PPN 301: 8-11

Benefits of Infant Feeding

Provides an opportunity for social and psychological interaction between parent and infant. ​

the gold standard of infant nutrition

establish a basis for developing good eating habits

Benefits of Breastfeeding ​for Infants & Children

1. Lower incidence of certain allergies

2. Less likely to die from SIDS

3. Protective against lymphoma & DM

4. Decreased risk of dental malocclusions

5. Pain relief for newborns undergoing painful procedure

Benefits of Breastfeeding ​for Mother

1. Decreased postpartum bleeding and more rapid uterine involution

2. Delayed return of menses --> decreased chance of pregnancy

3. Protection against perinatal mood disorders

4. Decreased risk of Cancers, Cardiac Disease & DM

Physiology of Lactation

Nipple Sucking —> impulse to Hypothalamus —> Posterior Pit release Oxytocin —> Milk ducts squeeze / contract to release Milk

Laid-back breastfeeding / biological nurturing

mother reclines in a comfortable position

Benefit: comfort, bonding, reduced stress, easier latch

Football hold Breastfeeding

breastfeeding position where the baby is held under the mom's arm

Benefit: for moms recovering from a C-section, those with large breasts, or when feeding twins. 

Cross Cradle Hold Breastfeeding

where the baby is held across the body, tummy to tummy

Benefits: good support, especially when babies are learning to latch, and allows for easier control over the latch

Latch On Position ​Correct

1. mother feels a firm tugging

2. no pinching or pain.

3. cheeks rounded, not dimpled.​

4. jaw glides smoothly with sucking.​

5. Swallowing is usually audible and sounds like a series of “ca”

6. baby cannot be easily removed

7. ​ mother’s nipple is not distorted

How to Break off Suction

inserting their finger in the side of the infant’s mouth between the gums and keeping it there until the nipple is completely out of their newborn’s mouth ​

1-2 Days Old Baby Requirements

Tummy: Cherry sized

Wet Diapers: 1-2

Soiled Diapers: 1-2 black / dark green

Weight: loss of 7% across first 3 days

3-4 Days old baby

Tummy: Walnut

Wet Diapers: 3-4

Soiled Diapers: 3 brown/green/yellow

Weight: loss of 7% across first 3 days

5-6+ Days old baby

Tummy: Apricot / egg

Wet Diapers: 6+

Soiled Diapers: 3 large, soft, seedy, yellow

Weight: 20-35g / day from initial loss & regain lost weight by 10-14 days

Nursing Care for Breastfeeding

1. Informed decision based on patient’s knowledge about the health benefits and comfort level

2. ongoing assistance and support = successful and satisfying breastfeeding experience

3. Ideal time to begin breastfeeding is within the first hour after birth, when the newborn is in the quiet, alert state​

4. Some cultures do not give colostrum and only feed when the milk comes in.

Sore nipples

Cause: due to poor latch, ineffective suck​

Solution: should break suction properly, reposition, attempt again

• rub breast milk on nipples after feed + air drying of nipples after feed

Engorgement

Cause: 2-6th days postpartum when increased milk production occurs​

• hard, throbbing, flattening of nipples

Solution: Feed frequently, warm compress, shower

Plugged ducts​

Cause: engorgement

• Sore Tender Lumps

Solution: encourage mother to massage lumps before/after feeds

• Feed on unaffected side, ensure complete emptying

Mastitis

Cause: Infection, 2-3 weeks postpartum

• Fever, Tachy, Chills, Malaise

Solution: breastfeed 2-3h, warm compress, massage, antibiotics

Attachment

emotional bond between baby and its parent that results from the satisfying interaction between parent and infant. ​

Optimizing Attachment

• Early contact​

  • May facilitate attachment process​

  • Early skin-to-skin contact​

• Extended contact​

  • Optimizes family-centred care​

  • Rooming-in

Factors that may influence decision to bottle feed:​

1. Lack of support for breastfeeding​

2. Multiple Births

3. Problems Breastfeeding

4. Lack of Interest / myths

5. Maternal Medication

6. Cultural Factors

Over-dilution

baby not getting adequate nutrients & calories

Under-dilution

can lead to hypernatremia – strain newborn kidneys​

Formula Feeding ​Safety

• Formula can be room temp or warm – not hot​

• Formula should never be microwaved​

• Bottle fed infants do not need supplemental vitamin D for first 6 months​

Formula Feeding Concerns

• Alternate milk sources should NOT be fed to infants​

• Honey or corn syrup should not be given to infants​

• Any formula left in the bottle after the feeding should be discarded because the infant’s saliva has mixed with it​

• Position infant to burp ​

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Postpartum Changes and Ongoing Physical Assessment​: BUBBLEE​
​

• B = Breasts (firmness) and nipples​

• U = Uterine fundus (location; consistency)​

• B = Bladder function (amount; frequency)​

• B = Bowel function (passing gas or bowel movements)​

• L = Lochia (amount; colour) --> secretion of the blood after delivery​

• L = Legs (peripheral edema)​

• E = Episiotomy/Laceration or Caesarean birth incision (perineum: discomfort; condition of repair, if done)​

• E = Emotional status (mood, fatigue)

Uterus Expected Findings - Postpartum

1. Loose floppy abdominal skin​

2. Uterus firm and contracting; not boggy

3. Involution: Uterus descending 1 fingerbreadth/day​

   1. Normal by 6 weeks

4. Afterpains-resolve in 3 to 7 days. ​

Uterus Abnormal Findings - Postpartum

• Uterine atony - failure of the uterus to contact-lead to postpartum hemorrhage ​

• Distended abdomen and hypoactive bowel sounds​

• Red, tender, dehiscing incision​

Vagina Expected Findings

• Returns to normal by 6-8 weeks​

• Some changes in vaginal rugae​

• Dryness until ovulation returns

• Edema, Clean Incision / Tear, Hemorrhoids possible

Vagina Abnormal Findings

Redness, ecchymosis, drainage, skin not approximated, hematoma, tenderness

Vagina Education

• Ice packs for first 24 hrs. (rotate 20 minutes on, 20 minutes off); then warm sitz baths ​

• Some women find witch hazel pads relieve pain​

• Adequate hydration​

• Potential need for stool softeners​

• Assess pain; discomfort​

Lochia rubra

(3 to 4 days)​

• Bright red or rust coloured flow

• Blood and decidual and trophoblastic debris

Lochia serosa

(lasting approximately 2 to 4 weeks)​

• Pink, brownish coloured​

• Old blood, serum, leukocytes, and debris

Lochia alba

(4-6 weeks)​

• Whitish, yellow​

• Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria

Signs of Postpartum Hemorrhage (PPH)

Soaking pad 1-2 hrs.; passing clots >golf ball; SOB, lightheaded, chest pains; palpitations ​

• Fundal Massage, Assess uterus, Call for Help​

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Postpartum Hemorrhage​

• Loss of 500 mL or more blood after vaginal birth

• 1000 mL or more after Caesarean birth

Cause: uterine Atony —> weak muscles / fail to contract

Primary PPH

occurs within 24 hours of the birth.

• s/s: atony, laceration, retained products, placenta accreta/increta, DIC

Secondary PPH

occurs between than 24 hours and 12 weeks after the birth

• s/s: subinvolution of uterus, retained products, infection, coagulopathy

Interprofessional care​ for PPH

involves restoring circulating blood volume and eliminating the cause of the hemorrhage​:

1. Establishing two venous access with a large-bore IV catheter: fluids & Blood restoration

2. Packed RBCs (prolonged bleeds) & Fresh Frozen Plasma (no clotting factors)

Bladder & Bowels​ Assessment

1. Voiding usually occurs within first 6 hrs.​

2. Usually attempt to empty bladder after 2hrs. ​

3. Potential for bladder distention due to normal postpartum diuresis ​

4. Epidural – potential for urinary retention​

5. Should have good bowel sounds; be passing gas.

Bladder Education/nursing consideration​

• assess ability to void Should be voiding regularly – minimum 360 cc/12 hrs

• Pat dry front to back to avoid infections

• Educate Kegel/pelvic muscles exercises to improve tone​

Postpartum Nursing Care​

1. Promote rest, ambulation, exercise, prevent infections and promoting comfort

2. Nutrition: caloric intake of 1800-2200 calories a day

3. Rubella Vaccination

4. Rh Globulin within 72 hours for Rh-Negative pts

Postpartum Blues​

Episodes of tearfulness, agitation, mood swings

• 1 to 5 days postpartum

• Resolves within 2 weeks and does not disrupt the postpartum patient’s ability

• S/S —> Mood swings, crying spells, feeling low, ​Fatigue

Nursing care for patients with postpartum blues

• validation​

• Reassurance​

• education

Perinatal Mood Disorders

• Triggered by a combination hormonal, physical, emotional and social factors

• Causes significant distress

• Indigenous, Black people, and adolescent have a higher chance of developing postpartum depression​

Risk Factors for PMD​

A history of psychiatric illness, Prenatal Symptoms of Anxiety

Complications of Having a PMD​

1. Mother–infant attachment issues​

2. Depression in the partner​

3. Long-term emotional behavioural and cognitive issues in the child​

4. Social, financial, and occupational complications​

5. Self-harm and suicide​

6. Infant and sibling neglect

Perinatal Anxiety​

Pervasive feeling of anxiety and constant worry​

Perinatal Anxiety​ Care & Education

1. Psychotherapy; cognitive behavioural therapy (CBT) and exposure response prevention (ERP)​

2. Medication: SSRIs and BZDs

3. Education: anticipatory guidance, help identify triggers

Perinatal Depression​

1. Intense and pervasive sadness with severe and labile mood swings that lasts more than 2 weeks

2. Feelings of detachment, Guilt and shame, reluctant to discuss symptoms

Collaborative care​ for Perinatal Depression

1. Psychotherapy; cognitive behavioural therapy (CBT)

2. SSRIs, Peer support, hospitalization (Severe)

Postpartum Psychosis​

episodes of abnormally elevated energy levels, cognition, and mood (mania)

• Hallucinations, delusions, thoughts of harm

• Psychiatric emergency

Collaborative care​ for Postpartum Psychosis

1. Antipsychotics, mood stabilizers, and benzodiazepines are the treatments of choice​

2. Psychotherapy after acute phase has passed​

3. Electroshock therapy (ECT)

PMD Screening

• Postpartum Depression Screening Scale (PDSS)​

• A maximum score on the EPDS is 30; patients with scores of 10 or higher may possibly have depression and need further assessment

Perinatal Loss and Grief​

Grief is a process of recovering from a loss.

Phase 1: Shock and numbness (Grief)

1. sense of unreality, loss of innocence, and powerlessness

2. Sadness, devastation,

3. May express lack of affect, euphoria, and calmness may occur and may reflect numbness

Phase 2: Searching and yearning​ (Grief)

1. feelings of loneliness, emptiness, and yearning.

2. guilt may emerge from the deep feelings

3. anger, resentment, bitterness, and irritability​

Phase 3: Disorientation​ (Grief)

• Deep sadness and depression​

• insomnia, social withdrawal, and lack of energy

Phase 4: Reorganization and resolution​ (Grief)

• self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

Adverse Childhood Experiences (ACE)​

Measure adverse childhood experiences including physical and sexual abuse, emotional neglect, household dysfunction

• Higher ACE score the worst outcome on addictive behavour, depression, anxiety, suicide​

ACE scores of 4 or higher

likely to smoke, 7x more likely to be alcoholics, 7x more likely to have sex before 15, 2x more likely to have cancer and heart disease​

ACE score of above 6

30x more likely to attempt suicide, 46x more likely to use drugs

ACE’s Abuse

1. Physical – Hitting – Contact​

2. Emotional – Screaming, Breaking down Self Confidence​

3. Sexual Abuse

ACE’s Neglect

• Physical Neglect --> not offering them basic necessities​

• Emotional Neglect --> ignore emotional needs​

ACE’s Household Dysfunction

• Mental Illness

• Mother treated violently

• Divorce

• Incarcerated Relative

• Substance Abuse

Sensorimotor Stage - 2 years

understand thru Sense & Action

Preoperational Stage - 2-7 years

Understand thru Language & mental Images

Concrete Stage - 7-12 years

Understand thru Logical thinking & categories

Formal Operational Stage - 12+ years

Understand thru Hypothetical thinking & Scientific Reasoning

Trust & Mistrust (18mths)

18 months – Trust​

• Meeting emotional & physical needs​

Mistrust: occurs with the opposite

Autonomy & Shame (3 yrs)

3 Years – Autonomy​

• Mastering toilet training – encouragement, training​

Shame: occurs with blaming and screaming​

Initiative & Guilt (3-7 yrs)

7 Years – Initiative​

• Exploring how to learn, making decisions – encouragement, appraising achievements

Industry & Inferiority (8-12y)

8-12 Years – Industry:​

• Reflection, Sharing, Loose validation with the parents, reinforcements, sense of accomplishments​

Identity & Role Confusion

Adolescent – Identity​

• Friends are crucial at this stage – Getting to know themselves, Future careers, Different social

Successful mastery of developmental tasks

• Engage in age-appropriate independent decision making​

• multiple perspectives

• Problem solve effectively at an age-appropriate level ​

• Develop & maintain age-appropriate relationships​

• Demonstrate a sense of resiliency

Factors central to child development​

1. Relationships: attachment & security & mental

2. Nutrition

3. Physical activity

4. cognitive development: Literacy, numeracy, language

IMPROVING EARLY CHILDHOOD DEVELOPMENT ​- WHO Guideline

1. First 3 Years – Responsive Care​

2. Early Learning – Exposure, learning activities, explore scenarios, play​

3. Integrate & Nutrition – optimal nutrition for development​

4. Support Maternal Mental Health

What are the determinants of early childhood development

1. Income

2. Effective Parenting & Family Functioning

3. Positive Social Interaction

4. Play

5. Poor neighborhoods

6. Safe Home environmnets

Living in geographic locales with limited resources or high levels of neighborhood violence

can produce adverse and toxic environments, which threaten family and child well-being

Poverty has lasting impacts: “Early catastrophe”

• much more likely to struggle with parental mental-health issues

• impact family functioning, parenting behaviours, level of parent involvement

• that children in richer homes were exposed to 30 million more words by age 3 than children in lower income households

Resilience does not mitigate poverty completely​

• adult life outcomes of low SES resilient kids are lower than those of advantaged/privileged underachievers. ​

• SES has a very strong influence both on individuals’ early development and on life chances.

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Bryant et al., 2011

1. Lack of social policies to support healthy child and family development ​

2. pre-primary spending show that Canada is 36th of 37 nations ​

3. Despite Federal promises to create a national childcare program, one does not exist in Canada​

Home Learning Environment matters

• supportive home learning environment can help mitigate the negative impacts of poverty on cognitive development​

  • increased cognitive and social abilities

Who is responsible for early childhood development

• Parents: Poor parenting skills are a strong predictor of anti-social behaviour. ​

• Family: Family members who could provide support now live hundreds of miles away. ​

• Communities – all members of the community have a responsibility for the healthy development of children. ​

• Government: Provision of accessible social programs

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Comprehensive School Health ​
​

• schools can directly influence students’ health and behaviours​

• recognizes that healthy young people learn better and achieve more

• ​encourages healthy lifestyle choices, and promotes students’ health

• Helps students develop the skills needed for academic success

Social Aspect of School health

• promoting quality of the relationships ​

• emotional well-being of students​

• relationships with families and the wider community​

• Supportive of the school community building competence, autonomy, and connectedness ​

Physical Aspect of School health

• buildings, grounds, play space, and equipment ​

• sanitation, air cleanliness, and healthy foods​

• promote student safety and connectedness and minimize injury​

• Safe, accessible, and supportive community

Teaching & Learning of School health

• Formal and informal provincial / territorial curriculum, resources, and associated activities

• Professional development opportunities for staff related to health and well-being.​

Healthy School Policy of School Health

Policies, guidelines, and practices that promote and support student well-being and achievement e.g. respectful, welcoming school environment for all

Nurses Role in School Health Promotion​

1. Assessment, support, counseling and referral of students

2. Health education and skill development

3. Clinical Services Provision, Wellness Clinics, Consultations and Coordination

4. Participation in Case Conferences

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Physical activity requirements for children​

• Children and youth aged 5 to 17 should get at least 60 minutes of moderate-to-vigorous intensity physical activity per day

Nasopharyngitis / Common Cold

Clinical manifestations: stuffy,, sneezing, low-grade fever, mild hacking

Therapeutic Management: treated at home, comfort, teaching signs

Respiratory syncytial virus (RSV)​

• Most common cause of bronchiolitis in infants

• If a child is at high risk for serious lung infections, they will need treatment once a month

  • Palivizumab --> injecting antibody into children to build immunity​

• Spread by touching, living on hard objects for more than 6 hours

Influenza​

• Caused by orthomyxoviruses​

• fever* or feeling feverish/chills + cough.

Therapeutic management/Nursing care​

• rest​

• fluids, like water​

• medication to reduce any fever or aches

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Prevention —> Yearly vaccination

Injectable influenza vaccines (IIV4)

approved for use in as young people 6 months and older

Live attenuated influenza vaccine (LAIV4)

Approved for non-pregnant, healthy people 2 through 49 years old. ​

• Not ideal for Immunocompromised​

Emergency Warning Signs of Flu​ - FBR CMD NS104 <12 Weeks R

• Fast breathing or trouble breathing​

• Bluish lips or face​

• Ribs pulling in with each breath​

• Chest pain​

• Severe muscle pain (child refuses to walk)​

• Dehydration (no urine for 8 hours, dry mouth, no tears when crying)​

• Not alert or interacting when awake --> ASK parents for Baseline​

• Seizures​

• Fever above 104°F​

• In children less than 12 weeks, any fever​

• Fever or cough that improve but then return or worsen

Acute Otitis Media (AOM)​

infection located in the middle ear d/t cold, sore throat, or respiratory infection.​

• Difficulty balancing can be indicator

​

Pharmacological: Amoxicillin​

Surgical: Placement of ear tubes — surgically inserted into the eardrum to enable drainage

Prevention: Pneumococcal 13-valent conjugate vaccine​

Otitis Media: Nursing Care​

1. Relieving pain --> Heat Packs

2. Facilitating drainage

3. Educating the family in care of the child

4. Have the child sit up, raise head on pillows, or lie on unaffected ear.

5. Healthy diet/fluid intake​

6. Hygiene( hand washing)​

7. Monitoring hearing loss

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Bronchitis​

increased mucus production and narrowing the airway --> associated with 2nd hand smoking​

Cause: virus/bacteria, allergens

Complication: pneumonia

Manifestations: persist cough, mucus, fever &chills, SOB, fatigue

Bronchitis: Nursing Care​

Avoid antihistamines because they dry up the secretions and can make the cough worse.

• Avoid secondhand smoke, humidify air, fluid intake, acetaminophen