breastfeeding -Breast milk jaundice
•Polycythemia (delayed cord clamping, maternal smoking)
•Maternal illness: e.g.Gestational diabetes
•Medications: Diazepam, oxytocin

Newborn Risk Factors for Hyperbilirubinemia

•Prematurity
•Birth trauma: Cephalohematomaor significant bruising
•Poor breastfeeding (inadequate fluid/nutrient intake, dehydration)
•Polycythemia
•Excessive weight loss after birth
•Previous sibling received phototherapy
•Induction (hypoxia, infection, hypothermia)
•Congenital syphilis and other neonatal infections
Note: Jaundice in the first 24 hours of life is always pathologic.
Laboratory and Diagnostic Testing
•Physical exam should always be supplemented by laboratory investigations.
•All cases of suspected hyperbilirubinemia should test:
–Unconjugated and conjugated serum bilirubin levels
–Direct Coombs test (ABO)
–Baseline complete blood count including hemoglobin and hematocrit levels, glucose
–Group and crossmatch for infant’s blood type, if unknown.
–G6PD Assay should be considered in all cases of severe or prolonged
hyperbilirubinemia or in patients with a positive family history.
–Investigations for sepsis are not routinely recommended, but should be performed if
warranted by the clinical presentation and assessment.
Definitions
•Total Serum Bilirubin (TSB): Serum conjugated bilirubin + unconjugated serum
bilirubin
•Hyperbilirubinemia: TSB greater then 340µmol/L (may vary by definition)
Assessment
•Comprehensive clinical history assessment of the mother and infant should be
performed including but not limited to:
–Prenatal, antenatal and postnatal/neonatal course
–Family history
–Assessment of risk factors for severe hyperbilirubinemia.
•Head-to-toe physical examination should include:
–Current naked weight
–Percentage of weight loss from birth weight
–Assessment of overall hydration status and feeding adequacy
–Observing for bruising, cephalhaematoma or other risk factors
–Careful assessment for any signs of bilirubin encephalopathy.
Overall Management
•The management of patients with hyperbilirubinemia is dependent on:
–Early detectionof hyperbilirubinemia
–Adequate hydrationand feeding(IV if necessary)
–Phototherapy as recommended
–Close monitoring of serum bilirubin
–Close monitoring of overall clinical status to ensure there is no worsening of
hyperbilirubinemia once treatment has commenced.

Nursing Priorities/Interventions
•Administer prescribed treatment.
•Keep the baby well fed and hydrated.
•With breast milk or formula, frequent feedings (up to 12 times a day) are important.
•Give a 20mL/kg isotonic fluid bolus (Ringer lactate or normal saline) to children with
severe volume depletion.
•Give IV fluids 10ml/kg maintenance to help hydrate the infant.
•Monitor vitals.
•Monitor urine output.
•Assist with exchange transfusion if necessary.
Care in Phototherapy
•Phototherapy unit: Use high-energy output (450 -460 nm).
•Expose all body.
•Keep baby at a distance of 45cm from the light source.
•Care of the eyes: Cover eyes and monitor eyes for discharge.
•Give more fluids.
•Manage diarrhoea: As a result of increased bile salt and unconjugated bilirubin in
the stool.
•Rashes maybe be noticed which will go on their own.
•Observe and monitor patient frequently.
•Phototherapy is contraindicated in hyperbilirubinaemiacaused by liver
disease or obstructive jaundice as it may lead to bronze baby syndrome
Breastfeeding
•Breastfeeding should continue during phototherapy.
•Mothers should be advised to breastfeed their infant at least 8 to 12 times per day.
Feeding Difficulties
•Increasing the frequency of feedings and providing support to breastfeeding
mother/infant days reduces the likelihood of severe hyperbilirubinemia in breastfed
infants.
•Interrupting breastfeeding as part of therapy for hyperbilirubinemia is associated
with a major increase in the frequency of stopping breastfeeding by one month.
•Where concerns regarding intake exist, pre-and post-breastfeeding weights should
be recorded.
Phototherapy: Precautions
•Monitor serum biliribin level 4 -12 hours
–Rationale?
•When to stop phototherapy
–Bilirubin levels are less than 5mg/dl (85 µmol/l)
–Toxic levels of bilirubin are eliminated.
–Baby is old enough to handle the bilirubin load.

Side Effects of Intensive Phototherapy

•Temperature instability
•Intestinal hypermotility
•Diarrhoea
•Dehydration
•Interference with maternal-infant interaction
•Risk to eyes if not covered
•Rash to skin (usually mild)
•Bronze baby syndrome
Supplemental Fluids
•Infants should not routinely receive supplemental intravenous or oral fluids.
•For breastfeeding mothers, supplemental fluids for infant should be avoided to
maintain maternal milk supply and encourage frequent breastfeeding.
•Use maternal expressed breast milk for supplemental feeds, when available.
•Supplemental fluids should be administered orally or by intravenous infusion to
infants receiving phototherapy who are at an elevated risk of progressing to
exchange transfusion.
•If intravenous fluids are required, serum electrolytes should be checked.
•Supplementary fluids should be stopped once phototherapy stops and infant is
feeding well.

Kernicterus: Chronic Bilirubin Encephalopathy

•Clinical Features
–Cerebral palsy
–Hearing loss
–Vision problems
–Dental problems
Exchange Transfusion
•If phototherapy fails to control the rising bilirubin concentrations, exchange
transfusion is indicated to lower TSB concentrations.
•For healthy term newborns without risk factors, exchange transfusion should be
considered when the TSB concentration is between 350μmol/L and 425μmol/L
(despite adequate intensive phototherapy).
Discharge Criteria
•Patient is off phototherapy and clinically well
•No concern for significant or ongoing haemolysis
•Feeding adequately
Discharge Summary Requirements
•Most recent bilirubin lab values within acceptable range
•Naked discharge weight (for comparison at follow-up visit)
•Current feeding plan and hydration status
•Follow-up plan including confirmed date and time of follow-up appointment

Birth Asphyxia
•Birth asphyxia occurs when a baby does not receive enough oxygen before, during
or just after birth.
•There are many reasons that birth asphyxia may occur.
Causes Before or During Birth
•Inadequate oxygen levels in the mother's blood due to heart or respiratory problems
or lowered respirations caused by anaesthesia
•Low blood pressure in the mother
•Inadequate relaxation of the uterus during labour that prevents oxygen circulation to
the placenta
•Early separation of the placenta from the uterus, called placental abruption
•Compression of the umbilical cord that decreases blood flow
•Poor placenta function that may occur with high blood pressure or in post-term
pregnancies, particularly those past 42 weeks
After Birth
•Severe anaemia or a low blood cell count that limits the oxygen-carrying ability of
the blood
•Low blood pressure or shock
•Respiratory problems that limit oxygen intake
•Heart or lung disease

Low oxygen levels may decrease a baby's heart rate, blood pressure and blood flow
out of the heart.
•This may limit the blood flow to organs and tissues, leading to improper cell function
or damage.
•Organs typically affected by lowered oxygen include the brain, heart and blood
vessels, gastrointestinal tract, lungs and kidneys.
Symptoms Before Delivery
•Abnormal heart rate or rhythm
•An increased acid level in a baby's blood
Symptoms at Birth
•Bluish or pale skin color
•Low heart rate
•Weak muscle tone and reflexes
•Weak cry
•Gasping or weak breathing
•Meconium stained amniotic fluid
Diagnosis
•Severe acid levels —pH less than 7.00 —in the arterial blood of the umbilical cord
•Apgar score of zero to three for longer than five minutes
•Neurological problems, such as seizures, coma and poor muscle tone
•Respiratory distress, low blood pressure or other signs of low blood flow to the
kidneys or intestines
Management
•Birth asphyxia is a complex condition that can be difficult to predict or prevent.
•Prompt treatment is important to minimize the damaging effects of decreased
oxygen to the baby.
Specific Treatment for Birth Asphyxia
•Treatment based on:
–The baby's age, overall health and medical history
–Severity of the baby's condition
–The baby's tolerance for specific medications, procedures or therapies
–Expectations for the course of the condition.
Treatment
•Treatment may include:
–Giving the mother extra oxygen before delivery
–Emergency delivery or Caesarean section
–Assisted ventilation and medications to support the baby's breathing and blood
pressure
Complications
•Hypoxic Ischemic Encephalopathy
•Seizures
•Brain damage
•Cerebral Palsy

NEONATAL RESUSCITATION

Prepare for Birth

•Identify helper and review emergency plan.
•Prepare area for delivery.
•Wash hands.
•Prepare area for ventilation.
•Assemble supplies and equipment.
•Check the bag and mask for ventilation.
•Check for penguin sucker.
Testing Equipment
•Test all functions of the ventilation device.
–Squeeze bag and watch for valve in the patient outlet to open as you squeeze.
–Seal mask to palm of hand and squeeze hard enough to open pressure relief valve.
–Check mask rim for any damage that could prevent an airtight mask seal to face.
–Squeeze the penguin and place the tip at your fingertip/palm, if it doesn’t return to
its original shape then its functioning well.
At Birth
•Dry thoroughly.
–Helps to warm and stimulate breathing.
•Note the TIMEof birth.
•Decide what care baby will need.
–Is the baby crying or not?
Baby Is Crying
•Follow routine care.
•Keep warm.
–Skin to skin
–Dry cloth and head covering
•Check breathing (look, listen and feel).
•Clamp/tie and cut cord.
•Encourage breastfeeding.
•Maintain skin to skin.
Baby Is NOT Crying
•Keep warm.
•Position the head.
•Clear the airway if needed.
•Stimulate breathing.
Assess the baby’s breathing!
Is Baby Breathing Well?
•Baby breathing well will be crying or breathing quietly and regularly –routine care.
•Baby NOT breathing well will be gasping or not breathing at all –bag-mask
ventilation.
•Delay in ventilation may result in preventable death or brain damage.
Ventilate with Bag-Mask
•Place the baby on clean, warm and dry area with good light.
•Stand at the baby’s head.
•Position head slightly extended.
•Position the mask on face –ensure fit.
•Make a firm seal and ventilate.
•Give 40 breaths per minute.
Is Baby Breathing Well?
•Yes
–Monitor closely with mother.
–Assess, listen, look.
–Maintain skin to skin, breastfeeding.

•NO
–Call for help.
–Improve ventilation.
Improve Ventilation
•Check mouth, back of throat and nose for secretions.
–Open mouth slightly.
•Suction if secretions present.
•Reposition head.
•Reapply mask to form a better seal.
•Squeeze the bag harder to give a larger breath.
•Look for chest movement.

Still Not Breathing Effectively

•Is the heart rate normal or slow?
–Evaluate pulse at umbilical cord.
–Listen to heart rate with stethoscope.
•What is a normal heart rate for newborns?
–Greater than 100 beats per minute
•If heart rate is normal, continue to ventilate until baby is breathing well.
Continued Ventilation and Advanced Care
•Why might the baby still not be breathing?
–Meconium aspiration, immature lungs, congenital malformation
•Continue ventilation during transport if the baby must be moved for advanced care.
•If baby has no heart rate and no breathing after 10mins of BVM, the baby is dead.
–Stop ventilation.

Post Birth Care

•Transport mother and baby together if needed.
•Communication assessment and actions via ISBAR
•Support the family of a baby who is ill or who has died.
•Debrief with care team and seek support.

Recognizing Danger Signs

•Teach parents to recognize the danger signs and when to seek immediate care and
treatment:
–Not breathing well
–Color abnormal
–Cold or hot to touch
–Not active
–Not breastfeeding well
–Pus or swelling of eyes; pus, redness or bleeding of umbilicus; pustules on skin
–Convulsions

Care for Preterm or Small Baby

•Cleanliness of all persons and objects

•Continued skin-to-skin care
•Frequent breastfeeding
•Expressed breastmilk

Recording Births
•Date and time of birth
•APGAR score
•Weight
•Birth attendant note

APGAR Score
•Completed at 1 minute and 5 minutes after birth, or every five minutes until score 7
or more.

Care of Equipment
•To Prepare:
–Maintain PPE and disassemble the ventilation bag and mask device as well as
suction device.
•To Decontaminate:
–Soak all parts in a 0.5% chlorine solution for 10 minutes.
•To Clean:
–Wash all parts with soap and water.
•To Highly Disinfect or Sterilize:
–Boil in water for 10-20 minutes OR steam autoclave.
•Dry completely and keep clean until next use.

SUMMARY
•All babies need to be kept clean, warm, and encouraged to breastfeed.
•A baby who does not breathe needs extra help in the first minute after birth.
•Action Plan has three main questions:
–Is the baby crying?
–Is the baby breathing?
–What is the heart rate?
•Ventilation with bag and mask can be lifesaving when a baby does not breathe after
clearing airway and stimulation

Oral candidiasis (thrush)

Yeast (fungal) infection found in the mouth
White patches on oral mucosa
Gentle attempt at removal are unsuccessful
Infant may refuse to feed because of discomfort
May also see appear area, skin folds of neck armpit and groin
Treatment
Oral antifungal
Nystatin or clotrimazole: apply to mouth and tongue after feedings
Mother's breast may be infected
Must treat with anti-fungal as well

BIRTH INJURIES
1. Cephal haematoma
Collection of blood under periosteum
Complication of birth
Takes 2-3 weeks to resolve
Does not cross suture lines
Can lead to jaundice
2. Caput succedaneum
Swelling of the scalp in the new born
Result from pressure from the uterus or
Vaginal wall during delivery
Cross suture lines, pit on pressure
Disappear 1-2 days
Keep clean and dry
3. Intracranial hemorrhage
Bleeding into the cranium
Most common site subgaleal space
Result from forceps or vacuum delivery
If small no symptoms
If large hypovolemia neurological changes and death
4. Facial palsy
Occurs after injury of facial nerve
5. Brachial palsy
During birth damage occurs to the 5th and 6th
Cervical nerve roots of brachial plexus
Asymemmetry of upper extremities (erb’s palsy -shorten arm
Paralysis of the upper arm
Unable to raise arm elbow held in extension with forearm pronate
6. Fractures
Most common in clavicle
Palpate clavicle to assess for ridge or mass over clavicle
Subcutaneous air
Limited range of movement in arm on side of fracture

CONGENITAL ABNORMALITIES
1. Cleft lip and palate
Facial defect that can occur alone or together
Cleft lip
Incomplete fusion of lip
Visible at birth
Repair at 10 weeks of age
Lip sutured together and dressing put in place
Repair helps infant for better seal around for feeding
Cleft palate
Incomplete fusion of the palate
May be less obvious if no cleft lip
Mainly involve soft palate
Repair occurs between 6-18 months
Want child to be able to develop normal speech pattern
2. Epispadias and hypospadias
Abnormal location of urethral meatus in males
Hypospadias
Urethral penis is open on the ventral surface of the penis
Epispadias
Urethral canal is open on the dorsal surface of the penis
Mild cases do not interfere with urinary function
Severe cases require surgical intervention
Infant should not be circumcised; foreskin may be used to repair
3.Cataract
Opacity in the lens of the eye occur in part or all of the eye
Can be present at birth
Signs and symptoms
Cloudiness of lens, distorted red reflex, vision loss, white pupil
Must be diagnosed early for successful treatment
Surgical removal of lens and corrective lenses
4. Imperforate anus
Absent anal opening
Should be identified during newborn exam
Absence of passing of meconium
Requires surgery to preserve bowel, urinary and sexual function
5. Megacolon (hirschprungs Disease
Inadequate motility causes a mechanical
Obstruction within the intestine
Lack of ganglion cells in portion of intestinal wall of rectum and colon
Prevent peristalsis, and causes accumulation of intestinal contents
Signs and symptoms
Abdominal distention
Failure to pass meconium
Vomiting
Treatment
Can lead to death if not treated
Surgical removal of ganglionic bowel

Oesophageal atresia and Tracheo-oesophageal fitula

Malformation that results from failure of the esophagus to develop during gestation
Atresia
Esophagus does not form or May end in blind pouch
Tracheoesophageal fistula
Esophagus is connected to trachea by fistula
Signs and Symptoms
Excessive salivation and drooling
Cyanosis, choking and coughing
During feeding fluid comes back out through nose and mouth
Treatment
NG tube to suction upper pouch
Surgery as soon as possible
Repair if possible

Nursing management
Emotional support for parents
Preoperative nursing care-suction mouth, elevate head of bed, IV fluids
Gastrostomy tube for feeding
Post-operative nursing care
I've and antibiotics
Slowly re-introduce feeds when ready
Monitor to tolerance of food
Monitor weight, growth and development

Pyloric stenosis and atresia

Hypertrophy of the circular muscle of the pyloric canal
Causes obstruction between the stomach and duodenum
Causes inflammation of the passage causing further narrowing
Signs and Symptoms
2-3 weeks after birth
Projectile vomiting
Non bilious
Hungary, failure to gain weight, smaller stool
Treatment
IV fluids to maintain hydration
Surgery
Pyloromyotomy to release circular muscle fibers
Allow for passage of food and
Spina bifida
Malformation of the spinal cord where
There is a defect in the vertebrae through which the spinal cord contents can
protrude (failure of fusion of the vertebral column)
This is the result of neural tube defect
Cause not fully known
Linked to decreased intake of folic acid during pregnancy
Signs and Symptoms
Different types and manifestations depend on location
Sensory loss below level of malformation
Loss of motor and sensory function in lower extremities
Treatment
Close and repair lesion within 24-48 hours after birth
Braces to support joint position and mobility

Syndactyly and polydactyly

Syndactyly
Webbing between digits
Polydactyly
Extra digit on hands or feet
String tied around extra digit eventually falls off

Talipes equines (club foot)

Congenital abnormality in which foot is twisted out of its normal position
Unknown cause, theories include
Abnormal uterine position
Neuromuscular or vascular problems
Genetic component
Signs and symptoms
Three areas of deformity
Mid foot is directed downwards
Hind foot towards inwards
Hind foot curls to the heel and twist upward
Foot is small with shortened Achilles muscles in lower leg are atrophied
Treatment
Serial casting
Must be done before short bones of foot hardened or else need surgery
Surgery to realign the bones and release constricting soft tissue

Hydrocephaly
Imbalance between the production and absorption of cerebrospinal fluid CSF
Increase volume
Enlargement of one or more ventricles within the brain occurs
Signs and symptoms
Vary depending on the age of the child
Rapidly increasing head circumference
Full bulging fontanel
Signs of increased intracranial pressure
Difficulty in holding the head
Treatment
Surgery
Removed obstruction if possible
Place a shunt to drain CSF from ventricles into the peritoneum