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 Brief Contents
1 Nurse’s Role in Care of the Child: Hospital, 19 Alterations in Eye, Ear, Nose, and Throat
Community, and Home 1 Function 440
2 Family-Centered Care and Cultural Considerations 17 20 Alterations in Respiratory Function 474
3 Genetic and Genomic Influences 45 21 Alterations in Cardiovascular Function 518
4 Growth and Development 66 22 Alterations in Immune Function 563
5 Pediatric Assessment 98 23 Alterations in Hematologic Function 589
6 Introduction to Health Promotion and 24 The Child With Cancer 610
Maintenance 144
25 Alterations in Gastrointestinal Function 655
7 Health Promotion and Maintenance for the Newborn
26 Alterations in Genitourinary Function 701
and Infant 154
27 Alterations in Neurologic Function 739
8 Health Promotion and Maintenance for the Toddler
and Preschooler 166 28 Alterations in Mental Health and Cognitive
Function 790
9 Health Promotion and Maintenance for the
School-Age Child and Adolescent 182 29 Alterations in Musculoskeletal Function 821
10 Nursing Considerations for the Child in the 30 Alterations in Endocrine Function 861
Community 207 31 Alterations in Skin Integrity 900
11 Nursing Considerations for the Hospitalized Appendix A Physical Growth Charts 942
Child 222
Appendix B Blood Pressure Tables 952
12 The Child With a Chronic Condition 246
Appendix C Dietary Reference Intakes 954
13 The Child With a Life-Threatening Condition
and End-of-Life Care 260 Appendix D S
 elected Pediatric Laboratory Values 956
14 Infant, Child, and Adolescent Nutrition 281 Appendix E Diagnostic Tests and Procedures 959
15 Pain Assessment and Management in Children 310 Appendix F Body Surface Area Nomogram 964
16 Immunizations and Communicable Diseases 333 Appendix G Conversions and Equivalents 965
17 Social and Environmental Influences on the Child 367
Glossary 966
18 Alterations in Fluid, Electrolyte, and ­Acid–Base Index 978
Balance 404

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 Principles of Pediatric
Nursing
Caring for Children
Seventh Edition

Jane W. Ball, RN, CPNP, DrPH

Consultant, Trauma System Development, Gaithersburg, Maryland

Ruth C. Bindler, RNC, PhD

Professor Emeritus, Washington State University College of Nursing, Spokane, Washington

Kay J. Cowen, RN-BC, MSN, CNE

Clinical Professor, University of North Carolina at Greensboro School of Nursing, Greensboro, North Carolina

Michele R. Shaw, RN, PhD

Associate Professor, Washington State University College of Nursing, Spokane, Washington

330 Hudson Street, NY NY 10013

A01_BALL7013_07_SE_FM.indd 1 10/11/2016 11:19 am

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Library of Congress Cataloging-in-Publication Data

Names: Ball, Jane (Jane W.), author. | Bindler, Ruth McGillis, author. |
   Cowen, Kay J., author. | Shaw, Michele R., author.
Title: Principles of pediatric nursing: caring for children / Jane W. Ball,
   Ruth C. Bindler, Kay J. Cowen, Michele R. Shaw.
Description: Seventh edition. | Hoboken, NJ : Pearson Education, [2017] |
   Includes bibliographical references and index.
Identifiers: LCCN 2016035091| ISBN 9780134257013 | ISBN 0134257014
Subjects: | MESH: Pediatric Nursing | Nursing Assessment--methods | Child |
  Infant
Classification: LCC RJ245 | NLM WY 159 | DDC 618.92/00231—dc23 LC
record available at https://lccn.loc.gov/2016035091
2014017177
10 9 8 7 6 5 4 3 2 1

ISBN-13: 978-0-13-425701-3
ISBN-10: 0-13-425701-4

A01_BALL7013_07_SE_FM.indd 2 10/11/2016 11:19 am

 Dedication
We dedicate this book to:

• Our families who are ever supportive and understanding about our passion for children
and writing,
• Our mentors, colleagues, and students who inspire us to apply our knowledge and
­challenge our thinking,
• The children, adolescents, and families with whom we work and who foster our
­philosophy of pediatric nursing.

iii

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 About the Authors
JANE W. BALL graduated from the
Johns Hopkins Hospital School of
Nursing and subsequently received a
BS from the Johns Hopkins University.
She began her nursing career work-
ing in the pediatric surgical inpatient,
emergency department, and outpa-
tient clinic of the Johns Hopkins Medi-
cal Center, first as a staff nurse and
then as a pediatric nurse practitioner.
After recognizing a need to focus on the health of children, she
returned to school and obtained both a master’s degree of pub-
lic health and a doctorate of public health degree from the Johns
Hopkins University Bloomberg School of Public Health with a
focus on maternal and child health. After graduation, Dr. Ball
became the chief of child health services for the Commonwealth
of Pennsylvania Department of Health. In this capacity she
oversaw the state-funded well-child clinics and explored ways
to improve education for the state’s community health nurses.
After relocating to Texas, she joined the faculty at the Univer-
sity of Texas at Arlington School of Nursing to teach community
pediatrics to registered nurses returning to school for a BSN.
During this time Dr. Ball became involved in writing her first
textbook, Mosby’s Guide to Physical Examination, which is cur-
rently in its eighth edition. After relocating to the Washington,
DC, area, she worked at Children’s National Medical Center on
a number of federally funded projects. The first project in 1986,
teaching instructors of emergency medical technicians from all
states about the special care children need during an emergency,
revealed the shortcomings of the emergency medical services
system for children. This exposure was a career-changing event.
A textbook titled Pediatric Emergencies: A Manual for Prehospital
Providers was subsequently developed. A second project led to
the development of a pediatric emergency education program
for nurses in emergency departments to promote improved care
for children. Both of these programs served as a foundation for
other pediatric emergency education developed and sponsored
by national organizations. For 15 years Dr. Ball managed the
federally funded Emergency Medical Services for Children’s
National Resource Center. As executive director, she provided
and directed the provision of consultation and resource devel-
opment for state health agencies, health professionals, families,
and advocates about successful methods to improve the health-
care system so that children get optimal emergency care in all
healthcare settings. After leaving that position, she continues
to be engaged in many projects with a focus on the emergency
care system. She is a consultant to the American College of Sur-
geons Committee on Trauma, supporting state trauma system
development. She recently completed a federally funded project
A01_BALL7013_07_SE_FM.indd 5
to study whether the implementation of a statewide pediatric
emergency department recognition program improved pediat-
ric emergency care. In 2010, Dr. Ball received the Distinguished
Alumna Award from the Johns Hopkins University.
RUTH C. MCGILLIS BINDLER re-
ceived her BSN from Cornell Uni-
versity—New York Hospital School
of Nursing. She worked in oncology
nursing at Memorial-Sloan Ketter-
ing Cancer Center in New York, and
then as a public health nurse in Dane
County, Wisconsin. Thus began her
commitment to work with children as
she visited children and their families
at home and served as a school nurse. Due to this interest in
child healthcare needs, she earned her MS in child development
from the University of Wisconsin. A move to Washington State
was accompanied by a new job as a faculty member at the Inter-
collegiate Center for Nursing Education in Spokane. Dr. Bindler
was fortunate to be involved for over 38 years in the growth
of this nursing education consortium, which is a combination
of public and private universities and colleges and is now the
Washington State University (WSU) College of Nursing. She
obtained a PhD in human nutrition at WSU, where she taught
theory and clinical courses in child health nursing, cultural di-
versity and health, graduate research, pharmacology, and as-
sessment, and served as lead faculty for child health nursing. Dr.
Bindler was the first director of the PhD in Nursing program at
WSU and most recently served as Associate Dean for Graduate
Programs, which include Master of Nursing, Post-Masters cer-
tificates, PhD, and Doctor of Nursing Practice (DNP) programs.
She recently retired and serves the college and profession as a
professor emeritus, continuing work with graduate students
and research. Her first professional book, Pediatric Medications,
was published in 1981, and she has continued to publish articles
and books in the areas of pediatric medications and pediatric
health. Research foci have been childhood obesity, type 2 dia-
betes, metabolic syndrome, and cardiometabolic risk factors in
children. Ethnic diversity and interprofessional collaboration
have been additional themes in her work. Dr. Bindler believes
that her role as a faculty member and administrator enabled
her to learn continually, foster the development of students in
nursing, lead and mentor junior faculty into the teaching role,
and participate fully in the profession of nursing. In addition
to teaching, research, publication, and leadership, she enhances
her life by professional and community service and by activities
with her family.
10/11/2016 11:19 am
 vi About the Authors
KAY J. COWEN received her BSN from
East Carolina University in Greenville,
North Carolina, and began her career
as a staff nurse on the pediatric unit
of North Carolina Baptist Hospital in
Winston-Salem. She developed a spe-
cial interest in the psychosocial needs
of hospitalized children and preparing
them for hospitalization. This led to
the focus of her master’s thesis at the
University of North Carolina at Greensboro (UNCG), where she
received a master of science in nursing education degree with a
focus in maternal child nursing.
Mrs. Cowen began her teaching career in 1984 at UNCG,
where she continues today as clinical professor in the Parent
Child Department. Her primary responsibilities include coor-
dinating the pediatric nursing course, teaching classroom con-
tent, and supervising a clinical group of students. Mrs. Cowen
shared her passion for the psychosocial care of children and the
needs of their families through her first experience as an au-
thor in the chapter “Hospital Care for Children” in Jackson and
Saunders’ Child Health Nursing: A Comprehensive Approach to the
Care of Children and Their Families published in 1993.
In the classroom, Mrs. Cowen realized that students learn
through a variety of teaching strategies and became especially
interested in the strategy of gaming. She led a research study to
evaluate the effectiveness of gaming in the classroom and sub-
sequently continues to incorporate gaming in her teaching. In
the clinical setting, Mrs. Cowen teaches her students the skills
needed to care for patients and the importance of family-cen-
tered care, focusing not only on the physical needs of the child
but also on the psychosocial needs of the child and family. Dur-
ing her teaching career, Mrs. Cowen has continued to work part
time as a staff nurse, first on the pediatric unit of Moses Cone
Hospital in Greensboro and then at Brenner Children’s Hospital
in Winston-Salem. In 2006, she became the part-time pediatric
nurse educator in Brenner’s Family Resource Center. Through
Mrs. Cowen’s expertise, she is able to extend her love of teach-
ing to children and families, and through her role as an author,
she is able to extend her dedication to pediatric nursing and
nursing education.
A01_BALL7013_07_SE_FM.indd 6
MICHELE R. SHAW received her BSN
from Pacific Lutheran University in
Tacoma, Washington. She began her
career as a nurse at a long-term care
facility and then as a home healthcare
nurse in Spokane, Washington. While
making home visits, she became in-
terested in the nursing care needs of
children and families. She realized
the importance of educating the fam-
ily about their child’s condition and to include family members
while planning and carrying out the nursing care plan. This in-
terest in family nursing led her into the area of maternal-child
nursing, where she served as a postpartum nurse for nearly 18
years. Her experience with providing nursing care to families in
various settings has highlighted her belief in the need of a fam-
ily-centered approach in order to provide optimal nursing care.
Dr. Shaw began her teaching career as a teaching assistant in
2001 at the Washington State University (WSU) College of Nurs-
ing, where she continues today as an associate professor. It was
during those early years as a teaching assistant that she began
to realize her passion for educating nursing students. This in-
terest led to her completing a master’s degree in nursing with
an emphasis on education at WSU. Knowing that she wanted
to continue working in nursing academia, Dr. Shaw went on to
receive her PhD in nursing from the University of Arizona in
Tucson. She has taught theory, seminar, and clinical courses in
maternal-child nursing, family health, evidence-based practice,
ethical decision making, physical assessment, and professional
practice. Dr. Shaw recently assisted in the development of the
Bachelor of Science-to-PhD in Nursing program at WSU. This
fast-track program will enable students with an earned bach-
elor’s degree to complete a PhD in nursing in four years.
Dr. Shaw enjoys working with undergraduate and gradu-
ate students and encourages active participation in research.
Her research interests include children with asthma and their
families, childbearing women and their families, and substance
use among youth and childbearing women. She is particularly
interested in children’s and families’ unique perspectives, and
thus much of her research uses qualitative approaches. She con-
tinues to publish articles in the areas of pediatric asthma and
substance use among childbearing women. Dr. Shaw believes
her active role in nursing academia and research allows her
to stay current in various pedagogical approaches to enhance
nursing students’ learning experiences, as well as continuous
learning about evidence-based interventions to provide nursing
care to children and families.
10/11/2016 11:19 am
 Thank You!
We are forever grateful to nurse geneticist Linda D. Ward, PhD, APRN, the author of this
book’s genetics chapter, Chapter 3, “Genetic and Genomic Influences.” We appreciate her
expertise in genetic and genomic science, her superb writing skills, and her willingness
to contribute such an essential chapter to our text. We are also thankful to Brenda Senger,
RN, PhD, for contributing the content on mitochondrial diseases in Chapter 30.
We are grateful to all the nurses, both clinicians and educators, who reviewed the
manuscript of this text. Their insights, suggestions, and eye for detail helped us prepare a
more relevant, useful, and current book, reflective of the present time and of the essential
components of learning in the field of child health nursing.

Mary Armstrong, MSN, RN,
CCRN, CPN
Carson Newman University
Jefferson City, Tennessee
Elizabeth Bettini, APRN,
MSN, PCNS-BC, CHPPN
Division of Anesthesiology &
Pain Medicine
Children’s National Medical
Center
Washington, D.C.
Melissa Black, PhDc, MSN,
FNP, RN
NCLEX Review Nurse
Kaplan
Greenville, South Carolina
Ann M. Bowling, PhD, RN,
CPNP-PC, CNE
Assistant Professor
Wright State University
Dayton, Ohio
Michele I. Bracken, PhD,
WHNP-BC
Associate Professor
Clinical Coordinator Ma-
ternal/Newborn/Women’s
Health
Salisbury University
Salisbury, Maryland
Robin Caldwell, RNC-OB
Instructor
Catawba Valley Community
College
Hickory, North Carolina
Karan Dublin, MEd, RN
Professor
Tyler Junior College
Tyler, Texas
Barbara S. Edwards, RN,
CPN
Staff Nurse
Brenner Children’s Hospital
Winston-Salem, North
Carolina
Linda B. Esposito, MSN, RN,
CCRN
Nurse Practice Specialist
Brenner Children’s Hospital
Wake Forest Baptist Medical
Center
Winston-Salem, North
Carolina
Julie Fitzgerald, PhD, RN,
CNE
Assistant Professor
Ramapo College of New
Jersey
Mahwah, New Jersey
Niki Fogg, MS, RN, CPN
Assistant Clinical Professor
Texas Woman’s University
Dallas, Texas
Vivienne Friday, EdD, RN
Nurse Educator
Bridgeport Hospital School of
Nursing
Bridgeport, Connecticut
Deborah Henry, MSN, RN
Nursing Faculty
Blue Ridge Community
College
Flat Rock, North Carolina
Indra Hershorin, PhD, RN,
CNE
Assistant Professor
Barry University
Miami Shores, Florida
Karen L. Hessler, PhD, FNP-C
Assistant Professor
University of Northern
Colorado
Greeley, Colorado
Catherine Hrycyk, MScN, RN
Faculty, Pediatric Nursing and
Pharmacology
De Anza College
Cupertino, California
Gina Idol, RN, BSN, CPN
Wake Forest Baptist Health
Brenner Children’s Hospital
Winston-Salem, North
Carolina
Laura Kubin, PhD, RN, CPN,
CHES
Assistant Professor
Texas Woman’s University
Dallas, Texas
Meredith Lahl, MSN, PCNS-
BC, PPCNP-BC, CPON
Senior Director of Advanced
Practice Nursing
Cleveland Clinic
Cleveland, Ohio
Robyn Leo, MS, RN
Associate Professor and
Chairperson for Nursing
Worcester State University
Worcester, Massachusetts
Angela P. Lukomski, RN,
DNP, CPNP
Associate Professor
Eastern Michigan University
Ypsilanti, Michigan
Patricia Novak, RN, BSN, MSN
Faculty
Gateway Community College
Phoenix, Arizona
Gloanna J. Peek, PhD, RN,
CPNP
Clinical Associate Professor
PNP Specialty Option
Coordinator
The University of Arizona
Tucson, Arizona
Susan Perkins, MSN, RN
Senior Instructor
Washington State University
Spokane, Washington
Linda Sue Pippin, MSN,
RN-BC
Adjunct Faculty
Newberry College
Newberry, South Carolina
Theresa Puckett, RN, CNE
Instructor
Stark State College
North Canton, Ohio
Colleen Quinn, RN, MSN,
EdD
Professor
Broward College
Davie, Florida
JoAnne Silbert-Flagg, DNP,
PNP, IBCLC
Assistant Professor
Johns Hopkins University
Baltimore, Maryland
Jennifer S. Simmons, MSN,
RN, CPNP-AC/PC, CPON
Pediatric Oncology Nurse
Practitioner
Brenner Children’s Hospital
Wake Forest Baptist Medical
Center
Winston-Salem, North
Carolina

vii

A01_BALL7013_07_SE_FM.indd 7 10/11/2016 11:19 am

 viii Thank You! 
Anita Smith, CPNP
Nurse Practitioner
Department of Pediatric
Hematology
Wake Forest Health Sciences
Winston-Salem, North
Carolina
Charla Smith, MSN, RN,
CPN, CNE
Associate Professor
Jackson State Community
College
Jackson, Tennessee
A01_BALL7013_07_SE_FM.indd 8
Nancy M. Smith, DNP,
CRNP, FNP-BC
Assistant Professor
Salisbury University
Salisbury, Maryland
Maureen P. Tippen, RN, C,
MS
Clinical Assistant Professor
University of Michigan
Flint, Michigan
Teresa Tyson, RN, PhD Amber Welborn, RN, MSN
Assistant Professor Lecturer
Winston-Salem State University of North Carolina
University Greensboro, North Carolina
Winston-Salem, North
Carolina Cecilia Wilson, PhD, RN,
CPN
Diane K. Van Os, MS, RN Associate Clinical Professor
Professor Texas Woman’s University
Westminster College Dallas, Texas
Salt Lake City, Utah
10/11/2016 11:19 am
 Preface
H
ealth care and healthcare delivery systems are chang-
ing dramatically. The Affordable Care Act, a focus
on interprofessional collaboration, an emphasis on
patient safety, and evidence-based practice will contribute to
ongoing challenges and evolution in health care in the com-
ing years. Pediatric nurses must respond to and integrate
these changes into their practice. In addition, pediatric nursing
presents its own unique challenges for practitioners of health
care. Student nurses must learn what helps them to provide
safe, effective, and excellent care today, while integrating new
knowledge and skills needed as nursing practice continues to
develop and respond to healthcare needs. Students must learn
how to think and apply information as new knowledge be-
comes available. “As the student uses knowledge in situations
of practice, new understanding is gained as well as knowing
how, when, and why it is relevant in particular situations. . . .
We call this teaching for a sense of salience.”*
Faculty are responsible for selecting patient care assign-
ments that assist the student in applying knowledge in the
clinical setting, as well as utilizing various pedagogies to assist
the student in focusing on the patient experience. We have in-
tegrated concepts from the Carnegie Report that foster ­clinical
­e xpertise by offering a variety of critical thinking and
­c linical reasoning questions, patient care scenarios, and re-
search and evidence-based practice features. Information tech-
nology plays a major role in both health care and teaching, and
therefore features in this text encourage the student to use and
analyze content available through information technology.
Preparation for Nursing
Excellence
The goal of this seventh edition of Principles of Pediatric Nurs-
ing is to provide core pediatric nursing knowledge that pre-
pares students for excellence in nursing and to offer the tools of
scholarship and critical thinking needed to apply this learning
in the future. Students must learn to question, evaluate the re-
search evidence available, apply pertinent information in clini-
cal settings, and constantly adapt to growing knowledge and
an evolving healthcare system.
This text reflects a multitude of approaches to learning that
can be helpful to all students. We acknowledge that many stu-
dents learn pediatric nursing in a very short time period. There-
fore, the approaches in this text are designed to assist students
to assess the child’s needs, take into account population-based
practice, and make care decisions based on the standards of pe-
diatric nursing practice.
Realities of Pediatric Nursing
Pediatric nursing occurs in many acute care and community
healthcare settings, such as hospitals, homes, schools, and
health centers. Procedures may be performed in short-stay
*Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation (p. 94). San Francisco, CA: Jossey-Bass.
A01_BALL7013_07_SE_FM.indd 9
units, and long-term care is often provided at home for children
with complex health conditions. Families are often the provid-
ers of care as well as the case managers for these children. Tech-
nologic advances are resulting in earlier diagnoses and new
therapies; these technologic approaches are integrated when-
ever pertinent throughout the text.
Pediatric nursing care is provided within the context of a
rapidly changing society. An examination of the major morbidi-
ties and mortalities of childhood guided the revision of material
and topics throughout the text. Specific chapters focus on the
family, health promotion across the life span, pediatric nutri-
tion, and care for children with chronic conditions. Chapter 2
addresses cultural influences on health care and provides guid-
ance for students caring for children in our growing intercul-
tural society. Chapter 3, on genetics and genomics, is intended
to help students recognize the impact of such knowledge on
pediatric nursing and apply these concepts when working with
families. Current social and environmental challenges for chil-
dren have guided the further development of Chapter 17, which
covers societal and environmental influences on child health.
Many graduating nurses practice in acute care facilities;
this text continues to emphasize the information necessary to
prepare students for working in hospitals. In addition, the in-
formation provided here will enable graduates to assume posi-
tions in ambulatory care facilities, home health nursing, schools,
and a variety of other settings. Effective communication meth-
ods, principles of working with families, and knowledge of
pathophysiologic, psychologic, developmental, and environ-
mental factors found in these chapters can all be applied in a
wide variety of settings. The importance of interprofessional
care is recognized; therefore, collaboration and communication
with various health professionals is emphasized.
Another major evolution involves access to i­nformation
and reliance on the Internet. Nurses must learn to ob-
tain ­information and then analyze and judge the quality of
­information they find. Increasingly, nurses need experience
with information technology and management. Nurses must
also advise children and family members to use the Internet
wisely to help them in making healthcare choices. This text will
assist the student in making practice decisions based on schol-
arship and evidence-based research.
Organization and Integrated
Themes
We have organized Principles of Pediatric Nursing: Caring for
Children, Seventh Edition, to present important information
on growth and development, family-centered care, culture,
genetics, physical assessment, health promotion, nutrition,
health issues in today’s world, and children’s responses to ill-
ness and injury. This information is needed to care for children
in the many healthcare settings where pediatric nursing care
is provided. Following the foundational chapters, this book is
ix
10/11/2016 11:19 am
 x Preface 
organized by body systems to facilitate the student’s ability to
locate information, focus studying, and prepare for clinical ex-
periences with children and families. The organizational frame-
work also eliminates redundancy, so that the student uses time
efficiently. Learning Outcomes begin the chapter, and Chapter
Highlights end the chapter.
The Bindler-Ball Child Healthcare Model is used to illustrate
the important core value that all children need health promotion
and health maintenance interventions, no matter where they seek
health care or what health conditions they may be experiencing.
The nursing process is used as the framework for nursing
care. Nursing Management is the major heading, with sub-
headings of Nursing Assessment and Diagnosis, Planning and
Implementation, and Evaluation. When it is appropriate to fo-
cus on care in a specific setting, Hospital-Based Care, Discharge
Planning, and Community Care are separated into sections. We
feature nursing care plans throughout the text to help students
approach care from the nursing process perspective. Some have
an acute care hospitalization focus, whereas others have a com-
munity-based focus. Nursing Care Plans include nursing diag-
noses, goals, interventions, and rationales.
Several major concepts are integrated throughout the text
to encourage the student to think creatively and critically about
nursing care. These major themes are interwoven throughout
the text through the many features and supplements, including:
• Nursing care is the critical and central core of this text.
Nursing assessment and management are emphasized in
all sections of the book, with examples of nurses provid-
ing care in a number of different settings. Nurses apply a
variety of guidelines related to the profession and to health
conditions. The new feature, Professionalism in Practice,
relates guidelines important to nursing care.
• Collaborative care descriptions of the diagnostic and therapeu-
tic care for various health conditions reflect the interprofes-
sional team role of nurses with other healthcare professionals
(e.g., physicians, physical therapists, mental health counsel-
ors, pharmacists, and others) as described in The Essentials
of Baccalaureate Education for Professional Nursing Practice
(American Association of Colleges of Nursing, 2008).
• Clinical reasoning and problem-solving principles are integrated
in the organization, pedagogy, and writing style. Examples
include the evidence-based practice features, clinical rea-
soning boxes, the end-of-chapter Clinical Reasoning in
Action feature, and art captions. Students practice clinical
reasoning and critical thinking in their everyday lives, but
they need help to apply these concepts to the practice of
nursing. This text and the accompanying learning materials
help students understand how their normal curiosity and
problem-solving ability can be applied to pediatric nursing.
• Communication is one of the most important skills that stu-
dents need to learn. Effective communication with chil-
dren is challenging because they communicate differently,
according to their developmental levels. Family members
have communication needs in addition to those of their
children. Effective communication with a variety of health-
care providers is essential for effective care. This book inte-
grates communication skills by applied examples that help
the student communicate effectively with children, their
families, and other health professionals.
• Patient safety is emphasized in nursing management sec-
tions and in the Safety Alert! boxes.
A01_BALL7013_07_SE_FM.indd 10
• Family and patient education about health care is an integral
part of the pediatric nurse’s responsibilities. Because hos-
pitalizations are often brief, leaving families increasingly
responsible for caring for recuperating children at home,
information about healthcare needs and procedures has be-
come even more important. The Families Want to Know
feature describes teaching strategies and content for vari-
ous patient conditions.
• Developing cultural competence is critical for all nurses in the
increasingly diverse community of today’s world. Students
have met people from different ethnic and cultural groups,
but they need help to understand, respect, and integrate
differing beliefs, practices, and healthcare needs when pro-
viding care.
• Growth and development considerations and physical assessment
are central to the effective practice of pediatric nursing. A
separate chapter is devoted to each area (Chapters 4 and 5,
respectively). In addition, both topics are integrated where
appropriate in narrative, growth and development boxes,
figures, and captions.
• Health promotion is an important focus of nursing care for
children with acute and chronic health conditions. Four
chapters focus on health promotion. One provides an over-
view of concepts related to health promotion; the other
three address health promotion principles for children of
different ages. In addition, a Health Promotion feature
helps illustrate opportunities for maintaining and improv-
ing the health of children with certain health conditions.
• Community care is an increasing part of nursing responsi-
bilities. To assist students in transferring knowledge to
caring for children in community settings, information is
provided in the nursing management sections of chapters.
In addition, an entire chapter is devoted to nursing care in
the community and directly addresses the nurse’s roles in
several community settings.
These themes and others are interwoven in the narrative
of most chapters and are reflected in the art as well as in the
supplements that students can use to augment their learning.
Resources for Student Success
• Online Resources are available at www.pearsonhighered.
com/nursingresources and aim to further enhance the
student’s learning experience, build on knowledge gained
from this textbook, prepare students for the NCLEX-RN®
examination, and foster clinical reasoning.
• The Clinical Skills Manual for Maternity and Pediatric
Nursing, ISBN 0134257006, is a useful resource to assist stu-
dents in successful planning and performance of essential
nursing skills. This manual helps translate theoretic con-
cepts into performance while caring for health clients in a
variety of settings.
• NEW! Pearson’s Maternity and Pediatric Nursing Reference
App, now available for both iPhone and Android devices,
provides a collection of handy tools and
additional content for students and profes-
sionals looking for a quick reference in ma-
ternity or pediatrics nursing. The pediatric
content provided in the Guidance for Chil-
dren and Families section includes insight
10/11/2016 11:19 am
  Preface xi

into the issues related to health maintenance, development,

and family that may present from birth to adolescence. Resources for Faculty Success
• MyNursingLab for Pediatric Nursing is designed to en- Pearson is pleased to offer a complete suite of resources to sup-
gage students with pediatric content while offering data- port teaching and learning, including:
driven guidance that helps them better absorb course • TestGen Test Bank
material and understand difficult concepts. The Pearson
• Lecture Note PowerPoints
eText version of Principles of Pediatric Nursing, Seventh
Edition, is available with MyNursingLab for Pediatric • Classroom Response System PowerPoints
Nursing. • Instructor’s Resource Manual

A01_BALL7013_07_SE_FM.indd 11 10/11/2016 11:19 am

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A01_GORD2302_01_SE_FM.indd 4 28/05/15 7:33 pm

 Acknowledgments
I
t is both exciting and challenging to have the opportunity to
write a textbook and to keep it updated with each revision.
It is inspiring to observe the evolution of pediatric nursing
practice and to encourage nursing students to share the excite-
ment and enthusiasm we feel for working with children and
their families. Although each edition carries its own unique set
of challenges and circumstances, it continues to be a privilege
to contribute to the education of the new generation of student
nurses.
This seventh edition integrates new features and digital
approaches developed in collaboration with Pearson Nursing.
Erin Rafferty, content producer at Pearson, has been responsive
and receptive, as well as an effective collaborator with us in
this new edition. We are grateful for the support of our port-
folio manager at Pearson, Katrin Beacom. The vice president
and publisher, Julie Alexander, enthusiastically supported this
venture and has supported us in decisions regarding changes,
updates, and features for the text.
For this edition, we have been blessed to have Mary Cook
as a development editor. Mary challenged us creatively, en-
sured consistency, and kept us on track. She has been support-
ive, ­innovative, and composed during the long months of hard
work.
We are grateful to the families and many healthcare
­facilities that have permitted us to capture the images used in
photographs throughout the book. George Dodson provided us
A01_BALL7013_07_SE_FM.indd 13
with much of the photography to help illustrate current nursing
concepts.
We also gratefully acknowledge the contributions of Linda
Ward, a nurse leader who authored Chapter 3, “Genetic and
Genomic Influences,” and Brenda Senger, who contributed the
mitochondrial disease content in Chapter 30.
Our thanks also go to Mary Siener, art director, for guiding
all aspects of the design for this edition. At SPi Global, it has
been a pleasure to work with Patty Donovan, who coordinated
production.
A special thank you goes to Katie m. Berggren, who gave
permission to use her painting A Day In May for the cover of
this edition. This work and others can be viewed at www.Km-
Berggren.com.
Finally, our families once again have supported us tire-
lessly through the revision process. They sacrificed by allowing
us to work on the book when we could have been with them.
Yet, they show others the book with pride. We could not have
accomplished this without their love and patience.
Jane W. Ball
Ruth C. Bindler
Kay J. Cowen
Michele R. Shaw
xiii
10/11/2016 11:19 am
 Features to Help You Use This
Textbook Successfully
Instructors and students alike value the in-text learning aids that we include in our textbooks. The fol-
lowing guide will help you use the features and resources from Principles of Pediatric Nursing, Seventh
Edition, to be successful in the classroom, in the clinical setting, on the NCLEX-RN® examination, and
in nursing practice.
Each chapter begins with Learning Outcomes and a chap-
ter-opening Quote. These personal stories illustrate the
diversity of cultures, parental concerns, and family situa-
tions that nurses will encounter throughout the course of
their careers. A Focus On section appears at the beginning
of each systems chapter as a reference to use while reading
the chapter. Each Focus On section includes the following:
• Anatomy and Physiology provides a quick review of
the body system.
• Pediatric Differences will help you recognize physi-
ologic and mental differences in children at various
ages.
• Diagnostic Tests and Laboratory Procedures offer
­information related to the specific body system to assist
in clinical application.
• Assessment Guides assist with diagnoses by incorpo-
rating physical assessment and normal findings, altera-
tions and possible causes, and guidelines for nursing
interventions.
As Children Grow: Children Are Not Just Small Adults
Body surface area large for weight,
making infants susceptible to
hypothermia.
Anterior fontanelle and open sutures
palpable up to about 18 months.
Posterior fontanelle closes between
2 and 3 months.
Tongue large relative to small
nasal and oral airway passages.
Short, narrow trachea in children
under 5 years makes them
susceptible to foreign body
obstruction.
Until late school age and
adolescence, cardiac output is
rate dependent not stroke volume
dependent, making heart rate more rapid.
Abdomen offers poor protection
for the liver and spleen, making them
susceptible to trauma.
Until 12 to 18 months of age,
kidneys do not concentrate urine
effectively and do not exert optimal
control over electrolyte secretion
and absorption.
Until later school age, proportion
of body weight in water is larger,
with more water in extracellular
spaces. Daily water exchange rate
is much higher.
Children are not just small adults. There are important anatomic and physiologic differences between children and
adults that will change based on a child’s growth and development.
Clinical Reasoning boxes provide brief case
scenarios that ask students to determine the
appropriate response.
xiv
A01_BALL7013_07_SE_FM.indd 14
Chapter 11
Nursing Considerations
for the Hospitalized Child
We live 50 miles from the hospital and have three other chil-
dren. We were worried about how we were going to be able to
stay with Sabrina. She’s only 4, and it’s her first time in the
hospital. Fortunately, they have beds for parents, so one of
us can always be by her side throughout her procedure and
recuperation.
Mel Curtis/Getty Images
—Mother of Sabrina, 4 years old
Learning Outcomes
11.1 Compare and contrast the child’s 11.5 Identify nursing strategies to minimize the
understanding of health and illness according stressors related to hospitalization.
to the child’s developmental level.
11.6 Integrate the concept of family presence
11.2 Explain the effect of hospitalization on the
child and family.
during procedures and nursing strategies used
to prepare the family.
11.3 Describe the child’s and family’s adaption to 11.7 Summarize strategies for preparing children
hospitalization. and families for discharge from the hospital
setting.
11.4 Apply family-centered care principles to the
hospital setting.
All brain cells present at birth;
myelinization and further
development of nerve fibers occur
during first year.
Head proportionately larger, making
child susceptible to head injury.
Higher metabolic rate, higher oxygen
needs, higher caloric needs.
Until puberty, percentage of cartilage
in ribs is higher, making them more
flexible and compliant.
As Children Grow boxes illustrate the anatomic and
Until about 10 years, there is a faster
respiratory rate, fewer and smaller
alveoli, and less lung volume. Tidal
physiologic differences between children and adults.
These features illustrate how the child progresses
volume is proportional to weight
(7 to 10 mL/kg).
Up to about 4 or 5 years, diaphragm
through developmental stages and the important
is primary breathing muscle. CO2 is
not effectively expired when child is
distressed, making child susceptible
to metabolic acidosis.
Until puberty, bones are soft and
more easily bent and fractured. ways in which a child’s development influences
healthcare needs.
Muscles lack tone, power, and
coordination during infancy. Muscles
are 25% of weight in infants versus
40% in adults.
Blood volume is weight
dependent: 80 mL/kg.
Clinical reasoning Health Promotion
The pediatric nurse should apply concepts of health promo-
tion and maintenance in all healthcare settings. If the child
is seen in an emergency room for treatment of a fracture,
what questions should the nurse ask about immunization
status and safety issues? If the nurse sees a child with a
chronic disorder of cerebral palsy in the outpatient clinic at
an orthopedic hospital, what health promotion and health
maintenance services should be integrated?
10/11/2016 11:19 am

Clinical Tip
Explain to the child and parents, in easy-to-understand terms, the
purpose of equipment that is being used. Answer alarms quickly
regardless of the reason for the alarm. Follow with an explanation
of why alarms sound, including the fact that many times monitor
alarms will sound when the child moves, if the monitor becomes
disconnected, or if the monitor patches are loose.
Developing Cultural Competence boxes highlight specific
cultural issues and their application to nursing care.
EVIDENCE-BASED PRACTICE Infant Sleep
clinical Question
Many babies have limited sleeping periods during the night,
and their night awakenings disturb parents’ sleep. Parents may
have busy days and be unable to nap and, hence, possibly not
be able to perform at a safe and productive level during the
day. Parental stress and depression are associated with fre-
quent child awakenings. What strategies are needed to assist
them in supporting the infant’s sleep?
the evidence
Sleep of the infant is an important concern for many parents,
but there is little research-based evidence about what strate-
gies really improve infant sleep. A study of 314 twin pairs found
that most sleep disturbances in early childhood are linked to
environmental factors, and thus behavioral interventions with
parents are suggested for altering infant sleep patterns (Bres-
cianini, Volzone, Fagnani, et al., 2011). Consistent with these
findings, a study evaluating 170 parents for knowledge of child
sleep found that most parents could not answer the majority
of questions correctly. The researchers suggested that evalu-
ating parental knowledge and teaching about developmental
progression of sleep patterns should occur during health visits
Families Want to Know features present special healthcare
issues or problems and the related key teaching points
to address with the family.
growth and Development
Children with chronic illnesses such as JIA may develop increased
dependence on their parents. It is essential that school-age chil-
dren maintain as much independence as possible to promote their
development of industry. These children should also have some
responsibility for their treatment plan. Children with JIA may also
need to miss school for periods of time. A plan should be devel-
oped so that the child is able to keep up with school assignments.
In addition, ongoing contact with peers should be maintained to
promote the child’s social development.
A01_BALL7013_07_SE_FM.indd 15
Features to Help You Use This Textbook Successfully xv
Clinical Tip features offer hands-on sugges-
tions and clinical advice. These are placed at
locations in the text that will help students ap-
ply them. They include topics such as legal and
ethical considerations, nursing alerts, and home
and community care considerations.
Developing Cultural Competence Smoking
Rates Among Youth
Among youth in the United States, White youth are sig-
nificantly more likely to smoke than either Hispanic or
African American peers. About 19% of White students
reported smoking in the previous month, while 14% of
Hispanic and 8% of African American students reported
this behavior (CDC, 2014a). American Indian and Alaska
Natives also have high smoking rates, while Asian Ameri-
cans have low rates. Youth smoking rates also vary by
state, ranging from 4% to 20% among various states (CDC,
2014a; USDHHS, 2011).
(Schreck & Richdale, 2011). A cross-cultural study found that
parents from predominantly Asian countries were more likely
to identify sleep disturbance in their children than those from
countries with a majority of White parents. These findings sug-
gest that information is needed about cultural differences in
sleep expectations of parents (Sadeh, Mindell, & Rivera, 2011).
best Practice
This evidence-based practice provides implications for nurs-
ing care. Ask parents of young newborns to record the infant Evidence-Based Practice boxes present recent nursing re-
sleep patterns. As the infant nears 3 to 4 months of age, pat-
terns should demonstrate few night wakenings and feedings. search, discuss implications, and challenge students to incor-
Teach parents about how to minimize stimulation and interac-
tion at night. Provide opportunities to review results at future porate this information into nursing practice through nursing
health supervision visits, or offer telephone or other support to
parents. actions.
clinical reasoning
What reasons might working parents have for responding
eagerly and interacting with an infant who awakens at night? Do
you think there are other reasons why infants awake at night?
What clues help you to decide if an infant sleep problem exists?
Families Want to Know
Ways to Decrease the incidence of cancer in children
Many parents ask what they can do to decrease the incidence of cancer in children as they grow into adulthood. Three major
teaching areas should be addressed:
1. Have children increase intake of fruits and vegetables. Most children do not eat enough of these foods, and increased
intake is associated with lower rates of many cancers. Aim for a minimum of five servings daily.
2. Protect skin with sunscreen. Early excessive exposure to sun, and having had one or repeated severe sunburns during child-
hood, increases chances of skin cancers developing in adulthood. Tanning bed exposure is a prime risk factor for skin cancer;
all children and adolescents, and particularly those with cancer, should strictly avoid tanning beds (Greinert & Boniol, 2011).
3. Discourage smoking among children and be sure children are not exposed to environmental tobacco smoke. This will
decrease the future chance of developing lung cancer.
When there is a history of cancer in the family, particularly of a type associated with familial incidence such as some breast or
ovarian cancers, encourage the family to learn more about the cancer and teach their children to receive regular surveillance as
they enter young adulthood.
Inform youth in all families about screening, such as the Papanicolaou test, breast self-examination, and testicular examination
that can lead to early detection. Encourage youth to receive the human papillomavirus quadrivalent vaccine recombinant (Gardasil) to
prevent cervical cancers and other health problems caused by human papillomavirus (HPV). (See Chapter 16 for further information.)
Growth and Development boxes provide information about the
­different responses of children at various ages to health conditions.
10/11/2016 11:19 am
 xvi Features to Help You Use This Textbook Successfully

Healthy People 2020 goals are cited throughout the text to ac-
Healthy People 2020 quaint students with national public health efforts and to assist
(MICH-30.1) Increase the proportion of children who have them in making connections between care of individual fami-
access to a medical home lies and broad-based community health care and public policy.
• While 57.5% of children under age 18 years had an estab- The coding in front of each objective identifies the specific
lished medical home in 2007, the objective of 63.3% of chapter—for example, “Maternal, Infant, and Child Health”
children with such access is the present goal (U.S. Depart- (MICH); “Adolescent Health” (AH); and “Injury and Violence
ment of Health and Human Services, 2011). Prevention” (IVP)—and number for the initiative. See the
Healthy People 2020 website to find the chapter abbreviations
for all objectives listed in our text.

496 Chapter 20

health Promotion The Child With Bronchopulmonary Dysplasia

A feature titled Health Promotion summarizes
the needs of children with specific chronic condi-
health Supervision Nutrition
• Assess blood pressure to detect abnormal findings associ- • Review caloric intake. Ensure that increased calories
ated with pulmonary hypertension. are provided to support growth. Assess feeding dif-
• Coordinate vision screening by an ophthalmologist ficulties related to oral motor function associated with
every 2 to 3 months during the first year of life. Myopia long-term enteral feeding. Refer to a nutritionist as
and strabismus are common in children who were born necessary.
prematurely. Physical Activity
• Coordinate pulmonary function tests annually or as • Organize care to provide rest periods during the day.
needed for clinical condition.
• Perform hearing and other screening tests as recom-
• Give parents ideas for promoting the infant’s motor devel-
opment, such as reaching for and moving toward toys and
mended for age. objects of interest.

tions, such as asthma or diabetes. These over-
views teach students that children with chronic
conditions, like all children, have health mainte-
growth and Developmental Surveillance
• Assess growth and plot measurements on a growth chart
family Interactions
• Identify ways to coordinate nighttime care to reduce child
corrected for gestational age. Even if length and weight and family sleep disturbances.
are lower than normal, monitor for continued growth fol-
lowing the growth curves.
• Provide discipline appropriate for developmental age.

nance
home and
afterpromotion
discharge needs thathospital
from the require preven-
for an acute illness. B, A nurse is providing information
• Perform a developmental assessment, correcting for
gestational age.
to a child visiting
Disease Prevention Strategies
• Reduce exposure to infections. Encourage selection
tionhealthcare
a mobile and education
van. to maximize potential. of a childcare provider who cares for a small number
of children, if one is used. If possible, avoid the use of
childcare centers during respiratory syncytial virus
(RSV) season.
• Immunize the child with the routine vaccine schedule
based on chronologic age.
• Administer the 23-valent pneumococcal vaccine at 2 years
of age.
• Provide monthly injections of palivizumab throughout the
M06_BALL7013_07_SE_C06.indd 146 RSV season. 7/19/16 9:28 AM
Condition-Specific guidance
• Develop an emergency care plan for times when the
infant’s condition rapidly worsens.

eTIoLogy AND PAThoPhySIoLogy Persistent inflammation causes the normal protective

Asthma is a chronic inflammatory disease caused by multiple mechanisms of the lungs (mucous formation, mucosal swell-
factors (e.g., environmental exposures, viral illnesses, allergens, ing, and airway muscle contraction) to overreact in response to
and a genetic predisposition) that occur at a crucial time in the a trigger (an inflammatory or noninflammatory stimulus that
immune system’s development. Asthma is now considered to be initiates an asthma episode). Triggers include exercise, infec-
a collection of several diseases that have similar characteristics tious agents, allergens, fragrances, food additives, pollutants,
and symptoms (Custovic, Lazic, & Simpson, 2013). weather changes, emotions, and stress. Inflammatory mecha-
Many potential genes or regions of chromosomes are nisms enhance airway responsiveness, and triggers stimulate
associated with asthma, such as those that are associated bronchospasms (smooth muscle contractions).
with increased immune and inflammatory response and The trigger leads B cells to activate IgE and cytokines that
airway remodeling. Approximately 70% of children have then activate the migration and proliferation of eosinophils and
an allergic or atopic form of asthma, whereas other children the release of proinflammatory mediators. Direct tissue injury,
Medications used for infective endocarditis: Prophylaxis for haveDental and invasive
genetic factors that reduce their responsiveness to beta- increased bronchial hyperresponsiveness, fibroblast proliferation,
adrenergic inhaled medications (Brashers & Huether, 2014; and airway scarring result. An exaggerated inflammatory response
Respiratory Procedures Chang, 2012). Environmental exposures also increase the leads to vasodilation, increased capillary permeability, mucosal
risk for asthma, including passive tobacco smoke, indoor air edema, contraction of smooth bronchial muscle, and secretion of
antibiotic recoMMendations nursing ManageMent contaminants (e.g., pet dander, cockroach feces), and out- thick mucus, which narrow and obstruct the airways. Impaired
Amoxicillin for oral use door air
• Give 1 large dose 30–60 minpollutants. Recurrent respiratory viral infections
before procedures, A Medications Used to Treat feature in tabular
expiration leads to air trapping, hyperinflation, and dyspnea, the
or up to 2 hr after also
the procedure
increase risk.if preprocedure
Protective factors are believed to include physiologic sequence that results in an acute asthma episode (see
Ampicillin for IM or IV use
dose is missed. a large family size, later birth order, childcare attendance, format provides an overview of the types of
Pathophysiology Illustrated: Asthma). Decreased perfusion of the
If allergic to penicillin:
• Teach parents andand theexposure to certain
child to keep at organisms. In theory, these factors medications that can be used for a specific con-
alveolar capillaries results from hypoxic vasoconstriction and
Cephalexin least 1 dose in theincrease
home for exposure to infections
dental visits or early in life, enabling the increased pressure due to hyperinflation of the alveoli. Hypox-
Clindamycin emergencies. child’s immune system to develop along a nonallergic path- dition and nursing considerations associated
emia leads to an increased respiratory rate, but because of airway
way (Brashers & Huether, 2014). resistance, less air is inspired per minute, worsening hypoxemia.
Azithromycin • Have parents inform each healthcare provider of
the child’s need for prophylaxis.
with their use.
Clarithromycin
Source: Data from American Academy of Pediatrics (AAP). (2015). Red book: 2015 report of the Committee on Infectious Diseases (30th ed., p. 971). Elk
Grove Village, iL: Author; Sabe, M. A., Shrestha, n. K., & Menon, V. (2013). Contemporary drug treatment of infective endocarditis. American Journal of
Cardiovascular Drugs, 13, 251–258; Park, M. K. (2014). Pediatric cardiology for practitioners (6th ed., p. 349). Philadelphia: Elsevier Saunders.
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 Features to Help You Use This Textbook Successfully xvii

Nursing care plan: The Child With a Visual impairment Secondary to Retinopathy
Nursing Care Plans are also provided. They address health
of Prematurity conditions and illustrate the conceptual approach that nurses
1. Nursing Diagnosis: Communication, Readiness for Enhanced, related to altered reception, transmission, need in caring for children, including assessment, NANDA
and integration resulting of visual images (NANDA-I © 2014)
nursing diagnoses, goals, plans, and interventions.
GoAl: The child will receive adequate sensory input.
InTervenTIon raTIonale
• Provide kinesthetic, tactile, and auditory stimula- • Because visual sensory input is not present, the
tion during play and in daily care (e.g., talking and child needs input from all other senses to com-
playing). Provide music while bathing an infant, pensate and provide adequate sensory stimula-
using bells and other noises on each side of in- tion.
fant. Verbally describe to a child all actions being
carried out by adult.
ExpEctED outcomE: Child will demonstrate minimal signs of sensory deprivation.

2. Nursing Diagnosis: Injury, Risk for, related to impaired vision (NANDA-I © 2014)
GoAl: The child will be protected from safety hazards that can lead to injury.
InTervenTIon raTIonale
• Evaluate environment for potential safety hazards • The child may be at risk for injury related both to
based on age of child and degree of impairment. developmental stage and to inability to visualize
Be particularly alert to objects that give visual hazards.
cues to their dangers (e.g., stairs, stoves, fireplac-
es, candles). Eliminate safety hazards and protect
the child from exposure. Take the child on a tour
of new rooms, explaining safety hazards (e.g.,
schools, hotel room, hospital room).
ExpEctED outcomE: Child will experience no injuries.

3. Nursing Diagnosis: Development: Delayed, Risk for, related to impaired vision (NANDA-I © 2014) Pathophysiology Illustrated: hypovolemic Shock
GoAl: The child has experiences necessary to foster normal growth and development.
If hemorrhage reduces the circulating blood
InTervenTIon raTIonale 1. Blood loss from 5. Blood is shunted
hemorrhage to vital organs in an volume, the body compensates by increasing the
• Help parents plan early, regular social activities • The child with a visual impairment benefits devel- occurs or attempt to maintain
perfusion. heart rate and constricting the peripheral blood
with other children. opmentally from contact with other children. continues.
vessels. This allows the remaining blood to be
• Provide opportunities and encourage self-feeding • To obtain adequate nutrients, the child needs to circulated to the vital organs. when blood loss
activities. feel comfortable feeding self.
exceeds 20% to 25%, the child’s body can no longer
• Provide an environment rich in sensory input. • Sensory input is needed for normal development compensate; blood pressure falls, and circulatory
to occur. 4. Tachycardia and vaso- collapse is imminent.
2. Signs and symptoms
constriction occur as
• Assess growth and development during regular • Regular examinations aid in early identification include altered
the body attempts
responsiveness
examinations to identify the child’s strengths and of growth problems or developmental delays, so and cool
to compensate for
falling blood pressure
needs. that appropriate interventions can be planned. extremities.
and flow.

ExpEctED outcomE: Child will demonstrate normal growth and development milestones.

4. Nursing Diagnosis: Family Processes, Interrupted, related to child’s prolonged disability from sensory
impairment (NANDA-I © 2014)
GoAl: The family will identify methods for coping with their child with a visual impairment. 3. Blood pressure
falls; if uncorrected,
InTervenTIon raTIonale circulatory collapse
results.
• Provide explanation of visual impairment as ap- • The parents may feel guilt about the child’s visual
propriate. impairment, which can be allayed by knowledge
of the cause.
• Refer parents to organizations, early interven- • The parents will receive needed information and ETIoLogY AND PATHoPHYSIoLogY • Peripheral vessels constrict to maintain systemic vascular
tion programs, and other parents of children with support from others.
visual impairments. Pathophysiology Illustrated boxes feature unique draw-
• Assist parents to plan for meeting the develop- • The child may require an enhanced environment
mental, educational, and safety needs of their
child with a visual impairment. Offer resources for
in order to foster developmental progress. ings that illustrate conditions on a cellular or organ level,
changing home environment to assist child. and may also portray the step-by-step process of a dis-
ExpEctED outcomE: Family will successfully cope with the experience of having a child with a visual
impairment. ease. These images visually explain the pathophysiology
of certain conditions to increase students’ understanding
of the condition and its treatment.

Professionalism in Practice accommodations for

Children With JIa
Section 504 of the Rehabilitation Act of 1973 and the Individ-
uals with Disabilities Education Act (IDEA) protect children
with disabilities from discrimination. A formal plan such as
an individualized education plan (IEP) should be developed
for the child with arthritis that outlines accommodations
and modifications that are needed at school (Solomon,
2014). The school nurse can work with the family and school
administration to determine the plan. Accommodations at
school may include providing a set of books for the home so SaFeTy aLerT!
that the child is not required to carry the books home daily. If you feel a mass during palpation of a child’s abdomen, stop
Additional time may be required for the child to move from palpating immediately and report the finding to the child’s primary
class to class. The school nurse can refer parents and chil- healthcare provider. Never palpate the liver or abdomen of a child
dren to the Arthritis Foundation and the American Juvenile with Wilms tumor as this could cause a piece of the tumor to
Arthritis Organization for further information and support. dislodge. Place a sign on the child’s bed and in the chart alerting
The adolescent should also be referred for vocational coun- healthcare providers not to palpate the abdomen.
seling and offered support for transition to adult services.

Professionalism in Practice boxes focus on important topics The SAFETY ALERT! features present essential information
growth and Development
related to contemporary nursing practice issues, including that calls attention to issues that could place a patient or a
legal and ethical considerations. This feature reflects a commit- nurse at risk and provide guidance on maintaining a safe envi-
ment to quality improvement in all aspects of care. ronment for all patients and healthcare providers.

A01_BALL7013_07_SE_FM.indd 17 10/11/2016 11:19 am

 xviii Features to Help You Use This Textbook Successfully
Each chapter ends with Chapter ­Highlights
that outline the main points of the chapter
and a list of References from which students
can locate additional resources. In addition,
the Clinical Reasoning in Action features
at the end of each chapter propose a real-life
scenario and a series of clinical reasoning
questions so that you can apply to the clinical
setting what you learned in class.
Where relevant, SKILLS found in the compan-
ion book, Clinical Skills Manual for Maternity
and Pediatric Nursing, Fifth Edition, are cited.
A01_BALL7013_07_SE_FM.indd 18
Chapter Highlights
• The hypothalamic-pituitary axis produces several releasing
and inhibiting hormones that regulate the function of many
endocrine glands.
• Puberty is the process of sexual maturation that occurs when
the gonads secrete increased amounts of the sex hormones
estrogen and testosterone, resulting in the development of pri-
mary and secondary sexual characteristics.
• Children with hypopituitarism have short stature as a result of
growth hormone deficiency. Treatment with growth hormone
early in life enables these children to potentially attain geneti-
cally appropriate heights.
• An excessive secretion of growth hormone or hyperpituitarism
may cause children to have tall stature, growing up to 7 or 8
feet in height if no intervention is provided before the epiphy-
seal plates close.
• Diabetes insipidus is a disorder of the posterior pituitary gland
and is defined as an inability of the kidneys to concentrate
urine.
• Syndrome of inappropriate antidiuretic hormone (SIADH)
results from an excessive amount of serum antidiuretic hor-
mone (ADH), leading to water intoxication and hyponatremia.
• Precocious puberty is defined as the appearance of any sec-
ondary sexual characteristics before 8 years in girls and 9
years in boys. If no treatment is provided, the hormones will
stimulate closure of the epiphyseal plates and the child will
have short stature as an adult.
• Untreated or ineffectively treated congenital hypothyroidism
results in impaired growth and intellectual disability.
• Signs of hyperthyroidism include an enlarged, nontender
thyroid gland (goiter), prominent or bulging eyes , eyelid lag,
tachycardia, nervousness, increased appetite with weight loss,
emotional lability, moodiness, heat intolerance, hypertension,
hyperactivity, irregular menses, insomnia, tremor, and muscle
weakness.
• During infancy, most cases of endogenous Cushing disease
are due to a functioning adrenocortical tumor. The most com-
mon cause of endogenous Cushing syndrome in children older
than 7 years of age is Cushing disease, in which a pituitary
tumor (adenoma) secretes excess ACTH.
• Congenital adrenal hyperplasia has two forms, salt-losing or
non–salt-losing with virilization. The salt-losing form accounts
for 75% of cases and is caused by aldosterone deficiency
and overproduction of androgen. The non–salt-losing form
accounts for the other 25% of cases.
• Congenital adrenal hyperplasia is the most common cause
of pseudohermaphroditism (ambiguous genitalia) in newborn
girls.
• Adrenal insufficiency, also known as Addison disease, is a
rare disorder in childhood characterized by a deficiency of
glucocorticoids (cortisone) and mineralocorticoids (aldoste-
rone). Symptoms include weakness, fatigue, weight loss, and
gastrointestinal symptoms such as nausea, vomiting, diarrhea,
constipation, and abdominal pain. Other symptoms include
hyperpigmentation, hypotension, dizziness, joint pain, salt
cravings, and hypoglycemia.
• Pheochromocytoma is a tumor that arises from the adrenal
gland and causes an excessive release of catecholamines.
Clinical manifestations include hypertension, palpitations
sweating, anxiety, tremors, and headache.
• Diabetes mellitus type 1 is the most common metabolic dis-
ease in children and one of the most common chronic dis-
eases in school-age children. It is a disorder of carbohydrate,
protein, and fat metabolism.
• Treatment of the child with diabetic ketoacidosis includes
intravenous fluids and electrolytes for dehydration and acido-
sis. Insulin is given by continuous infusion pump to decrease
the serum glucose level at a slow but steady rate to prevent
the development of cerebral edema.
• Common causes of hypoglycemia in children with type 1 dia-
betes include an error in insulin dosage, inadequate calories
because of missed meals, or exercise without a corresponding
increase in caloric intake.
• Type 2 diabetes mellitus is a condition that results from insulin
resistance. Children most commonly affected are obese, and
many have family members with the same type of diabetes.
• Secondary amenorrhea is the cessation of spontaneous men-
strual periods for at least 120 days and occurs 6 months or 3
cycles after menarche.
10/11/2016 11:19 am
 Contents
Dedicationiii Special Family Considerations 25
About The Authors v Divorce and Its Effects on Children 25 •
Thank You! vii Stepparenting 26
Prefaceix Foster Care 26
Acknowledgmentsxiii Foster Parenting 27 • Health Status of Foster
Children 27 • Transition to Permanent
1 Nurse’s Role in Care of the Child: Placement 27
Hospital, Community, and Home 1 Adoption27
Legal Aspects of Adoption 28 • Preparation
Pediatric Healthcare Overview 1 for Adoption 28 • Responses by Adopted
Role of the Nurse in Pediatrics 2 Children 28 • International Adoptions 29
Direct Nursing Care 2 • Patient Education 3 • Family Theories 29
Patient Advocacy 3 • Case Management 4 • Family Development Theory 29 • Family Systems
Research 4 Theory 30 • Family Stress Theory 30
Nursing Process in Pediatric Care 4 Family Assessment 31
Clinical Reasoning 4 • Evidence-Based Practice 4 Family Stressors 31 • Family Strengths 31 •
Settings for Pediatric Nursing Care 5 Collecting Data for Family Assessment 31 • Family
Contemporary Climate for Pediatric Nursing Care 5 Assessment Tools 32
Culturally Sensitive Care 5 • Family-Centered Cultural Considerations 33
Care 6 Cultural Assessment 34 • Cultural Practices That
Pediatric Health Statistics 6 Influence Health Care 35
Mortality 6 • Morbidity 7 Complementary and Alternative Modalities 38
Healthcare Issues 8 Safety Issues Concerning CAM Therapies 39
Healthcare Financing 8 • Healthcare Technology 8
Legal Concepts and Responsibilities 9 3 Genetic and Genomic Influences 45
Regulation of Nursing Practice 9 • Accountability
Partnering With Families: Meeting the Standard of Genetic
and Risk Management 9
Nursing Care Delivery 45
Legal and Ethical Issues in Pediatric Care 11
Impact of Genetic Advances on Health Promotion and
Informed Consent 11 • Child Participation in Health Maintenance 47
Healthcare Decisions 12 • Child’s Rights Versus Parents’
Rights 12 • Patient Self-Determination Act 13 • Genetic Basics 48
Ethical Issues 13 • Partnering With Families 15 Cell Division 48 • Chromosomal
Alterations 49 • Genes 49
2 Family-Centered Care and Principles of Inheritance 51
Cultural Considerations 17 Classic Mendelian Patterns of Inheritance 51 •
Variability in Classic Mendelian Patterns of
Family and Family Roles 17 Inheritance 54 • Multifactorial Inheritance 55
Family-Centered Care 18 Collaborative Care 55
History of Family-Centered Care 18 • Promoting Diagnostic Procedures 55 • Quality and Accuracy
Family-Centered Care 18 of Genetic Tests 57
Family Composition 19 Visions for the Future 63
Family Functioning 21
Transition to Parenthood 21 • Parental Influences on 4 Growth and Development 66
the Child 21 • Family Size 21 • Sibling
Relationships 22 Principles of Growth and Development 66
Parenting22 Major Theories of Development 68
Authoritarian Parents 23 • Authoritative Freud’s Theory of Psychosexual Development 68 •
Parents 23 • Permissive Parents 23 • Indifferent Erikson’s Theory of Psychosocial Development 69 •
Parents 23 • Parent Adaptability 23 • Assessing Piaget’s Theory of Cognitive Development 69 •
Parenting Styles 23 • Discipline and Limit Kohlberg’s Theory of Moral Development 72 •
Setting 24 Social Learning Theory 73 • Behaviorism 73 •
xix

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 xx Contents
Ecologic Theory 74 • Temperament Theory 74 •
Resiliency Theory 77
Influences on Development
Infant (Birth to 1 Year)
Physical Growth and Development 79 • Cognitive
­Development 80 • Psychosocial Development 83
Toddler (1 to 3 Years)
Physical Growth and Development 85 • Cognitive
Development 86 • Psychosocial Development 86
Preschool Child (3 to 6 Years)
Physical Growth and Development 87 • Cognitive
Development 89 • Psychosocial Development 89
School-Age Child (6 to 12 Years)
Physical Growth and Development 91 • Cognitive
Development 91 • Psychosocial Development 92
Adolescent (12 to 18 Years)
Physical Growth and Development 94 • Cognitive
Development 94 • Psychosocial Development 94
5 Pediatric Assessment
Anatomic and Physiologic Characteristics of Infants
and Children98
Obtaining the Child’s History
Communication Strategies 98 • Data to Be Collected
100 • Developmental Approach to the
Examination 103
General Appraisal
Assessing Skin and Hair Characteristics
Inspection of the Skin 106 • Palpation of the
Skin 106 • Capillary Refill Time 107 • Skin
Lesions 107 • Inspection of the Hair 107 •
Palpation of the Hair 107
Assessing the Head for Skull Characteristics and Facial
Features108
Inspection of the Head and Face 108 • Palpation
of the Skull 109
Assessing Eye Structures, Function, and Vision
Inspection of the External Eye Structures 109 • Vision
Assessment 112 • Inspection of the Internal Eye
Structures 112
Assessing the Ear Structures and Hearing
Inspection of the External Ear Structures 112 •
Inspection of the Tympanic Membrane 112 • Hearing
Assessment 113
Assessing the Nose and Sinuses for Airway Patency and
Discharge115
Inspection of the External Nose 115 • Palpation
of the External Nose 115 • Assessment
of Smell 115 • Inspection of the Internal
Nose 116 • Inspection of the Sinuses 116
Assessing the Mouth and Throat for Color, Function,
and Signs of Abnormal Conditions
Inspection of the Mouth 117 • Palpation of
the Mouth Structures 118 • Inspection of the
Throat 118
A01_BALL7013_07_SE_FM.indd 20
Assessing the Neck for Characteristics, Range of Motion,
and Lymph Nodes 118
77 Inspection of the Neck 118 • Palpation of the
79 Neck 119 • Range of Motion Assessment 119
Assessing the Chest for Shape, Movement, Respiratory
Effort, and Lung Function 120
85 Inspection of the Chest 120 • Palpation of the
Chest 122 • Auscultation of the Chest 122 •
Percussion of the Chest 123
87 Assessing the Breasts 124
Inspection of the Breasts 124 • Palpation of the
Breasts 124
91 Assessing the Heart for Heart Sounds and Function 124
Inspection of the Precordium 124 • Palpation
of the Precordium 124 • Heart Rate
and Rhythm 125 • ­Auscultation of the
94 Heart 125 • ­Completing the Heart Examination 126
Assessing the Abdomen for Shape, Bowel Sounds, and
Underlying Organs 127
Inspection of the Abdomen 127 • Auscultation
98
of the Abdomen 127 • Percussion of
the Abdomen 128 • Palpation of the
Abdomen 128 • Assessment of the Inguinal
Area 128
98 Assessing the Genital and Perineal Areas for External
Structural Abnormalities 128
Inspection of the Female External
Genitalia 129 • Inspection of the Male
Genitalia 129 • Palpation of the Male
105
Genitalia 130 • Anus and Rectum 130
105
Assessing Pubertal Development and Sexual
Maturation130
Girls 130 • Boys 131 • Sexual Maturity
Timeline 131
Assessing the Musculoskeletal System for Bone and Joint
Structure, Movement, and Muscle Strength 132
Inspection of the Bones, Muscles, and Joints 132 •
Palpation of the Bones, Muscles, and Joints 132 •
Range of Motion and Muscle Strength Assessment 133 •
109 Posture and Spinal Alignment 133 • Inspection of
the Upper Extremities 134 • Inspection of the Lower
Extremities 134
Assessing the Nervous System 134
112 Cognitive Function 136 • Cerebellar
Function 136 • Cranial Nerve Function 138 •
Sensory Function 138 • Common Newborn
Reflexes 138 • Superficial and Deep Tendon
Reflexes 140
Performing an Intermittent Examination 141
Analyzing Data From the Physical Examination 142
6 Introduction to Health Promotion
and Maintenance144
117
General Concepts 145
Components of Health Promotion/Health Maintenance
Visits147
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 Contents xxi

7 Health Promotion and Maintenance 11 Nursing Considerations for the

for the Newborn and Infant 154
Health Promotion and Maintenance for the Newborn
and Infant154
Early Contacts With the Family 155 • General
­Observations 155 • Growth and Developmental
­Surveillance 156 • Nutrition 157 • Physical
A
­ ctivity 157 • Oral Health 158 • Mental and
Spiritual Health 158 • Relationships 160 •
Disease Prevention Strategies 160 • Injury
Prevention Strategies 161
8 Health Promotion and Maintenance
for the Toddler and Preschooler 166
Health Promotion and Maintenance for the Toddler and
Preschooler166
General Observations 167 • Growth and
Developmental Surveillance 167 • Nutrition 169 •
Physical Activity 170 • Oral Health 171 • Mental
and Spiritual Health 172 • Relationships 173 •
Disease Prevention Strategies 174 • Injury
Prevention Strategies 174
Hospitalized Child 222
Effects of Hospitalization on Children and Their Families 223
Children’s Understanding of Health and
Illness 223 • Family Responses to
Hospitalization 226 • Family Assessment 227
Nurse’s Role in the Child’s Adaptation to
Hospitalization228
Planned Hospitalization 228 • Unexpected
Hospitalization 229
Nursing Care of the Hospitalized Child 230
Special Units and Types of Care 230 • Parental
Involvement and Parental Presence 231 •
Performing the Procedure 232 • Preparation for
Surgery 234
Strategies to Promote Coping and Normal Development
of the Hospitalized Child 238
Rooming In 238 • Child-Life
Programs 238 • Therapeutic Play 238 •
Therapeutic Recreation 241 • Strategies to Meet
Educational Needs 241
Preparation for Home Care 243

9 Health Promotion and Maintenance for Assessing the Child and Family in Preparation for
Discharge 243 • Preparing the Family for Home
the School-Age Child and Adolescent 182 Care 243 • Preparing Parents to Act as Case
Managers 243
Health Promotion and Maintenance for the School-Age
Child182
General Observations 183 • Growth and 12 The Child With a Chronic
Developmental Surveillance 183 • Nutrition 184 • Condition246
Physical Activity 184 • Oral Health 186 • Mental
and Spiritual Health 187 • Relationships 189 • Overview of Chronic Conditions 246
Disease Prevention Strategies 190 • Injury Role of the Nurse 248
Prevention Strategies 191
The Child With a Newly Diagnosed Chronic
Health Promotion and Maintenance for the Adolescent 195 Condition 248 • Discharge Planning and Home Care
General Observations 196 • Growth and ­ Teaching 249 • Coordination of Care 252
Developmental Surveillance 196 • Nutrition 197 • Community Sites of Care 253
Physical ­Activity 197 • Oral Health 198 • Mental
Office or Health Center 253 • Specialty Referral
and Spiritual Health 199 • Relationships 201 •
Centers 254 • Schools 254 • Home Care 257
Disease Prevention Strategies 201 • Injury
Prevention Strategies 202
13 The Child With a Life-Threatening
10 Nursing Considerations for the Child Condition and End-of-Life Care 260
in the Community 207
Life-Threatening Illness or Injury 260
Community-Based Health Care 207 Child’s Experience 261
Community Healthcare Settings 208 Coping Mechanisms 261
Nursing Roles in the Office or Healthcare Center Parents’ Experience of a Child’s Life-Threatening Illness
Setting 208 • Nursing Roles in the Specialty
or Injury264
Healthcare Setting 209 • Nursing Roles in the
School Setting 210 • Nursing Roles in the Childcare The Family in Crisis 264 • Parental Reactions to
Setting 211 • Nursing Roles in the Home Healthcare Life-Threatening Illness or Injury 265
Setting 213 The Siblings’ Experience 268
Assessment of Community Needs and Resources 216 End-of-Life Care 269
Community Assessment 216 • Planning and Palliative and Hospice Care 269
Evaluation 217 Ethical Issues Surrounding a Child’s Death 269
Preparation for Disasters 217 Brain Death Criteria 269 • Withdrawal of or
Clinical Manifestations 218 • Clinical Withholding Treatment 270 • Do-Not-Resuscitate
Therapy 218 Orders 271

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 xxii Contents

Care of the Dying Child 271 Communicable Diseases in Children 348

Awareness of Dying by Developmental Age 271 Clinical Manifestations 348
Bereavement276 Sepsis and Septic Shock 364
Parents’ Reactions 276 • Sudden Death of a Emerging Infection Control Threats 364
Child 276 • Death of a Newborn or Young
Infant 276 • Grief and Bereavement 276 •
Siblings’ Reactions 276 • Staff Reactions to the
Death of a Child 278
17 Social and Environmental Influences
on the Child 367
14 Infant, Child, and Adolescent Basic Concepts 368
Nutrition281 Social Influences on Child Health 368
General Nutrition Concepts 281 Poverty 368 • Stress 369 • Families 371 •
Nutritional Needs 282 School and Child Care 372 • Community 372 •
Culture 373
Infancy 282 • Toddlerhood 286 •
Preschool 286 • School Age 287 • Lifestyle Activities and Their Influence on
Adolescence 288 Child Health 374
Nutritional Assessment 289 Tobacco Use 374 • Alcohol Use 376 • Drug
Use 376 • Physical Inactivity and Sedentary
Physical and Behavioral Measurement 289 • Dietary
B
­ ehavior 380 • Injury and Protective
Intake 290
Equipment 380 • Body Art 382 • Sexual
Common Nutritional Concerns 292 Orientation 383
Childhood Hunger 292 • Overweight and Effects of Violence 384
Obesity 293 • Food Safety 295 • Common Dietary
Schools and Communities 384 • Bullying 384 •
Deficiencies 296 • Celiac Disease 297 • Feeding
Incarceration 385 • Hazing 385 • Domestic
and Eating Disorders 298 • Food Reactions 304 •
Violence 385 • Dating Violence 386
Lactose Intolerance 304
Child Abuse 388
Nutritional Support 305
Physical Abuse 388 • Physical
Sports Nutrition and Ergogenic Agents 305 • Herbs,
Neglect 389 • Abandoned Babies 389 •
Probiotics, and Prebiotics 305 • Health-Related
Emotional Abuse 389 • Emotional
Conditions 306 • Vegetarianism 306 • Enteral
Neglect 389 • Sexual Abuse 389 • Münchausen
Therapy 306 • Total Parenteral Nutrition (TPN) 307
Syndrome by Proxy (Factitious Disorder) 393
15 Pain Assessment and Management Environmental Influences On Child Health 394
in Children310 Environmental Contaminants 394 •
Poisoning 395 • Ingestion of Foreign
Pain310 ­Objects 398 • Lead Poisoning 399
Misconceptions About Pain in Children 311 •
Developmental Aspects of Pain Perception, Memory,
and Response 311 • Cultural Influences on 18 Alterations in Fluid, Electrolyte,
Pain 312 • Consequences of Pain 314
and Acid–Base Balance 404
Pain Assessment 314
Pain History 314 • Pain Assessment Tools 315 Extracellular Fluid Volume Imbalances 409
Acute Pain 317 Extracellular Fluid Volume Deficit
(Dehydration) 409 • Extracellular Fluid Volume
Clinical Manifestations 318 • Clinical
Excess 416 • Interstitial Fluid Volume Excess
­Therapy 318 • Nonpharmacologic Methods of Pain
(Edema) 418
­Management 322
Sodium Imbalances 420
Chronic Pain 328
Hypernatremia 420 • Hyponatremia 422
Clinical Manifestations 328 • Clinical Therapy 328
Potassium Imbalances 423
Sedation and Analgesia for Medical Procedures 329
Hyperkalemia 423 • Hypokalemia 425

16 Immunizations and Communicable

Calcium Imbalances
Hypercalcemia 427 • Hypocalcemia 428
427

Diseases333
Magnesium Imbalances 430
Special Vulnerability of Infants and Children 333 Hypermagnesemia 430 • ­Hypomagnesemia 430
Public Health and Communicable Diseases 334 Acid–Base Imbalances 432
Immunization335 Respiratory Acidosis 433 • Respiratory
Clinical Manifestations 340 • Collaborative ­Alkalosis 435 • Metabolic Acidosis 436 • Metabolic
Care 340 Alkalosis 437 • Mixed Acid–Base Imbalances 437

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 Contents xxiii

19 Alterations in Eye, Ear, Nose, Congestive Heart Failure

Etiology and Pathophysiology 543 • Clinical
542

and Throat Function 440 Manifestations 543 • Clinical Therapy 543

Disorders of the Eye 440 Acquired Heart Diseases 547
Infectious Conjunctivitis 440 • Periorbital Cardiomyopathy 547 • Heart Transplanta-
Cellulitis 445 • Visual Disorders 445 • Color tion 549 • Pulmonary Artery Hypertension 550 •
Blindness 446 • Retinopathy of Infective Endocarditis 550 • Acute Rheumatic
Prematurity 448 • Visual Impairment 452 • Fever 551 • Kawasaki Disease 552 • Cardiac
Injuries of the Eye 455 Arrhythmias 553 • Dyslipidemia 555 •
Disorders of the Ear 455 Hypertension 556
Otitis Media 455 • Otitis Externa 460 • Hearing Injuries of the Cardiovascular System 556
Impairment 460 • Injuries of the Ear 465 Shock 556 • Hypovolemic Shock 556 •
Disorders of the Nose and Throat 465 Distributive Shock 559 • Obstructive Shock 559 •
Epistaxis 465 • Nasopharyngitis 467 • Cardiogenic Shock 559 •
Sinusitis 468 • Pharyngitis 468 • Tonsillitis and Myocardial Contusion 560 •
Adenoiditis 469 Commotio Cordis 560
Disorders of the Mouth 471
22 Alterations in Immune Function 563
20 Alterations in Respiratory Function 474 Immunodeficiency Disorders 563
Respiratory Distress and Respiratory Failure 474 B-Cell and T-Cell Disorders 566 • Severe Combined
Foreign-Body Aspiration 478 • Respiratory Immunodeficiency Disease 567 • Wiskott-Aldrich
Failure 480 Syndrome 569 • Human Immunodeficiency Virus
and Acquired Immune Deficiency Syndrome 569
Apnea481
Autoimmune Disorders 578
Apparent Life-Threatening Event (ALTE) 481 •
Obstructive Sleep Apnea 482 • Systemic Lupus Erythematosus 578 • Juvenile
Sudden Infant Death ­Syndrome 483 Idiopathic Arthritis 581
Croup Syndromes 485 Allergic Reactions 583
Latex Allergy 585
Lower Airway Disorders 488
Bronchitis 488 • Bronchiolitis and Respiratory Graft-Versus-Host Disease 585
Syncytial Virus 488 • Pneumonia 491 •
Tuberculosis 492
23 Alterations in Hematologic
Chronic Lung Conditions 493
Function589
Bronchopulmonary Dysplasia (Chronic Lung
Anemias589
Disease) 493 • Asthma 495 • Cystic Fibrosis 506
Iron Deficiency Anemia 589 • Normocytic
Injuries of the Respiratory System 512
Anemia 592 • Sickle Cell Disease 593 •
Smoke-Inhalation Injury 512 • Blunt Thalassemias 601 •
Chest Trauma 513 • Pulmonary Hereditary Spherocytosis 601 •
Contusion 513 • Pneumothorax 513 Aplastic ­Anemia 602
Bleeding Disorders 602
21 Alterations in Cardiovascular Hemophilia 602 • Von Willebrand
Function518 Disease 604 • Disseminated Intravascular
Coagulation 604 • Immune Thrombocytopenic
Congenital Heart Disease 522 Purpura 605
Etiology and Pathophysiology 522 • Clinical Hematopoietic Stem Cell Transplantation 605
Manifestations 522 • Clinical Therapy 523
Congenital Heart Defects That Increase Pulmonary
Blood Flow 525 24 The Child With Cancer 610
Etiology and Pathophysiology 525 • Clinical
Childhood Cancer 613
Manifestations 525 • Clinical Therapy 528
Incidence 613 • Etiology and
Defects Causing Decreased Pulmonary Blood Flow and Pathophysiology 613 • Clinical
Mixed Defects 530 Manifestations 615 • Diagnostic Tests 615 •
Etiology and Pathophysiology 530 • Clinical Clinical Therapy 616 • Special Issues in Childhood
Manifestations 531 • Clinical Therapy 534 Cancer 622
Defects Obstructing Systemic Blood Flow 539 Solid Tumors 636
Etiology and Pathophysiology 539 • Clinical Brain Tumors 636 • Neuroblastoma 640 • Wilms
Manifestations 539 • Clinical Therapy 542 Tumor (Nephroblastoma) 641

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 xxiv Contents
Bone Tumors
Osteosarcoma 643 • Ewing Sarcoma 643
Leukemia645
Etiology and Pathophysiology 645 • Clinical
Manifestations 645 • Clinical Therapy 646
Soft-Tissue Tumors
Hodgkin Disease 648 • Non-Hodgkin
Lymphoma 649 • Rhabdomyosarcoma 649 •
Retinoblastoma 650
25 Alterations in Gastrointestinal
Function655
Structural Defects
Cleft Lip and Cleft Palate 655 • Esophageal Atresia
and Tracheoesophageal Fistula 663 • Pyloric
Stenosis 665 • Gastroesophageal Reflux 668 •
Omphalocele and Gastroschisis 669 •
Intussusception 670 • Volvulus 671 •
Hirschsprung Disease 672 •
Anorectal Malformations 672 • Hernias 674
Ostomies674
Inflammatory Disorders
Appendicitis 676 • Necrotizing
Enterocolitis 679 • Meckel
Diverticulum 680 • Inflammatory Bowel
Disease 680 • Peptic Ulcer 682
Disorders of Motility
Gastroenteritis (Acute
Diarrhea) 682 • Constipation 686 •
Encopresis 687
Intestinal Parasitic Disorders
Disorders of Malabsorption
Short Bowel Syndrome 687
Hepatic Disorders
Hyperbilirubinemia of the Newborn 690 • Biliary
Atresia 691 • Viral Hepatitis 692 • Cirrhosis 694
Injuries to the Gastrointestinal System
Abdominal Trauma 695
26 Alterations in Genitourinary
Function701
Urinary Tract Infection
Etiology and Pathophysiology 701 • Clinical
Manifestations 705 • Clinical Therapy 705
Structural Defects of the Urinary System
Bladder Exstrophy 706 • Hypospadias
and Epispadias 707 • Obstructive
Uropathy 709 • Vesicoureteral Reflux 710 •
Prune Belly Syndrome 710
Enuresis711
Renal Disorders
Nephrotic Syndrome 712 • Acute Postinfectious
Glomerulonephritis 715
Renal Failure
Acute Renal Failure 718 • Chronic
Renal Failure 721 • Renal Replacement
A01_BALL7013_07_SE_FM.indd 24
643 Therapy 725 • Hemolytic-Uremic
Syndrome 729 • Polycystic Kidney Disease 730
Structural Defects of the Reproductive System 731
Phimosis 731 • Cryptorchidism 731 • Inguinal
Hernia and Hydrocele 731 • Testicular
Torsion 732
648
Sexually Transmitted Infections 732
Pelvic Inflammatory Disease (PID) 735
27 Alterations in Neurologic Function 739
Altered States of Consciousness 739
655 Etiology and Pathophysiology 743 • Clinical
Manifestations 743 • Clinical Therapy 743
Seizure Disorders 747
Etiology and Pathophysiology 747 • Clinical
Manifestations 747 • Clinical Therapy 747
Infectious Diseases 754
Bacterial Meningitis 754 • Viral (Aseptic)
Meningitis 758 • Encephalitis 759 • Reye
Syndrome 759 • Guillain-Barré Syndrome
675 (Postinfectious Polyneuritis) 760
Headaches761
Etiology and Pathophysiology 761 • Clinical
Manifestations 761 • Clinical Therapy 761
Structural Defects 761
682
Microcephaly 761 • Hydrocephalus 761 •
Neural Tube Defects 765 • Craniosynostosis 769 •
Positional Plagiocephaly 770 • Neonatal Abstinence
Syndrome 770 • Neurofibromatosis 771
687
Cerebral Palsy 772
687
Etiology and Pathophysiology 772 • Clinical
Manifestations 773 • Clinical Therapy 773
689 Injuries of the Neurologic System 777
Traumatic Brain Injury 777 • Concussion 782 •
Scalp Injuries 782 • Skull Fractures 782 •
695 Penetrating Injuries 783 • Spinal Cord Injury 783 •
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712 Depression 803 • Bipolar Disorder (Manic
Depression) 806
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718 Generalized Anxiety Disorder 807 • Separation
Anxiety Disorder 807 • Panic Disorder 808 •
Obsessive-Compulsive Disorder 808 •
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 "You are nothing more than a traitor!" cried Collot; "it is our indictment
you are drawing up there, I suppose?"

"Yes, traitor! threefold traitor!" exclaimed Elie Lacoste. "Traitor and

perjurer, you form with Robespierre and Couthon a triumvirate of calumny,
falsehood, and betrayal."

Saint-Just, without losing self-possession a moment, stopped in his

writing, and coldly offered to read them his speech.

Barère disdainfully refused to listen.

"We fear neither you nor your accomplices! You are but a child,
Couthon a miserable cripple, and as to Robespierre..."

At this moment an usher brought in a letter to Barère. He looked uneasy

after he had read it, and signed to his colleagues to follow, leaving Saint-
Just free to continue his work. In the lobby Barère told them it was a letter
from Lecointre announcing the approaching attack upon the Committee by
the troops of the Commune, and offering the battalion of his section for
their defence.

"It is exactly as I told you!" cried Elie Lacoste. "The leaders of the
Commune must be instantly arrested, and with them Robespierre and his
two accomplices!"

"Commencing with Saint-Just and his speech," said Collot.

"Robespierre was here just now," observed Billaud-Varennes, who had

followed his colleagues out of the room; "he wanted to know what we had
done with the prisoner from La Force. We told him we had not to render
account to him, whereupon he went away in a rage, crying out, 'You want
war? War you shall have then!' We have been warned by the Incorruptible
himself, you see!"

"Yes, but we shall crush him through his Englishman! We have

witnesses enough now!"
 "Nay, unhappily we have not!" replied Billaud.

"What! we have no witnesses?" exclaimed Barère in surprise. "What do

you mean? ... Has not Coulongeon...?"

"Coulongeon arrived too late at La Bourbe Lebas had just taken them
off, by Robespierre's orders—no one knows whither."

"Oh! the villain! he suspected something, then, and abducted them to

suppress their evidence; but we have at any rate the young man from La
Force."

"He is upstairs, but he knows nothing."

"He lies, he is a traitor!"

"No, he seemed quite sincere, and he execrates Robespierre; but I shall

question him again to-morrow."

"And meanwhile we must resort to stratagem," remarked Barère.

They discussed and debated the question, and all came to the conclusion
that Barère was right. Their safety lay in stratagem. After all, there was no
immediate peril. Robespierre was not fond of violent measures, he would
not break the bounds of the law unless driven to it. It was out of sheer
vexation that he had thrown that challenge in Billaud-Varennes' face; and
after all, since Saint-Just had again assured them of the Incorruptible's pure
intentions, it would be perhaps prudent to dissemble and to disarm the
triumvirate by simulating confidence.

On the whole the members of the Committee were undecided, hesitating

between two alternatives, one as dangerous as the other. Either they must
openly attack Robespierre and overthrow him, and thus add to the already
unbounded power of the Committee, which would then more easily crush
the Convention; or they must leave the power in Robespierre's hands, who,
when once master, would lose no time in annihilating them.
 The members returned to the Committee-room where Saint-Just was
still writing. They spoke as if they had altered their mind on thinking things
over. They regretted their hasty words, for after all the patriotism of
Robespierre and his friends had stood a long test. They spoke of precautions
to be taken in case of an unexpected attack, for warnings had reached them
from every quarter. All this was discussed aloud before Saint-Just,
ostensibly to show their complete confidence in him.

Saint-Just, to all appearance the dupe of their hypocrisy, assured them

they were unnecessarily alarmed. If the Jacobins and the Commune had
formed any projects against the Committee, he would have heard of it.
There was certainly considerable excitement in the streets among the people
whose anger had been aroused at the calumnies to which Robespierre had
been subject. But the Incorruptible would soon calm them down. As far as
he, Saint-Just, was concerned, he was ready to forget the somewhat hasty
words which one of his colleagues had addressed to him in the heat of the
moment.

Collot d'Herbois upon a sign from Barère feigned to regret his hasty
speech, which was, of course, he said, the outcome of excitement. It was so
easy in these times of anger and enmity to be carried away by the fever of
the moment. The dissensions of the Committee were making them the
laughing-stock of their enemies.

Saint-Just, cold and impassive as before, quietly assented, and

meanwhile continued to draft his speech, and when he had finished put it in
his pocket, and looked up at the clock. It was five in morning.

"At ten, the speech will be copied, and I shall read it to you before the
sitting, so that there may be no unpleasantness," said Saint-Just, rising to
go.

Taking his hat and stick, he moved off, the others, to all appearance
reassured, pretending to do likewise; but Saint-Just had no sooner
disappeared than they returned to the Committee-room. It was agreed to
send for the three leaders suspected of assisting Robespierre in the
insurrection: Hauriot, the Commander of the troops; Payan, the Commune
agent; and Fleuriot-Lescot, Mayor of Paris. The ushers returned with the
two last named, but Hauriot was not to be found. For the space of four
hours they retained Payan and Fleuriot-Lescot, smoking, drinking, eating,
talking, and discussing, in the sultry and oppressive heat which heralded the
near approach of a storm. They thus held them in check for the time being,
overwhelming them meanwhile with questions, to which they replied in
terms that tended to calm the anxiety of the Committee.

During this time the Parisian populace, who had not slept either, had
entered the Convention, the assembly-hall of which, situated also in the
palace of the Tuileries, within ear-shot of the Committee, had been filling
since five o'clock that morning, though the sitting was not to commence
until noon.

Every moment messengers arrived at the Committee-room, ushers out

of breath bringing news, messages, and reports in an endless succession,
which increased as the hours advanced. Payan and Fleuriot-Lescot had just
left, after completely reassuring the Committee. It was now half-past ten,
and the sitting was opened. Saint-Just did not put in an appearance, but the
thump of crutches was heard in the corridor, announcing the arrival of
Couthon, the cripple.

"Where is Saint-Just?"

"He is coming!"

For one hour Couthon kept the Committee in suspense, entertaining

them with Saint-Just's favourite theme, Robespierre's single-minded
patriotism, but still no Saint-Just appeared. The Committee began to feel
annoyed, and soon Carnot, who suspected treachery, spoke out boldly. It
was nothing less, he said, than a preconcerted plan between Couthon, Saint-
Just, and Robespierre.

Couthon protested.

"You do wrong to speak ill of the patriot Robespierre! You are basely
calumniating a friend of your childhood!"
 "If I am base, you are a traitor!" retorted Carnot, beside himself with
rage.

But Couthon, anticipating a storm, took up his crutches and stumped

off, protesting as he went. Sinister sounds now reached the Committee.
They had been betrayed! Saint-Just was going to denounce them from the
tribune! The document he had been drafting before them, there on that
table, was nothing more or less than the indictment of the Committee!
Barère had just received trustworthy information to that effect. Robespierre
had drawn up a list of eighteen names of those destined for the scaffold. A
deputy entered and asked for Billaud-Varennes. He was told that Billaud
had just gone out, but would return shortly.

"Ah! Here is Fouché!" some one exclaimed.

It was in truth Fouché, the deputy, who now entered. He was beset with
questions. Yes! they were not mistaken, he told them. Robespierre was now
going to throw off the mask, and denounce some of his colleagues. "And I
am sure he has not forgotten me," added Fouché, ironically.

He was immediately surrounded by eager questioners. The names? Did

he know the names? they asked anxiously. Fouché did not know; but
everybody was threatened, and each must look after himself; the sitting
would soon begin.

All turned their eyes anxiously to the clock. It was not yet noon; they
had still twelve minutes! Now another deputy came in, breathless with the
news that Robespierre had just entered the Hall of the Convention, with his
brother Augustin, Couthon, Saint-Just, Lebas, and all his followers. The
galleries, crowded to excess, had received the Incorruptible with loud
cheers.

"Hark, the rabble are applauding; he has hired his usual claque," said
one.

"That's true," another answered. "Since five this morning the

Robespierrists, male and female, have taken possession of the galleries,
yelling, feasting, and drinking."
 "They are already drunk."

"Well! Let us go and offer our heads to the drunkards!" exclaimed

Fouché.

But just then a door on the right opened, and Billaud-Varennes entered.
Every one paused.

"Here is Billaud at last."

Billaud was looking anxious, and wiping his brow, worn out with the
heat, he asked for a glass of beer. They eagerly questioned him.

"Was it true, then? They would have to fight?"

"Yes! fight to the death. They ought to have listened to him. Robespierre
had told him plainly enough that there would be war. And now that they
could not prove the plot...."

"What plot?" asked Fouché.

"Ah, yes! It's true; you don't know...."

Billaud made a sign to shut the doors, as Robespierre had spies in all the
corridors. The doors securely closed, Billaud-Varennes again told the story
of the Englishman. Fouché listened with curiosity. Other members, Vadier,
Amar, Voullaud, who had just entered, also followed Billaud's story with
keen interest, while those who already knew of the plot, came and went,
deep in discussion, waiting for Billaud to finish, to give their opinion.

Billaud-Varennes now produced the order of release for the two women,
signed by Robespierre, and brought from the prison of La Bourbe by
Coulongeon.

"There can be no doubt. We have in this quite enough to ruin him," said
Fouché; "but what about that young man from La Force?"

"I questioned him again closely just now in the next room. He persists
in his first statement, which appears to me quite genuine—as genuine as is
his rage against Robespierre, whom he regrets, he says, not to have stabbed
at the Fête of the Supreme Being."

"Ah! if he had! what a riddance!" was the cry with which one and all
greeted Billaud's last words.

"True; but he has not done it," observed Fouché drily. "As to the plot, it
has escaped our grasp."

"Not so," some one remarked; "his treason is evident."

A warm discussion ensued. The treachery was obvious to the

Committee, but it would not be so in the eyes of the public. It must be
proved. And where was the Englishman? Where were the women? To
accuse Robespierre thus, without sufficient proof, was sheer folly. The only
witness available, the agent Coulongeon, was in the pay of the Committee.
Robespierre would make a speech on it, call it a concocted plan, and
annihilate his accusers with an oratorical flourish.

"Nothing truer!" remarked another deputy.

"He has only to open his mouth and every one trembles."

"Very well; let us gag him," said Fouché. "It's the only means of putting
an end to it all."

They looked at him, not quite catching his meaning. Fouché explained
his idea. They had but to drown Robespierre's voice at the sitting by their
clamour. They had but to howl, scream, vociferate; the people in the
galleries would protest noisily, and their outcry would add to the tumult.
Robespierre would strain his voice in vain to be heard above the uproar, and
then fall back exhausted and vanquished.

"That's it," they cried unanimously.

Billaud also thought this an excellent idea, and at once began to arrange
for letting all their friends know as soon as possible, for Robespierre must
be prevented from uttering a single audible word. Every one approved. Just
then a door opened.

"Be quick! Saint-Just is ascending the tribune!" called a voice.

"Very well. We may as well commence with him."

And they one and all made for the doors in an indescribable disorder.

"Now for it," cried Billaud, laying his glass down on the sideboard.

But meanwhile Fouché signed to Vadier, Amar, and Voullaud to remain.

They looked at him in surprise. Fouché waited for the noise to subside, then
assuring himself that no one could overhear him, he confided his fears to
them. It was not everything to drown Robespierre's voice. Even arrested,
condemned, and on the death-tumbril, his hands bound, Robespierre would
still be dangerous; a sudden rush and riot could deliver him, and crush them
all! Then lowering his voice, he continued—

"The young madman of whom Billaud spoke just now...."

"Well?"

"Where is he?"

Amar pointed to a door on the left.

"Let him come in!" said Fouché; "I will speak to him in the name of the
Committee."

They did not yet quite grasp his meaning, but Voullaud went all the
same and opened the door.

"Hush!" said Fouché, "here is the young man!"

Olivier entered, followed by a gendarme, who, on seeing Fouché and

the other members, stopped on the threshold. Olivier looked at them
indifferently, expecting to be again cross-examined about the Englishman.
Fouché had taken his hat and put it on, as if going out.
 "Young man, you were the first to charge the despot, whom we are
about to fight, with his crimes! This is sufficient to recommend you to the
indulgence of the Committee."

As Olivier advanced in astonishment, he continued—

"You may go if you like!"

Fouché turned to the gendarme—

"The citoyen is free!"

The gendarme retired.

Vadier now understood Fouché's idea. Taking up his hat also, he

remarked—

"And if our enemy is victorious, take care not to fall again into his
clutches!"

Olivier who was preparing to go, stopped suddenly. Unhappily, he said,

he had not only himself to tremble for. His mother and fiancée were in
prison and Robespierre would revenge himself on them.

"Most probably!" replied Fouché.

"Then the Committee ought to release them also, and with even more
reason!"

Fouché shrugged his shoulders regretfully.

It had been the intention of the Committee, but the two prisoners were
beyond their reach.

"How?" asked Olivier anxiously.

Simply because they were no longer at the prison of La Bourbe.

Olivier gasped—
 "Condemned?"

"Not yet! But Lebas had taken them away with an order from
Robespierre."

Here Fouché, picking up the order left on the table by Billaud-Varennes,

showed it to Olivier, who read it in horrified amazement.

"Where are they then," he cried.

"At the Conciergerie, where they would be judged within twenty-four

hours."

"The wretch! the wretch!"

He implored them that they might be released. The Committee were all-
powerful!—They, powerful, indeed? They looked at him pityingly. He
believed that? What simplicity! How could they release the two women
when they were on the point of being sacrificed themselves? They would
have difficulty enough to save their own heads!

"To-morrow," continued Fouché, "we shall most likely be with your

mother, at the foot of the scaffold."

Olivier looked at them in terror. Was it possible? Was there no one that
could be found to kill this dangerous wild beast?

Fouché, who had consulted his colleagues in a rapid glance, now felt the
moment ripe.

"Assassinate him, you mean?" he asked.

Olivier lost all self-control. Is a mad dog assassinated? He is killed,

that's all! What did it matter if the one who did it were torn to pieces; he
would have had his revenge, and would save further victims.

"Certainly," said Fouché, "and if Robespierre is victorious, it is the only

chance of saving your mother."
 "But don't rely on that!" Vadier remarked.

Amar went even further.

"Patriots like Brutus are not often found!" he said.

But Olivier cried out in his fury that only one was wanted, and then
looked about for the door.

"Which is the way out?"

Vadier pointed to the exit.

"Thank you, citoyens! ... Adieu! au revoir!"

The four men silently watched him disappear, and then looked at each
other.... Would he do it? It was not impossible!

"Meanwhile, let us go and howl!" suggested Fouché.

And they rushed into the Convention-room.

CHAPTER XIII

A BROKEN IDOL

Saint-Just is in the tribune. Collot d'Herbois occupies the presidential

chair, Collot who, at two in the morning, suspecting Saint-Just's treachery,
had openly charged him with it. War is in the air, and every member is at his
post.

Fouché looks round for Robespierre as he crosses to his seat. There he

is; in the semicircle before the bust of Brutus, at the foot of the tribune
which he seems to guard like a vigilant sentinel.

"He is dressed as he was at the Fête of the Supreme Being," whispers

Fouché ironically to his neighbour.

Yes, the Incorruptible has on his sky-blue coat, white-silk embroidered

waistcoat, and nankeen knee-breeches buttoned over white stockings, nor
has he omitted the powder and the curls. What a strange figure, with his
dapper daintiness, his old-fashioned attire, in that seething furnace of fifteen
hundred people, actors and spectators, so closely packed, and, most of them
with bared breasts, suffocating in the awful heat which oppresses them! The
sans-culottes up in the gallery have even taken off their traditional red
nightcaps, which they hang on the handles of their sword-sticks like
bloodstained trophies.

It is as they expected. Since five the hall has been taken possession of
by Robespierrists. All the worst scum of Paris has gathered there; all the
bloodhounds of the Revolution, all the riff-raff who accompany the death-
tumbrils to the scaffold to the song of the Carmagnole; fish-wives and
rowdies, recruited and hired at twenty-four sous apiece to drown with their
vociferations every hostile attempt made against the idol of the Commune.

This brutish mob, reeking of sausages, pressed meat, gingerbread and

beer, eating and drinking, poison the atmosphere of the Hall.

Robespierre's arrival at twelve o'clock is hailed by repeated rounds of

loud applause, which he acknowledges with a gracious bow, proud and
smiling. Turning to Lebas who accompanies him, he remarks, "Did I not tell
you it would be a success?"

So certain is he of victory that before starting he had set the Duplays

quite at ease as to the issue of the struggle. "Believe me," he had said, "the
greater part of the Convention are unbiassed."

But suddenly, at the commencement of the sitting, when Saint-Just

appears in the tribune, a counter movement makes itself felt in the
assembly. Robespierre realising the importance of at once preventing any
hostile demonstration, advances to the foot of the tribune, determined to
daunt his opponents by a bold front. Saint-Just at once renews the
accusation brought against the Committee by the Incorruptible the day
before, accentuating it without mentioning names.

It is now that the anti-Robespierrist plot, admirably planned, begins to

work.

Tallien, one of the conspirators, breaks in upon Saint-Just violently.

"Enough of these vague accusations!" he cries. "The names! Let us have

the names!"

Saint-Just, encouraged by a look from Robespierre, simply shrugs his

shoulders, and continues. But his voice is immediately drowned in a
thundering clamour, and in spite of the vehement protestations of
Robespierre, he is unable to finish his speech. The anti-Robespierrist cabal
are playing their part well. They simply roar.

Billaud-Varennes demands a hearing. He is already in the tribune,

greeted by sustained applause.

Robespierre, growing excited, protests and persists in speaking, but his

voice is drowned in cries of "Silence! Silence! Let Billaud-Varennes
speak!" Collot d'Herbois rings the president's bell, and adds to the noise
under the pretext of repressing it.

"Let Billaud-Varennes speak! Let Billaud-Varennes speak!"

But Robespierre continues to protest—

"Don't listen to that man! His words are but poisonous drivel!"

Immediately loud cries are heard—

"Order! Order! Robespierre is not in the tribune! Billaud-Varennes is in

the tribune! Silence! Silence!"

And Robespierre, with a shrug of contempt, returns to his place.

 Silence being gradually restored, Billaud-Varennes begins to speak.

"I was at the Jacobins' yesterday; the room was crowded with men
posted there to insult the National representatives, and to calumniate the
Committee of Public Safety which devotes its days and nights to kneading
bread for you, to forging arms and raising armies for you, to sending them
forth to victory!"

A voice is heard in approval, and fresh applause breaks out; but the gaze
of the orator is fixed on that part of the assembly called the Mountain. He
seems to recognise some one, at whom he points with lifted arm.

"I see yonder, on the Mountain, one of the wretches who insulted us
yesterday. There he stands!"

This is the signal for renewed uproar. Several members spring up and
turn round towards the person indicated.

"Yes, yes, behold him!" cries Billaud.

The agitation increases. Cries of "To the door with him! Turn him out!"
are heard. The man pleads innocence, and tries to weather the storm, but
seeing the majority against him escapes as best he can, mixes with the
crowd and disappears. Silence is with difficulty restored among the
infuriated members.

The orator continues, throwing violent and insidious phrases broadcast

among the assembly like lighted fire-brands. His thrusts strike nearer home
now; he accuses Robespierre openly to his face.

"You will shudder when I tell you that the soldiery is under the
unscrupulous control of that man who has the audacity to place at the head
of the section-men and artillery of the city the degraded Hauriot, and that
without consulting you at all, solely according to his own will, for he listens
to no other dictates. He has, he says, deserted the Committees because they
oppressed him. He lies!"
 Robespierre rises, his lips quivering at the insult, and attempts to reply
from his place.

"Yes, you lie!" continues Billaud. "You left us because you did not find
among us either partisans, flatterers, or accomplices in your infamous
projects against Liberty. Your sole aim has been to sow dissension, to
disunite us that you might attack us singly and remain in power at the head
of drunkards and debauchees, like that secretary who stole a hundred and
fifty thousand livres, and whom you took under your wing, you, the
Incorruptible, you who make such boast of your strict virtue and integrity!"

Laughter, mixed with some applause is heard, but Robespierre shrugs

his shoulders contemptuously at such vulgar abuse. Fouché, from his bench,
laughs loudly with the rest, and leaning towards his neighbour, whispers—

"Clever tactics! ... Billaud is splendid!"

The speaker, in conclusion, appeals to the patriotism of the assembly,

and implores the members to watch over its safety. If they do not take
energetic measures against this madman, he says, the Convention is lost, for
he only speaks of purifying it that he may send to the scaffold all those who
stand in the way of his personal ambition. It is, he insists, the preservation
of the Convention which is at stake, the safety of the Republic, the salvation
of their country.

"I demand," so runs his peroration, "that the Convention sit permanently
until it has baffled the plans of this new Catiline, whose only aim is to cross
the trench which still separates him from supremacy by filling it with our
heads!"

Thunders of applause greet Billaud-Varennes' words; shouts, cheers, and

waving of hands which continue long after he has left the tribune.

Robespierre now leaves his seat in great agitation, crying—

"It is all false, and I will prove it!"

 But his words are again drowned in an uproar of voices, and cries of
"Silence! Silence!"

"I will give the traitor his answer!" exclaims Robespierre, trying to
make himself heard above the tumult which increases at every word he
utters, so that his voice is now completely lost. Some of the members rush
into the semicircle, forming a living rampart round the tribune.

The din is dominated by a new voice from the presidential chair.

"Silence, let no man speak!" it thunders forth.

It is Thuriot, who has just replaced Collot d'Herbois in the chair.

"I demand a hearing!" vociferates the Incorruptible, "and I will be

heard!"

"You shall not!"

"I wish to speak!" cries a deputy, taking at the same time possession of
the tribune.

It is Vadier.

Thuriot rings the president's bell.

"Vadier has speech!"

"Yes, Vadier! Vadier!" members exclaim from all sides.

Robespierre continues to protest, disputing frantically with his

neighbours in his fury.

"It is infamous treachery! Infamous!"

Again they call out—

"Vadier! Silence! Vadier! Vadier!"

 "Citoyens!" commences Vadier—

But the speaker is interrupted by Robespierre who furiously persists in

claiming a hearing.

"Compel him to be quiet!" cries some one.

Thuriot rings his bell, and orders Robespierre to let Vadier speak.

"Vadier is to speak! Silence!"

Robespierre once more resigns himself to his fate, and returns to his
place.

The tumult dies away in a low murmur, above which Vadier's

mellifluous voice is heard.

"Citoyens!" he begins, "not until the 22nd Prairial did I open my eyes to
the double-dealing of that man who wears so many masks, and when he
cannot save one of his creatures consigns him to the scaffold!"

Laughter and applause run round the assembly. Thus encouraged,

Vadier continues—

"Only listen to him. He will tell you, with his usual modesty, that he is
the sole defender of Liberty, but so harassed, so discouraged, so persecuted!
... And it is he who attacks every one himself!"

"Hear, hear!" shouts a voice. "Excellent! That's it, exactly!"

"He says," continues Vadier, "that he is prevented from speaking. Yet,

strange to say, no one ever speaks but he!"

This new sally is hailed with renewed roars of laughter, and on every
side members are convulsed with merriment. Robespierre writhes in his
seat, casting glances of hatred and contempt around him.

But Vadier is in the right mood, and goes on—

 "This is his regular refrain: 'I am the best friend of the Republic, and as
So-and-so has looked askance at me, So-and-so conspires against the
Republic, since I and the Republic are one!'"

Again laughter and cheers. "Very good, Vadier! That's it, Vadier!"

By this time the orator's ironical and facetious allusions have served
their purpose well, covering Robespierre with ridicule, and lowering him in
the eyes of many who were still wavering, hardly daring to join the
opposition.

But Vadier, carried away by success, wanders presently from the main
point, and loses himself in a maze of petty details. He repeats anecdotes
going the rounds of taverns and wine-shops, speaks of Robespierre's spies
dogging the heels of the Committee, and quotes his personal experience.
The attention of the assembly begins to flag. Robespierre feels this and,
taking instant advantage of it, tries to bring the Convention back to a sense
of its dignity.

"What! can you give credence to such arrant nonsense?"

But Tallien has realised the danger, and rushing towards the tribune
cries—

"I demand a hearing! We are wandering from the main question!"

"Fear not! I shall return to it!" replies Robespierre, who has now
reached the semicircle, and tries to enter the tribune by another stairway.

But several members standing on the steps push him back.

"No! we will have Tallien! Tallien!"

"After me!" cries Robespierre, still struggling.

"Tallien! Tallien has speech now!"

But Robespierre climbs up by the banister with the fury of a madman.

 "Unjust, infamous judges! Will you then only listen to my enemies!"

The Incorruptible is answered by the one cry rising from a hundred

throats.

"Silence! Order! Order! Tallien! Tallien!"

Tallien is in the tribune.

"Citoyens!" he breaks out in a stentorian voice.

"Hold! Scoundrel!" shouts Robespierre, desperately.

"Have the madman arrested!" cries a voice in the crowd.

Robespierre still does his utmost to force a passage on the stairway.

"I will speak! I will be heard, wretches! I will speak!"

The uproar increases, aggravated by Robespierre's boisterous

pertinacity. The jingling of Thuriot's bell at last restores order, though not
without difficulty.

The opening words of Tallien's speech are already audible, amidst

enthusiastic cheers. Robespierre, held firmly by some of the deputies, has
ceased his struggles, and stands on the steps in an indignant attitude, his
features twitching convulsively, his eyes, glaring in hatred, fixed on the new
speaker who is preparing to hurl at him another shower of insults.

"The masks are torn away!" cries Tallien.

"Bravo! Bravo!"

"It was the speech delivered yesterday in this very hall, and repeated the
same evening at the Jacobin Club, that brought us face to face with this
unmasked tyrant, this vaunted patriot, who at the memorable epoch of the
invasion of the Tuileries and the arrest of the King, only emerged from his
den three days after the fight..."
 Sneers and hisses reach Robespierre, repeated up to the very steps of the
tribune, below which he stands.

"This honourable citizen, who poses before the Committee of Public

Safety as champion of the oppressed, goes home, and in the secrecy of his
own house draws up the death-lists which have stained the altar of new-
born Liberty with so much blood!"

Renewed cheers and cries of "Hear! hear!" rise from nearly every seat in
the hall.

"But his dark designs are unveiled!" continues Tallien. "We shall crush
the tyrant before he has succeeded in swelling the river of blood with which
France is already inundated. His long and successful career of crime has
made him forget his habitual prudence. He has betrayed himself at the very
moment of triumph, when nothing is wanting to him but the name of king!
... I also was at the Jacobins' yesterday, and I trembled for the Republic
when I saw the vast army that flocked to the standard of this new Cromwell.
I invoked the shade of Brutus, and if the Convention will not have recourse
to the sword of justice to crush this tyrant, I am armed with a dagger that
shall pierce his heart!"

Tallien makes a movement as if to rush on Robespierre dagger in hand;

but he is arrested by a burst of unanimous applause. A hundred deputies
have risen and are calling out: "Bravo, Tallien! Bravo!"

The orator, in an attitude of defiance, gazes steadily at Robespierre,

who, grasping convulsively at the railings of the tribune, screams himself
hoarse, challenging Tallien and the deputies around, while they answer him
with abuse, shaking their fists in his face. It is a veritable Babel of cries,
appeals, and insults. The President, now upstanding, vainly tries to restore
order with his bell.

At last there is a lull, of which Robespierre attempts to take advantage.

"Vile wretches!" he cries, "would you condemn me unheard?"

But he is answered by a telling home-thrust—