‫بسم هللا الرحمن الرحيم‬

➤Easy Nursing

Summarization of Chapters 1.2.3.4

For Pediatric Nursing

Prepared By:
NS-Hamdan Farhan Hegazi

Teacher:
Mr. Bara' Al-Habbash
 Chapter (1)
Introduction to child health and Pediatric Nursing
Pediatrics is the branch of medicine that deals specifically with children, their development,
childhood diseases, and the treatment of such diseases.
Pediatric nursing is the practice of nursing involved in the health care of children from infancy
through adolescence.

Roles of the Pediatric Nurse

1) Family advocacy
2) Health teaching
3) Support /Counseling
4) Therapeutic role
5) Coordination/Collaboration
6) Health care planning
7) Disease prevention/health promotion:
8) Research

Measurement of Children's Health Status

Health :is a state of complete physical, mental and social well-being and not merely the absence of
disease or deformity
Mortality is the number of individuals who have died over a specific period.
Infant Mortality Rate: Is a number of deaths per 1000 live births during the first year of life.
Neonatal mortality rate: number of deaths per 1000 live births during neonatal period (the first 28
days of life).
Post-neonatal mortality rate: number of deaths per 1000 live births during Post-neonatal period
(29 day to 1 year).
In Palestine
▪The infant mortality rate is used as an index of the general health of a country. Generally, this
statistic is one of the most significant measures of children's health.
Major causes of infant mortality in Palestine were ranked as:
1. Congenital anomalies
2. Respiratory problems
3. Prematurity and low birth weight
4. Heart diseases
5. Sudden infant death syndrome
6. Septicemia
Preterm birth is the leading cause of newborn deaths worldwide
Childhood Mortality:
After 1 year of age there is a dramatic change in causes of death with injuries (accidents) being
the leading cause during childhood "injuries is the leading killer". They include:
1. Motor vehicle 2. Drowning 3. Fire and burns
4. Ingestion of food/object 5. Mechanical suffocation 6. Falls
Morbidity:
▪ Is the prevalence of specific illness in the population at a particular time.
▪ Unlike mortality statistics, morbidity is often difficult to define and record because the
definitions used vary widely.
Growth:
-The natural increase in body size as well as sizes of different body organs.
-It is quantitative change and can be measured in cm. or kg.
Development:
▪Maturation of organs and systems, gaining of skills and ability of adaptation and assuming
responsibilities.
▪It is qualitative change that cannot be weighed or measured in cm, or kg.
▪It can be observed.
▪Development is a continuous process from conception to maturity, Examples are:
Child sits before standing.
Stand before walking.
Learn alphabet before wards.
Rate of development, varies with each child.
Developmental Age Period
1.Prenatal period: From conception to birth
a. Germinal conception to 2-3 weeks .
b. Embryonic 3 - 8 weeks
c. Fetal 8 - 40 weeks (birth)
2. Infancy period: From birth to 12 months.
a. Neonatal birth to 28 days
most critical period
The main problems: prematurity, birth injuries, congenital anomalies and infections.
b. Post-neonatal (Infancy) 29 days to 12 months
most rapid physical growth and mental development
The main problems: infectious diseases and nutritional disorders.
3. Early childhood: From 1 to 6 years.
a. Toddler 1 to 3 years
b. Preschooler 3 to 6 years

4. Middle childhood: 6 to 12 years. (School age).

5. Later childhood: 12 to 18 years. The period of passage from childhood to
adulthood
a. Pre-pubertal period 11 to 13 years

b. Adolescence 13 to 18 years
Factors affecting growth and development
1) Genetic factors:
▪ Some genetic disorders affects growth and development e.g. achondroplasia (an inherited
skeletal disorder characterized by impairment in the formation of cartilage at the epiphyses of
long bone and cartilage is converted to bone resulting in dwarfism)
2) Endocrinal factors: the growth hormone, thyroid hormone and sex hormones are essential for
normal growth and development. Congenital hypothyroidism is a good example for delayed
growth and development.
3) Environmental factors
4) Nutritional factors
5) Congenital anomalies
6) Chronic diseases
7) Activities

Assessment of Growth
Anthropometric measurements (Weight, Height, Head circumference, Chest circumference)
1: Weight:
▪The average weight at birth = 3.5 Kg (2.7-4.2 kg)
3/4 every month in the first 4 months (i.e. 3 kg in 4 months).
1/2 kg every month in the second 4 months (i.e. 2 kg in 4 months).
1/4 kg every month in the third 4 months (i.e. 1 kg in 4 months).
▪ After the first year, the average weight of a child can be calculated by the following formula:

2. Length or height:
The length is measured in the recumbent position below the age of 2 years while the height is
measured in the standing position usually after the age of 2 years.
▪The average length at birth = 50 cm (45-55 cm).
▪During the first year of life, the length increases as follows :
3 cm every month in the first 3 months.
2 cm every month between the 3rd and 6th month.
1.5 cm every month from the 6th -12th months of age.
▪ After 2 years, the average length is calculated by the following formula:

Length in cm = Age in years x 5 + 80

3. Head circumference:
The size of the skull depends on the growth of the brain. If the brain does not grow adequately,
the skull will be small (microcephaly).
At birth the average HC = 35 cm (32.5-37.5)
During the 1st year, the average increase in HC = 2 cm/month in 1st 3 months then 0.5
cm/month in next 9 months.
Average head circumference for Birth 35 cm
Average head circumference for 1 year 47 cm
NB: Head circumference increases 12 cm during the first year and only 6 cm during the next 11
years. This demonstrates the importance of brain growth in the first year.
4. Chest circumference
It is usually measured in mid-respiration at the level of the xiphoid. It is usually related to head.
At birth: The head is larger by 2 cm.
Between 1-2 years: both are equal
After 2 years: the chest is larger than the head.

Growth Charts
- Is used to follow a child's growth over time.
These percentiles are (5th, 10th, 25th, 50th, 75th, 90th, and 95th percentile) where 50th percentile
represents the average and indicates that 50% of the normal children are below this value.
25th, 10th, and 5th percentiles are low normal values while 75th, 90th and 95th are high normal
values.
Values below 5th and above 95th are abnormal.
A child falls on the 25th percentile means that this child weighs more than 25% of other
children of the same age but less than 75% of them.

Assessment of Vital Signs in Pediatric ‫قراءة من الكتاب العتبارها من المهارات العملية‬

NB: Each degree rise in body temperature increases the respiratory rate about 5 breath/minute
and heart rate about 10 beats/minute.

Development and developmental assessment

 Development is intimately related to the maturation of the nervous system.

Children’s Reactions to Hospitalization

1) Anxiety and fear.
2) Separation anxiety
3) Feeling of anger and guilt
4) Regression
5) Resistance and violence
 Chapter (2)
Overview of Neonatal Nursing
Neonatal Adaptation to Extra-uterine Life
The neonatal period (the first 28 days of life) is a highly vulnerable period during which many of
physiologic adjustments

Physiologic Adaptations
Cardiovascular System Adaptations
Successful transition from fetal to postnatal circulation requires removal of the placenta,
increased pulmonary blood flow, and closure of the intra-cardiac (foramen ovale) and
extra-cardiac shunts (ductus venosus and ductus arteriosus).
The most important factor controlling ductal closure is the increased oxygen concentration
of the blood, secondary factors are the fall in endogenous prostaglandin's and acidosis.

Respiratory System Adaptation:

Stimuli that help initiate the first respiration:
1. Chemical factors: ↓O2, ↑CO2, ↓ pH → stimulate respiration by stimulating the aortic and
carotid chemoreceptors initiating impulses that trigger the medulla's respiratory center.
2. Thermal stimuli: There is a significant decrease in environmental temperature after birth
from 37oC to 21oC -24oC. The cold stimulates skin nerve endings that are initiating impulses that
trigger the respiratory center and the newborn responds with rhythmic respirations.
3. Mechanical factor
4. Sensory stimuli: Tactile, auditory, visual stimuli (Intrauterine Life....dark, sound-dampened,
fluid-filled environment that is nearly weightless
5. Re-absorptive changes: Most of the lung fluid is reabsorbed within 2 hours after birth and is
completely absorbed within 12 to 24 hours after birth.
Thermoregulation
Why premature neonate high risk for hypothermia?
1. Large body surface area relative to body weight.
2. Lack of subcutaneous fat, which provides insulation
3. Immature heat regulation center in the hypothalamus.
4. Inability of neonates to generate heat by shivering until 3 months of age.
5. Thin skin with blood vessels close to the surface

Methods of Heat Loss

1. Evaporation: when wet surfaces are exposed to the air evaporation occurs. Heat is lost when
the surface dries.
Ways to prevent heat loss by evaporation:
1. Drying the infant as quickly as possible after birth.
2. Drying the infant immediately after bathing.
2. Conduction: when heat is transferred to cooler objects that are in direct contact with infant
Ways to prevent heat loss by conduction:
1. Warming the objects that will touch an infant.
2. Placing an infant against the mother’s skin helps prevent conductive heat loss.
3. Radiation: when heat is transferred to cooler objects that are not in direct contact with the
neonate
Ways to prevent heat loss by radiation:
1. Incubators must have double walls.
2. Cribs and incubators should be placed away from the walls and windows
4. Convection: when heat is transferred to the air surrounding the infant heat loss by convection
takes place.
Ways to prevent heat loss by convection:
1. Keeping the newborn out of drafts.
2. Maintaining warm environmental temperature.
3. Keeping a preterm neonate in an incubator

Hepatic System Function

At birth, the newborn’s liver assumes the functions that the placenta handled during fetal life.
The liver is the most immature of the GI organs, which affect the followings:
1. Conjugation of bilirubin with glucourinic acid leading to physiological jaundice.
2. The liver is deficient in forming plasma protein which leading to edema.
3. Deficiency of Prothrombin, and other coagulation factors especially the vitamin K-dependent
clotting factors leading to bleeding.
4. Store less glycogen at birth leading to hypoglycemia, which can be relieved by feeding.
Liver immaturity leads to:
1) Jaundice 2) Edema 3) Bleeding 4) Hypoglycemia
Breast milk is a relatively poor source of vitamin K and endogenous synthesis by the GI
flora is not established for the first few weeks after birth.
vitamin K prophylaxis is administered to all newborn babies to protect against hemorrhagic
Gastrointestinal System Adaptations
Stomach capacity: at birth is 30 -60 ml, 90 - 130 ml at one month of age with a variable
emptying time of 2 to 4 hours.
Bowel Elimination
The evolution of a stool pattern begins with a newborn’s first stool, which is meconium.
Hematology.
Neonatal blood contains both adult (HbA) and fetal hemoglobin (HbF). Fetal hemoglobin
(HbF) makes 80% of the total Hb at birth.
(HbF) has a greater affinity for oxygen but has lower life span than HbA.
A combination of low levels of erythropoietin due to improved tissue oxygenation after birth,
decreased lifespan of (Hb F) leading to the physiological anemia of infancy which usually
occurs at around 8-10 weeks of age.
Hematopoiesis occurs in the liver in uterus but is restricted to bone marrow from 6 weeks
post-delivery, thus limiting potential sites for hemoglobin synthesis.
White cells: higher at birth, fall over 2-3 weeks then rise again.

Renal system
The first voiding (urine) should occur within the first 24 hour
Musculoskeletal system:
At birth the skeletal system contain larger amount of cartilage than have ossified bone
The muscular system is almost completely formed at birth.
Immunology:
The first line of defense against infections is the skin and mucus membrane.
The second line is the cellular elements, which produce several type of cells capable of
attacking a pathogen e.g. neutrophils, monocytes and lymphocytes.
The third line is the formation of specific antibodies to an antigen, this process requires
exposure to foreign agent. Newborn receive antibodies from mother (IgG) and not capable to
produce antibodies till the age of 2 months.
Placenta can pass Ig G only

Endocrine system
▪ Limited quantities of ADH, so the infant is susceptible to dehydration.
▪ The effect of maternal sex hormones leading to breast engorgement and production of milk
from the first few days until 2 months of age.
▪ The female newborn may has pseudo-menorrhea.

Neurologic System Adaptations

The newborn’s sensory capabilities include:
o Hearing—well developed at birth, responds to noise by turning to sound
o Taste—ability to distinguish between sweet and sour by 72 hours old
o Smell—ability to distinguish between mother’s breast milk and breast milk from others
o Touch—sensitivity to pain, responds to tactile stimuli
o Vision—ability to focus on objects only in close proximity (7–12 inches away(

Assessment of the newborn

Examination in the delivery room should not be extensive and consist largely of:
o Observation & inspection for congenital anomalies
o Auscultation of the chest
Look for signs that a child has a medical problem:
• Nasal flaring • Chest retractions • Grunting on exhalation
• Labored breathing • Generalized cyanosis
• Abnormal breath sounds: crackles, wheezing, stridor
• Abnormal respiratory rates (tachypnea (↑60 breaths/minute) bradypnea↓25 /minute)
• Flaccid body posture
• Abnormal newborn size: small or large

The number of umbilical cord vessels should be determined. Normally, there are two
arteries and one vein.

APGAR Score
Introduced in 1952 by Dr. Virginia Apgar, is used to evaluate newborns at 1 minute and 5
minutes after birth
• A = appearance (color) • P = pulse (heart rate) • G = grimace (reflex irritability)
• A = activity (muscle tone) • R = respiratory (respiratory effort)

A total score of 7 to 10 neonate is in good condition

A total score of 4 to 6 indicates fair condition (the neonate may have moderate CNS depression,
muscle flaccidity, cyanosis, and poor respirations)
A total score of 0 to 3 indicates danger (the neonate needs immediate resuscitation, as ordered).

Classification of newborn
1. According to gestational age:
Systematic physical examination
General look and posture
▪ Active or not (crying, movements and suckling)
▪ Pale, cyanotic, or in respiratory distress (grunting, acting alae nasi)
▪ Convulsions
Normally, the newborn takes the position of the intrauterine life with flexed extremities, which
are somewhat hypertonic and clinched fits.

Anthropometric measurements:
o Weight: average: 3.5 Kg (range: 2.7- 4.2 Kg)
▪ Newborn typically loses up to 10% of birth weight in the first week of life due to elimination
of extracellular fluids (edema) and meconium.
o Length: average: 50 cm (range: 45-55 cm)
o Head circumference: average: 35 cm (range: 32.5-37.5 cm)
o Chest circumference: 30.5 to 33 cm

Skin Assessment:
1. Non-pathological conditions:
Color: pink ,often mottled (due to vasomotor instability).
Vernix caseosa: Whitish greasy material covered the newborn skin at birth. It has a protective
value as it contains antibodies absorbed by the skin.
Lanugo hair: fine hair characteristic of the newborn best seen on the forehead, cheeks, shoulder
and back.
Mongolian spots: irregular areas of blue pigmentation usually present in the sacral and gluteal
regions due to increased melanin.
Acrocyanosis: means peripheral cyanosis of the hands and feet. It's probably caused by venous
stasis and not hypoxia.
Edema of subcutaneous tissues: is commonly present and is more evident in the eyelids, face,
dorsum of the hands, feet and legs. It disappears after several days.
Milia: distended sebaceous glands seen as minute white papules on the cheeks, nose, and chin.

2. Pathological conditions:
Jaundice: may be seen in the 60% of the normal full term infant on the 2nd or 3rd day of life and
disappear by the 7th day. Jaundice in the first 24 hours is abnormal and should be evaluated.
Seborrhea of the scalp (Cradle cap): is a yellowish, patchy, greasy, scaly and crusty skin rash
that occurs on the scalp of newborn babies.

Warning signs of the skin assessment that would warrant further investigation and/or
immediate intervention include:
• Long nails and desquamation, indicating postmaturity
• Thin translucent skin with abundant vernix and lanugo, indicating prematurity
• Pallor, possibly caused by hypothermia, anemia, sepsis, or shock
• Cyanosis, possibly caused by cardiorespiratory disease, hypoglycemia, polycythemia
• Meconium staining, possibly caused by intrauterine asphyxia
• Pustules, possibly caused by staphylococcal infection

Head Assessment:
Anterior fontanel:
▪ Diamond-shaped. It can be palpated midline, above the forehead.
▪ Its antero-posterior measurement is approximately 4–5 cm
▪ Normally closes by 18 months of age (range from 4 months to 26 months).
Posterior fontanel:
▪ Its postero-lateral measurement is approximately 0.5–2 cm
▪ Normally closes by 2 months of age or at birth.
▪ Delayed closure of posterior fontanel is associated with congenital hypothyroidism
Abnormality of head shape and size:
Molding: overriding of cranial bones due to compression during birth. The bones return to their
normal positions in a few days.
Craniosynostosis: premature closure of cranial sutures causing problems with normal brain and
skull growth and skull and facial deformities.
Caput succedaneum: edema of the newborn’s scalp that is present at birth and caused by head
compression against the cervix.
Cephalhematoma: is a collection of blood between the periosteum and the skull

Face Assessment:
▪ Cleft lip ▪ Microcephaly
▪ Characteristics of the Pierre Robin syndrome with a small mandible (micrognathia)
▪Forceps marks: Forceps often leave bruises on the face, usually in the shape of the
forceps blade.
Eyes Assessment:
o The eye lids appear puffy, the iris is grey in color, tears are absent
Abnormal findings:
▪ Subconjunctival, sclera, and retinal hemorrhage
▪ Congenital lid ptosis (a drooping of the eyelid)
▪ Purulent eye discharge (Opthalmia neonatorum)

Ear Assessment:
Malformed auricles or low-set-ears are found in many dysmorphic syndromes and are
associated with urogenital malformations
Nose Assessment:
▪The nose should be assessed for placement, shape, patency, and the presence of drainage
▪ Obstructed nasal passages(Choanal atresia) are an important finding as newborns are
obligatory nose breathers and usually cannot breathe orally even when compromised
Mouth Assessment:
▪ Large tongue (macroglossia)
▪ Excessive oral secretions suggest esophageal atresia or a swallowing disorder.
▪ Natal teeth
Neck Assessment
Chest Assessment:
▪ Neonatal Gynecomastia is common in either gender and may be noted as late as the second
or third day of life. It is caused by high levels of maternal estrogen that have passed through the
placenta and should resolve spontaneously.
▪ The most frequent birth injury to the thoracic region is fracture of the clavicles, identified
by crepitation when the clavicle is palpated.
Heart Assessment:
▪ The heart rate may be 160 to 180 bpm during the first few hours after birth.
Abdomen Assessment:
▪ Meconium (first passed stool which is odorless, very dark olive green-colored, viscous and
sticky like tar) should be passed within 24 hours . By the second or third day, the infant should
begin to have transitional stool, which is green or yellowish and may have a seedy appearance.
▪ The shape of abdomen should be domed or cylindrical because of immature musculature.
▪ Omphalitis (infection of the umbilicus)
▪ The anus should be inspected for patency and absence of fissures
Spine Assessment:
o Meningomyelocele: A severe form of spina bifida in which the spinal cord and nerves
develop outside of the spine and are contained in a fluid-filled sac
o Meningocele: an opening in the spine in which a sac-like cyst of meninges, filled with spinal
fluid, but involves no nerves or neurological defects and covered by skin
 Genitourinary:
▪ Failure to void with in the first 24 hours is considered a warning sign and needs further
evaluation.
▪ The normal urine output for an infant is at least 1–2 cc/kg/hr.
Output may be as high as 4 cc/kg/hr. in the first few days of life.
▪ Exstrophy of the bladder: is a congenital anomaly in which part of the urinary bladder is
present outside the body.
▪ Hypospadias: is malposition of the urethral opening. The urethra open on the lower surface
of the penis.
▪ Epispadias: is malposition of the urethral opening. The urethra open on the upper surface of
the penis
▪ Cryptorchidism: ( undescended testis): is the absence of one or both testes from the
scrotum. The testes may be located in the abdominal cavity or inguinal canal.
▪ Pseudo-menstruation Mucous and possible blood-tinged vaginal discharge may be present
for several days.

Neurological examinations:
Assess the newborn’s reflexes to evaluate neurologic function and development
Moro reflex (also called Startle reflex)
• Trigger: Loud noise (even baby’s own cry!), sudden movement, or sensation of falling
• Response: baby quickly abducts extremities and forms the index finger and thumb into a “c”
shape.
• Appears: As early as 32 weeks gestation
• Disappears: Until baby is four to six months old
• Reason: Baby’s first attempts to protect himself from harm
• Absence or poor Moro response: it indicates either marked prematurity <28 weeks or
depression of CNS (sedation ,or anesthesia given to the mother during delivery).
• Asymmetrical or unilateral Moro response: indicates fracture clavicle or Erb's palsy.
• Persistence of the reflex beyond 6months: indicates cerebral palsy or mental retardation

Care of the Well Newborn

Immediate care of the newborn includes:
1. Obtaining the APGAR score
2. Provide resuscitation (if needed)
3. Providing a neutral thermal environment
4. Immediate umbilical cord care
5. Proper identification of the infant
6. Perform a brief physical examination
7. Parent/infant bonding:
8. Prophylactic care.
✓Give vitamin K1 (0.5-1 mg IM) within 2 hrs. of life. to prevent .
✓Apply antibiotic eye drops (e.g. erythromycin) within 1 hr. of delivery to prevent
ophthalmia neonatorum

Routine umbilical cord care

✓ Keep the cord dry and loosely covered with clean sterile gauze.
✓ Fold the diaper below the umbilicus.
✓ If soiled, wash with soap and clean water and dry it well.
✓ Apply alcohol after each diaper change.
Screening:
-Bilirubin screening is recommended before discharge.
-Congenital hypothyroidism screening (3rd to 7th day of life)
-Phenylketonuria (PKU) (the baby must be full milk feeds for 3 days).
-Galactosemia
Vaccination
-Educate parents about vaccination schedule.
-Administer HBIG (0.5 ml/kg IM) to all newborns of HBs Ag-positive mothers as soon as
possible after birth (within 12 hrs.), followed by HBV vaccine (0.5 ml IM).

An important definitions
 Chapter (3)
Health problems of newborn infants
Pre-term Infant
-Preterm birth, also known as premature birth, is the birth of a baby at less than 37 weeks
gestational age
Etiology:
1. Idiopathic (Unknown)
2. Maternal factors:
■ Poor nutrition ■ Diabetes ■ Multiple pregnancy ■ Drug abuse
■ IUD in gravid uterus ■ Chronic disease (heart disease, kidney disease, infection)
■ Complications of pregnancy (PIH, bleeding, placenta Previa, abruptio placenta)
3. Fetal factors:
■ Chromosomal abnormalities ■ Feto-placental dysfunction.
Clinical features:
▪ Low anthropometric measurements (Weight, length, Head circumference).
▪ Hypoactive with weak cry and poor suckling.
▪ The head and abdomen appears large as compared with the limbs.
▪ Skin: thin, red, shiny, wrinkled and translucent with excess lanugo hair and vernix caseosa.
▪ Subcutaneous fat is decreased or absent.
▪ Respiration is irregular with attacks of apnea.
▪ Frog leg position due to hypotonicity
Pathophysiology: immature and often poorly developed systems
Respiratory system:
Respiratory distress is a common problem due to:
1) Alveoli begins to form at 26-28 weeks’ gestation so lungs is poorly developed.
2) Respiratory center and muscles are poorly developed.
3) Production of surfactant is reduced.
4) Gag and cough reflexes are poor (aspiration is a problem).
Digestive system:
Weak suckling and swallowing reflexes .
Lack of bile salts that aid digestion of fats and absorption of vitamin D and other fat-soluble
vitamins.
Weak cardiac sphincter with active pyloric sphincter and small capacity of stomach lead to
gastro-esophageal reflux (GER) and vomiting.
Temperature regulation mechanisms:
Preterm baby is liable to hypothermia because preterm baby:
1) very little subcutaneous fat
2) Limited ability to shiver
3) large body surface area in comparison to body weight
Liver function: immature liver leads to edema, jaundice, hemorrhage, and hypoglycemia
Eyes:
✓ If preterm baby is receiving oxygen at high concentration, retinopathy of prematurity or
retrolental fibroplasia will develop which to lead eventually blindness
Complication of prematurity:
1. Respiratory system: such as Asphyxia, Apnea, Aspiration pneumonia, Atelectasis & RDS
2. Cold injury secondary to hypothermia
3. Hypoglycemia
4. Brain damage
5. Jaundice
6. Malnutrition, rickets, and anemia
7. Liability to hemorrhage
8. Liability to infection
Nursing care for preterm infants:
1. Improving respiratory functions
2. Maintaining Body Temperature
3. Preventing Infection
▪The primary means of preventing infection is hand-washing.
4. Maintaining Adequate Nutrition
▪NG tube feeding is essential before age of 32 weeks of gestation because gag & swallowing
reflexes are not developed before this time.
5. Maintaining Skin Integrity
Post-term infant
Post term infant is a viable infant born after completed 42 weeks of gestation regardless of birth
weight
Predisposing factors:
▪ Primigravida
▪ Woman older than 35 years with multiple pregnancies
▪ History of prolonged gestation in the previous pregnancies
Altered physiology:
▪ The postmature infant appear to have suffered from intrauterine malnutrition and hypoxia,
before termination of pregnancy but at the point when birth should have occurred the placental
function begins to diminish resulting in impaired oxygen exchange and inadequate nutrient
transfer to the fetus.
Clinical manifestations:
▪little subcutaneous fat ( long, thin appearance).
▪Long fingernails and toenails.
■ Reduced amount of vernix caseosa.
▪Absence of lanugo hair.
■ Abundant scalp hair.
▪Skin is dry, cracked, peeling, loose and wrinkled.
▪Hypoglycemia
▪Meconium staining of skin
Complications:
▪Meconium aspiration.
▪Hypoglycemia
▪Polycythemia
▪Pulmonary hemorrhage, pneumonia and pneumothorax.
Infant of diabetic mother (IDM)
Is the infant born to a mother with diabetes
Maternal diabetes leads to trans-placental passage of high amount of glucose.
Insulin does not cross placenta.
Clinical manifestations:
Macrosomia and obesity
Plump with plethoric face resembling that of patients who receive cortisone.
Cardiomegaly, hepatomegaly.
Abundant fat, hair and vernix caseosa.
Tendency to be large for gestational age, some may be AGA or SGA.
Intrauterine growth retardation
Hypoglycemia (first 6-12 hrs. after birth)
Diagnostic evaluation:
Blood glucose level
Serum calcium & magnesium level
Hematocrit
Serum bilirubin levels
Other tests: blood gas analysis, CBC and cultures
Complications:
Hypoglycemia:
Hypocalcemia
Macrosomia and organomegaly
Prematurity ■ Perinatal asphyxia
Infection
Birth injuries: fracture clavicle, Erb's palsy
Respiratory distress syndrome (due to delayed lung maturation, because hyperinsulinemia
may block cortisol induction which affect lung maturation and surfactant synthesis).
Congenital anomalies (most common skeletal and cardiac)
Hyperbilirubinemia due to:
• Polycythaemia (increased RBC mass).
• Increased extravascular haemolysis (bruising, Cephalhematoma).
• Delayed oral feeding (increased enterohepatic circulation).
• Liver immaturity.
Polycythemia

Management:
Observe closely for hypoglycemia.
Check by dextrostix at delivery and at 1, 2, 3, 6, 12, 24, 36, and 48 hrs. of age; readings <45
mg/dl should be verified by serum glucose measurements.
Monitor infant closely for changes in acid-base status, respiratory distress temperature,
hypocalcemia, sepsis, cardiac anomalies and hyperbilirubinemia.
Correction of hypoglycemia, hypocalcemia, hypomagnesaemia.
Oxygen therapy.
Support the mother who may have feeling of sever guilt
Neonatal Sepsis or septicemia neonatorum
Is the systemic invasion and proliferation of pathogenic bacteria into the blood stream and
frequently involves the meninges
Etiology:
The etiologic bacterial agents varies from year to year and from institution to another.
Predisposing factors:
1. Perinatal factors:
▪ Maternal complications e.g. prolonged rupture of membranes, prolonged and difficult labor,
UTI, maternal illness, and abruption placenta
▪ Infant complications e.g. prematurity, LBW, congenital heart disease, RDS, IDM,
2. Iatrogenic or environmental factors e.g. unclean equipment, surgical procedures
Clinical manifestations:
1. Early manifestations:
Poor suckling
Lethargy, hypotonic
Hypothermia or hyperthermia.
2. Manifestation in an established case:
▪ GIT: vomiting, constipation, diarrhea, abdominal distension
▪ Lungs: tachypnea, respiratory distress, apnea, cough
▪ CVS: tachycardia, bradycardia, heart failure, hypotension, pallor or cyanosis or shock
▪ CNS: tremors, convulsions, apnea, , hypotension, weak cry, absent Moro reflex
▪ Blood: jaundice, anemia, thrombocytopenia, purpura, ecchymosis, splenomegaly.
3. late manifestation:
- Organomegaly - Direct hyperbilirubinemia - DIC - Purpura - Convulsions
Investigations:
▪ Septic work-up including: Culture and sensitivity for blood, urine, umbilical stump, skin
lesions, nose, throat, rectum, CSF, external auditory canal or/and gastric fluid.
▪ CBC, Blood chemistry, bilirubin and blood gas analysis.
▪ CXR
▪ Seroassays for TORCH infections
Complications:
● Meningitis and neurological damage ● Shock ● Pneumonia ● Congestive heart failure
● DIC (Disseminated intravascular coagulation) ● High mortality rate.
Medical management:
▪ Antibacterial: Ampicillin and aminoglycoside or according to culture and sensitivity.
▪ Supportive therapy: - Observation. - Isolation if indicated. - Oxygen therapy.
- Fluid and caloric maintenance

Nursing interventions:
■ Review maternal history, identify infant at risk for infections.
■ Practice measures, which will prevent the transmission of infection in the nursery.
■ Observe infants for the vague symptoms that appear early in the course of sepsis.
■ Administer the prescribed antibiotic therapy to control infection.
■ Maintain isolation as prescribed to minimize exposure to infectious organisms.
■ Observe the infant for convulsions which may occur with sepsis
Neonatal jaundice
Yellow discoloration of skin, mucous membranes and sclera due to excess bilirubin in the
blood (hyperbilirubinemia).
Jaundice appears clinically when serum bilirubin reaches 5-7 mg/dl in newborn and more
than 2 mg/dl in adult.
Incidence: Occurs in 50% of term infants, 80% of preterm.
Types of jaundice:
1) Un-conjugated hyperbilirubinemia (golden yellow in color)
2) Conjugated hyperbilirubinemia. (greenish color).

Causes of jaundice:
1. Bilirubin overproduction
2. Decreased bilirubin conjugation
3. Impaired bilirubin excretion

Physiological Jaundice in the Newborn

It occurs in about 60% of normal full term infants during the first week of life.
Why newborn infant is more likely to develop physiologic jaundice?
1) Polycythemia
2) Short life span of neonatal hemoglobin which is mainly fetal hemoglobin with life span of
90 days instead of 120 day (adult hemoglobin).
3) Immature hepatic
4) Increased enterohepatic circulation
Pathological un-conjugated jaundice
1. Rh incompatibility
The mother is Rh negative and the infant is Rh positive.
It usually does not occur in the first infant (except if there is history of previous abortion or
blood transfusions).
Jaundice starts to appear few hours after birth. Rh incompatibility is one of the major causes
of jaundice in the first day.
The laboratory investigations reveal the following
✓ Increased unconjugated bilirubin
✓ Anemia.
✓ Positive direct Coomb's test.
✓ Elevated reticulocyte count
2. ABO Incompatibility
The mother blood group is (O) while the infant has blood group A or B.
3. Breast Milk Jaundice
Cause is supposed to be due to certain substances in the milk of these mothers
(progesterone metabolite or free fatty acids) that inhibit the glucuronyl transfers enzyme and
thus inhibits bilirubin conjugation.
It starts 5-7 days after birth.
It reaches a maximum in 2nd or 3rd week.
No kernicterus.
If breast feeding is stopped for 3-4 days
4. Breast- feeding jaundice
o Also called "lack-of-breast-milk jaundice.
o The pathogenesis is probably poor enteral intake and increased enterohepatic circulation
Evaluation of un-conjugated jaundice:
1. Initial evaluation:
• Transcutaneous bilirubinometer • Total serum and direct bilirubin
• Blood type and Rh (infant & mother) • Hematocrit • Direct (Coombs) test on infant
2. Later evaluation (as indicated):
• RBC smear, reticulocyte count
• Blood culture, urinalysis, urine culture
• Thyroid function tests, G6PD assay, Hb electrophoresis.
Complication of un-conjugated hyperbilirubinemia:
Kernicterus or Bilirubin encephalopathy is the deposits of bilirubin in the brain tissues
causing brain damage. Kernicterus is the most dangerous complication of jaundice
Kernicterus usually occurs if the level of unconjugated bilirubin exceeds 20 mg/dl in full-term
babies and 15 mg/dl in premature.
Essentials of Diagnosis & Typical Features:
• Lethargy, poor feeding.
• Irritability, high-pitched cry.
• Arching of the neck (retrocollis) and trunk (opisthotonos).
• Apnea
Management of Un-conjugated Hyperbilirubinemia
1. Phototherapy: By exposing the naked jaundiced baby with unconjugated hyperbilirubinemia
to certain wave lengths of florescent light (blue or white) with wave length 425-475 nanometer
▪ Nursing care for infant under phototherapy:
1) The infant should be undressed except for eye patches
2) The lamp should be 5-8 cm over the incubator and 45 cm above the infant.
3) Give phototherapy continuously and turn the infant every 2 hrs.
4) Infant’s temperature should be carefully
5) Weigh the infants daily
6) Carefully monitor infant’s fluid balance to avoid dehydration
Side effects of phototherapy:
1. Retinal damage by light
2. Temporary weight loss
3. Looseness of stools
4. Skin rash
2. Exchange Transfusion:
▪ A catheter is introduced into the umbilical vein after cutting the cord. Through a special
valve, the umbilical catheter is connected with the donor blood.
▪ Exchange is carried out over 45-60 minutes periods by alternating aspirations of 20 ml of
infant's blood and infusions of 20 of donor blood.
▪ The donor blood in Rh incompatibility should be of the same group of the infant but Rh
negative, while in ABO incompatibility it should be group (O).
Side effects of exchange transfusion:
● Cardiac arrhythmias ● Electrolyte disturbances (hypocalcemia)
● Infection (septicemia). ● Embolism (blood clots or air)
3.Pharmacologic agents
▪ Intravenous immunoglobulin (IVIG)
▪ Enzyme induction agent: Phenobarbital
Transient Tachypnea of Newborn (TTN)
The development of mild respiratory distress in a newborn as a result of a delay in absorption
of fetal lung fluid after birth.
Occurs after birth, approximately 36 hours after birth. and disappears spontaneously around
the 3rd day.
TTN is also called wet lung syndrome.
Contributing Factors:
Newborns born by cesarean delivery.
Newborns who are preterm or SGA
Infant of diabetic mother
Clinical Manifestations:
Mild respiratory distress, with a respiratory rate greater than 60 breaths per minute.
Mild retractions, nasal flaring, and some expiratory grunting may be noted.
However, cyanosis usually does not occur. Although some infants will require oxygen to
remain pink
Often the newborn has difficulty feeding because he or she is breathing at such a rapid
Diagnostic tools:
▪ABG ▪ CXR
Treatment:
-Supplemental oxygen
-IV fluids and gavage feedings

Meconium Aspiration Syndrome (MAS)

Condition in which the fetus or newborn develops respiratory distress after inhaling
meconium mixed with amniotic fluid.
The meconium can block the airway partially or completely and can irritate the newborn’s
airway, causing respiratory distress.
Risk Factors:
Post-term pregnancy, pre-eclampsia, eclampsia, maternal hypertension, maternal diabetes
mellitus, IUGR, and evidences of fetal distress.
Clinical manifestations:
Low Apgar score at delivery
Meconium staining
Tachypnea, intercostal and subcostal retractions, cyanosis
X- ray chest:
Flattened diaphragm, hyper-inflated lungs, areas of collapse or consolidation may be seen
Air leak
Management:
1. Prevention: by suction and clearing of airway
2. Treatment:
-Oxygen administration
-Antibiotics
-Mechanical ventilation
Congenital Diaphragmatic Hernia
Herniation of abdominal contents into the thorax with collapse of lung and shifting of
mediastinum. The infant fails to establish spontaneous respiration.
The baby will have poor chest movements, intercostal retractions, and cyanosis
Management: ventilate by endotracheal tube. Mask should not be used as air enters stomach
increasing the distress(True/false). Surgery is mandatory.
Respiratory distress syndrome (RDS)
Also called Hyaline Membrane Disease (HMD)
Is the commonest cause of respiratory distress among immature infants.
The incidence increases from 5% of infants born at 35–36 weeks' gestation to more than 50%
of infants born at 26–28 weeks' gestation.
Altered physiology:
This condition is caused by a deficiency of surfactant which typically begins in production
at 24–28 weeks of gestation and but mature levels of pulmonary surfactant are present
usually after 35 wk.
Risk factors for RDS:
Synthesis of surfactant depends in part on normal pH, temperature, and perfusion. Conditions
with high risk for RDS:
● Prematurity ● Maternal diabetes ● Cold stress ● Acidosis
● Hypothermia ● Hypovolemia ● Multiple births
Clinical manifestation:
Expiratory grunting (When infant is not crying).
Sub-sternal and inter-costal retractions.
Inspiratory nasal flaring.
Tachypnea (up to 80-120 breaths/minute).
Hypothermia.
Cyanosis
Complications:
1. Complications related to respiratory therapy:
- Pneumothorax - Pneumo-mediastinum - Pneumonia - Pulmonary emphysema
2. Patent ductus arteriosus.
3. DIC "due to consumption of clotting factors".
4. Tracheal stenosis.
5. Retrolental fibroplasia
6. Broncho-pulmonary dysplasia (BPD): chronic lung disease
Diagnostic evaluation:
1. laboratory test:
▪ Arterial blood gases (ABG): ● ↓ PH ● ↑ PC02 ● ↓P02 (Respiratory acidosis)
2. Chest x-ray: ground-glass appearance.
Management:
1. Prevention:
-Early CPAP administration -Delaying premature birth. Tocolytics may delay delivery
-Prophylactic administration of a 1st dose of surfactant
Treatment:
1. Supportive care in neonatal intensive care unit (NICU)
2. Specific treatment: Surfactant replacement therapy by intra-tracheal installation.
NB: Artificial surfactant may be synthetic or animal derived surfactant e.g. cow, pig and calf
lungs.

Apnea in the newborn

Cessation of breathing more than 20 seconds accompanied by bradycardia (HR less than 100
beats/minute) and cyanosis.
Etiology:
● Prematurity ● Septicemia ● Intracranial hemorrhage ● Hypoglycemia
● Hypocalcemia ● Pharyngeal suction
Pathophysiology:
Mechanisms of apnea of
1) Central Apnea: there is no signal to breathe being transmitted from the CNS to the
respiratory muscles
2) Obstructive Apnea: A pause in alveolar ventilation due to obstruction of airflow within the
upper airway, particularly at the level of the pharynx e.g. neck flexion & excessive secretions
3) Mixed Apnea: A combination of both types of apnea
Management:
1) Treat the underlying causes is essential.
2) Tactile stimulation
3) Positioning: (head and neck in neutral position) to maintain a patent airway.
4) Clear airway
5) Provision of positive pressure ventilation (CPAP or Intermittent Mandatory Ventilation
6) Stop oral feeding.
7) Pulse oximeter / cardio-respiratory monitor
8) Apnea monitor
9) IV Aminophylline may help in premature babies.

Chapter (4)
Child With a Respiratory Disorder
Bronchiolitis
Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs.
Bronchiolitis is the most common serious acute respiratory illness in infants and young
children especially infant from 1 to 6 months.
The causative agents:
The most common organism is respiratory syncytial virus.
Para-influenza virus.
Influenza virus.
Mycoplasma pneumonia.
Pathophysiology: hypoxemia early, and hypercapnea later
Clinical manifestations:
Respiratory infection, nasal discharge, sneezing with or without fever and coryza of 1-3 days.
Tachypnea with a respiratory rate of 60-80\minute.
Dyspnea, irritability.
Dry cough, paroxysmal cough.
Central cyanosis, dehydration and fever.
Intercostal and substernal retraction.
Expiratory wheezes or rhonchi
Diagnostic evaluation:
X-ray chest
Serologic studies to isolate virus on throat swab.
ABG analysis (decreased PaO2, increased PaCO2 finding).
Course:
The most critical is the first 2-3 days during which the patient may develop apneic spells and
respiratory acidosis.
It has a good prognosis.
Death may occur from prolonged apneic spell or attack
Treatment and nursing management:
1. Antibiotic therapy given to severely ill child
2 Humidified oxygen to relief arterial hypoxemia.
3. Inhalation of adrenaline is commonly used.
4. Monitor ABG and correction acidosis.
5. Possible ventilatory assistant.
6. Maintain fluid, electrolyte and acid base and nutritional balance.
7. Keep nasal air way open and clear of mucus.
8. Position (semi-sitting position).
9. Be alert for signs of impending respiratory acidosis, dehydration and cardiac involvement.
10. Intravenous fluids

Cystic fibrosis (CF)

CF is a genetic multisystem disorder that primarily affects the exocrine (mucus producing)
glands.
It is the most common serious pulmonary and gastric disease of children and accounts for a
large percentage of lung disease of children
Etiology:
CF is inherited as an autosomal-recessive trait and has an equal sex distribution.
Pathophysiology:
In CF, the mutant gene results in epithelial ion transport on mucosal surfaces resulting in
generalized dysfunction of exocrine glands.
Respiratory system:
Decreased ciliary action and thus decrease expelling of secretion
Bronchi and bronchioles become plugged, resulting in bronchiectasis and bronchiolitis
Atelectasis and hyperinflation of lungs
Irreversible fibrotic changes occur in lungs.
Gastrointestinal and Pancreatic:
Mal-absorption of fats, proteins, and carbohydrates
Localized Biliary obstruction and fibrosis
Biliary cirrhosis
Clinical Manifestations:
The earliest manifestation of CF is meconium ileus in the newborn, in which the small intestine
is blocked with thick, tenacious meconium (in about 10% of cases).
▪ Gastrointestinal manifestations:
o Large, bulky, loose, frothy, and extremely foul smelling stools.
o Voracious appetite (early m disease). Loss of appetite (later in disease).
o Weight loss with marked tissue wasting.
o Distended abdomen and thin extremities.
o Anemia and pale skin .
o Evidence of deficiency of fat-soluble vitamins ( A,D,E, and K).
▪ Pulmonary manifestations
Initial Signs: Wheezy respirations, dry non-productive cough.
Eventually: Increased dyspnea, paroxysmal cough, emphysema and atelectasis.
Progressive Involvement: Cyanosis, clubbing of fingers and toes
Complication:
Pulmonary infections
Emphysema, atelectasis, hemoptysis and pneumothorax.
Growth retardation.
Biliary cirrhosis with portal hypertension.
Chronic sinusitis, nasal polyps
Pancreatitis, diabetes and hyperglycemia (after 10 years).
Fibrosis of epididymis and vas deferens (aspermia) in males and amenorrhea and decreased
fertility in females (cervical mucus plug).

Evaluation:
Measurement of sodium and chloride in sweat (Sweat test).
Chloride content is less than 40 mEq/L
40- 60 mEq/L is borderline and should be repeated.
Chloride concentration greater than 60 mEq/ L is diagnostic of CF.
NB: Two reliable positive results on two separate days is diagnostic for CF.
Measurement of trypsin concentration in duodenal secretions. Absence of normal
concentration is diagnostic.
Analysis of digestive enzymes in stool.
Chest X-Ray
Analysis of stool for steatorrhea.
The diagnosis of CF is established on the basis of:
1. A history of the disease in family.
2. Absence of pancreatic enzymes.
3. Increase in electrolyte concentration in sweat.
4. Chronic pulmonary involvement.
Therapeutic Management:
1. Pulmonary Therapy:
Antimicrobial
Bronchodilators to relief bronchospasm.
Aerosol expectorants and mucolytic agents to decrease viscosity of secretions.
Postural drainage and chest physiotherapy.
-Usually follows aerosol therapy 3-4 times per day ideally done before eating to prevent
vomiting.
-Clapping "with cupped hands and vibrating for 1 or 2 minutes in each area loosens mucus plugs.
-Coughing should be encouraged after postural drainage, otherwise suctioning
Oxygen therapy
2. Gastrointestinal Therapy:
• Pancreatic enzyme supplements with each feeding (Creon).
• Increased caloric (carbohydrate) and protein intake.
• Decrease fat intake.
• Daily intake of water-soluble and fat-soluble vitamins.
• Adequate fluid and salt intake
3. Promote Normal Growth and Development: