NuCM 109 CARE OF MOTHER AND CHILD AT RISK (ACUTE & CHRONIC)

RESPONSIBILITIES OF THE NURSE AT BIRTH OF AN INFANT BORN PHYSICALLY OR DEVELOPMENTALLY CHALLENGED

 Nurses need to be familiar with the anomalies.

 Serves as back up informants to answer parent’s questions.
 Give direction about where and how parents should proceed in beginning to seek help for their child.

GASTROINTESTINAL SYSTEM PHYSICAL & DEVELOPMENTAL DISORDERS

1. ANKYLOGLOSSIA (TONGUE TIE) is an abnormal restriction of the tongue caused by an abnormally tight
frenulum, the membrane attached to the lower anterior tip of the tongue.
A. Causes

Typically, the lingual frenulum separates before birth, allowing the tongue free range of motion. With tongue-
tie, the lingual frenulum remains attached to the bottom of the tongue. Why this happens is largely unknown,
although some cases of tongue-tie have been associated with certain genetic factors.

B. Risk factors

Although tongue-tie can affect anyone, it's more common in boys than girls. Tongue-tie sometimes runs in
families.

C. Signs and symptoms of tongue-tie include:

 Difficulty lifting the tongue to the upper teeth or moving the tongue from side to side.
 Trouble sticking out the tongue past the lower front teeth.
 A tongue that appears notched or heart shaped when stuck out.
D. Complications

 Tongue-tie can affect a baby's oral development, as well as the way he or she eats, speaks and swallows.

For example, tongue-tie can lead to:

 Breast-feeding problems. Breast-feeding requires a baby to keep his or her tongue over the lower
gum while sucking. If unable to move the tongue or keep it in the right position, the baby might chew
instead of suck on the nipple. This can cause significant nipple pain and interfere with a baby's ability
to get breast milk. Ultimately, poor breast-feeding can lead to inadequate nutrition and failure to
thrive.
 Speech difficulties. Tongue-tie can interfere with the ability to make certain sounds — such as "t,"
"d," "z," "s," "th," "r" and "l."
 Poor oral hygiene. For an older child or adult, tongue-tie can make it difficult to sweep food debris
from the teeth. This can contribute to tooth decay and inflammation of the gums (gingivitis). Tongue-
tie can also lead to the formation of a gap or space between the two bottom front teeth.
 Challenges with other oral activities. Tongue-tie can interfere with activities such as licking an ice
cream cone, licking the lips, kissing or playing a wind instrument.
2. CLEFT LIP & PALATE
 The maxillary and median nasal processes normally fuse between week 5 and 8 intrauterine life. In infants
with cleft lip, the fusion fails to occur in varying degrees, causing this disorder to range from a small notch
in the upper lip to total separation of the lip and facial structure up into the floor of the nose, with the
even the upper teeth and gingiva absent.
 The nose is generally flattened because the incomplete fusion of the upper lip has allowed it to expand in
horizontal dimension
A. Risk factors
 More prevalent in boys than girls
 It occurs at a rate of approx. 1 in every 700 live births.
 Occurs as a familial tendency or most likely occurs from the transmission of multiple genes
 Twice as prevalent in the Japanese population and occurs rarely in African Americans.
 Formation may be aided by teratogenic factors present during week 5-8 of intrauterine life such as viral
infection or possibly a deficiency of folic acid

The deviation may be unilateral or bilateral

3. Cleft Palate- a opening of the palate, is usually on the midline and may involve the anterior hard palate,
the posterior soft palate or both. It may be a separate anomaly but as a rule it occurs in conjunction with
cleft lip
A. Risk Factors

 More frequently in girls than boys

 Result of polygenic inheritance or environmental influences

 In connection with cleft lip, the incidence is approx. 1 in every 1,000

live births.

 As a single entity, it occurs in approx. 1 in every 2,000 live births.

B. Assessment
 Detected by sonogram while in utero.
 Can be determined by pressing tongue with tongue blade after birth and reveals the total palate and the
extent of the cleft palate
 It is a component of many syndromes a child with cleft palate must be assessed for other congenital
anomalies.
C. Therapeutic management

Cleft lip is repaired surgically shortly after birth or between 2 and 10 weeks of age.

 A reversion of the original repair may be necessary when the child reaches 4-6 years of age.

Cleft palate is usually postponed until a child is 6-18 months to allow the anatomic change in the palate
contour that occurs during the 1st year of life to take place.

D. Perioperative care

 feeding method with cleft lip and cleft palate is to use a Breck or Haberman feeder.
 if cleft extends to the nares it can cause the oral mucous membrane and lips to dry, offer small sips of
fluid between feedings to prevent cracks and fissures.

 bubble the infant after feeding.

 If it is delayed beyond 6months, teach parents to be certain any food offered is soft.

 Infants whose surgery is delayed can be fitted with a plastic palate to form a synthetic palate and prevent
aspiration.

Haberman Feeder- Named after Handy Haberman for babies with impaired
sucking abilities.

E. Postoperative care

 After surgery, kept the infant NPO for approx. 4 hours

 Avoid any tension on a lip suture line

 Assess the Logan Bar or band-aid after each feeding

 Furnish adequate pain relief, if infant cry it increases tension on the suture

 After palate surgery, liquids are generally continued for the first 3 or 4 days and then a soft diet is
followed until healing is complete.

 When the child begins eating soft food, he or she should not use spoon until the sutures are removed.

 Be certain that milk is not included in the first fluids offered because milk curds tend to adhere to the
suture line.

 After feeding, offer the child clear water to rinse the suture and keep it as clean as possible.

 Observe the child for respiratory distress

 Suction gently not to touch the suture line with catheter

4. OMPHALOCELE

Is a protrusion of abdominal contents through abdominal wall at

the point of the junction of the umbilical cord and abdomen. The
herniated organs are usually the intestines, but may include
stomach and liver. They are usually covered and contained by a
thin transparent layer of peritoneum.

 As the baby develops during weeks 6-8 of pregnancy, the

intestines get longer and push out from the belly into the
umbilical cord. By the 7 th-10th week of pregnancy, the
intestines normally go back into the belly. If this does not happen, an omphalocele occurs.
  The incidence is 1 in 6000 live births.

A. Assessment
 Are diagnosed by prenatal sonogram
 May be revealed by an elevated Maternal Serum Alpha Fetoprotein during pregnancy
 If identified inside utero, caesarean birth may be performed to protect the exposed intestine.
 Be sure to document the omphalocele’s general appearance and its size in centimeters at birth.
B. Therapeutic management
 Will have immediate surgery to replace the bowel before the thin peritoneal membrane ruptures or
becomes infected.
 If large, infants may prescribed a topical application of a solution such as silver sulfadiazine followed by
delayed surgical closure
 A nasogastric tube is inserted at birth to prevent intestinal distention
 Parenteral nutrition
C. Perioperative care

 Keep the sac moist by covering it with either sterile saline-soaked gauzed or sterile plastic bowel bag until
surgery

 The saline used must be at body temperature to prevent lowering body temperature

 Don’t feed the infant orally until bowel repair is complete

D. Postoperative care
 Maintained on total parenteral nutrition
 Observe infant carefully for signs of obstruction (abdominal distention, constipation, or diarrhea, or
vomiting) when they begin oral feedings
5. GASTROSCHISIS

Is a condition similar to omphalocele except that the abdominal wall disorder is a distance from the umbilicus and
abdominal organs are not contained by peritoneal membrane but rather spill freely from the abdomen

A. Causes and Risk Factors

 The exact causes of gastroschisis are often unknown.
 It is likely caused by a combination of genes and other factors, such as
things the mother comes into contact within her environment, what
the mother eats or drinks, or certain medicines used during pregnancy.

 Children with gastroschisis often have decreased bowel motility, and

even after surgical correction they may have difficulty with absorption
of nutrients and passage of stool

 Increasing incidence from 2 in 10,000 live births to 4.5 per 10,000 live
births.

6. Diaphragmatic hernia

 Is a protusion of an abdominal organ (stomach or intestine) through defect in the diaphragm into the
chest cavity.
  This occurs at the left side, causing cardiac displacement to the right side of the chest and collapse of the
left lung.

 It occurs when the diaphragm at week 8 intrauterine life does not completely form and the intestines
herniates through the diaphragm opening into the chest cavity.

A. Assessment

 Detected in utero by sonogram

 Newborns will have respiaretory difficulty from the moment of birth because one of the lobes of their
lungs cannot expand completely

 Abdomen appears sunken

 Breath sounds will be absent on the affected side

 There may be cyanosis and intercostal or subcostal retractions

B. Therapeutic management

 Treatment is emergency surgical repair that usually requires a thoracic incision and the placement of
chest tubes.

C. Perioperative care

 Kept on NPO

 Position the infant in a semi-fowler’s position

 A nasogastric tube is inserted immediately to prevent distention of the herniated intestine

D. Postoperative care

 On semi-fowler’s position

 Keep the infant in a warmed humidified environment to encourage lung fluid drainage from now
uncompromised lung

 Chest physiotheraphy

7. Imperforate Anus

Is a stricture of the anus. In week 7 intrauterine life, the upper bowel elongates to pouch and combine with
the pouch invaginating from the perineum. These two sections of bowel meet, the membranes between them
are absorbed, and the bowel is then patent to the outside. If this motion toward each other does not occur or
if the membrane between the two surfaces does not dissolve, imperforate anus occurs.

A. Assessment

 First stool is not passed within 24 to 48 hours after birth

 Stool passes out of the vagina, base of penis, scrotum, or urethra

 Swollen belly area

B. Types
 A rectoperineal fistula (opening) on the skin behind the genitals (an area called the perineum).
  Boys may have a rectourethral fistula, which connects the rectum to the urethra, the urine (pee) tube.
Both pee and poop come out of the urethra's opening, which is usually at the tip of the penis
 In girls, the rectum may open in:
o the vagina (rectovaginal fistula)
o the area around the vaginal opening (rectovestibular fistula)
o a cloaca, which is a single opening that connects to the rectum, vagina, and urethra
C. Therapeutic management

 If the repair will be extensive, the surgeon may create a temporary colostomy, anticipating final repair
when the infant is somewhat older (6-12 months).

D. Perioperative care

 Keep the infant NPO to avoid bowel distention

 Nasogastric tube is attached to low intermittent suction for decompression will be inserted to relieve
vomiting and prevent pressure

 Intravenous theraphy or total parenteral nutrition will be inserted to mainatin fluid and electrolyte
balance.

 Take axillary or tympanic temperatures rather than rectal temperatures

 Infants should have no any rectal procedures

 Clean the suture line well after bowel movements by irrigating it with normal saline

 Put the infant in side-lying position not on the abdomen

 Rectal dilatation done once or twice a day for months to ensure proper patency of the anal sphincter

E. Postoperative care

 With NGT still in place. When bowel sounds are present and NGT is removed, small oral feedings of glucose
water, formula or breast milk are begun

 Infant with temporary colostomy who are scheduled for repair in a 2nd stage operation are not permitted
high-residue foods to lessen bulk of stools.

Nervous System Physical and Developmental Disorders

1. HYDROCEPHALUS
 Cerebrospinal fluid is formed in the first and second ventricles of the brain and then passes through the
aqueduct of Sylvius and the fourth ventricle to empty into the subarachnoid space of the spinal cord,
where it is absorbed.
 Is an excess of CSF in the ventricles or the subarachnoid space. In the infant whose cranial sutures are not
firmly knitted, this excess fluid causes enlargement of the skull.
 Congenital- at birth
 Acquired- incident later in life

Reasons:

1. Overproduction of fluid by a choroid plexus in the firstor second ventricle as could occur from a growing
tumor
 2. Obstruction of the passage of fluid in the narrow aqueduct of Sylvius (foramina of Magendie & Luschka)-
infections such as meningitis or encephalitis, hemorrhage from trauma, or tumor

3. Occur form interference with the absorption of CSF from the subarachnoid space if a portion of the
subarachnoid membrane is removed as occurs with surgery for meningocele, or after extensive
subarachnoid hemorrhage.

TYPES:

 Communicating hydrocephalus/ Extra ventricular hydrocephalus - If the fluid can reach the spinal cord,
the disorder is called
 Obstructive Hydrocephalus- if there is a block to such passage of fluid

Assessment

• Occurs approx. 3-4 per 1,000 live births

• It can be detected on a sonogram

• Infants fontanelles widen and appear tense

• Suture lines on the skull separate

• Head diameters enlarges

• Scalps becomes shiny

• Scalp veins become prominent

• Brow bulges

• Eyes become sunset

• Increase intracranial pressure (decrease pulse, decrease respirations, increased temperature and blood
pressure)

• Shrill, high-pitched cry

• Motor function becomes impaired because of heavy head

• It can be demonstrated by sonography , CT scan, or MRI

• Skull xray film may reveal the separating sutures and thinning of the skull.

• Transillumination against the skull with the child in a dark-light will reveal
the skull is filled with fluid rather than solid brain.

Therapeutic management

• Acatazolamide (Diamox) to promote the excretion of fluid.

• Laser surgery to reopen the route of flow or bypassing the point of obstruction by shunting the fluid to
another point of absorption.

• Shunting procedure involves threading a thin polyethylene catheter under the skin from the ventricles to
the peritoneum. Fluid drains by this route into the peritoneum and is absorbed across the peritoneal
membrane into the body circulation.
 • Prognosis is improving everyday as shunting and surgical procedures become more common and more
effective. The ultimate prognosis for a child depends on whether brain damage occurred before shunting
and if a shunt is in place, whether the parents can recognize when it needs to be replaced to prevent
increased intracranial pressure.

POSTOPERATIVE CARE

 Assess for signs of increased intracranial pressure after surgery : tense fontanelles, increasing head
circumference, irritability or lethargy, decreased level of consciousness, poor sucking, vomiting, an
increase in blood pressure, increasing temperature, and decrease pulse and respiratory rates.

 Have NGT until bowel sounds return and the tube can be removed.

 Introduced fluid gradually in small quantities after removal of the tube.

 Support the head well when moving them to avoid strain

 Hold head with the whole palm
 No contraindications for breast feeding exist
 Note how the child sucks
 Observe constipation
 Urge parents to increase fluid and roughage in the diet as a preventive measure.
 Observe the pump site daily for signs of swelling or redness
 Have child sleep with his head slightly elevated at night to help ensure fluid flow through the tube
 Wash the head daily and position it every 2 hours to relieve pressure.
 As the child grows taller, the shunt will eventually need to be replaced for proper functioning.
 Use helmet to protect the head
 Preschool and school age parents need to confer to make the nurse/ teacher aware that the child has a
shunt in place and that the child may need special head protection

NEURAL TUBE DISORDERS

Spina bifida is most often used as a collective term for all spinal cord
disorders, but there are well-defined degrees of spina bifida
involvement and not all neural tube.

• Incidence of neural tube defect disorders has fallen from

3/1000 to 0.6/1000

• Polygenic inheritance pattern

• Poor nutrition (deficient in folic acid-major contributing

factor)

• The risk of bearing a 2nd child with neural tube disorder once one child is born with such disorder increases
as 1 in 20.

• Serum assessment is done at week 15 of pregnancy when AFP reaches its peak concentration

• Sonogram help to determine the presence of the disorder

Types of disorders
 1. Anencephaly- is absence of the cerebral hemispheres. It occurs when the upper end of the neural tube
fails to close in early uterine life. It is revealed by an elevated level of AFP in the maternal serum or
amniocentesis and confirmed by a sonogram.

• Infants with anencephaly may have difficulty in labor because the underdeveloped head does not engage
the cervix well.

• Children cannot survive with this disorder because they do not have cerebral function.

2. Microcephaly- is a disorder in which brain growth is so slow that it

falls more than three standard deviations below normal on growth
charts. It is associated with intrauterine infection such as rubella,
cytomegalovirus and toxoplasmosis. It can be a result of severe
malnutrition or anoxia in early pregnancy.

• Prognosis for normal life is guarded and depends on the extent of

restriction of brain growth and the cause.

• Infant is cognitively challenged because of lack of functioning brain

tissue.

• True microcephaly must be differentiated from craniosynostosis

(normal brain growth but premature fusion of the cranial sutures) which also causes decreased head
circumference. Infants with craniosynostosis have abnormally closed fontanelles and often show bulging
(bossing of the forehead and signs of increased intracranial pressure).

• Craniosynostosis can be relieved by surgery and brain growth will be normal

Infant with microcephaly

3. Spina bifida occulta- occurs when the posterior laminae of the vertebrae fail to fuse. This occurs most
commonly at the fifth lumbar or first sacral level but may occur at any point along the spinal cord.

• Noticeable as a dimpling at the point of poor fusion; abnormal tufts of hair or discolored skin may be
present

• Benign disorder (1 in every 4 child)

4. Meningocele- if the meninges covering the spinal cord herniate through unformed vertebrae, a meningocele
occurs. The anomaly appears a protruding mass usually approximately the size of an orange at the center of the
back. It generally occurs at the lumbar region although it might be present anywhere along the spinal canal. The
protrusion may be covered by a layer of skin or only clear dura mater.
5.Myelomeningocele- the spinal cord and the meninges protrude through the vertebrae the same with a
meningocele. The difference is that the spinal cord ends at the point, so motor and sensory function is absent
beyond this point.

• Flaccidity

• Lack of sensation of the lower extremities

• Loss of bowel and bladder control

• They may have accompanying talipes (clubfoot) disorders and hip dysplasia

• 80% with myelomeningocele infants have hydrocephalus due to lack of a subarachnoid membrane for CSF
absorption; higher
myelomeningocele occurs on the
cord the more likely it is that
hydrocephalus will accompany it.

• CT scan, MRI and sonogram will

reveal the size of the skull disorder

Assessment

• May be discovered during

intrauterine life by sonogram,
fetoscopy, amniocentesis or analysis of AFP in the maternal serum.

• Infants may born cesarean section to avoid pressure and injury to the spinal cord

• Assess the newborn if they have lower motor function

• Assess the nature and pattern of voiding and defecation

Therapeutic management

• Needs surgery to replace the contents that are replaceable and to close the skin disorder to prevent
infection.

• Before surgery is done only after the infant has survived the newborn period. Currently it is done as soon
after birth as possible (within 24-48 hrs)

• Parents needs to be cautioned that the prognosis for the child depends on the extent of the disorder.

• Parents need a great deal of support of care for a child with myelomeningocele because the child has
multiple challenges; they continue to have paralysis of the lower extremities and loss of bowel and
bladder control
Motor function ability in Myelomeningocele

PERIOPERATIVE CARE

• Use sterile gloves and sterile linens when caring for the infant

• Position the infant carefully (prone or supported on their side)

• Placing a piece of plastic or sturdy plastic wrap below the meningocele to prevent feces from touching the
open lesion.

• Sterile wet compress of saline, antiseptic or antibiotic gauze over the lesion to keep the sac moist.

• Any seepage of clear fluid from the disorder should be reported promptly (check for glucose in urine &
mucus)

POSTOPERATIVE CARE

• Child will be placed on the abdomen until the skin incision has healed

• Careful precaution of the feces and urine not to touch the incision area

• Hold the baby in as normal feeding position

• Remind parents when to burp the baby (do not tap the back over the disorder

• Parents must make routine of inspecting lower extremities and buttocks for irritation or infection

Arnold-Chiari Disorder

• Caused by overgrowth of the neursl tube in weeks 16-20 fetal life.

• The anomaly is a projection of the cerebellum, medulla oblongata and fourth ventricle into the cervical
canal

• Lumbosacral myelomeningocele is present in aprrox 50% of children with anomaly

• The prognosis depends on the extent of the disorder and the surgical procedures possible.
Skeletal physical & developmental disorders

1. Absent or malformed extremities- Maternal drug ingestion, virus invasion amniotic band formation

• Lower and upper prostheses are fitted as early as age 6 months

• Introducing a prosthesis early also prevents a child from adjusting missing extremity

• Introduce parents to the rehabilitation team who will be following their child.

2. Finger and toe conditions

• Polydactyly- presence of one or more additional fingers or toes. This extra fingers are often just cartilage
or skin tags

• Syndactyly-two fingers or toes are fused, the fusion is usually caused by a simple webbing.

• Parents may need reassurance that their child’s development is normal in other ways so they can
accept and help the child develop self-esteem.

3. Chest deviations

• Pectus excavatum- is an indentation of the lower portion of the

sternum (they may develop COPD or rickets)lung volume
decreases and heart is displaced to the left

• Pectus carinatum- the sternum is displaced anteriorly,

increasing anterior posterior diameter of the chest.

Torticollis (Wry neck)

Torticollis is termed derived from tortus (twisted) and collum (neck). It

occurs as a congenital anomaly when the sternocleidomastoid muscle is injured and bleeds during birth. Tends to
occurs in newborns with wide shoulders

• The injury may be noticeable at 1 to 2 months; a thick mass over the muscle can usually be palpated at
this time.

• To relieve torticollis, parents need to begin program of passive stretching exercises and always
encouraging the infant to look in the direction of the affected muscle.

• Position during feeding the child may look in the desired direction

• If simple exercises are not effective until 1 year of age, surgical correction will be done followed by a neck
immobilizer

Talipes disorders

• Latin word talus (ankle) and pes (foot)

• The deformities are ankle-foot disorders, popularly called clubfoot.

• 1 in every 1000 livebirths

 • More often in boys than girls

• A true talipes disorder can be one or four separate types: plantarflexion (equinus or “horsefoot” position
with the forefoot lower than the heel); dorsiflexion (heel is held lower than the forefoot or the anterior
foot is flexed toward the anterior leg); varus (foot turns in); valgus deviation “foot turns out)

• Most children with talipes deformities have a combination of these conditions or have an equinovarus or
calcaneovalgus disorder ( a child walks on the heel with the feet everted)

Assessment

• The earlier a true disorder is recognized, the better the correction will be. Make a habit of straightening all
newborn feet to the midline as part of initial assessment to detect this disorder.

Therapeutic management

• Cast is applied while the foot is placed in an overcorrected position. The cast extends above the knee to
ensure firm correction.

• Teach the parents how to assess the infant’s toes for coldness or blueness and how to blanch nails to
assess for good circulation.

• Crying episodes in the infant must be evaluated carefully.

• Cast must be changed every 1 or 2 weeks (infants grow rapidly)

• After 6 weeks the final cast is removed

• Parents need to perform passive foot exercises such as putting the infant’s and ankle through a full range
of motion several times a day for several months.

• The infant may have to sleep in Denis Browne splints

Developmental hip dysplasia

• Improper formation and function of the hip socket. It may be evident as subluxation or dislocation of the
head of the femur. The acetabulum of the pelvis is flattened or shallow which prevents the head of the
femur from remaining in the acetabulum and rotating adequately.

• In a subluxated hip, the femur “rides up” because of the flat acetabulum

• Caused is unknown

• Polygenic inheritance pattern

• Most often in child of Mediterranean ancestry

• 6 times more common in girls than boys

Assessment

• The affected leg appear slightly shorter than the other

• Noticeable when the child is lying supine and the thighs are flexed to a 90 degree angle toward the
abdomen.

• Unequal skin folds may be present on the posterior thighs

 • Hips abducts properly

• Difficult to detect to infant born from a footling or frank breech position

• Xray, MRI, sonogram will reveal the shallow acetabulum more lateral placement of femor head than
ordinary

ORTHOLANI’S & BARLOW’S SIGNS

Therapeutic management

• Splints, halters or casts may be used.

• If the child is older, traction is used first to bring the femur head into good position with the acetabulum

• Splint correction is begun during newborn’s initial hospital stay by placing two or three diapers between
the legs

Frejka splint is made of plastic and buckles onto the child like a huge confining diaper.

• Parents need to keep the splint in place at all times except when changing diapers or bathing the baby.

• Remind parents to have a good diaper area care

• Be certain, parents understand that bringing the child’s legs together with a tight swaddling blanket will
not be good fo their child.

• Pavlik Harness- is an adjustable chest halter that abducts the legs. It it’s the method of choice for long-
term theraphy because it reduces the time interval for theraphy to 3-4 weeks and simplifies care.

• The harness is worn continually except for bathing.

• Advise parents to assess skin under the straps daily for irritation or redness

• Harness will be ineffective if parents remove it too frequently.

Spica cast- if a hip is fully dislocated or subluxation is severe, an infant may be placed immediately in frog-leg cast
or spica cast. The child may first be placed in a Bryant’s traction for a week to better position of the hip. The hip is
then placed in an abducted position and a large hip spica cast or an A-line cast.
 • Assess circulatory constriction (hourly for the 1st 24 hrs and then daily thereafter)

• Teach parents how to do neurovascular assessment (check temperature and circulation of the toes.

• Cast will be changed periodically but maintained for 6-9 months

General care guidelines

• No matter what type of therapy is used – double diapering, splint, harness or cast- surgery may still be
necessary for final correction.

• The child and parents will be visiting their orthopedist frequently during these early years

• Teach parents to hold their child for feeding and to rock and cuddle the infant, even though a large cast or
a brace may be bulky and awkward.

• Teach parents to bring experiences to the infant

• Assure parents that the child will quickly catch up with developmental step