Pediatrics - Nurses Revision

Theories of Growth and Development

Growth involves physical changes in height and weight and appearance of the body, while development refers to a change in functional ability, such as cognitive, motor, and psychological aspects of the client.

Growth and development start from the time of conception and progress until a person dies. Growth and development theories provide a framework to understand this wide array of changes, and they help healthcare providers plan individualized care for clients based on their stage of development, and to provide anticipatory guidance for parents and caregivers.

Major growth and development theories include biophysical developmental theory by Gesell, psychosocial development theory by Erikson; cognitive development theory by Piaget; moral development theory by Kohlberg; and finally, the psychoanalytic development theory by Freud.

Theories of Growth and Development

Theories associated with growth and development include:

Erikson Theory of Development

The theory describes the major developmental issues or problems Erikson identified for each of the stages of development.

The major psychosocial and intellectual issues involved:

Infancy: Basic trust versus mistrust

Central task is to establish a sense of basic trust in predominance to mistrust.
Infants who find that their needs for food and comfort are constantly and effectively met, learn that the world is a safe and predictable place and that they can trust others.
In contrast, a sense of mistrust may predominate in infants who do not receive constant care and those who experience long spells of discomfort.
Mistrust creates formation barriers to interpersonal bond.
Mistrust interferes with the development of confidence, security, and assertiveness.

2. Toddlerhood: Autonomy versus shame and doubt

A child must establish a sense of autonomy in this phase rather than shame & doubt.
Autonomy – a kind of self-trust, a growing awareness that their behavior is under their control. This is the desired, and outcomes are usually like “I can do it”.
Shame “I can do it but that is not nice”.
Doubt “I cannot do it”.
It is hazardous when self-mistrust is carried on from infancy onwards.

3. Pre-school years: initiative versus guilt

Central task is to develop a sense of initiative in predominance to the sense of guilt.
Explore what they can create and do with the motor, language, interpersonal and social world.
Behavior is characterized by intrusiveness manifested in endless questions, noise, physical and intellectual exploration.
Guilt is a major developmental hazard because what they try to do is difficult or unacceptable to people they wish to please.

4. The school age period: Industry versus inferiority

Central task is a sense of industry in predominance to a sense of inferiority.
Industry – the child uses physical, cognitive (intellectual), and social skills and turns his attention to learning what he must know in preparation for success in the adult world.
Learns self-worth as workers and producers.
Inferiority – Negative self-concept comes when children have difficulty in school, interpersonal relationships, or other expectations. They get discouraged and consider themselves inadequate.

5. Adolescence: Identity versus role confusion

Central task is developing a sense of identity with the undesirable alternative being role confusion.
Attachment of identity is a process of young people coming to feel that they are consistent with others, in terms of views (own views in relation to other people’s views).
The major hazard is role confusion. Arises from rapid changes in the experience of self and from sometimes overwhelming numbers of possible ways to behave and roles to select.

2. Freud: Stages of Psychosexual Development

Freud’s theory revolves around sexual pleasure and has five stages: oral, anal, phallic, latency, and genital.

Oral Stage: This starts from birth to until 1 year. During this stage, the primary source of pleasure and gratification is through the mouth, such as sucking and feeding. Freud believed that unresolved conflicts during this stage, such as weaning issues or oral fixation, could lead to oral-related behaviors in adulthood, such as overeating, smoking, or excessive talking.
Anal Stage: The anal stage occurs between the ages of 1 and 3 years. This stage focuses on the child’s pleasure and control over their bowel movements. Freud believed that conflicts related to toilet training during this stage could lead to fixation, resulting in anal-retentive behaviors (being overly neat, organized, and controlling) or anal-expulsive behaviors (being messy, disorganized, and rebellious).
Phallic Stage: The phallic stage takes place between the ages of 3 and 6. During this stage, children develop a strong attachment to their opposite-sex parent (Oedipus complex for boys and Electra complex for girls). Freud believed that unresolved conflicts during this stage could lead to sexual and gender identity issues or difficulties with relationships in adulthood.
Latent Stage: The latent stage occurs from around 6 years old until the onset of puberty. During this stage, sexual desires and impulses are repressed, and the focus of the child’s energy is on developing social and intellectual skills. Freud believed that this stage is relatively calm and that there are no significant conflicts or fixations.
Genital Stage: The genital stage begins at the onset of puberty and continues into adulthood. This stage marks the reawakening of sexual desires and the development of mature sexual relationships. Freud believed that successful resolution of previous stages’ conflicts leads to healthy sexual development and the ability to form intimate relationships.

3. Piaget: Periods of Cognitive Development

Piaget’s theory focuses on cognitive development and stages, including sensorimotor, preoperational thought, concrete operation, and formal operation.

Sensorimotor Stage: The sensorimotor stage occurs from birth to around 2 years of age. During this stage, infants primarily learn about the world through their senses and motor actions. They develop object permanence, the understanding that objects continue to exist even when they are out of sight. Infants also engage in trial-and-error experimentation and begin to demonstrate intentional actions.
Preoperational Stage: The preoperational stage typically occurs between the ages of 2 and 7. During this stage, children become more adept at using symbols, such as words and images, to represent objects and events. They engage in pretend play and develop language skills. However, children in this stage often struggle with logical reasoning and exhibit egocentrism, where they have difficulty understanding other people’s perspectives.
Concrete Operational Stage: The concrete operational stage takes place between the ages of 7 and 11. During this stage, children become capable of concrete, logical thinking. They can understand conservation, the idea that certain properties of objects remain the same despite changes in appearance. Children also develop the ability to classify objects into different categories and engage in more systematic problem-solving.
Formal Operational Stage: The formal operational stage begins around the age of 11 and extends into adulthood. During this stage, individuals develop abstract thinking and can reason hypothetically. They can engage in deductive reasoning, logical thinking, and hypothetical-deductive reasoning. They can also think about multiple possibilities and engage in more complex problem-solving.

Piaget believed that individuals progress through these stages in a fixed sequence, with each stage building upon the previous one. He proposed that cognitive development occurs through a process of assimilation and accommodation, where individuals assimilate new information into their existing mental structures (schemas) and accommodate their schemas to fit new information.

4. Kohlberg: Theories of Moral Development

Kohlberg’s theory explores moral development through stages of moral reasoning.

Level 1: Preconventional Morality

Stage 1: Obedience and Punishment Orientation: At this stage, individuals focus on avoiding punishment and obeying authority figures. They make moral decisions based on the fear of being punished and seek to satisfy their own needs.
Stage 2: Individualism and Exchange: In this stage, individuals start to consider their own interests and begin to understand that others have their own needs and desires. Moral decisions are driven by self-interest and the expectation of receiving something in return.

Level 2: Conventional Morality

Stage 3: Interpersonal Relationships: At this stage, individuals value social harmony and seek approval from others. They make moral decisions based on the desire to be seen as a good person and to maintain positive relationships with others.
Stage 4: Maintaining Social Order: In this stage, individuals focus on following rules and maintaining social order. They make moral decisions based on a sense of duty, respect for authority, and the need to uphold societal norms and laws.

Level 3: Postconventional Morality

Stage 5: Social Contract and Individual Rights: At this stage, individuals recognize that different societies may have different moral standards, and they begin to question and evaluate these standards. Moral decisions are based on principles of fairness, justice, and the protection of individual rights.
Stage 6: Universal Principles: In this final stage, individuals develop their own set of moral principles that are based on universal ethical principles, such as justice, equality, and respect for human dignity. Moral decisions are guided by these principles, even if they conflict with societal norms or laws.

Growth Monitoring and Promotion

Growth Monitoring

Growth monitoring involves regularly weighing a child, plotting the weight on a child health card, interpreting the results, and counseling parents or caregivers.
Monitoring includes height for age, weight for age, head circumference, body mass index (BMI), and skinfold thickness.

In totality, parameters used to monitor growth are:

Height for age.
Weight for age.
Head circumference.
Body mass index (BMI).
Skin fold thickness.

Importance of Growth Monitoring

Children whose growth is abnormal are easily recognized from the growth chart.
Helps in the identification of chronic disorders.
Helps in the attainment of the nutrition status and improvement of nutrition.
It supports research.
It helps the parents to get nutritional knowledge and reduce anxiety and be reassured about child’s health.
Helps to find out if there are influential, psychological, social factors that may affect the growth of the child and address them. E.g. parent neglect or separation, orphans, etc.
Helps parents determine if children are naturally short stature.
Helps to prevent illness, malnutrition, and death.
Helps to evaluate health or nutritional interpretation, e.g. breastfeeding.
Helps to determine if the child is failing to thrive.

To combat growth problems, we need growth promotion. This includes the following:

Antenatal care.
Prevent, detect and treat pregnancy-related complications.
Provide advice on breastfeeding to the mothers.
Provide health education on dangers of smoking, alcohol consumption, and drug abuse.
Health education on good baby care.
Identify parents who may need extra support in caring for the children, e.g. parents with learning disorders or mental problems.
Health education on good nutrition.
Provide preventive treatment – IPT, iron supplements, deworming tablets, etc.
Monitor the progress of pregnancy.
Health education on hygiene.
Encourage the mothers to deliver in the hospital.

Less than 6 weeks

Physical/medical examination of the child.
Immunization, e.g. polio 0, BCG.
Exclusive breastfeeding.
Hygiene-cord care.
Growth monitoring, weighing.
Early detection of disease, e.g. fever, diarrhea.

At 6 weeks

Physical examination.
Immunization.
Care safety.
Growth monitoring.
Proper nutrition.
Hygiene.
Early detection of disease.

At 2, 3, 4 months of age

Immunization.
At 10 weeks, polio 2, Hib, Hep b 2DPT2.
At 14 weeks, polio3, Hib, Hep b3, DPT3.
Check weight.

8 months, 2 years, 3 years

Immunization: At 9 months, measles vaccine.
Respond to mothers who have concerns about their children’s development.
Prevent, detect and treat illnesses.
Monitor growth.
Hygiene.
Good nutrition.

At 4-5 years

A review at school entry provides an opportunity to check that:
Immunization is up-to-date.
Children have access to immunization and dental care.
Appropriate assessment and intervention for any physical, social, emotional, problems.
Provide children, parents, and school staff with information about specific health issues.
Check the child’s weight and height.

School entry – 5 years

School nurse checks:

Weight and height.
Reviews immunization status.

Child Health Card

The child health card is a clinical tool used to monitor the health of children from birth to 5 years.

It is a clinical tool designed by the Ministry of Health (MoH) Uganda to assist in monitoring the general health of children from birth up to 5 years of age.

Components of the Child Health Card

Family Information: Includes child demographics, parents’ details, and address.
Immunization Schedule: Lists the recommended immunizations.
Interpretation Section: Guides for interpreting growth trends.
Growth Chart: Tracks weight growth.
Vitamin A Supplementation: Records doses for both the child and mother.
Special Care Categories: Flags children with specific needs.
Remarks and Referrals: Notes for additional comments and referrals.
Child demographics include: child’s name, birth weight, sex, date of birth, birth order, mother’s occupation, father’s name and occupation, where child lives.

Counseling the mother After Weighing the Child

0-6 Months (Gained Weight)

Show the mother the growth curve and congratulate her for the child’s weight gain.
Find out what the mother knows or believes about exclusive breastfeeding.
Find out if the mother has sickness or problems.
Find out how the mother is feeding her child and reinforce breastfeeding.

0-6 Months (Did Not Gain Adequate Weight)

Create rapport.
Show the mother the growth curve and explain that the baby did not gain weight as expected.
Find out if the baby is sick or has problems.
Find out if the baby is fed on other foods.
Find out if mother’s nutrition is appropriate and adequate.
Find out if the baby has problems with sucking.
Find out if the mother has problems with attaching the baby to the breast during breastfeeding.

Ask:

How many times a day and night does the baby breastfeed?
Does the baby breastfeed long enough to empty the breast?
Is the child fed on other liquids or foods?
Does the mother stay away from the baby any time during the day?
Information to the mother
Breastfeed for at least 8-10 times per day.
Encourage the mother to feed long enough to empty one breast before moving to the other breast.
Help the mother to know the correct position and attachment of the baby to the breast.
Encourage exclusive breastfeeding unless there are other reasons.
Check child’s immunization status.
Check and give vitamin A.

6-12 Months (Gained Weight)

Repeat the counseling steps.
Ask about additional foods besides breast milk.

6-12 Months (Did Not Gain Adequate Weight)

Show the mother the card and explain that the baby did not gain weight as expected.
Ask about the child’s health; if sick, refer.
Find out how the mother is feeding the child and discuss with her the improvements she can make.
Find out if the mother’s nutrition is appropriate and adequate.
Praise all good practice.

Note: Indicate in the child’s card any reasons necessitating special care, including:

Birth weight less than 2.5kg.
Birth defects.
Fifth and above child.
Birth less than 2 years after the last birth.
Sibling under-nourished.
Mother or father dead.
Three or more children dead in the family.
Twin child.

Theories of Growth and Development Read More »

Growth and Development of a Child

Growth is the progressive increase in the size of a child or parts of a child. Development is progressive acquisition of various skills (abilities) such as head support, speaking, learning, expressing the feelings and relating with other people.

Patterns of Growth and Development

Growth and development are directional and follow detectable patterns.

Cephalo-caudal: Meaning that growth and development proceed from head to tail. Structures and functions originating in the head develop before those in the lower parts of the body. The fetal head initially grows the fastest, followed by the trunk and later the legs. At birth, the head is larger, the trunk is long, and the arms are larger than the legs. As the child matures, body proportions gradually change, and by adulthood, the legs have increased in size from 38% to 50% of total body weight.
Proximal-distal pattern: Growth occurs from the center outwards. In the respiratory system, the trachea develops first in the embryo, followed by branching and growth outwards in the bronchi, bronchioles, and alveoli in the fetus and infant. Motor control of the arms comes before control of the hands, and hands control comes before finger control.

Critical Periods in Growth and Development

These are sensitive periods during which children demonstrate readiness to learn particular tasks, such as walking. Many factors affect a child’s sensitive learning period, including injury, illness, and malnutrition.

Factors Influencing Growth and Development

Genetics (Heredity): Existence of certain traits may hinder or facilitate growth and development.
Environment: Conditions affecting the child before and after birth, such as smoking, infections, socioeconomic factors, and environmental hazards.
Culture: Habits, beliefs, and values.
Nutrition: Adequate nutrition is necessary for brain growth prenatally and in the first year of life.
Infections: Infections can affect the delivery of nutrients, hormones, and oxygen to organs and tissues.
Play: Play is most frequent during periods of rapid growth and development and may be related directly to expanding intellectual, motor, language, and social development.

Factors Contributing to Effective Growth and Development

Breastfeeding for at least 2 years with exclusive breastfeeding for at least 6 months.
Supplementing breastfeeding with the right (quality and quantity) food at 6 months.
Providing regular meals containing all nutrients.
Prevention of childhood illnesses through immunization and proper environmental sanitation.
Early diagnosis and treatment of malaria, worm infestations, diarrhea, vomiting, and respiratory infections.
Use of family planning services to prevent risks resulting from a mother getting pregnant too soon.
Raising awareness among mothers regarding balanced nutrients in relation to the growth and development of children under five.
Seeking treatment for early childhood illnesses as early as possible.
Involving parents in growth monitoring, interpretation of the weight chart, and seeking help.

Factors Contributing to Poor Growth or Failure to Thrive

Low birth weight or prematurity due to general health status of the mother during pregnancy, such as anemia, malaria, STIs.
Unsuccessful breastfeeding due to improper position and attachment of the baby to the breast.
Very early introduction of complementary feeds before 6 months.
Early weaning of the baby off breastfeeding.
Lack of information by the mother.
Ill health of the baby due to childhood diseases.
Late introduction of solids in the diet.
Children born to mothers with too many, too close, too early, multiple pregnancies.
Poor socioeconomic status of the family leading to poor feeding or food shortage.
Generalized famine in the community.
Ignorance of the mother on how to mix available food to provide a balanced diet.
Poor general health of the mother.
Death of the mother or both parents.

Developmental Milestones

Birth to 1 Month

Important pediatric age.
Birth weight is usually 2.5 to 4.3kg.
The newborn will lift the head when placed in a prone position (normal reflex).
Demonstrates reflex activities.
Maintains eye contact; vision is poor.
Communicates by crying.
Mongolian spots may occur in dark-skinned children.
Vaginal bleeding/discharge is not uncommon due to maternal hormones.
Vital signs: Pulse 100-180 b/m, Temperature 36.5-37.5°C, BP 50-100/20-60mmHg, RR 30-50 breaths/min.

2nd Month

Closure of the posterior fontanelle.
Several newborn reflexes disappear.
Less head lag.
Can lift head almost 45 degrees when placed on abdomen.
Less flexing of arms and legs while lying on the stomach.
Sensory and cognitive markers: beginning to look at close objects, coos, different cries for different needs.
Play recommendations: expose the baby to sounds outside the home, take the baby for rides in the car or walks in the neighborhood, provide bright room with pictures and mirrors, bright-colored toys, read to the baby, talk to the baby about objects and people in the environment, hold and comfort the baby if they are upset or crying.

3rd Month

Major motor skills: Rests on forearms, lifts head and upper chest while lying on abdomen, sits with support, holds a rattle briefly and moves it towards their face.
Language: Begins to laugh, ‘coo,’ and vocalize in vowel sounds.
Vision and hearing: Eyes converge on near objects, attend to nearby voice or meaningful sounds.
Social achievements: Coo, cry, smile, chuckle, and have a quick social response to friendly faces.
Play recommendations: read, sing, and talk to your child, imitate words to help baby learn language, play peek-a-boo, provide an unbreakable mirror, provide large, bright-colored toys, provide paper to tear, blow bubbles, speak clearly, start pointing to and naming body parts and the environment.

4th Month

Physical and motor skills: Gains weight at a slower rate, sits for long periods, rolls from front to back, holds and lets go of an object, plays with a rattle, grasps a rattle with both hands, places objects in the mouth, sleeps 9 to 10 hours at night with 2 naps during the day.
Sensory and cognitive skills: Well-established close vision, increased eye contact with parents, beginning hand-eye coordination, ability to coo and laugh out loud, memory and anticipation of feeding.
Play recommendations: place the baby in front of a mirror, provide bright-colored toys, repeat sounds the infant makes, help the infant roll over, use an infant swing at the park, play on the abdomen.

5th Month

Physical and motor skill markers: Hold almost all weight when supported in a standing position, transfer objects from one hand to the other, lift chest and head while on abdomen, able to pick up a dropped object, sit in a high chair with a straight back, sit on the floor with lower back support, beginning of teething, increased drooling.
Sensory and cognitive markers: Begins to fear strangers, imitates actions and sounds, understands the permanence of objects, can locate sounds not made directly at ear level, enjoys hearing own voice, makes sounds to mirror and toys, makes sounds resembling one-syllable words.
Play recommendations: provide picture books, expose to different stimuli, build vocabulary, teach hot and cold, provide large, bright-colored toys, read, sing songs, and avoid television time until age 2.

6th Month

Social and Emotional: Knows familiar faces, likes to play with others, especially parents, responds to other people’s emotions and often seems happy, likes to look at self in a mirror.
Language/Communication: Responds to sounds by making sounds, strings vowels together when babbling, responds to own name, makes sounds to show joy and displeasure, begins to say consonant sounds (jabbering with “m,” “b”).
Cognitive (learning, thinking, problem-solving): Looks around at things nearby, brings things to mouth, shows curiosity about things, begins to pass things from one hand to the other, begins to realize that if an object is dropped, it is still there and just needs to be picked up, can locate sounds not made directly at the ear level, enjoys hearing own voice, makes sounds resembling one-syllable words, prefers more complex sounds, recognizes parents.
Play: Place the baby in front of a mirror, provide bright-colored toys, repeat sounds the infant makes, help the infant roll over, use an infant swing at the park if the baby has head control, play on the abdomen.

9th Month

Physical characteristics and motor skills: Gains weight at a slower rate, increases in length, bowel and bladder become more regular, demonstrates reflex activities, maintains eye contact, vision is poor, communicates by crying.
Cognitive (learning, thinking, problem-solving): Able to crawl, sit for long periods, pull self to a standing position, reach for objects while sitting, bang objects together, grasp objects between the tip of the thumb and index finger, feeds self with fingers, throws or shakes objects.
Sensory and cognitive skills: Babbles, has separation anxiety and may cling to parents, is developing depth perception, understands that objects continue to exist even when they are not seen (object constancy), responds to simple commands, responds to name, understands the meaning of “no,” imitates speech sounds, may be afraid of being left alone, plays interactive games.
Play: provide picture books, expose to different stimuli, build vocabulary, teach hot and cold, provide large, bright-colored toys, read, sing songs, avoid television time until age 2, try using a transition object to help decrease separation anxiety.

1 Year

Social and Emotional: Is shy or nervous with strangers, cries when mom or dad leaves, has favorite things and people, shows fear in some situations, hands you a book when he wants to hear a story, repeats sounds or actions to get attention, puts out an arm or leg to help with dressing, plays games such as “peek-a-boo” and “pat-a-cake.”
Language/Communication: Responds to simple spoken requests, uses simple gestures, like shaking head “no” or waving “bye-bye,” makes sounds with changes in tone, says “mama” and “dada” and exclamations like “uh-oh,” tries to say words you say.

Cognitive (Learning, Thinking, Problem-Solving)

Counts 10 or more things, can draw a person with at least 6 body parts, can print some letters or numbers, copies a triangle and other geometric shapes, knows about things used every day, like money and food.

Movement/Physical Development

Stands on one foot for 10 seconds or longer, balances with eyes closed, hops, may be able to skip, can do a somersault, uses a fork and spoon, and sometimes a table knife, can use the toilet on her own, swings and climbs.

6-12 Years

Can learn to swim, ride a bicycle.
Ties shoes.
Uses pencil well.
Forms clubs or gangs.
Demonstrates awareness of rule-governed behavior.
Has a strong sense of “what’s fair.”
Uses complex sentences.
Reads.
Counts.

Growth and Development of a Child Read More »

Immediate Care of the Newborn

Immediate Care of the Newborn.

Care of the Baby at Birth

Ensure Infection Prevention and Control.

As soon as the head is born:

Clean the eyes.
Wipe the face.
Clear the airway – clear mucus from the nose and mouth.
Feel for the cord around the neck.
Safely deliver the rest of the baby.
Note the time of delivery.
Dry and keep the baby warm.
Establish respirations and maintain it.
Apgar score and record.
Clean the eyes.
Instill tetracycline eye ointment.
Cut the cord and tie it securely.
Show the baby to the mother to identify sex and key features.
Maintain warmth (use kangaroo method if the mother and baby are in good condition).
Promote bonding.
Initiate breastfeeding.
Assess the baby’s condition at 1 and 5 minutes using APGAR.

Table of APGAR score

	0	1	2
Appearance	Blue/ Pale	Body pink, Extremities Blue	Completely Pink
Pulse	Absent	< 100 b/m	>100 b/m
Grimace	None	Minimal	Cough/Sneeze
Activity	Limp	Some reflex of limps	Active
Respiration	Absent	Slow and irregular	Good or crying

Care After 1 Hour

Examine the baby’s head to toe for maturity, abnormalities, etc.
Re-ligature and shorten the cord.
Ascertain the passage of meconium and urine.
Weigh the baby.
Ensure warmth.
Ensure no bleeding from the cord.
Ensure bonding.
Ensure the comfort of the mother and the baby.
Communicate to the mother all the findings.
Report to the ward in-charge and document.

Examination of a Newborn

Aims/Reasons of Examination

To detect certain malformations or abnormalities that may be a threat to the life of the baby and may need urgent intervention.
To detect illness or injury that has arisen before or during delivery.
To take body measurements and record them.

Important Points to Observe:

Room should be warm and draught-free.
Adequate light.
Equipment prepared.
Parent or caretaker should be around.
Explain the procedure to the parent or caretaker.
Baby should be in good condition.

Equipment

Overhead warmer if required.
Stethoscope.
Ophthalmoscope.
Tape measure.
Infant scales.
Documentation – infant personal health record and hospital medical record.

Procedure

Use a systematic approach to examine the baby – ‘head to toe’ and ‘front to back.’
Observe infection prevention measures, i.e., wash hands, put on gloves.
Ensure hands are warm.
Undress the baby and wrap in a warm towel. Expose the part you are to examine.

General Appearance

The newborn assumes a flexion posture.
While the baby is settled, observe skin color. It should be pink.
Observe the state of alertness and activity.
Observe the range of spontaneous movement, posture, and muscle tone.

Head

Assess size, shape, and symmetry; rule out excessive molding which may suggest the possibility of intracranial injury.
Scalp (vault) for swelling e.g. cephalohematoma, caput succedaneum, meningocele, etc.
Fontanelles: anterior and posterior fontanels should be flat, soft, and firm, but abnormalities may be a bulge or swelling.
Sutures; if separate or wide, it is suggestive of prematurity.
Head circumference 33-35cm (use a tape measure). Encircle occipital protuberance and frontal eminences.

Face

Assess the symmetry of structures, features, and movement.
Inspect the eyes: setting, rule out Down’s syndrome – upward slanting of the eyes and the upper lip is shorter.
Check for cataracts, subconjunctival, nystagmus, strabismus hemorrhage, discharge.
Position in relation to the nasal bridge.
Palpate the eye to confirm the presence of normal eyeballs. Do this gently.
Hold the baby upright – eyes will open spontaneously.
Note the space between the eyes (should be 3cm apart).

Nose

Located in the middle of the eye.
Check position, patency, and symmetry of the nares and septum. Nares should be equal in size and shape. Lack of patency may indicate choanal atresia (a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue).

Mouth

Located in the midline.
Size, shape, symmetry, and movement.
Press the angle of the jaw to open the baby’s mouth.
Check the tongue for tongue tie (ankyloglossia). The tongue should be pink.
Lips and gums should be intact, pink, and moist.
Inspect tongue, gum, and palate: Pass a little finger in the baby’s mouth and feel for the palate for abnormalities like cleft palate or cleft lip.
Note the protrusion reflex of the tongue. The baby will suckle the finger.
Excessive salivation may be indicative of tracheoesophageal fistula (TEF).
Macroglossia, a protruding tongue that appears too large for the mouth, is indicative of a congenital disorder, e.g., Down’s syndrome or endocrine disorder like hypothyroidism.

Ears

Assess for shape and cartilage development.
Observe the tympanic membrane.
Assess hearing acuity by evaluating the blink or startle reflex.

Neck

The newborn’s neck is short.
Note symmetry.
The neck should be soft and free from masses.
The thyroid is non-palpable, palpable in hyperthyroidism.
Observe a web neck (extra and redundant skin).
Flex the neck gently. A web neck is associated with genetic disorders, e.g., Down’s syndrome or Turner’s syndrome.

Clavicles, Arms, and Hands

Assess length, proportions, structure.
Count fingers and separate them.
Check for extra digits.
Rotate the wrists.

Chest

Assess chest size, shape, and symmetry. Chest circumference is 30-36cm, approximately 2cm lower than the head circumference.
Observe respiratory movement.
Take respiration rate.
Observe the location of the nipples. Note size and shape. Nipples should be equally spaced from the middle.
Breast engorgement may be due to maternal hormones in both sexes.

Abnormalities

If the sternum is protruding, it indicates pectus carinatum, or pigeon chest, or sunken-pectus excavatum or funnel chest.
Widely spaced nipples are commonly seen in genetic disorders like Turner’s syndrome.
Supernumerary nipples 5-6cm below true nipples are often associated with congenital abnormalities.

Lungs

Newborns are diaphragmatic breathers.
They may have paradoxical breathing: the thorax pulls inwards and the abdomen bulges.
Periods of apnea may exist lasting less than 15 minutes.
On auscultation, breath sounds should be equally distributed and clear.
Abnormal sounds may be; crackles, stridor, and wheeze. These should be reported.

Heart

Assessment of the cardiovascular system begins with the assessment of color. Skin should be pink, including the mucous membrane.
Palpate chest point of maximum intensity.
Auscultate for heart rate, rhythm, and quality of heart sounds.
Assess peripheral pulses for rate, character, and quality. Pulses should be strong in the limbs.

Abnormalities

Bounding pulses are associated with patent ductus arteriosus.
Weakened or absent femoral pulses are associated with aortic lesions, e.g., coarctation of the aorta or low cardiac output.

Abdomen

The abdomen should be round and soft.
Assess for visible peristalsis.
Check for major organs.
The umbilical cord should be located in the midline.
Two arteries and one vein should be visible on the umbilical cord. Absence of one of the arteries is associated with cardiovascular or renal anomalies.
Type of the cord.
Auscultate bowel sounds before palpation. They are audible within 15 minutes after birth.
Note the position of the liver, 1-2 cm below the right costal margin.
The spleen is felt 1-2 cm below the left costal margin.
The lower portion of the kidney is found 1-2 cm above the umbilicus on deep palpation.

Genitalia

Female Baby

At birth, the female genitalia are edematous, especially in breech deliveries. Labia majora is enlarged in full-term babies.
Inspect vulva for normal formation of: presence of labia, vaginal orifice, urethral orifice, and clitoris.
White mucoid discharge is common in the first week. Blood-tinged discharge may be noted as a result of withdrawn hormones.

Male Baby

The foreskin completely covers the glans penis.
Abnormalities may include:
Hypospadias, epispadias.
Foreskin, check for phimosis.
Testes are present in the scrotum.
Scrotum: examine for undescended testes. The scrotum may be edematous at birth.
If testes have not descended by age 18 months, surgical intervention is required.

Anus

Inspect for patency and masses.
Take the temperature, normal – 36.5-37°C.
Abnormalities: Anorectal malformations (imperforate anus).

Musculoskeletal System

Examine the back when a child is in a prone position.
The back is gently rounded. Skin along the spine should be intact.
Any depression or openings along the spine may indicate a neural tube defect e.g. spina bifida.
Full range of motion should be easy in the newborn. When legs or arms are extended, they should return to the flexion position.
Hips, legs, and feet:
Assess hips for stability.
Assess legs and feet for length, proportions, and symmetry.
Assess the structure and number of digits. Toes and fingers should be straight.

Abnormalities Hands and Feet

Extra digits (polydactyly).
Absence of a digit (syndactyly).
Webbing of fingers or presence of a simian crease – a single long crease that crosses the entire palm is indicative of Down’s syndrome.
Macrodactyly (enlarged fingers or toes): indicative of neurofibromatosis, and overlapping 2nd and 3rd fingers, seen in infants with trisomy 18.
Clubfoot.

Neurologic

Assess behavior.
Posture: position the baby adopts. In normal full-term, a baby lies with limbs flexed while in a supine position. In preterm babies, limbs are stretched out along the side of the trunk.
Muscle tone.
Cry: it should be lusty and full cry.
Reflexes: Moro, suck, rooting, grasp.

Gastrointestinal Tract

Examine for rooting and swallowing reflexes.
An immature cardiac sphincter often leads to regurgitation.
Meconium is passed in the first 2 days after birth.

Renal System

Expected urine output of a newborn is 250ml in 24hrs. The bladder capacity is 15mls full.
Because the urinary system is immature, urine is not concentrated. Urine is colorless or clear yellow; odorless with a specific gravity of approximately 1.020.

Immune System

Infants are born with passive immunity from the mother, IgG through the placenta, IgA through breast milk. The immunity lasts 3-6 months.

Thermoregulation

Newborns have a limited capacity to regulate heat loss and pain. The child’s ability to produce heat is immature and ineffective, thus prone to hypothermia. Infants lose heat because:
The metabolic rate is higher.
The surface area for heat loss is large.
Infants cannot shiver to generate heat.
Infants metabolize brown fat to generate heat.
Subcutaneous tissue is small.
Newborns lose heat by or through conduction, evaporation, convection, and radiation.

Hemopoietic System

The blood volume of a newborn is 80-110ml/kg.
The lifespan of RBCs is 50-90 days.

Hepatic System

There is unconjugated bilirubin in the 1st week of birth, and this is due to:
Increased bilirubin load on hepatocytes.
The lifespan of fetal RBCs is short.
Increased enterohepatic bilirubin circulation.
Defective bilirubin conjugation and excretion.
Physiological jaundice occurs after 1st day. This is due to the increased number and short lifespan of RBCs, and an immature liver to conjugate bilirubin.
When the examination is completed, make the baby comfortable and warm.
Record findings
Report abnormalities detected to the in-charge of the ward pediatrician for appropriate action.

Danger Signs in a Newborn

Breathing Difficulty: This includes rapid, labored, or irregular breathing patterns. If a newborn is struggling to breathe, it’s a serious concern.
Convulsions, Spasms, Loss of Consciousness, or Arching of the Back: These signs may indicate neurological issues or seizures.
Cyanosis (Blueness): Bluish discoloration of the skin or lips can be a sign of inadequate oxygenation and requires immediate attention.
Hot to Touch (Fever) or Cold to Touch: Abnormal body temperature, whether too high (fever) or too low, is a concern.
Bleeding: Any unexplained bleeding, especially from the umbilicus, eyes, or skin, is a danger sign.
Jaundice: While some level of jaundice is common in newborns, excessive or rapidly progressing jaundice may indicate a problem.
Pallor: An unusually pale complexion can signal anemia or other issues.
Diarrhea: Persistent diarrhea in a newborn is a cause for concern and can lead to dehydration.
Persistent Vomiting or Abdominal Distention: Frequent or forceful vomiting and abdominal swelling can indicate various medical conditions.
Poor Sucking or Not Feeding: If the baby is not feeding properly or is experiencing difficulty in sucking, it may not be getting adequate nutrition.
Pus or Redness of Umbilicus, Eyes, or Skin: Any sign of infection, such as pus or redness in these areas, should be addressed.
Swollen Limb: Unexplained swelling of a limb is a sign that requires immediate attention.
Lethargy: If the newborn is unusually tired, unresponsive, or lacks energy, it can indicate a medical issue.

Daily Care of the Baby

After one hour in the labor ward, the baby should be transferred with its mother in her arms to avoid heat loss and promote mother-baby attachment. The following are the main points considered during the care of the baby to prevent neonatal complications:

1. Maintenance of Respiration

A baby with mucus should be observed and the airway cleared frequently using a suction catheter or bulb syringe.

2. Provision of Warmth

The baby should be kept at a comfortable temperature between 21 – 25 degrees Celsius.
Overdressing and overheating should be avoided.
Baby’s temperature is maintained by proper monitoring of the incubator for those admitted in the nursery or skin-to-skin contact with the mother for babies who are sick.

3. Provision of Food

A normal baby should be put onto the breast immediately after delivery or within the first 30 minutes.
Exclusive breastfeeding is up to 6 months. Mother should breastfeed the baby on demand.

4. Protection from Injury and Infection

Midwives as well as mothers should not keep long nails, and even those for babies should be cut short to avoid injuring themselves.
Prevention of infection is important to minimize the risk of cross-infection to both midwives and mothers.
Infected babies should be isolated.
Installation of tetracycline eye drops as prophylaxis against gonococcal infection.

5. Hygiene

The baby should be bathed daily and twice if the weather is not cold.
Special care is paid where two skin folds meet, and this is important.
The first and other non-urgent procedures may be deferred in order to minimize heat loss.

6. Umbilical Cord

The cord is a source of infection in the neonatal period.
The midwives should aim at preventing hemorrhage and getting the cord dried up and separate cord cleaned with normal saline 0.9% at least 3 times in 24 hours.

7. Prevention of Hemorrhage

Prophylactic vitamin K (1 mg) is given intramuscularly or orally to promote prothrombin formation.

8. Observations

Temperature, respiration, and heart rate are checked every four hours.
The child is weighed twice weekly.
The condition of the cord is observed.
The color of the skin is monitored.
Urine and stool color and amount passed are noted.

9. Assessment of Baby’s Progress

A thriving baby is a baby who is growing well. A baby who is growing well has bright eyes.
It is active and kicks rigorously.
It is free from infection.
Feeds well and is always eager to eat.
Fontanelles are not depressed.
Has a pink color with firm muscles.
Baby sleeps well, and when it wakes up, it stretches and yawns.
Passes normal quality of urine, stools are semi-solid and yellow.
In order to assess the above, it is necessary to examine the baby thoroughly at least once daily.

10. Education of the Mother

Education of the mother should start from the antenatal period.
After delivery, the mother should be educated about the care of the baby and herself.
As the baby and mother’s condition is good, discharge is considered.
Every procedure that is carried out on the baby should be done when the mother is observing so that after discharge, she is able to carry it out, for example, dressing the baby, baby bathing, and care of the cord.

11. Immunization

All neonates should be immunized with BCG vaccine and ‘OPV’ at birth.
Mother should be given vitamin A so that the baby can get it through breast milk.
The mother should be informed about the recommended national immunization schedules and the importance of completing immunization.

Follow-up

Each infant should be followed up at least once every month for the first 3 months and subsequently at 3-month intervals until one year of age.
Follow-up is necessary for assessment of growth and development, early detection and management of health problems, and health education for prevention of childhood illnesses.

Immediate Care of the Newborn Read More »

Changes in the newborn at birth

Changes in the newborn at birth are a number of changes that an infant’s body undergoes to allow it to survive outside the womb and adapt to life in a new environment.

During intrauterine life, the fetus receives oxygen and nutrients by absorption through the placenta. It does not use its lungs or the digestive organs. Similarly, it excretes carbon dioxide and other waste products through placental structures into the mother’s blood.

It is protected from many harmful factors/organisms by the placenta, and it is kept in a warm environment.

Size and Growth: The term infant weighs about 3000g. Boys weigh approximately 250g more than girls. Infants of less than 2500g are classified as ‘low birth.’ During the first 3–5 days, up to 10% of birth weight is lost. This is regained by 7–10 days. In the first month, average weight gain per week is 200g.

Skin: The newborn skin is immature, with a thin epithelial layer and incompletely developed sweat and sebaceous glands. Combined with the high surface area to body mass ratio, this renders the baby prone to heat and water losses. Numerous benign skin lesions occur, e.g. a greasy protective layer, the vernix caseosa.

Temperature Regulation: The neonate has a low metabolic activity resulting in a poor ability to produce heat. The infant enters a much cooler environment than to which it is used. Its body is wet and thus liable to lose heat through evaporation. Receptors on the baby’s skin send messages to the brain that the baby’s body is cold. The baby’s body then creates heat by shivering and by burning stores of brown fat, a type of fat found only in fetuses and newborns.

Head: The average occipito-frontal head circumference is 35 cm. Two soft spots or fontanels are present. The anterior fontanel closes at 18 months of age, and the posterior closes by 6–8 weeks.

Respiratory System: Changes that occur at birth allow the newborn to convert from dependence on the placenta to breathing air for the exchange of respiratory gases. In utero, the airways and lungs are filled with fluid that contains surfactant. The lung fluid is removed by the squeezing of the thorax during vaginal delivery and by reduced secretion and increased absorption mediated by fetal catecholamine during labor and after birth. Surfactant lines the air–fluid interface of the alveoli and reduces the surface tension, thereby facilitating lung expansion. This is associated with a fall in pulmonary vascular resistance. The rate is variable and normally ranges between 30 and 60 breaths/min. Brief self-limiting apnoeic spells might occur during sleep.

Cardiovascular System: Major changes in the lungs and circulation allow adaptation to extra-uterine life. In the fetal circulation, the right-sided (pulmonary) pressure exceeds the left-sided (systemic) pressure. Blood flows from right to left through the foramen ovale and ductus arteriosus. At birth, these relationships reverse: Left-sided (systemic) pressure rises with clamping of umbilical vessels. Right-sided (pulmonary) pressure falls as the lungs expand, and the rising pressure triggers a prostaglandin-mediated vasodilatation. The foramen ovale and ductus arteriosus close functionally shortly after birth. The ductus closes due to muscular contraction in response to rising oxygen tension.

Gastrointestinal System: At term, the secretory and absorbing surfaces are well developed, as are digestive enzymes, with the exception of pancreatic amylase. Meconium is usually passed within 6 hrs, and delay beyond 24 hrs is considered abnormal. Normally, meconium is replaced by yellow stool by day 3-4.

Liver: In the fetus, the liver acts as a storage site for sugar (glycogen) and iron. When the baby is born, the liver has various functions: It produces substances that help the blood to clot. It begins breaking down waste products such as excess red blood cells. It produces a protein that helps break down bilirubin. Immaturity of the liver enzymes responsible for conjugation of bilirubin is responsible for the ‘physiological jaundice’ which can occur from the second day of life.

Genitourinary System: The infant should void within the first 24 hours of life.

Immune System: The neonatal immune system is incomplete compared to older children and adults: Impaired neutrophil reserves. Diminished phagocytosis and intracellular killing capacity. Decreased complement components. Low IgG2, leading to infections with organisms. The presence of maternal antibody in babies born greater than 30 weeks’ gestational age provides some protection against infection.

Central Nervous System: The central nervous system (CNS) is relatively immature at birth. Newborn infants sleep for a total of 16–20 hours each day. The touch of a nipple on the baby’s face initiates the sequence of rooting and the complex coordination of lip, tongue, palate, and pharynx required for sucking and swallowing. Crying (without tears) is the main means of communication.

Changes in the newborn at birth Read More »

Paediatrics Introduction

Paediatrics is a branch of medicine that focuses on the prevention, diagnosis, treatment and management of all types of health problems that affect young patients – from infants and children to adolescents.

It includes the clinical and psychological aspect of medical care. It requires detailed knowledge of genetics, obstetrics, physiological development, management of disabilities at home and school and the effects of social condition on the child’s health.

As the child is totally dependent on the care-givers, it is important that the care provided is family centered. Providing quality care for sick children depends on you, understanding developmental variations as anticipated in different age groups.

Antenatal care

Good antenatal care is important to the future development of the child. Attendance by the mother at maternity clinic at regular intervals during pregnancy will ensure that any problems which may influence fetal development are recognized promptly, as well as providing an opportunity for the mother and father to attend parentcraft sessions, e.g. in breastfeeding, in order to help the parents rear their baby happily and successfully.

Fetal development

Development of the fetus during pregnancy is a time of rapid growth. After fertilization, when the spermatozoon meets an ovum usually in the outer third of the fallopian tube, the cells multiply rapidly into a morula which passes into the uterine cavity and embeds in the endometrium.

After four weeks the fetal shape resembles a mammal and is about 1cm long. By about 8 weeks limbs have developed.
At 12 weeks the fetus is obviously human. The length is now about 9 cm. All essential organs have formed before the twelfth week.
After this the fetus continues to grow, peaking at about the 34th week of pregnancy.
About the 27/28th week the fetus is said to be viable i.e. if born the fetus attempts to breath.
After 28 weeks the fetal muscles develop and fat is laid down. The fetus is coated with a greasy substance known as vernix. The fetus is now able to move quite freely within the amniotic cavity.

End of pregnancy occurs after a gestation period of about 40 weeks.

Nursing goals

Normalize the life of the child during hospitalization in preparation for the family home, school and community.
Minimize the impact of the child’s unique condition.
Foster maximal growth and development.
Develop realistic, functional and coordinated home care plans for the children and families.
Respect the roles of the families in the care of their children.
Prevention of disease and promotion of health of the child

Definition of Terms

Pediatrics: The term pediatrics is derived from Greek words. ‘Paed’ means child, ‘icitrike’ means treatment, ‘..ics’ means the science of child care and scientific treatment of childhood diseases.
Neonatal Period: Neonatal period is the period from birth to 28 days of life or the first month of life.
Normal Baby: A normal baby should have the following characteristics. A normal term baby weighs approximately 3.5 kg, when fully extended measures 50 cm from the crown of the head to the heels, and has an average occipitofrontal head circumference of 34-35 cm. Most babies are plump and have a prominent abdomen. They lie in an attitude of flexion, with arms extended; their fingers reach upper thigh level.
Infant: An infant is a child from birth up to one year of life.
Toddler: A toddler is a child from one year to three years of life.
Preschool: A child of three to five years is considered as a preschooler.
Middle Childhood: Is defined as ages six to twelve years.
Adolescent: WHO defines adolescence as the period in human growth and development that occurs after childhood, from ages twelve to nineteen years.
Preterm Baby: A preterm baby is a baby born with a gestational age of less than 37 completed weeks (or less than 259 days) but greater than 28 weeks. These babies are also termed as immature, born early, or premature.
Term Baby: A baby born with a gestational age between 37 to 41 weeks (259-293 days).
Low Birth Weight Baby: Any baby weighing 2500 g or less at birth.
Post-Term Baby: A baby born with a gestational age of 42 weeks or more (294 days or more).
Live Birth: Any signs of life at delivery.
Stillbirth: A baby born after 24 weeks of gestation with no sign of life at birth.
Perinatal Mortality: Stillbirths and first-week deaths per 1000 total births.
Neonatal Mortality: Deaths of live births in the first month of life per 1000 live births.
Infant Mortality: Deaths of all live births in the first year of life per 1000 live births.
Post-Neonatal Mortality: Post-neonatal mortality is referred to as the deaths of all babies from 1 month to 1 year per 1000 babies alive at 1 month.

The Newborn

A newborn is a just or recently born child (0-28 days).

Weight: The normal full-term infant weighs approximately 3.5 kgs. In Uganda, the weight may range from 2.5 kg-3.5 kg. Babies in the tropics tend to be smaller than European babies. Newborn infants usually are considered to be tiny and powerless, completely dependent on others for life.

Length: Measurement is taken from the highest point of vertex of the head to the heel. It ranges from 45-50 cm (average 50cm).

Lie: He lies in an attitude of flexion – in the supine position with his head turned to one side and one shoulder elevated off the mattress or in the prone position with his buttocks elevated, his knees drawn up under his abdomen and his head turned to one side with his arms extended; his fingers reach to mid-thigh level.

Temperature: Ranges between 36°C to 37.5°C

Blood Pressure: Systolic 50 to 75mmHg and Diastolic 30 to 45mmHg

Nails: The nails are fully formed and adhered to the tips of the fingers, sometimes extending beyond the fingertips.

Head and Hair: The head circumference is approximately 33-35 cm (13-14 in) with a cranium that is disproportionately large compared with the face. This is from molding of the skull bones during labor and birth or due to swelling of the scalp or slight bleeding under the scalp. The anterior and posterior fontanels or “soft spots” are open and the sutures can be felt. The anterior fontanel is diamond-shaped and closes by 18 months. The fontanel on the back (posterior) is shaped like a triangle and closes by 6 weeks of age. The baby may be born with a full head of hair or none at all.

Vision: The baby’s eye color depends on skin tone, blue-gray if fair-skinned or brown if dark-skinned. By 6 months to 1 year of age, the baby’s eye color will be permanent. Eyes: When the newborn cries, tears may be absent. Tear ducts may not function for the first few weeks after birth. Cross-eyed: A newborn’s eye muscles are weak at birth. Over the next few weeks, eye muscle strength will improve, and the baby can better focus on objects.

Hearing: Babies can hear loud and soft noises at birth. Loud noises may cause the baby to startle, while soft noises may help to calm your baby. The baby quickly learns the difference in voice sounds. The baby will turn its head to a familiar voice, especially mom’s and dad’s voice.

Taste and Smell: Newborns can taste and smell at birth. The baby will be able to taste breast milk.

Skin: At birth, the baby may have a thick cheese-like covering. This is called vernix caseosa. Vernix helps to protect the baby’s skin while in the uterus. Over the baby’s forehead, nose, and cheeks, you may see “whiteheads” or milia. These are immature oil glands that will go away in several weeks. The baby may have soft downy hair that may cover its face and body. This is called lanugo, and it will go away within a few weeks after birth. The baby may have pale pink marks on the face and neck. They are called stork bites and will fade during childhood. The baby may have bluish-black marks on the lower back or bottom. These are called Mongolian spots and are more common on dark-skinned children. The subcutaneous fat is small and the skin looks red and elastic.

Chest and Breathing: Babies take little breaths and use abdominal muscles to help breathe. You may even notice short pauses between some breaths. The rate of breathing is 30 to 60 times a minute. This is because their heart rate is rapid at 120 to 160 times a minute. The breasts of boy and girl babies may look enlarged after birth. The hormones that cross the placenta during the last two weeks before birth cause the breasts to fill with milk. Do not squeeze the breasts. The enlarged breasts will go away in about 2 weeks.

Abdomen: The abdomen may be round or stick out slightly (big compared to the thorax). The umbilical cord is clamped, cut, and tied. It will dry and fall off in 1 to 2 weeks. If there is redness around the umbilical cord or pus-like drainage, give the necessary care.

Genitalia: In boys, the testicles are descended into the scrotum which has plentiful rugae. The urethral meatus opens at the tip of the penis, and the prepuce is adhered to the glans. In girls born at term, the labia majora normally cover the labia minora. The hymen and clitoris may appear disproportionately large. The hormones in a girl may cause the baby to have white vaginal discharge or vaginal spotting (false period).

Arms and Legs: After birth, the baby’s arms and legs may look bowed and are held close to the body. Hands are in tight fists, the arms and legs may appear too short for the body because of their bent appearance. This is temporary; by 3 to 4 months, the arms and legs stretch out.

Behavior: The newborn baby will probably spend a lot of time sleeping. The baby may be very alert and gaze at the mother or people or be very quiet and drowsy right after birth. During the next month, the baby will spend less time sleeping and more time awake.

The Common Reflexes Observed in the Newborn

A reflex is an automatic or voluntary response to a stimulus, which is brought about by relatively simple nervous circuits without consciousness being necessarily involved. They include:

Pupil Reflexes: The newborn infant will turn his head towards the source of light, providing it is not too bright.
Moro Reflex (Startle): Response to sudden stimulus or sound causing the infant’s body to stiffen, the arms to go up and out, then forward and towards each other. This reflex usually disappears at about the age of 3-4 months and may be difficult to elicit in a preterm baby.
The Grasp Reflex: This may be obtained in the hand or foot by either introducing a finger into the palm of the hand, which the infant grasps quite strongly, or by gently stroking the sole of the foot behind the toes.
Rooting Reflex: When the corner of the mouth is touched with a finger which moves towards the cheek, the infant will turn his head towards the object and open his mouth.
Withdrawal Reflex: Pricking the sole of the foot will result in the infant’s leg being flexed at the hip, knee, and ankle.
Babinski Reflex: This occurs when the sole of the baby’s foot is stimulated. This has an effect of causing an unusual extension of the big toe as well as fanning the other toes. The simulation may be started from the heel all the way to the base of the baby’s toes. This reflex is normally used to ascertain the adequateness of the central nervous system.
Sucking and Swallowing Reflexes: This is essential for safe feeding and adequate nutrition. Place a nipple or finger in the mouth of the baby, the infant should suck vigorously and swallow.
Traction Response: When the baby is pulled upright by the wrists to a sitting position, the head will lag initially, then right itself momentarily before falling forward onto the chest.
Blinking and Corneal Reflex: This protects the eyes from trauma.
Walking and Stepping Reflexes: When the baby is supported upright with his feet touching a flat surface, the baby simulates walking. If held with the tibia in contact with the edge of a table, the baby will step up onto the table.

Paediatrics Introduction Read More »

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

Integrated Management of Childhood Illnesses is a child management process where care/treatment of a sick child is done in totality.

IMCI stands for Integrated Management of Childhood Illness is an approach developed by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) to improve the health and well-being of children under the age of five.

IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

IMCI aims to reduce death, illness, disability, and to promote improved growth and development among children under five years of age.

IMCI aims to reduce preventable mortality, minimize illness and disability, and promote healthy growth and development in young children.

IMCI guidelines help to interview caretakers accurately and recognize clinical signs, choose appropriate treatments, provide counseling and preventive care of children aged unto 5 years.

Goals of IMCI

Identify key causes of childhood mortality.
Explain the meaning and purpose of integrated case management.
Describe the major steps in the IMCI strategy.
Introduce use of IMCI tools including chart booklet, wall posters and case management sheets.

Key Components of IMCI

IMCI aims at three (3) main components of health care.

Improving case management skills of healthcare providers.
Improving health systems to provide quality care.
Improving family and community health practices for health, growth, and development.

CHILD HEALTH AND MORTALITY

In 2015, approximately 5.9 million children under the age of five died worldwide, which translates to nearly 16,000 deaths every day. The leading causes of death in this age group are infections, neonatal conditions, and nutritional issues. Alarmingly, the majority of these deaths are preventable.

Uganda has been reported to have a high child mortality rate. According to the World Health Organization (WHO), Uganda ranks 168th out of 188 countries in terms of infant mortality rates.

The under-five mortality rate in Uganda was reported at 53 deaths per 1,000 live births in 2016, according to the World Bank.

Seventy five percent (75%) of the common causes of child mortality in developing countries include:

Infectious Diseases: Acute respiratory infections, diarrhea diseases, malaria, and measles are leading causes of death among children under five years old. These diseases can be severe and life-threatening, especially in resource-constrained settings where access to healthcare and preventive measures may be limited.
Malnutrition: Malnutrition is a significant contributor to child mortality in developing countries. Children who are malnourished have weakened immune systems, making them more susceptible to infectious diseases and less able to recover from illness.

It is important to note that these causes often overlap, and children may suffer from a combination of these conditions. The clinical presentations of these diseases can be similar, which may lead to challenges in diagnosing and treating children effectively.

WHY IMNCI? (Need for IMCI)

Multiple Conditions:

Children often present with multiple potentially deadly conditions at the same time. IMCI takes a holistic approach, considering all the conditions that may affect a child and put them at risk of preventable mortality or impaired growth and development. By facilitating an integrated assessment and combined treatment of these conditions, IMCI focuses on effective case management and prevention of diseases, contributing to healthy growth and development.

Lack of Diagnostic Tools:

In many healthcare settings, there is a lack of diagnostic tools such as laboratory tests or radiology. IMCI recognizes this challenge and provides clinical algorithms that rely on patient history, signs, and symptoms for diagnosis. By training healthcare providers in IMCI, they can effectively assess and manage childhood illnesses even in resource-limited settings.

Reliance on Patient History:

IMCI acknowledges the importance of patient history in diagnosing and managing childhood illnesses. Healthcare providers are trained to gather comprehensive information about the child’s symptoms, medical history, and other relevant factors. This information, combined with the IMCI clinical algorithms, helps providers make accurate diagnoses and provide appropriate treatment.

Need for Referrals:

In cases where a child has a serious illness that requires specialized care, IMCI emphasizes the need for timely referrals to a higher level of care . By identifying severe illnesses and facilitating prompt referrals, IMCI ensures that children receive the necessary treatment and support from specialized healthcare providers.

IMCI PROCESS

The IMCI (Integrated Management of Childhood Illness) process is a comprehensive approach to the identification and management of childhood illnesses in outpatient settings.

It aims to improve the quality of care for children under the age of five by providing standardized guidelines and interventions.

Here is an overview of the IMCI process and the interventions included in the IMCI guidelines:

IMCI Process:

List of Conditions: The IMCI process involves checking for a list of conditions in children and infants to ensure comprehensive assessment and treatment.
Assessment and Treatment: Children are assessed and treated for all conditions that are present, following standardized algorithms that guide management decisions.
Decision to Transfer: If necessary, the IMCI guidelines provide guidance on when to transfer a child to higher levels of care for further management.

Interventions Included in the IMCI Guidelines:

The IMCI guidelines include both curative and preventive interventions for various childhood conditions.

Curative Interventions:

Acute Respiratory Infections (ARI) including pneumonia
Anaemia
Diarrhoea (dehydration, persistent, dysentery)
Ear infections
HIV/AIDS
Local bacterial infections
Meningitis and sepsis
Malnutrition
Wheeze
Malaria
Measles
Neonatal jaundice

Preventive Interventions:

Breastfeeding support
Immunization
Nutrition counseling
Periodic deworming
Vitamin A supplementation
Zinc supplementation

Who Can Use IMCI:

The IMCI process can be used by all doctors, nurses, and other health professionals who provide care for young infants and children under the age of five. It is primarily designed for first-level facilities such as clinics, health centers, or outpatient departments of hospitals.

The Case Management Process

IMCI classifies children into two categories:

Sick young infants who range from 1 week to 2 months. Less than 1 week infants are not managed under IMCI, mainly because their illnesses are usually related to antenatal, labour and delivery.

Sick child who range from 2 months to 5 years.

IMCI is designed for health workers (doctors, nurses etc) who treat sick children and infants in a first level health facility e.g. clinic, health center or OPD in a hospital.

In the management process the following steps are taken:

Assessing the child/young infant.
Classify the illness.
Identify treatment.
Treating the child/ young infant.
Give counseling to the mother.
Give follow up care.

Assessing the child means taking the history and performing a physical examination.
Classifying the illness implies making a decision on the severity of illness i.e. you select a category of classification which corresponds with the severity of the disease.

Note that, classifications are not specific diagnoses but can be used to determine treatment e.g. severe febrile disease is a classification for a child who could be having cerebral malaria, meningitis, septicemia etc, but treatment for this classification covers for all the possible causes of the problem.

Steps in Integrated Case Management according to IMCI guidelines:

STEP 1: ASSESS

The assess column in the chart booklet describes how to take history and do a physical exam.

Establish good communication with the mother of the child.
Screen for general danger signs, which would indicate any life-threatening condition.
Specific questions about the most common conditions affecting a child’s health (diarrhea, pneumonia, fever, etc).
If the answers are positive, focus on a physical exam to identify life-threatening illness.
Evaluation of the child’s nutrition and immunization status.
The assessment includes checking the child for other health problems.

STEP 2: CLASSIFY

The classify (signs and classify) column of the chart lists clinical signs of illnesses and their classification. “Classify” in the chart means the health worker has to make a decision on the severity of the illness.

Classify the child’s illnesses based on the assessment using a specially developed color-coded triage system.
Because many children have more than one condition, each condition is classified according to whether it requires:

COLOUR	CLASSIFICATION
PINK	Severe classification needing admission or pre-referral treatment and referral.
YELLOW	Classification needing specific medical treatment and advice.
GREEN	Not serious, and in most cases, no drugs are needed. Simple advice on home management given.

STEP 3: IDENTIFY TREATMENT

The identify treatment column helps the healthcare workers to quickly and accurately identify treatments for the classifications selected. If a child or young infant has more than one classification, the healthcare worker must look at more than one table to find the appropriate treatments.

COLOUR	CLASSIFICATION
PINK	If a child requires urgent referral, determine essential treatment to be given before referral.
YELLOW	If a child needs specific treatment, develop a treatment plan and identify the drugs to be administered at the clinic. Also, decide on the content of the advice to be given to the mother.
GREEN	If no serious conditions have been found, provide appropriate advice to the mother on the actions to be taken for the child’s care at home.

STEP 4: TREAT

The treat column shows how to administer the treatment identified for the classifications. Treat means giving the treatment in the facility, prescribing drugs or other treatments to be given at home and also teaching the mother/caregiver how to administer treatment at home.

The following rules should be adhered to.

COLOUR	CLASSIFICATION
PINK	If a child or young infant requires admission or referral, it is important the essential treatment is offered to the child or young infant before admission or referral.
YELLOW	If the child or young infant requires specific treatment, develop a treatment plan, administer drugs to be given at the facility and advise on treatment at home and counsel the mother/caregiver accordingly.
GREEN	If no serious conditions have been found (green classification), advise the mother/caregiver on care of the child at home.

STEP 5: COUNSEL

If follow up care is indicated, teach the mother/caregiver when to return to the clinic. Also teach the mother/ caregiver how to recognize signs indicating that the child or young infant should be brought back to the facility immediately.
Assess feeding, including breastfeeding practice, and provide counseling to solve any feeding problems found. This also includes counseling the mother about her own health.

STEP 6: FOLLOW-UP

Some children or young infants need to be seen more than once for a current episode of illness. Identify such children or young infants and when they are brought back, offer appropriate follow up care as indicated in the IMNCI guidelines and also reassess the child or young infant for any new problems.

The guidelines also aim to empower healthcare workers to:

Identify children who require additional follow-up visits.
Provide appropriate follow-up care as indicated in IMCI guidelines.
Correctly counsel the mother about her own health.
Provide counseling for appropriate preventative and treatment measures.
If necessary, reassess the child for any new problems.

Assessing and Classification of a Sick Child and General Danger Signs.

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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI) Read More »

nursing exam Nursing Management nursing exam

Nursing Exam Question Approach

Nursing Exam Question Approach.

In this comprehensive guide, we will explore and provide examples of the Question Approach for nurses preparing for their nursing exams. We will cover question types such as EXPLAIN, OUTLINE, DESCRIBE, MENTION, IDENTIFY, STATE, LIST, WHAT, and GIVE.

Also, we will dive into question approaches specifically related to Nursing Management questions, including specific nursing interventions, considerations, concerns, issues, and interventions.

The EXPLAIN Question Approach

In Simple Terms: "Explain" means to give details and reasons. You need to show *how* or *why* something happens, not just what it is.

The EXPLAIN question requires nurses to provide a detailed explanation of a particular concept, process, or condition. When approaching an EXPLAIN question, follow these steps:

Step 1: Understand the question

Carefully read the question and identify the main topic or concept that needs to be explained. Pay attention to any specific instructions or requirements.

Step 2: Organize your response

Create an outline or mental map of the key points you want to include in your explanation. Start with a concise introduction that provides context and a clear thesis statement. Then, present your main points in a logical order, supporting them with relevant evidence or examples.

Step 3: Provide a thorough explanation

Elaborate on each key point using clear and concise language. Use appropriate nursing terminology and provide examples or case studies to enhance your explanation. Aim to cover all relevant aspects of the topic while maintaining a coherent and structured response.

Example EXPLAIN question:

“Explain the pathophysiology of diabetes mellitus and its effects on the body.”

Sample response:

Diabetes mellitus is a chronic metabolic disorder characterized by high blood glucose levels due to impaired insulin secretion, insulin action, or both. The pathophysiology of diabetes involves multiple factors that contribute to the development and progression of the disease.

Firstly, in type 1 diabetes, an autoimmune process leads to the destruction of insulin-producing beta cells in the pancreas. This results in a deficiency of insulin and requires external insulin administration. On the other hand, type 2 diabetes is primarily characterized by insulin resistance, where the body’s cells become less responsive to insulin.

Insulin is a hormone produced by the beta cells of the pancreas, and its main function is to regulate glucose metabolism. In diabetes, the lack of insulin or the body’s inability to use it effectively leads to hyperglycemia. Persistently high blood glucose levels can have detrimental effects on various organs and systems in the body.

The effects of diabetes on the body are many. It can lead to macrovascular complications, such as cardiovascular disease, stroke, and peripheral vascular disease. Also, microvascular complications may arise, affecting small blood vessels in the eyes, kidneys, and nerves. Diabetes can also increase the risk of infections, slow wound healing, and cause diabetic neuropathy and nephropathy.

The OUTLINE Question Approach

In Simple Terms: "Outline" means to create a structured summary. Use main headings and sub-points to show the main parts of a topic in a clear, organized way.

The OUTLINE question requires nurses to present a structured overview of a particular topic, process, or care plan. When approaching an OUTLINE question, follow these steps:

Step 1: Analyze the question

Carefully read the question and identify the main components or aspects that need to be outlined. Pay attention to any specific instructions or requirements.

Step 2: Organize your response

Create a clear and logical outline for your response. Identify the main headings or sections that you will include and arrange them in a coherent order. Each section should address a specific aspect of the topic or process.

Step 3: Provide detailed information

Under each heading or section, provide detailed information, explanations, or examples related to that particular aspect. Use concise and informative language, ensuring that your outline is well-structured and easy to follow.

Example OUTLINE question

“Outline the steps involved in the nursing process.”

Sample response:
The nursing process is a systematic framework that guides nurses in delivering patient-centered care. It consists of five essential steps: assessment, diagnosis, planning, implementation, and evaluation.

Assessment:

Diagnosis:
Analyze the assessment data to identify health problems, risks, or potential complications. Formulate nursing diagnoses based on the identified issues. Ensure that the diagnoses are accurate, concise, and specific. Collaborate with other healthcare professionals when necessary.

Planning:
Establish patient-centered goals and outcomes in collaboration with the patient. Develop a nursing care plan that includes evidence-based interventions and strategies. Prioritize nursing actions based on the urgency and importance of each goal. Ensure that the care plan is feasible, realistic, and adaptable.

Implementation:
Execute the planned nursing interventions effectively and efficiently. Provide safe and compassionate care while considering the patient’s preferences. Document the implementation process and any modifications made. Collaborate with the interdisciplinary healthcare team to deliver comprehensive care.

Evaluation:
Assess the patient’s response to the nursing interventions and the achievement of goals. Compare the actual outcomes with the expected outcomes. Modify the care plan if needed based on the evaluation findings. Document the evaluation results and communicate them to the healthcare team.

The DESCRIBE Question Approach

In Simple Terms: "Describe" means to paint a picture with words. You need to give a detailed account of the characteristics or features of something.

The DESCRIBE question requires nurses to provide a detailed account or characterization of a particular topic, condition, or intervention. When approaching a DESCRIBE question, follow these steps:
Step 1: Understand the question
Carefully read the question and identify the main topic or subject that needs to be described. Pay attention to any specific instructions or requirements.
Step 2: Provide a comprehensive description
Offer a thorough and comprehensive description of the topic or subject. Include relevant details, characteristics, features, or components. Use clear and concise language to ensure clarity and understanding.
Step 3: Use appropriate terminology
Utilize appropriate nursing terminology to accurately describe the topic or subject. This will demonstrate your knowledge and understanding of the nursing concepts related to the question.
Step 4: Provide examples (if applicable)
Enhance your description by providing relevant examples. These real-life scenarios will help illustrate the topic or subject and provide a practical way for understanding.

Example DESCRIBE question:

“Describe the stages of wound healing.”

Sample response:
Wound healing is a complex process that involves several distinct stages. Understanding these stages is essential for nurses to provide appropriate wound care and promote optimal healing.

Hemostasis:
This initial stage begins immediately after the injury occurs. Blood vessels constrict to reduce blood flow and prevent excessive bleeding. Platelets aggregate to form a temporary clot. The clotting process releases various growth factors and cytokines, initiating the subsequent stages of healing.

Inflammatory phase:
This phase typically lasts for 2-3 days. Inflammation occurs as a response to tissue injury. Vasodilation and increased vascular permeability allow immune cells to migrate to the wound site. Neutrophils arrive first to eliminate debris and prevent infection. Macrophages then remove dead tissue and release additional growth factors to stimulate healing.

Proliferative phase:
This phase generally occurs between days 3 and 20. New blood vessels form to supply oxygen and nutrients to the wound. Fibroblasts produce collagen, which provides structural support for wound healing. Epithelial cells migrate from the wound edges to resurface the wound. Granulation tissue forms, consisting of new blood vessels, fibroblasts, and extracellular matrix.

Maturation phase:
This final phase can last for several months to years. Collagen fibers reorganize and remodel, increasing the wound’s tensile strength. Scar tissue forms, but it may not possess the same strength and flexibility as the original tissue. The scar gradually becomes more refined and fades over time.

The MENTION / IDENTIFY / STATE Question Approach

In Simple Terms: These words mean "give a short, direct answer." Just name the specific facts or points asked for, without extra explanation.

The MENTION/IDENTIFY/STATE question requires nurses to highlight or state specific information or facts related to a particular topic or condition. When approaching such a question, follow these steps:
Step 1: Understand the question
Carefully read the question and identify the specific information or facts that need to be mentioned, identified, or stated. Pay attention to any specific instructions.
Step 2: Provide a direct response
Offer a direct and concise response to the question. Avoid unnecessary elaboration or providing excessive details beyond what is asked.
Step 3: Use precise language
Use precise and accurate language to give the required information. Ensure that your response aligns with the question and provides the requested details.
Step 4: Provide examples if applicable
If the question allows for it or if it helps clarify the information, you can provide relevant examples or scenarios to support your response.

Example MENTION / IDENTIFY / STATE question:

“Mention/ Identify/ State the types of delusions.”

Sample response:

Grandiose delusions; the patient believes s/he is somebody great /important ,knowledgeable or powerful contrary to the social cultural ,religious background and experiences.

Delusion of guilty and worthlessness; the patient believes s/he is not worth to live even though there’s nothing to justify this belief.

Delusions of jealousy; the patient believes that spouse/partner is being unfaithful even when there is no evidence to suggest so.

Delusion of persecution: the patient believes they’re being deliberately wronged, conspired or harmed by another person or agency even when there’s no evidence to suggest so.

Religious delusions; the individual believes he or she has a special link with God that is out keeping with people of the same religious belief.

Delusions of control, influence or phenomenon; these are three types; belief that the person performs activities as a result of an extreme force.

The LIST Question Approach

In Simple Terms: "List" means to present points one after another, usually with a short description for each one.

The LIST question requires nurses to present a series of items, factors, or elements related to a specific topic or condition. When approaching a LIST question, follow these steps:
Step 1: Understand the question
Carefully read the question and identify the specific items or factors that need to be listed. Pay attention to any specific instructions or requirements.
Step 2: Organize your response
Create a well-structured list that presents the items or factors in a logical and coherent order. Consider using bullet points or numbered lists for clarity.
Step 3: Provide concise descriptions
Under each item or factor, provide a concise description or explanation. Keep your descriptions clear, informative, and relevant to the question.

Example LIST question:

“List the risk factors for cardiovascular disease.”

Sample response:

Hypertension: High blood pressure increases the strain on the heart and blood vessels, leading to an increased risk of cardiovascular problems.

High cholesterol levels: Elevated levels of LDL (low-density lipoprotein) cholesterol, also known as “bad” cholesterol, can lead to the formation of plaque in the arteries, restricting blood flow and increasing the risk of cardiovascular events.

Smoking: Tobacco smoke contains harmful chemicals that can damage blood vessels and promote the development of atherosclerosis.

Obesity: Excess body weight, especially when concentrated around the abdomen, increases the risk of hypertension, high cholesterol, and diabetes, all of which contribute to cardiovascular disease.

Sedentary lifestyle: Lack of regular physical activity can contribute to obesity, hypertension, and other risk factors for cardiovascular disease.

Diabetes mellitus: Individuals with diabetes have a higher risk of developing cardiovascular disease due to the impact of chronically elevated blood glucose levels on blood vessels and the heart.

Family history: Having a close relative, such as a parent or sibling, with a history of cardiovascular disease increases an individual’s risk.

Age and gender: Advancing age and being male are additional risk factors for cardiovascular disease.

The WHAT Question Approach

In Simple Terms: "What" asks for a definition. Give a clear, simple explanation of the term or concept.

The WHAT question requires nurses to provide an explanation or definition of a specific term, concept, or procedure. When approaching a WHAT question, follow these steps:
Step 1: Understand the question
Carefully read the question and identify the specific term, concept, or procedure that needs to be explained or defined. Pay attention to any specific instructions.
Step 2: Provide a clear explanation or definition
Offer a clear and concise explanation or definition of the term, concept, or procedure. Use simple language and avoid unnecessary words.
Step 3: Provide examples if applicable
If the term, concept, or procedure can be further elucidated with examples or scenarios, provide relevant and practical illustrations to enhance understanding.

Example WHAT question:

“What is sepsis?”

Sample response:

Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection becomes unregulated, leading to widespread inflammation and organ dysfunction. It is often triggered by bacterial, fungal, or viral infections, but can also result from other sources of inflammation.

Nursing Exam Question Approach Read More »

Osteogenesis Imperfecta

Osteogenesis Imperfecta
Osteogenesis imperfecta (OI) also known as brittle bone disease, is a genetic disorder characterized by fragile bones that break easily.
OR
Osteogenesis imperfecta is a disorder of bone fragility chiefly caused by mutations is the COL1A1 and COL1A2 that encode type I procollagen.
Osteogenesis imperfecta (OI) is a genetic disorder that results in fragile bones.
▪ OI affects both bone quality and bone mass
▪ It is a genetic disorder
▪ OI is the most common cause of osteoporosis and it is a generalised disorder of
connective tissue.
▪ Osteoporosis is fragility of the skeletal system and a susceptibility to fractures of the
long bones or vertebral compressions from mild or inconsequential trauma.

Aetiology
❑ OI is caused by a mutation on a gene that affects the body’s production of collagen found in bones and other tissues. People with OI have less collagen than normal or a poorer quality than normal
❑ OI is caused by defects in or related to a protein called type 1collagen. Collagen is an essential building block of the body. The body uses type 1 collagen to make bones strong and to build tendons, ligaments and teeth.
❑ Certain gene changes or mutations cause the collagen defects
❑ About 80%-90% of OI cases are caused by autosomal dominant mutations in type 1 collagen genes, COL1A1 and COL1A2. These mutations cause the body to make either abnormally formed collagen or too little collagen
❑ The remaining cases of OI are caused by autosomal recessive mutations in any of the six genes ( SERPINF1 ,CRTAP ,LEPRE 1 ,PPIB ,SERPINH1 ,and FKBP10)
❑ These gene changes are inherited, or passed down from parents to their children.
Epidemiology
The autosomal dominant forms of OI occur equally in all racial and ethnic groups whereas recessive forms occur predominately in ethnic groups with consanguineous marriages.
The west African founder mutation for type VIII OI has a carrier frequency of 1 in 200- 300 among African-Americans.
The incidence of OI detectable in infancy is approximately 1 in 20,000
Pathophysiology
People with OI are born with defective connective tissue or without ability to make it, usually because of deficiency of type 1 collagen. This deficiency arises from an amino acid substitution of glycine to bulkier amino acids in the collagen triple helix structure.
The larger amino acid side-chains create steric hindrance that creates bulge in the collagen complex, which in turn influences both the molecular Nano mechanics and the interaction between molecules which are both compromised
As a result, the body may respond by hydrolyzing the improper collagen structure.
If the body doesn’t destroy the improper collagen, the relationship between the collagen fibrils and hydroxyapatite crystals to form bone is altered, causing brittleness.

Clinical Manifestations
❑ Short stature
❑ Weak tissues, fragile skin, muscle weakness and loose joints
❑ Bone deformities such as bowing of the legs
❑ Hearing loss
❑ Discolouration of the sclera, may be blue, purple in colour
❑ Curvature of the spine
❑ Breathing problem
❑ Easy bruising of skin
❑ Soft, discoloured teeth

Classification of OI
The silence classification divides OI into 4 types based on clinical and radiographic criteria. Types V and VI were later proposed based on histologic distinctions.
❖ Osteogenesis imperfecta Type I (mild)
OI type 1 is sufficiently mild that is often found in large pedigrees. Many type 1 families have blue sclerae, recurrent fractures in childhood and presenile hearing loss (30%-60%). Other possible connective tissue abnormalities include hyperextensible joints, easy bruising, thin skin, scoliosis, hernia and mild short stature compared with family members.
❖ Osteogenesis imperfecta Type II (Perinatal Lethal)
Infants with OI type II maybe stillborn or die in the first year of life. Birth weight and length are small for gestational age. There is extreme fragility of the skeleton and other connective tissues. There are multiple intrauterine fractures of long bones which have a crumpled appearance on radiographs.
There are striking micromyelia and bowing of extremities; the legs are held abducted at right angles to the body in the frog leg position. The skull is large for body size, with enlarged anterior and posterior fontanels. Sclerae are dark blue-grey.
❖ Osteogenesis imperfecta Type III (Progressive Deforming)
OI type III is the most severe non-lethal form of OI and results in significant physical disability. Birth weight and length are often low normal. Fractures usually occur in utero. There is a relative macrocephaly and triangular faces.
Disorganization of the bone matrix results in a “popcorn” appearance at the metaphysis
All type III patients have extreme short stature
Dentinogenetic imperfecta, hearing loss and kyphoscoliosis may be present or develop over time
❖ Osteogenesis imperfecta Type IV (moderately severe)
Patients with OI type IV can present with utero fractures or bowing of lower long bones. They can also present with recurrent fractures after ambulation and have normal to moderate short stature.
Most children have moderate bowing even with infrequent fractures • Children with OI type IV requires orthopaedic and rehabilitation intervention.
Fracture rates decrease after puberty. Radiographically they are osteoporotic and have metaphyseal flaring and vertebral compressions.
Patients with type IV have moderate short stature. Scleral hue maybe blue or white.
Classification of OI
Forlino and Marini in 2015 offered an alternate way of understanding the genetics of osteogenesis imperfecta by sorting into five functional categories as follows:
Group A. These are the primary defects in collagen structure and function.
Group B. These are the collagen modification defects.
Group C. These are the collagen folding and crosslinking defects.
Group D. This group includes ossification or mineralization defects.
Group E. The group includes osteoblast development defects with collagen insufficiency.

Assessment and Diagnostic Findings
Results of diagnostic tests on people with osteogenesis imperfecta are useful in ruling out other metabolic bone diseases.
Collagen synthesis analysis. Collagen synthesis analysis is performed by culturing dermal fibroblasts obtained during skin biopsy.
Prenatal DNA mutation analysis. Prenatal DNA mutation analysis can be performed in pregnancies with the risk of osteogenesis imperfecta to analyze uncultured chorionic villus cells.
Bone mineral density. (DEXA scan). A scan of the bones to check for softening. Bone mineral density, as measured with dual-energy radiographic absorptiometry, is generally low in children and adults with osteogenesis imperfecta.
X-ray. Images may reveal thinning of the long bones with thin cortices or it may reveal beaded ribs, broad bones and numerous fractures with deformities of the long bones.
Biochemical testing which may include a skin sample to examine the collagen
Blood tests or urine tests; usually to rule out other conditions such as rickets
Differential Diagnosis
• Child abuse
• Rickets
• Scurvy
• Osteopetrosis
• Leukaemia
• Cushing syndrome

Treatment and Management
There is no cure for OI
Aims of management
To reduce fracture rate
prevent long bone deformities
minimize chronic pain
maximize functional capacity.
The main modalities of treatment can be grouped into medications, surgical intervention, physical therapy, and experimental therapies.
Medications:
Bisphosphonate therapy
It is the mainstay of pharmacologic fracture prevention therapy for most forms of OI. Observational studies show that bisphosphonates for children reduced fracture frequency up to 100%.
Intravenous pamidronate
– For patients with all forms of OI, IV pamidronate is advised, except Type VI, in whom clinical benefits are likely to outweigh potential long-term risks (i.e., those with long bone deformities, vertebral compression fractures, and ≥3 fractures/year)
– Pamidronate is administered IV in cycles of 3 consecutive days at 2–4-month intervals with doses ranging from 0.5–1 mg/kg/day, depending on age, with a corresponding annual dose of 9 mg/kg.
– Smallest effective dose should be used, with careful monitoring of vertebral geometry and long-bone fractures
– NOTE : Pre-treatment evaluation and monitoring
– Calcium and vitamin D intake are based on recommended dietary allowance for child’s age (700–1300 mg/day calcium and 400–600 IU vitamin D) should be supplemented before treatment is initiated if dietary intake is inadequate. Indices of calcium homeostasis (e.g., calcium, phosphorous, and parathyroid hormone) and renal function test should be assessed before initiation of treatment and followed every 6–12 months.
– Calcium levels are to be assessed before each IV bisphosphonate infusion to assure that child is not hypercalcaemic.
Surgical intervention
Management of fractures (with quick mobilization to prevent bone loss due to inactivity) and placement of intramedullary rods to prevent or correct long-bone deformities are advised. Telescoping rods is advised for patients older than >2 years who are actively growing. Those with severe scoliosis may benefit from surgery.
Intramedullary rod replacement. In patients with bowed long bones, intramedullary rod replacement may improve weight bearing and, thus, enable the child to walk at an earlier stage than he or she might otherwise.
Surgery for basilar impression. This procedure is reserved for cases with neurologic deficiencies, especially those caused by compression of brain stem.
Correction of scoliosis. Correction of scoliosis may be difficult because of bone fragility, but spinal fusion injury may be beneficial in patients with severe disease. • In utero bone marrow transplant. In utero bone marrow transplantation of adult bone marrow has been shown to decrease perinatal lethality.
Physical and occupational therapy
Physical therapists are instrumental in designing physical activity program that minimizes fracture risk, ensuring mobilization to prevent contractures and bone loss from immobility.
Occupational therapists can address impairments in activities of daily living secondary to upper or lower limb deformities.
Experimental therapies
Growth hormone
In a single randomized trial, thirty prepubertal children with OI (Types I, III, and IV) were observed for 12 months during ongoing neridronate therapy and then randomized to recombinant growth hormone (GH) plus neridronate or neridronate alone.
Growth velocity were found to be significantly higher in the group that received GH compared with control group, but no differences were observed in the fracture risk.
Cell replacement therapies
Pilot study of allogeneic hematopoietic cell transplantation was performed in five children with OI; three children had successful engraftment, and in these 3, improvements in growth velocity and reduction in fracture rate were noted following transplantation. More clinical research is needed for exploring this modality.
Complications.
➢ Respiratory infections such as pneumonia
➢ Kidney stones
➢ Joint problems
➢ Hearing loss
➢ Eye conditions and vision loss
➢ Basilar invagination
➢ Brain stem compression
➢ Hydrocephalus

Nursing Care
Nursing Diagnosis
Desired Outcomes
Intervention
Rationale
Deficient
Knowledge related new diagnosis of
osteogenesis
imperfecta, as
evidenced by
patient’s
verbalization of “I want to know more how to manage my illness.”
At the end of the health teaching
session, the patient will be able to
demonstrate
sufficient knowledge of his/her condition and its
management.
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of
diagnosis or poor lifestyle habits)
To address the
patient’s cognition and mental status towards disease
management and to help the patient
overcome blocks to learning
Activity
intolerance related to bone pain, as
evidenced by bone pain score of 7 out of 10, fatigue,
disinterest in ADLs due to pain,
verbalization of
tiredness and
generalized
weakness
The patient will
demonstration
active participation in necessary and
desired activities and demonstrate
increase in activity levels
Assess the patient’s activities of daily
living, as well as
actual and perceived limitations to
physical activity. Ask for any form of
exercise that he/she used to do or wants to try.
Encourage
progressive activity through self-care and exercise as
tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods.
Administer
analgesics as
prescribed prior to exercise/ physical activity.
Teach deep
breathing exercises and relaxation
techniques.
To create a baseline of activity levels and mental status related to chronic pain,
fatigue and activity intolerance.
To gradually
increase the
patient’s tolerance to physical activity.
To provide pain
relief before an
exercise session.
To allow the patient to relax while at rest and to facilitate
effective stress
management.

Provide adequate ventilation in the
room.
To allow enough
oxygenation in the room.
Acute Pain related to the fragility of the bones evidenced by pain score of 7 out of 10, verbalization of sharp pain,
guarding sign on the affected areas
especially long
bones, facial
grimace, crying, and restlessness
The patient will
demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital
signs, and absence of restlessness.
Administer
prescribed pain
medications.
Assess the patient’s vital signs and
characteristics of
pain at least 30
minutes after
administration of medication.
Place the patient in complete bed rest during severe
episodes of pain.
To alleviate
acute/chronic bone pain. Pain is usually described as sharp and spasmic.
To monitor
effectiveness of
medical treatment for the relief of bone pain. The time of
monitoring of vital signs may depend on the peak time of the drug
administered.
To enable to patient to rest and to
provide comfort.
Risk for injury
related to fragile
bones
The patient will be able to prevent
injury by means of exercising falls
prevention protocols and maintaining
his/her treatment regimen in order to regain normal
balance and healing.
Complete a falls risk assessment, which includes:
Factors contributing to falls risk
Functional ability
Use of mobility
devices
Use of bedrails
Put the bed at the lowest level.
Place items within the patient’s reach.
The use of a
standard tool will help identify the
status of the
patient’s risk for
falling and will help determine the
factors contributing to the falls risk.
Low set beds reduce the possibility of
injuries related to falls.
Items far away from the patient’s reach may contribute to falls and fall-related injuries.

Refer to
physiotherapy and occupational
therapy.
Patients with
fracture may need therapies to help them regain
independence and lower their risk for injury.
Impaired Physical Mobility related to vertebral and joint inflammation as
evidenced by severe leg pain rated 8 out of 10, leg muscle weakness, failure to perform ADLs, and verbalization of
fatigue
Patient will maintain or regain functional mobility.
Perform a mobility assessment. Assess the patient’s
function ability to perform activities of daily living (ADLs) such as eating,
bathing, oral and perineal care.
Refer the patient to the physiotherapist.
To identify patient’s current strengths and problems
related to
performing ADLs
To provide
specialized care and individualized
exercise program.

Practice Test: Osteogenesis Imperfecta
1. The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents:
A. That the baby will need daily calcium supplements.
B. To lift the baby by the buttocks when diapering.
C. That the condition is a temporary one.
D. That only the bones are affected by the disease.
1. Answer: B. To lift the baby by the buttocks when diapering.
Option A is incorrect because children with osteogenesis imperfecta have normal calcium and phosphorus levels.
Option C is incorrect because the condition is not temporary.
Option D is incorrect because the teeth and the sclera are also affected.
2. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
A. Likes to play football.
B. Drinks several carbonated drinks per day.
C. Has two sisters with sickle cell trait.
D. Is taking acetaminophen to control pain.
2. Answer: A. Likes to play football.
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports.
Options B, C, and D are not factors for concern.
3. A patient presents with multiple fractures and blue sclera of the eye. The same disease in infants would result in:
A. Death.
B. A, C, D.
C. Fractures.
D. Blue sclera.
3. Answer: B. A, C, D.
Death, fractures, and blue sclera can all occur in a patient with osteogenesis imperfecta.
Options A, C, D: All options can be found in a patient with osteogenesis imperfecta.
4. What bone disorder is caused by an autosomal dominant defect in the synthesis of collagen type 1?
A. Osteogenesis imperfecta.
B. Achondroplasia.
C. Osteopetrosis.
D. Osteomyelitis.
4. Answer: A. Osteogenesis imperfecta.
Osteogenesis imperfecta can be caused by an autosomal dominant defect in the synthesis of collagen type 1.
Option B: The FGFR3 gene instructs your body to make a protein necessary for bone growth and maintenance. Mutations in the FGFR3 gene cause the protein to be overactive. This interferes with normal skeletal development.
Option C: Osteopetrosis, literally “stone bone”, also known as marble bone disease and Albers-Schönberg disease, is an extremely rare inherited disorder whereby the bones harden, becoming denser, in contrast to more prevalent conditions like osteoporosis, in which the bones become less dense and more brittle, or osteomalacia, in which the bones soften. Osteopetrosis can cause bones to dissolve and break.
Option D: Most cases of osteomyelitis are caused by staphylococcus bacteria, types of germs commonly found on the skin or in the nose of even healthy individuals.
5. Which drug reduces the incidence of fracture and increases bone mineral density, while reducing pain levels and increasing energy levels?
A. Risedronate.
B. Gentamycin.
C. Tramadol.
D. Pamidronate.
5. Answer: D. Pamidronate.
Cyclic administration of intravenous pamidronate reduces the incidence of fracture and increases bone mineral density while reducing pain levels and increasing energy levels.
Option A: Oral biphosphates such as risedronate may have some effect in reducing fractures in patients with osteogenesis imperfecta.
Option B: Gentamycin is an antibiotic that reduces the signs and symptoms of infection.
Option C: Tramadol is an opioid pain medication used to treat moderate to moderately severe pain.

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Osteomyelitis

Osteomyelitis
Osteomyelitis is a pus forming infection of the bone.
It is among the commonest conditions in children, decreasing as the child grows, and it increases in patients who are immune compromised, mainly aﬀecting older children.
Cause
Children develop infection in a long bone metaphysis. The commonest causative organism is Staphylococcus aureus, following infection elsewhere in the body despite the infrequency of staphylococcal
bacteremia, presumably because of that organism’s particular ability to infect bone
Common causes

Age group
Most common organism
Newborns (less than 4 months
S. aureus ,Enterobacter species & group A&B streptococcus species.
Children (aged 4months to 4yrs )
S. aureus, group A streptococcus species, haemophilus influenza and enterobacter species.
Children 4yrs to adult
S. aureus (80%), groupA streptococcus species, H influenza and enterobacter species
Adult
S. aureus and occasionally Enterobacter or streptococcus species
Sickle cell anemia patients
Salmonella species are the most common in patients with sickle cell disease
Note;
In children the long bone are usually affected. in adults, the vertebrae and the pelvis are most commonly affected.
Acute osteomyelitis invariably occurs in children because of rich blood supply to the growing bones.
When adults are affected it may be because of compromised host resistance due to debilitation, intravenous drug abuse, infectious root canaled teeth or other disease like immunosuppressive.

Wald Vogel Classification of Osteomyelitis
Osteomyelitis can be classified according to;
Duration of Infection
Mechanism of bone infection
Duration of Infection
Acute osteomyelitis ( suppurative osteomyelitis) is usually regarded as that which occurs before there is actual bone death. Initial episodes of Edema, formation of pus, vascular congestion, thrombosis of small vessels, e.t.c
Chronic osteomyelitis (suppurative osteomyelitis phase ) osteomyelitis involves infection both, within and around, the bone that has died. Recurrence of acute cases, Large areas of ischemia, necrosis, and bone sequestra.
N.B.: Acute osteomyelitis can lead to chronic osteomyelitis because without treatment, the infection and inflammation block the blood vessels and causes the bone to die. Chronic osteomyelitis is harder to treat Sequestra= a fragment of dead bone attached to healthy bone
Mechanism of Bone Infection
Hematogenous: Secondary to bacterial transport through the blood. Majority of infections in children
Associated with vascular insufficiency: Infections in patients with diabetes affecting the feet, or peripheral vascular insufficiency
Contiguous: Bacterial inoculation from an adjacent focus. E.g. Posttraumatic Osteomyelitis like from neighboring tissue, infections from prosthetic devices

Pathophysiology of Osteomyelitis
Causative bacteria enters bone causing an infection. Bacteria can enter bone via bloodstream, from a nearby infection, or direct contamination Risk factors include: Open wound over a bone, Open fracture, Recent surgery, Injection around bone, Medications that weaken immune system, Pre-morbid conditions (diabetes).
In general, microorganism may infect the bone through one or more of the three basic methods.
Via the blood stream. (haematogeneously) the most common method. From nearby areas of infection (as in cellulitis )
Penetrating trauma including Iatrogenic causes such as joint replacement or internal fixation of fractures or secondary peripheral periodontitis in teeth
The area usually affected when the infection is contracted through the blood stream is the metaphysis of the bone. Once the bone is infected, leukocytes enter the infected area and in their attempt to engulf the infectious organisms, release enzymes that lyse the bone.
Pus spreads into the bone’s blood vessels, impairing their flow and areas of devitalized infected bone known as sequestra, form basis of chronic infection. Often the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucium.
On histologic examination these areas of necrotic bone are the basis for distinguishing between acute osteomyelitis and chronic OM
The history is usually short, 48 hours or less. Initially, there is bone pain and marked tenderness without visible inflammation. When infection spreads sub periosteally, local and systemic signs of infection appear. Pus then forms in bone and soft tissues. The appearance of the bone does not change for 10–14 days so radiographs are a baseline for future change and to exclude differential diagnoses (Ewing’s sarcoma, leukaemia). Softening of soft-tissue planes may be seen. OM is all infective process of bone (osseous) component including the bone marrow. When it is chronic, it can lead to bone sclerosis and deformity.

PREDISPOSING FACTORS
Pyomyositis (bacterial infection of muscle)
Cellulitis
Sickle-cell disease (thrombotic crisis)(causative agent mostly S.Aureus, Salmonella also common)
Diabetes
Intravenous drug use
Prior removal of spleen
Age
Immune suppression
Autoimmune disorder
Systemic infections
Signs and Symptoms of Osteomyelitis.

Acute osteomyelitis
Onset is usually over several days
Fever, usually high but may be absent, especially in neonates
Pain (usually severe) in the affected limb
Tenderness and increased “heat” at the site of infection, swelling of the surrounding tissues and joint
Reduced or complete loss of use of the aected limb
The patient is usually a child of 4 years or above with reduced immunity, but adults may also be afected.
History of injury may be given, and may be misleading, especially if there is no fever
Malaise
Redness of the limb
Edema of the limb
Chronic osteomyelitis
May present with pain, erythema, or swelling, sometimes in association with a draining sinus tract
Deep or extensive ulcers that fail to heal after several weeks of appropriate ulcer care (e.g. in diabetic foot), and non-healing fractures, should raise suspicion of chronic osteomyelitis
Deferential diagnosis
Infection of joints
Injury (trauma) to a limb, fracture (children)
Bone cancer (osteosarcoma, around the knee) and adults.

Management of Osteomyelitis
Management can be medical or surgical or both.
Aims of management
To preserve limb and joint function
To prevent further complications
Admission
Child is admitted to pediatric ward.
Patient’s history is taken of including name, sex, address, nationality. Past medical history, past surgical history are taken
Assessment
Vital observation T,P,R and BP and recorded in patients chart
Assessment of patient limb for redness, hotness, edema, general examination of the patient from head to toe
Doctor is informed who will order the following investigations.
Investigations / Diagnosis
Diagnosis is through physical examination, laboratory findings and radiological findings.
¾ X-ray shows
– Nothing abnormal in first 1-2 weeks
– Loss of bone density (rarefaction) at about 2 weeks
– May show a thin “white” line on the surface of the infected part of the bone (periosteal reaction)
– Later, may show a piece of dead bone (sequestrum)
¾ Blood: CBC, ESR, C&S: Type of bacterium may be detected
Medical Management
Immobilize the limb, splint
Elevate the affected limb
Provide pain and fever relief with paracetamol, or ibuprofen
Typically patient need antibiotic for several weeks to properly treat the infections.
Drain the infected site.
Immobilize or stabilize the bone if necessary.
Administer intravenous antibiotics like Cloxacillin Child: below 12yrs 50 mg/kg every 6 hours; Above 12year 500 mg IV every 6 hours for 2 weeks. Then Continue orally for at least 4 weeks (but up to 3 months) if it fails; then,
Ceftriaxone 50mg-100mg/kg for about 10 days, vancomycin, penicillin and ciprofloxacin can also be used depending on results from culture and sensitivity.
Administer analgesics depending on severity like, ibuprofen acetaminophen, morphine for pain relief.
Failure to improve after 48-72 hours of antimicrobial therapy surgical intervention is considered by;
Surgical intervention may be indicated in the following cases: Drainage of subperiosteal , soft tissue abscesses, and intramedullary purulence
Removal of necrotic bone tissue and local pus or drainage is often necessary to speed up healing.
– Debridement of contiguous foci of infection (which also require antimicrobial therapy)
– Excision of sequestra (i.e. weak and lifeless bone) Debridement of the area to remove necrotic tissue.
Failure to improve after 48-72 hours of antimicrobial therapy
Chronic osteomyelitis
Surgery and antibiotics
Continue with the Administration of intravenous antibiotics like ceftriaxone 50mg-100mg/kg for about 10 days, vancomycin, penicillin and ciprofloxacin can also be used depending on results from culture and sensitivity

Nursing Care
Nursing Diagnosis
Ineffective Tissue Perfusion Related to: Inflammatory reaction, Thrombosis of vessels, Tissue destruction, Edema, Abscess formation As evidenced by: Bone necrosis, Continuation of the infectious process, Delayed healing, Pain, Erythema, Swelling, Altered sensation in the affected area, Weak peripheral pulses.
Ineffective Tissue Perfusion Interventions:
1. Establish blood flow at the site.
Blood circulation distributes nutrients throughout the body, aids in controlling waste production, enhances site recovery, and speeds up the healing process. Healthy blood flow across vessels, arteries, veins, and capillaries maximizes perfusion.
2. Manage chronic conditions and lifestyle factors.
Diabetes, peripheral vascular disease, sickle cell disease, neuropathy, smoking, malnutrition, and more affect the revascularization of the affected area. These need to be addressed before surgical intervention.
3. Provide DVT prophylaxis.
Anticoagulants should be administered as ordered to promote circulation and prevent the development of blood clots.
4. Prepare for possible surgery.
Depending on the degree of vascular insufficiency, procedures to restore adequate blood flow, such as debridement or vascular surgery may be necessary.
5. Prevention through pressure ulcer prophylaxis.
Patients who are immobile or bed-bound are at an increased risk of experiencing osteomyelitis due to pressure ulcers. By implementing appropriate interventions such as turning schedules and skin care, this can be prevented.

2. Hyperthermia Related to: Increased metabolic rate, Infection, Inflammatory response, Trauma As evidenced by: Increased body temperature, Warmth to touch, Flushed skin, Tachypnea, Tachycardia
Hyperthermia Interventions:
1. Provide a tepid sponge bath.
Tepid sponge baths lower body temperature and provide comfort to the patient.
2. Apply a cooling blanket.
A cooling blanket can lower the internal body temperature by surface cooling. Monitor closely to prevent a rapid drop in body temp.
3. Initiate antibiotics.
Long-term antibiotics are required for the treatment of osteomyelitis to control the infectious process. Instruct patients that antibiotic therapy may be required for weeks.
4. Instruct on symptoms.
Teach the patient and family that if fever, chills, warmth to the skin, or skin flushing is observed that the body is attempting to fight off infection and to seek immediate assistance.

3. Acute pain Related to: Inflammation, Tissue necrosis As evidenced by: Verbalization of pain, Tenderness with palpation, Guarding behaviors, Facial grimacing, Increased vital signs.
Acute Pain Intervention
1. Reposition as needed.
Repositioning and turning can decrease the stimulation of the pain and pressure receptors.
2. Administer pain medication as prescribed.
Mild or moderate pain may be controlled with non-steroidal anti-inflammatory drugs (NSAIDs). More severe pain or pain related to debridement or surgical intervention may require oral or IV opioid medications.
3. Elevate or immobilize the site.
Elevation or splinting of an extremity may improve pain by increasing circulation.
4. Collaborate with physical and occupational therapists.
Physical and occupational therapists assist in pain management through exercise, stretching, and other techniques.
5. Anticipate referral to a pain specialist.
Osteomyelitis and its treatment can be very painful and prolonged. Acute pain can turn into chronic pain depending on the severity and pain tolerance of the patient, which may need a referral to a pain specialist.

Complications
Necrosis
Gangrene
Amputation
Sepsis
Cancer of the bone.

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Osteopenia of Prematurity

Osteopenia of Prematurity
Osteopenia of prematurity is the decrease in the amount of calcium and phosphorus in bones which makes the bones weak and brittle resulting into broken bones.
Prematurity affects bone mineralization and bone growth—thus the condition osteopenia of prematurity;
Normal bone is formed by the deposition of minerals, predominantly calcium (Ca⁺²) and phosphorus (P), onto an organic matrix (osteoid) secreted by the osteoblasts. Osteoclasts play an important role in bone resorption and remodeling.
Osteopenia of prematurity is principally a result of inadequate calcium intake to meet bone growth demands.
Causes
Lack of vitamin D (vitamin D helps in absorption of calcium from intestines and kidneys) by the mother during pregnancy which has to be transferred from the mother to the fetus.
Prematurity these neonates lose much more phosphorous in their urine than babies that are born full-term
Liver problems which may lead to deficiency of vitamin D e.g
cholestasis(obstruction of bile flow).
Signs and symptom
Clinically, osteopenia manifests between 6 and 12 weeks of age and is usually asymptomatic; however, severe manifestations may include the following:
Severe manifestations
Poor weight gain and growth failure.
Rickets-like findings may include growth retardation, frontal bossing, and epiphyseal widening.
Fractures may manifest as pain on handling.
Respiratory difficulties or failure to wean off ventilator support due to poor chest wall compliance.
Consequences of osteopenia. Osteopenia can result in myopia of prematurity due to alterations in the shape of the skull. In childhood, infants remain thinner and shorter with a decreased total BMC(Bone Marrow Concentration) and density. Increased urinary calcium excretion has also been reported.
Decreased movements
Swelling of the arm or legs due to unknown fractures.

Pathophysiology
Bone mineralization begins during embryonic phase of human development, but the large part of this process occurs in the third trimester of gestation, during this period .
The most of placental transfer of calcium and phosphorous occurs in the third trimester at the 34th week of gestation .when 80% of the mineral content is stored.
By the 28th week of gestation mineral accumulation is about 60mg/day then increases to more 300mg /day between 35-38th week .
The osteoblast produce the organic bone matrix for deposition of calcium and phosphate with a progressively expansion of bone volume through an increase in trabecular thickness. This This activity is thought to be important for bone development and it helps the baby to grow, If this doesn’t occur the child develops osteopenia of prematurity. Which leads to fractures of long bones including ribs resulting into respiratory insufficiency.
A premature infant may not receive the proper amount of calcium and phosphorus needed to form strong bones.
Premature babies lose much more phosphorus in their urine and they have limited physical activities which lead to weak bones.

Risk Factors
Fetal and neonatal causes
Prematurity and birthweight. Preterm birth results in Calcium and Phosphorus deficiency. The frequency of osteopenia is inversely related to gestational age and birthweight. Both conditions predispose these infants to mineral deficiencies in the face of increased nutritional and growth requirements.
Feeding practices. Delayed enteral feeding, prolonged use of parenteral nutrition, use of unfortified human milk, enteral feeding restrictions, and malabsorption states can result in mineral deficiencies.
Human milk is low in Phosphorus, and donor milk content is even lower compared with preterm maternal milk. Prolonged use can result in low serum phosphate levels and decreased incorporation into the organic bone matrix. Unfortified human milk cannot match the mineral accretion that can be achieved across the placenta.
Drugs. Corticosteroids, furosemide, and methylxanthines are commonly used in preterm infants and cause mobilization of Calcium from the bone, resulting in decreased bone mineral content.
Lack of mechanical stimulation. Bone growth requires mechanical stimulation that is interrupted by preterm birth, illness, sedation, and paralysis. Neurologically impaired infants with spina bifida have limited mobility and poor bone growth.
Vitamin D. Postnatal vitamin D deficiency may occur in breast-fed infants without fortification due to low levels (25–50 IU/L) in breast milk. Other causes of vitamin D deficiency in preterm infants include the following:
Renal (osteodystrophy) disorders.
Drugs such as phenytoin and phenobarbital increase vitamin D metabolism.
Aluminum contamination of parenteral nutrition.
Malabsorption of vitamin D and Ca⁺² can occur in infants with prolonged cholestasis and short gut syndrome.
Maternal factors
Maternal deficiency of vitamin D results in low fetal levels.
Maternal smoking, thin body habitus, low Calcium intake, and increased physical activity in the third trimester result in a decreased Calcium in the fetus.
Exposure to high doses of magnesium in utero, preeclampsia, chorioamnionitis, and placental infections are associated with osteopenia.
Higher incidence of postnatal rickets is seen in infants with intrauterine growth restriction (chronic damage to the placenta may alter phosphate transport).
Increased maternal parity and boys have higher incidence.
Placental hormones including estrogen and parathyroid hormone (PTH) and PTH-related protein also play a role.

Predisposing factors
Prematurity ;Gestation period of less than 30 weeks
Chronic use of medication that increase mineral excretion e.g diuretics ,theophylline.
Vitamin D deficiency.
Low parathyroid hormone during pregnancy which suppresses the fetal calcium and phosphorous levels.
A less effective intake of calcium and phosphorous occurs in infants with Poor tolerance to Enteral feeds with low mineral content who require total parenteral nutrition.
Common neonatal morbidities like sepsis, acidosis, necrotizing enterocolitis can impair bone remodeling by reducing osteoclast activity, decreasing calcium absorption and increasing calcium renal excretion.
Paralysis may increase calcium renal excretion.
Short gut syndrome(malabsorption of vitamin D and calcium

Diagnosis and Investigations
Radiographs. Most commonly, osteopenia is recognized on radiographs, which are often subjective.
Calcium levels may remain normal until late in the course.
Phosphorous. Serum phosphate levels are low (<3 mg/dL).
Ultrasound.  Ultrasound offers several advantages, including easy accessibility and lack of exposure to ionizing radiation. It uses peripheral sites such as the calcaneus and tibia. It measures both qualitative and quantitative bone properties, such as bone mineralization and cortical thickness, respectively, in addition to bone mass (osteopenia), elasticity, and microarchitecture.
Dual-energy x-ray absorptiometry (DEXA). DEXA is the gold standard used to assess both bone size and bone mineral status and can predict risk of fractures in newborn infants. However, limitations in its use and interpretation of data preclude wide clinical application.

Management
Aims
To restore normal calcium and phosphorus in the body
To prevent further complications or disease progress
Admission
The child is admitted to pediatric ward in case the child is referred from outside the hospital.
Assessment
A demographic data of patient is taken which includes name, age, sex, etc
A detailed medical and obstetric history,prenata and natal data,birth weight, APGAR score at birth history are taken
Physical examination is done from head to toe putting more emphasis on bone formation to notify any abnormalities.
Immediate care
Baby is put in a comfortable, warm bed to prevent hypothermia.
Analgesics like paracetamol 2.5mg 8hourly for three days are administered to relieve pain which may be due to unknown fractures.
In case of fractures immobilisation is done which helps to maintain the bone in position.
Meanwhile the doctor is called who will come and perform a quick assessment and order for investigastions which will help him make a diagnosis depending on the results.
Investigations will include:
Blood to detect calcium and phosphorus levels and a protein called alkaline phosphate.
Ultra sound to rule out fractures.
X-rays to rule out the extent of fractures.
TREATMENT
The following treatment is administered to the patient as prescribed by the doctor.
Calcium 1.25mmol/kg /dose added to iv fluids like normal saline and ringers lactate given until the condition is stable.
Iv Phosphorus 1mmol/kg/dose added to iv fluids until the condition stabilizes.
Vitamin D supplements are given to children with liver problems.
Nursing interventions
Ensure the baby is warm and comfortable.
Monitoring of vital observations i.e. TPR
Ensure the patient is getting a diet rich in calcium and phosphorus. By feeding the baby with fortified milk
Physical exercises by the physiotherapists are encouraged
Ensure the baby is getting adequate rest and sleep by providing a conducive environment.
Psychological care is done to the mother to allay the anxiety
Both environmental and personal hygiene is promoted to prevent cross infection.
Administration of medicine to the patient as prescribed by the doctor.
Weekly monitoring of urine calcium, phosphorus.
When the patient improves discharge is considered.
Advise on discharge
Mother is advised to continue feeding the baby on a diet containing calcium and phosphorus.
Mother is also advised to handle the baby gently since there is a risk of broken bones.
A return date is given to help in the follow up and to know the prognosis of the disease

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