Concepts in Maternal & Child Health Care | CONTINUOUS

Testable Questions

1. Which of the following is true about health inequity in Canada?

   1. Canadian youth report higher happiness scores, and lower rates of poverty than most developed countries

   2. Homelessness concerns adult males more than any population

   3. Poor health outcomes seen in high-risk populations are essentially inevitable

   4. Adolescent girls from low-income families should e a focus for health care prevention and intervention

4. Adolescent girls from low-income families should e a focus for health care prevention and intervention

1. A nurse is caring for a family whose mother has been dx w/a highrisk pregnancy due to maternal morbidity. During a family meeting the husband expresses feelings of anxiety & uncertainty about the future. The nurse understands that this situation is best described as 

   1. A maturational crisis

   2. A situational crisis

   3. A developmental crisis

   4. A psychosocial adjustment

2. A situational crisis

1. Which scenario qualifies as a maternal death according to definition provided by WHO

   1. Women dues in car accident 3 days after birth

   2. Woman dies due to chronic medical condition 

   3. Woman dies from complications of preeclampsia one week after C-section

   4. Woman dies workplace accident

3. Woman dies from complications of preeclampsia one week after C-section

1. 25 yr old pt asks nurse during prenatal visit is pregnancy bad for my health?

1. Pregnancy is generally not harmful to health but an present risks for certain ___

1. Nurse is educating a group of expectant parents about pregnancy complications/ Which of the following definitions best describes a stillbirth?

1. An infant who died in utero and at birth demonstrates no signs of life, such as breathing, heartbeat, voluntary movement……

1. Newborn presents w/resp. Distress shortly after delivery, the baby was born at 41 weeks and the amniotic fluid was noted to be green-stained during delivery. Which of the following historical or mythical references might est represent the tx hornet for the condition

   1. Jason and the Golden Fleece

   2. Hercules and the hydra

   3. Prometheus & the fire

   4. Persephone and the seasons

1. Jason and the Golden Fleece

1. A public health nurse is working w/low-income family in a community w/high infant mortality rates. Mother has a low level of education & is expecting her first child. Based on the SDOH which of the following interventions should the nurse prioritize to address potential inequalities in infant mortality?

1. Provide education on nutrition prenatal and proper infant care

2. Refer family to social support, ie housing or financial assisted programs

3. Discuss importance of regular prenatal care & assist in accessing healthcare providers

1. Nurse providing preconception counseling to a 38 year old woman. What statement indicates she knows and has understood the nurse

“My age increases the risk of my baby having chromosomal abnormalities”

1. Public health nurse working to improve maternal health outcomes for indigenous families in a remote community. Which intervention aligns w/reducing barriers to care?

Increase the availability of culturally safe sexual & reproductive health services

1. Nurse provides care to pregnant homeless lady. Which nursing strategy is most appropriate to address the pts concern? Pt expresses 

Use trauma and violence informed approaches

1. A nurse is educating a community group about human trafficking, what indicates that someone needs further education

Primarily occurs only in developing countries, not developed ones like canada

1. Which of the following activities is the primary role of health canada….. 

Developing policies & procedures…. 

Aboriginal Head Start in Urban & Northern Communities

• Population:

• Goal of the Program:

Canada Prenatal Nutrition Program

• Population:

• Goal of the Program: “Community based, supports new moms and moms to be, goal is to improve pregnant people and infants“

Community Action Program for Children

• Population:

• Goal of the Program: “Promotes healthy development for children, specifically help people who face teen preg, poverty, violence, substance use, goals include increase access to programs, decrease social isolation“

Healthy Early Years Program (Hey Program)

• Population:

• Goal of the Program:

Nobody’s Perfect Parenting Program

• Population:

• Goal of the Program:

Healthy Baes, Healthy Children Program

• Population:

• Goal of the Program:

EarlyON Child & Family Centers

• Population:

• Goal of the Program:

• Free programs from birth to 6 years of age that are open to all families in Ontario that launched in January 2018

• Ontario has over 750 EarlyON Centres in Ontario, 7 in North Bay that operate in both english and french 

• They operate commonly through libraries, schools, community centers both in person and virtually 

• And offer services such as reading, storytelling, sing-alongs, games for children and they help families build connections with other families and provide professional advice in early childhood development 

• 4 foundational conditions: belonging, engagement, expression, and well-being that they believe are crucial for childhood growth and development 

• These services are primarily funded through a partnership between the provincial and federal government

Canada Child Benefit

• Population:

• Goal of the Program: “Monthly payment for however many kids you have under the age of 18, reduces childhood poverty 

• Canada invests 1.7% of their GDP into childcare and families complain“

Week 2 Case Study: Pre-Conception

Week 2 Case Study: Adolescent Pregnancy

Week 2 Case Study: Breastfeeding & Spinal Cord Injury

Week 2 Case Study: Maternal Decision-Making

Week 2 Case Study: Menopause

Week 2 Case Study: Female Genital Cutting

2016 Census on Canada’s Black Population

Over 1 million black people in Canada, 51% being black women

Estimated to double by 2036

What approach does Canada take to reduce racism in healthcare?

Colour-blind approach

• it creates gaps that don’t allow for depiction of the marginalization & health disparities that black women may face & may not reflect how communities understand and talk about health

______ is a social determinant of health evidenced by the extreme rates of morbidity & mortality among black women

anti-black racism

Ontario Government (2022) Definition of Anti-Black Racism

“prejudice, attitudes, beliefs, stereotyping and discrimination that’s directed at people of African descent” … “rooted in their unique history & experience of enslavement & its legacy”

Dr. J. Marion Sims

• Father of Gynecology

• Dating back to decades of reproductive oppression & dehumanization within the healthcare system → perfecting & experimenting techniques & instruments on black women w/o consent & pain management

Addressing Black Maternal Mortality

• Black women are 3 times more likely to die during pregnancy & childbirth compared to white women 

• Black women are more likely to receive poorer quality of obstetrical care in hospitals than white women 

• Causes of maternal mortality are…direct obstetrical causes, pre-existing medical conditions, socioeconomic factors, environmental factors

MATERNAL & NEONATAL HEALTH IN CANADA’S BLACK COMMUNITIES

• High preterm birth rate

• Increased risk for gestational diabetes mellitus, preeclampsia, placental abruption, preterm birth, spontaneous preterm birth, all C-sections, emergency C-section, low birth weight, small-for-gestational-age, neonates, NICU admission, hyperbillirubinemia requiring tx 

• Fibroids are 3x more common in black women & oral hormonal therapy for fibroids may not be effective for fibroids in black women. Melanin plays a key role, lack vitamin D

• High odds of not receiving a pap smear

• High maternal mortality rate 

OBSTETRIC RACISM IN PERINATAL CARE IN CANADA

• Obstetric racism: beliefs & practices that harm the reproducing black body

• Forms of violence & abuse experienced by black women when assessing maternal healthcare services 

• Intersection of obstetric violence & medical racism 

ANTI-BLACK MEDICAL GASLIGHTING DIAGRAM (photo on slides)

• Not being understood: privileging of medical knowledge contributing to the downplaying of health concerns → 

• Listen to us: turning off the cycle of medical gaslighting → 

• Not being believed: stereotype contributing to dismissive healthcare encounters

x8 RECOMMENDATIONS FOR HEALTHCARE PROVIDERS

1. Address implicit bias & establish training for culturally safe & unbiased care throughout pregnancy

2. Improve awareness & education on health inequalities in marginalized groups and their root causes

3. Hold authorities accountable for improving comprehensive Canadian research on health disparities and gaps in black maternal health 

4. Develop community partnerships & hospital programs to increase access to maternal health for all women & implement standardized protocols for care

5. Acknowledge & listen to lived experiences of black women & ask questions to better understand concerns

6. Prioritize earlier screening and prompt tx of conditions that may arise during pregnancy or postpartum for at-risk pts

7. Educate ALL pts during pregnancy & postpartum periods on risk factors, urgent warning signs & when to seek immediate care

8. Develop a national system to track maternal morbidity & mortality in Canada so that important changes can be made 

THE ACT OF BLACK MOTHERING (movie?)

• Black motherwork → embodying the intersection between survival, identity, and power as crucial to the histories, lived realities, and systemic vulnerabilities endured by black women

• Black mothering is familial

• Good mothers → challenging the belief that black women are not the true standard for mothering

• Black mothers engage in resistance when they disengage from ableist & racist educators & decide to instruct (teach) and repair their children in the home

• Resist the oppressive interaction between home & school 

• Instill a strong sense of self-confidence in kids to counteract the negative impacts of racial discrimination

• Hypervigilant & overprotective of kids, knowing they're liable to encounter racial violence 

RECLAMATION OF THE BLACK WAYS OF KNOWING & BEING THROUGH BLACK MOTHERING 

• Systemic racisms in the institution of schooling (streaming, suspensions, unfair discipline, condition of schools)

• Black mothering school navigation survival strategies 

  • Knowing one’s right, drawing on community support, othermothering, knowledge transmission of black mothers, avoid presenting themselves in ways that might lead them to be stereotyped “angry black woman” 

Queer Mothering - Guest Speaker

gender based violence

• defined as any form of abuse/assault/harassment that can be linked to dominant societal gender norms

Intimate partner violence (IPV)

• one highly prevalent form of violence situated under the umbrella of GBV and include the multiple forms of harm inflicted on an intimate partner

• 44% of women in Canada & globally 

IMPACT OF GV ON MATERNAL HEALTH (inc. risk of… & social consequences)

• Increased risk of…

  • Loneliness, depression, anxiety, PTSD, premature labor, miscarriage, stillbirth 

• Social Consequences: 

  • Lack of autonomy, social isolation, negative mental health & wellbeing, lack of freedom & movement in action, limited access to healthcare, feelings of loneliness & maternal stress

IMPACTS OF IPV ON PARENTING & PRIOR TO OR DURING PREGNANCY 

• Reproductive coercion, unplanned pregnancies, pregnancy can be a trigger for increased violence (further stressors & doubt their parenting abilities) 

IMPACTS ON FETAL HEALTH (increased risk of…)

• Low birth weight, preterm birth, mortality & morbidity, neonatal care unit admission

IMPACTS OF GBV ON THE BIRTHING PROCESS & OUTCOMES DURING LABOR 

• Dissatisfaction w/the birthing process

• Greater need for pain relief

• Higher levels of anxiety

• Preterm birth

• Lower birth weight

• Increased risk for c-section due to maternal fears

• Pooer breast-feeding outcomes

• Antepartum hemorrhage

IMPACTS OF GBV ON POST-PARTUM 

• Women who experience GBV during pregnancy often experienced increased GBV in postpartum period

• Children exposed to GBV in first 6 months to 8 years of age 

• Psychological IPV being the most prevalent form

• Increased risk of postpartum depression

• Emotional dysregulation (hypervigilance, intrusive thoughts,numbing)

• Lower rates of meeting WHO breastfeeding guidelines 

• Poor bonding 

KEY FACTORS THAT INFLUENCE A MOTHER’S DECISION TO LEAVE AN ABUSIVE RELATIONSHIP 

• Hitting rock bottom, relationship fatigue, safety fears, shifts in mother-infant bond, awakened maternal identity and leaving violent relationships for the infant/child

• Custody & access issue

• Children and support during transition

• Legal system & protection

MULTIPLE SYSTEMS OF OPPRESSION FOR SURVIVOR-MOTHERS

• Intersectional systems & structures of oppression that influence their experiences of IPV (ie:help-seeking) and parenting: welfare, criminal justice systems, medical institutions, family courts 

  • Construct survivor-mothers as “bad mothers” who have willingly made the decision to live with violent partners 

• Indigenous women: colonial dynamics→ child welfare system often perpetuate harmful stereotypes and family separation 

• Survivor-mothers in same-sex relationships: stigma from homophobia & heterosexism  affecting access to support

• Women in rural & remote communities: isolation that limits services, opportunities, and escape options

• Newcomers and immigrant women: instances rooted in racisms, immigrant status, cultural expectations, and a lack of diverse support services

HOW ABUSIVE PARTNERS USE CHILDREN AS TOOLS OF POWER/CONTROL

• They may portray themselves as better parents especially during separation, inserting themselves into children’s routines in ways that may not support their well-being 

• Survivor-mothers parenting is frequently criticized, blamed, and undermined, sometimes directly in front of the children

• Some abusive partners expose children to violence–or threaten harm or child protection involvement –to control survivor-mothers

CONSIDERATIONS FOR SUPPORTING SURVIVOR-MOTHERS & CHILDREN 

• Focus of the behavior of abusive partners: “all-of family approach”

  • Focus on accountability & change in men who use violence & their impact

  • Support & collaborate w/mothers to promote safety

  • Expect the same standards of parenting & co-parenting from fathers as for mothers and primary caregivers

  • Keep children safe, and where possible, together with a protective parent

  • Recognize & harness the power of informal support networks 

• Use strengths-based approaches to better understand & support survivor-mothers

• Programs supporting mothers and children exposed to IPV across Canada include:

  • Mothers in Mind, Kids Club & Mom’s Empowerment, Motherscraft Society

EFFECTIVE STRATEGIES TO PREVENT & RESPOND TO GBV

• Integrated Approach

  • Address both practical needs & broader social/health/political aspects to fully support mothers experiencing GBV

• Ecological Approach

  • Multi-level approach to address to the roots of GBV, recognizing its social, cultural, economic, and political context

  • Interventions should span individual, interpersonal, community, and societal levels

• Trauma and Violence Informed Care

WHAT IS TRAUMA?

• Trauma = experience of and response to, a negative event or events that threaten the person’s safety, life or integrity, and overwhelms their ability to cope

• More than everyday “stress”, PTS is an anticipated response to significant threat

• Traumatic stress can be acute (rx from a single event) or chronic & complex (from repeated experiences) 

• Includes responses such as shock, terror, shame, and powerlessness (flight, fight, freeze, fawn)

EXAMPLES OF TRAUMATIC EXPERIENCE 

• Interpersonal Trauma

  • Child abuse & neglect

  • Abandonment

  • Sexual assault

  • Intimate partner violence

  • Children’s experience of IPV

  • Sudan death of a loved one

  • Torture or confinement

  • Abuse of older adults

• Situational Trauma

  • War, being victim of crime, unexpected job loss, being a refugee, extreme poverty, homelessness, natural disasters, accidents 

IS TRAUMA IS A COMMON EXPERIENCE 

• Canada = 76% 

TRAUMATIC STRESS REORGANIZES THE BRAIN 

• Decreased activity in prefrontal cortex, chronic hyper-arousal (brain stem driven) 

• Brain stem (increased arousal that is chronic even w/o threat, irritability, anger, insomnia)

• Neocortex (high-order thinking)

• Limbic Brain (emotions)

• Amygdala (signals releases of stress hormones such as cortisol)

COMPLEX INTERACTION OF GENETIC, BIOLOGICAL, AND SOCIAL FACTORS 

• Genetics & gene-environment interactions

• Epigenetics (ie: changes to DNA) 

• Early life experiences/ACEs

• Social disadvantages (greater exposure to adversity and stress and future trauma)

• Severity & chronicity of the trauma/violence

• Community factors such as social cohesion

VICARIOUS TRAUMA 

• Negative reaction to exposure to the trauma of those around us, including those we serve

• Is an anticipated response to hearing and seeing the effects of trauma & violence

• Often mirrors the symptoms of primary traumatic stress (flight, fight, freeze, fawn)

SUPPORTING STAFF

• Staff education about VT and its impacts

• Opportunities for debriefing reflective supervision 

• Employee assistance programs

• Organizational supports for self-care 

BEING TRAUMA AWARE…

• Means recognizing that traumatic stress affects how people think, feel, and behave

• Clients who have experienced (multiple) traumatic events may experience traumatic stress…this influences how they….

  • Think: dissociation, difficulties concentrating, feeling out of control, avoidance of certain people/places/situations, overwhelmed, angry, hypervigilance, feel distracted 

  • Talk about their Health: sleep, problems, chronic pain, migraines, GI problems, heart palpitations, breathing difficulties, pelvic pain, anxiety, depression

  • Behave: including in risky ways, especially substance use, smoking

  • Feel: irritable, disconnected, ashamed, guilty, w/o meaning/purpose, numb, hopeless, self-hating, self-blaming

TRAUMA-SPECIFIC CARE VS TRAUMA-INFORMED CARE/PRACTICE (TIC/P)

• Traum-Specific Care 

  • Specialized health services delivered by practitioners who have expertise & skills in all stages of trauma treatment

  • Focuses directly on the trauma itself and on trauma recovery using evidence-based approaches 

• Trauma-Informed Care/Practice 

  • Universal approach for use in all services settings

  • Focuses on understanding the impacts of trauma and creating environments that promote emotional & physical safety for all

  • However, may reinforce ideas that trauma exists in the minds of individuals

INTERPERSONAL VIOLENCE: A UNIQUE TYPE OF TRAUMA 

• Abuse of power and violation of trust in important relationship–deep impacts that can change beliefs & disrupts attachments

• Often ongoing (chronic experience) and inter-generational 

• Risk of physical injury, harm, death…safety is paramount

IMPLICIT BIAS 

• Attitudes/stereotypes that affect our understanding, actions and decisions in an unconscious manner 

• Research has found that health care providers often have implicit biases towards, for example, people w.mental illness who come into ED, labelling such pts as unfixable or difficult. They avoid these pts because they don’t feel like they can offer any help

• From the point of view of a service user, however, this avoidance may be experienced as stigma & discrimination

TRAUMATIC IMPACTS OF STRUCTURAL VIOLENCE 

• Racism, stigma, discrimination, collective/historical violence & persistent poverty are structural issues that impact well-being

MOVING FROM TRAUMA-INFORMED TO INCLUDE VIOLENCE-INFORMED

• TVIC brings attention to…

  • Broader social conditions, including policies, that affect well-being

  • Ongoing & historical violence including collective violence

  • Discrimination & harmful practices embedded in the ways systems & people know/do things

  • Safety & well-being of providers, teams, organizations

• Responses to trauma/violence including substance use are anticipated effects of highly threatening events and their ongoing impacts

• Shift the focus from what’s wrong to what’s happened and is it still happening in the persons head/life 

Acknowledges that interpersonal violence are complex and often chronic forms of trauma→ different from other traumatic experience

TVIC’S GOALS

• Prevent Harm: by creating safe environment

• Universal Approach: disclose or knowledge of hx of trauma/violence is not necessary

• Accountability: at the organizational & individual provider levels 

TVIC PRINCIPLES FOR ORGANIZATIONS & INDIVIDUALS (X4)

• 1. Understand trauma, violence and its impact on people’s lives & behavior

  • Organizations can develop policies to build a culture based on understanding trauma and violence, train staff on the effects, all services start w/violence & trauma awareness as a foundation for a culture of TVIC

  • Provider should view challenging behaviors through a trauma lens, be mindful or potential hx/red flags, disclosures handled appropriately 

• 2. Create emotionally, culturally, and physically safe environments for all clients & providers

  • Organizations can seek client input about sfe & inclusive strategies, support staff at risk of vicarious trauma, safety protocols developed w/clients in a TVI way

  • The provider should be aware of impacts of power differences & boundaries, non-judgemental approach so people feel accepted and deserving, clear info & predictable expectations, consider safety in relationships can impact them seeking help

• 3. Foster opportunities for choice, collaboration, and connection

  • Organization create policies/processes thta allow flexibility & encourage person-led decision making & participation

  • Involve staff & clients in identifying implementation and evaluation strategies for services/programs

  • Providers should use non-judgemental responses, provide realistic options, consider choices collaboratively, actively listen 

• 4. Use a strength-based and capacity-building approach to support clients 

  • Organization should allow sufficient time for meaningful engagement, program options that can be tailored to people’s needs, strengths and contexts & include client input, staff are provided w/ongoing opportunities for development

  • Provider should listen & validate clients strengths, acknowledge the effects of hx, teach skills for recognizing triggers, calming, centering 

TVI LANGUAGE

• Use persons first language to describe someone’s ehaviro or circumstances, this avoids labeling people in stigmatizing ways and reflects the potential for change

• Convey optimism & give hope

• Respect a person's autonomy, that they are the expert on their own life and use language that reflects collaboration with provider

• Use language that normalizes and re-frames responses to trauma, is strength-based and future-orientated 

WHAT IS ATTACHMENT

• Attachment = the dependency relationship children develop towards their primary caregivers

• The process by which a parent comes to love and accept a child and a child comes to love and accept a parent 

• Begins to show during the latter half of their first year post-birth & develops progressively over the first 4 years

• Most readily observed when children are sick, injured, tired, anxious, hungry, and at reunion after temporary separations

• Early attachment research focused on the mother-infant dyad 

• An attachment figure = someone who provides physical & emotional care, has continuity & consistency in the child’s life and an emotional investment in the child’s life 

• Vasopresin and oxytocin are attachment hormones 

ORIGINS OF ATTACHMENT THEORY?

• Harlow & Zimmerman Experiment (1959)

  • Monkey baby experience → baby separated from mother and reared by surrogates. One surrogate was terry cloth covered and other was wire mesh → monkey preferred soft cloth covered mother DONC rx: developing a close and does not depend on hunger satisfaction; contact comfort is more important and need for closeness and is much deeper 

  • There was this belief that attachment strayed from hunger & food provider 

• Mary Ainsworth 

  • Strange situation study with mother, infant, and stranger and leaving the infant in the room and evaluating how the child reacts when mother leaves and returns

• John Bowlby

  • Infant’s goal directed behavior was governed by 2 kinds of drive: primary and secondary 

    • The alleviation of hunger & thirst was thought of as a primary drive (infants were considered to form a close bond to their mother because she feeds them)

    • Relational aspects of the infant-mother interaction (referred to as dependency) were considered to be secondary 

  • His theory is evolutionary because his view of attachment is behavioral and has evolved because of both its survival and reproductive value

    • Attachment is adaptive and innate 

    • A secure base

    • Safe haven

    • Proximity maintenance

    • Separation anxiety

HOW DOES ATTACHMENT DEVELOP

• Pre-attachment (broth to 3 months)

• Recognition/discrimination (3-8 months)

• Active attachment (8-36 months)

• Partnership (36 months onwards)

WHAT DOES ATTACHMENT LOOK LIKE 

• At its most obvious during early childhood, can be observed throughout lifespan especially in emergencies

• Attachment behaviors serve to keep the caregiver connected to the child: physically, emotionally, and cognitively

• Eye-to-eye gaze, reaching smiling, signalling or calling to, pouting, holding or clinging, protesting separation, seeking to be picked up, following, sitting with, searching, verbal engagement/need expression 

TYPES OF ATTACHMENT/ATTACHMENT STYLES

• Secure

• Insecure-avoidant

• Insecure-ambivalent

• Disorganised/disoriented

SECURELY ATTACHED INFANTS & CHILDREN 

• 60& of 12-20 month old infants in western countries are securely attached

• They exhibit a [reference for contact & involvement with their attachment figure though after an initial period of shyness will feel comfortable enough to engage with strangers towards whom their attachment figure shows no anxiety

• Content to explore an unfamiliar setting w/o apparent anxiety in presence of their attachment figure

• Move away from the attachment figure to explore his physical and social world

• Basic trust: content to be left alone w/a relative stranger for a short period of time

INSECURE–AVOIDANT INFANTS & CHILDREN

• Difficult to cope best with separation form their attachment figure 

• No clear preference for their attachment figure or a relative stranger (lacking a strong emotional connection) 

• Appear relatively detached and self-reliant, even self-absorbed

• Appear relatively disinterested in their attachment figure following temporary separations

• Described as loners: likely to prefer solitary activities 

• Appear to have learned that relating to others is an unsatisfying experience 

INSECURE–AMBIVALENT/ANXIOUS-RESISTANT INFANTS AND CHILDREN

• Excessively clingy towards their attachment figure & distressed during separation

• Inconsistent caregiving 

• Caregiver’s distress can amplify the infant’s own distress, making regulation more difficult

• Challenging to soothe

• Infants & children w/insecure-ambivalent attachment exhibit both dependency and resistance, making them difficult to settle

• Often perceived as angry, demanding, needy due to their intense emotional response to separation and reunion 

DISORGANISED/DISORIENTATED INFANTS AND CHILDREN 

• No consistent or organized attachment behavior in response to reunion with their attachment figure 

• Bizarre and contradictory behaviors

• Incomplete movement and emotional displays

• Signs of worry in the presence of their attachment figure

THE CARE MODEL 

• C: consistency

• A: accessibility 

• R: responsiveness

• E: emotional connectedness

Application of the CARE model 

• Used in parenting strategies to promote secure attachment

• Apple in therapeutic settings to help caregivers improve their interactions with children

• Integrated into early childhood education to foster emotional resilience in young children

PARENTING FACTORS THAT IMPACT ON CARE

• Positive factors: 

  • Good parental role models, parenting experience, positive attitude to parenting/children, capacity to identify with others/empathy, secure attachment as a child

• Negative factor:

  • Parental mental health problems, parental substance use, domestic violence, poor parenting ability/knowledge, insecure attachment as a child 

WHY ATTACHMENT IS IMPORTANT?

• Development, concept of self, relatedness with others, resilience to adversity 

ATTACHMENT DISORDER (DSM-5 CRITERIA) 

• Reactive Attachment Disorder (RAD) 

  • Reduced dependency & responsiveness to care

  • Disturbed emotions and emotional responsiveness to others

  • These kids appear to avoid dependency on others

• Disinhibited Social Engagement Disorder (DSED)

  • Reduced dependency

  • Overfamiliarity

  • Indiscriminate sociability

  • These kids appear to treat everyone as if they’re a potential source of care

CARE & ATTACHMENT 

Attachment security & representations regarding self, other and world 

CARE & AROUSAL

• Gross deficiencies in CARE (neglect)/abuse

  • In the person (ie mental incapacities or lifestyles issues such as drug use)

  • In the environment 

  • In care arrangements (lack of consistent care) 

• Emotional distress

• Elevated arousal (the level of activation of a person’s NS)

CARE TO PROMOTE ATTACHMENT SECURITY

• Photo on slide 23 

• How can you be responsive to their needs? How can you be responsive? Know that there is a reason for everything and all behavior therefore listen and understand what they need of you…speak their mind. 

• Behavior management → correct their bad behaviors and provide explanations. Especially provide explanation when child’s request is reasonable but the timing is poor

DR. SEARS’ 7 B’S OF ATTACHMENT 

• Birth bonding

• Breastfeeding

• Babywearing

• Bedding close to baby

• Belief in baby’s cries

• Beware of baby trainers

• Balance & boundaries

ATTACHMENT PARENTING INTERNATIONAL (API)’S 8 PRINCIPLES

• Use nurturing touch

• Response with sensitivity

• Provide consistent and loving care

• Feed with love and respect

• Ensure safe sleep, physically and emotionally

• Guide for growth:practice positive discipline

Nutrition Across the Lifespan - Infants

• First 6 months: breastfeeding recommended (up to 2yrs)

  • Maternal iron depletes at 6months

  • No water → water intoxication & hyponatremia

• Second 6 months: human or formula milk is main source of nutrition, select solid foods, intro to solid food, no cow milk (should wait 9-12 minths before intro to cow milk

• No honey or corn syrup as they may contain bacterium Clostridium botulinum

Thawing Breast Milk

• Microwave BAD…reduces its anti-infective properties & vitamin C levels, milk layers separate and alters the fat content

• Should be thawing in lukewarm water or fridge overnight

Nutrition Across the Lifespan - 1+ Years Old

Canada’s Food Guide Reccommendations:

• emphasis on eating together as familiy, encourage kids to be a part of food preperation, let kid decide how much they want to eat

• Limit juice consumption (poor nutrition, obesity, tooth decay)

Nutrition Across the Lifespan - Toddlers

• Phenomenon of “physiological anorexia”

• ritualism

• offer cup rather than sippy cup

• 500ml of milk per day no more than 750ml as this amount rx in a deficiency of dietary iron & other nutrients

• Low fat milk after 2 years

Nutrition Across the Lifespan - Preschooler

• food fads, strong tastes: common

• amount of food: varies greatly day-to-day

• Enjoy helping adults prepare food and are more likely to try new food if they help in the preparation

Nutrition Across the Lifespan - School Age

• “junk-food” concerns

• no more than 250-375ml of juice per day

Nutrition Across the Lifespan - Adolescent

• increased nutritional requirements due to rapid growth

• Iron deficiency possible in females

Vegetarian Diets

• Kids have the right to be vegetarian

• Lacto-ovo vegetarian

• Lactovegetarian

• Vegans

• Macrobiotics

• Semivegetarians

Obesity in Canada

• Increased incidence of obesity across all ages

• Childhood obestoy has negative health outcomes

• Overweight has a BMI greater than 25 (85th -97th percentile)

• Obesity has a BMI greater than 30 (95th-99.9th percentile)

• Etiology & Pathophysiology

  • multifactorial

  • sedentary lifestyle

  • genetic influence

  • breastfeeding - decreased risk

  • family & ultural eating patterns

  • SDOH

  • psychological factors

Obesity - DX Eval & Management

• Diagnostic Evaluation:

  • estimate degree of obesity

  • psychosocial hx

  • BMI calculations

  • access for co-moriiity conditions

• Nursing Care & Management

  • holistic plan

  • diet, exercise, behavior modification, occasional pharmacological measures

  • bariatric surgery

  • nutritional counselling

  • behavioural therapy

  • group and family involvement

  • physical activities

Complementary & Alternative Medicine (CAM)

• Misuse or overuse

• Ensure safety & efficacy of supplement use in children

• Herbs known for adverse effects in children: ephedra, comfrey, pennyroy

  • Comfrey → oil for skin, acne, wound (can cause liver failure)

  • Ephedra → can cause heart palpitations

  • Pennyroy → used as mosquito repellant (can cx kidney & liver failure)

• Important to assess for use of CAM

• May interact w/medications

• More research is needed on safety

• Vitamins

• Herbal therapies

  • Ginger: has anticoagulant properties (needs to stop taking 2 weeks prior to sx)

Dental Health

• Developmental aspects of dental health

  • first dental visit should not be traumatic

  • dental hygiene

• Oral health

  • Early Childhood Caries (ECC)

• use of fluoride (don’t use for kids under 3 years of age, can cause brown stained teeth)

• removal of plaque

• dietary factors

• periodontal disease

• malocclusion

• dental avulsion - replacement or reattachment

• Dental pain in kids can lead to lost sleep, poor growth, behavioral issues, reduced ability to learn

• Poor oral health can negatively influence communication skills, social interactions, and overall self esteem

• WHO connects oral disease to major chronic conditions, including heart disease, cancer, chronic resp. disease, diabetes

Sleep, Rest, and Activity Integration - Infant

• Kids require high levels of physical activity, low levels of sedentary activity & sufficient sleep each day

• Sleep allows repair & recovery of tissues after activity

• Infants

  • (4-12 mo) need 12-16 hours

  • Establish bedtime routine

  • Concept of “graduated extinction” or “controlled crying” is of value in managing nighttime crying

    • They need to learn how to self-sooth

  • Back to sleep

Sleep, Rest, and Activity Integration - Toddlers

• Sleep 12/hr/night

  • infrequent naps, waking during night, difficulties falling asleep

• motor activity remains high

  • sedentary activity should be limited

  • longer electronic time = shorter sleep duration