PEDS exam 1

ACEs

Traumatic events that can occur during childhood and the teenage years and can have a lasting impact on a person's health and increase risk for chronic illnesses 

Protective measures 

• Promoting positive parenting 

• Reducing stigma around seeking help 

• Strengthening social connection and support systems 

• Public education campaigns 

• Legislative approaches to reduce corporal punishment 

• Bystander approaches to teach skills to intervene safely 

Developmental changes in growth and development

Growth

• Increase in physical size 

Development

• Sequential process of skill attainment 

Maturation 

• Increased functionality of body system or developmental skills 

Growth chart measures

• Weight 

• Length 

• Head circumference

premature baby adjusted age

• Use the infants adjusted age to determine expected outcomes 

• Plot growth parameters and assess developmental milestones based on adjusted age 

To calculate adjusted age 

• Subtract number of weeks infant was premature for infants chronologic age 

• Example 6-month-old-born at 32 weeks gestation 

  • 6 months minus 8 weeks - 4 months 

  • This infant's growth and development skills should be that of a 4month old 

Percentiles 

• Measures usually approximately the same growth percentiles over time 

• Significant deviations in percentiles requires further assesment 

infant weight changes

weight - average 3,400g (7.5 lb) at birth 

• Double by 6 months 

• Triples by 12 months 

infant length changes

• average 50 cm (20 in) at birth 

• Increases by 50% by 12 months

infant head circumference changes

• 35 cm (13.5 in) at birth 

• Increases by about 10 cm by 12 months 

• Posterior fontanel closes by 2 months, anterior fontanel closes between 12-18 

months 

failure to thrive

Definition: inadequate growth or inability to use calories so the weight is going to fall below 5th percentile or/and not being growth trajectories. 

• Organic - physiological reason (chronic cardiac, lung and metabolic diseases, cleft lip/palate, trisomy 21 - down syndrome)

• Nonorganic - related to psychosocial problem/parenting

• Idiopathic - most common , no explanation 

Factors leading to inadequate feeding 

• Poverty 

• Beliefs

• Feeding 

• Lack of knowledge 

• Family stress 

• Inadequately supplied 

• Care management 

• Goal is to restore nutritional status and treat underlying cause 

neurologic infant development disappearing at 4 months

• moro

• asymmetric tonic neck

• palmar grasp

• suck (2-5)

neurologic infant development disappearing at 9 months months

• plantar

neurologic infant development disappearing at 12 months

• babinski

neurologic infant development disappearing at 4-8 weeks

• step

neurologic development of babies

• Central nervous system not fully myelinated 

• Primitive reflexes present at birth 

• As primitive reflexes disappear, protective reflexes develop 

• Protective reflexes 

• Involuntary motor responses maintaining equilibrium 

• Persist throughout life 

respiratory of infants

• Nasal passages are narrower 

• Larynx is more funnel shaped 

• Trachea and chest wall are more compliant 

• Bronchi and bronchioles are shorter and narrower 

• Alveoli are significantly fewer in number 

• Respiratory rate is fast (60/min - decreases as the child matures) 

• Infants are abdominal breathers 

cardiovascular assessment

Heart doubles in size in the first year 

Average pulse rate 

• 120-140 in newborn 

• Decreases to about 100 in the 1-year-old

Blood pressure 

• Average of 60/40 in the newborn 

• Steadily increases to 100/50 in the 12-month-old

Peripheral capillaries closer to skin surface 

• Newborn and young infant more susceptible to heat loss 

• Thermoregulation becomes more effective over first few months

Gastrointestinal of infant

Tongue large relative to oral cavity size 

• Allows for nipple latch so infant can feed 

Stomach capacity increases as the infant grows 

Teeth emerge in a predictable pattern 

• First primary teeth (incisors) erupt at age 6-8 months 

Consistency and frequency stools 

• Meconium as new born 

• Change over the first year of life based on intake 

• Not uncommon to see undigested food 1-2 years of life due to immaturity of digestive process 

Genitourinary of infant

• Frequent urination 

• Low specific gravity of urine

• All renal functions reduced as compared to adult 

• More susceptible to dehydration 

• Poorer urine concentration ability 

integumentary of infant

Newborns 

• Lanugo and vernix may be present 

• Acrocyanosis is normal; decrease over first few days of life 

Infants skin relatively thinner than adults 

• Peripheral capillaries more superficial 

• Increased absorption of topical medications

Hematopoietic and immunologic of infant

High hemoglobin level at birth 

• Decreases over 2-3 months 

• Stabilizes by 6-9 months with adequate iron intake 

Maternal IgG stores transmitted to infant 

Infant igM level reaches adult level by 9 months of age 

Infant IgG levels reaches adult level by 12 months of age 

Assessing developmental milestones

Ask the parent if the skill has been attained 

Observe the skill during assessment 

Screening tools 

• Ages and stages questionnaire (ASQ) 

• Infant - toddler checklist (ITC) 

• Infant development inventory (IDI) 

• Parents evaluation of developmental status - developmental milestones (PEDS-DM)

social and emotional development of infant

• Infants trust their comfort needs will be met; necessary for strong sense of self to develop

  • Feeding 

  • Stimulation; tactile is important for developing trust 

  • Primary narcissism is peak 

• Mistrust 

  • Occurs when gratification of needs is delayed 

• Social modifications 

  • Grasping; initially reflexive 

  • Biting: aggressive; attempt to control what's theirs

  • Smiling: approximately 2 months as response to pleasurable stimuli

Stranger anxiety 

• Develops around 8 months of age 

• Infant recognizes self as separate from others

Separation anxiety 

• Developed in later infancy 

• Infants become stressed when parents leave 

Temperament ranges between 

• Low to moderately active regular, and predictable

• Highly active, more intense, and less adaptable 

Imitation

• Imitative wave (backwards initially) 

Play

• Repeat play once they master the act; develop a preference for certain toys around 4 months; play is a child's work 

Language development

• Crying, laughing, coo 4 months; “mama” “dada” 10-12 months; understand words such as “no” by 10-12 months 

Toys help to develop object permanence

• Jack in the box 

• Peak a boo 

motor skills of infant

• Gross motor skills develop in cephalocaudal passion (head to toe, center to out) 

• Fine motor skills develop in proximodistal fashion 

• Progression 1 

• Tummy times (supervised) is a important to do several times a day to help with infants develop head control, strengthen shoulders/neck muscles and prevent plagiocephaly 

• Starts at about 4 months 

1 month old motor skill

• lifts , turns head when prone, head lag

2 month old motor skill

•  raises head and chest, improving head control

3 month old motor skill

• raises head 45 degrees in prone, slight head lag

4 month old motor skill

• lifts head and look around, rolls from prone to supine

5 month old motor skill

• rolls from supine to prone and back, sits upright with support

6 month old motor skill

•  tripod sits 

7 month old motor skill

• sits alone with some use of hands

8 month old motor skill

• sits unsupported

9 month old motor skill

• crawls, abdomen off floor

10 month old motor skill

• pulls to stand "cruises”

12 month old motor skill

• sits from standing position, walks independently

1 month old fine motor skill

• fist mostly clenched, involuntary hand movements

3 month old fine motor skill

•  holds hand in front of face, hand open

4 month old fine motor skill

• bats at objects

5 month old fine motor skill

• grasp rattle

6 month old fine motor skill

• releases object in one hand to another

7 month old fine motor skill

• transfer object from one hand to the other

8 month old fine motor skill

• gross pincer grasp (rake)

9 month old fine motor skill

• bangs object together

10 month old fine motor skill

• fine pincer grasp, puts objects into container and takes them out

11 month old fine motor skill

• offers objects to others and releases them

12 month old fine motor skill

• feeds self with spoon pokes with finger index

Early warning signs: hearing or vision 

• Does not respond to loud noises 

• Does not make sounds or babble by 4 months of age 

• Does not turn to locate sound at age 4 months

• Crosses eyes most of the time at age 6 months (infants establish binocularity at 4 months) 

• Does not track (follow interesting item) 

• Doe snot try to study an object in visual field 

Breast feeding vs bottle feeding 

• Breast is best when possible 

• Health benefits for mother and infant 

• Requires correct use of breastfeeding techniques to be successful 

• Bottle feeding allows for increased paternal bonding 

• Cultural considerations 

• support systems 

• Breast milk production 

• Multiple types of formula available 

• Most formula adequate essential vitamins and minerals 

• Formula must be prepared according to package directions

• Formula requires cleaning bottles and nipples between feeding

• Increase bonding with infant 

• Lessens maternal blood loss postpartum 

• Decrease risk of ovarian and premenopausal breast cancers 

• Possible delay of ovulation

• Economic advantage 

• Decrease baby diarrheal diseases, asthma, otitis media, bacterial meningitis, botulism, urinary tract infections 

Promoting healthy eating habits 

• Breast - and bottle - fed infants feed “on demand”; don't microwave; transition to whole milk at 1 years 

• Introduce the cup early (6 months) 

• Adding solids 

• When tongue extrusion reflex disappears (4-6 months) 

• Soft or mashed until teeth erupt 

• 1 new food every 3 to 4 days (observe for allergy) 

• May require 20 exposures to accept food 

• Family models acceptable eating behaviors 

• Parent provides the food, the child will decide how much to eat 

 Dental health 

• Maternal dental health 

• Cleaning: washcloth to clean gums; begins when primary teeth erupt 

• Fluoride at 6 months (rural, well, bottle-need fluoride) 

Prevention of dental caries 

• No bottle propping 

• No milk or even water in bed 

• No fruit juices-water it down and limit to 4oz at most 

Spitting up; thumb-sucking; teething; shoes 

Spitting up 

• Common in many infants; smaller, frequent feedings, upright during and after feeding/ avoid infant seat after feeding, frequent burping 

• Avoid over feeding and frequently changing formulas 

• Monitor growth 

• Evaluate if vomiting ⅓ or more of feeding 

• Choking

• And forceful emesis 

Thumb sucking 

• APP says pacifier OK first 6 months 

• Can cause occlusion of teeth and affect language development 

Teething 

• Average 8 months 

Infant shoes 

• Soft, well constructed and athletic type shoes that are flexible best for infant/children, goal is foot protection 

Promoting healthy sleep and rest 

• Place newborns and young infants on their backs to sleep to decrease SIDS

• Newborns sleep up to 20 hours per day (waking only to feed) 

• By 3 months they should be sleeping per night and take 2-3 naps per day 

• Around 4 months establish a bedtime routine and facilitates relaxation and predictable sleep 

• By 12 months infants sleep 8-12 hours per night and takes 2 naps per day

Sudden infant death SIDS

• Sudden unexplained death of child less than one year of age 

• Risk factors

• Maternal substance use 

• Lwo apgar scores 

• Male sex

• Recent viral illness 

• Tobacco exposure

• Bed sharing/co sleeping

• Belly or side laying

• Overheating exposure 

prevention of SUIDS

• Back sleep

• Breast-feeding

• Pacifier 1-6 months 

• Immunizations up to date 

• Cool sleeping environment

• No tobacco exposure 

Safety promotion and injury prevention 

Car seats 

• Correct type, positioning of infant in seat-back, middle seat, rear facing, LATCH systems, securing of seat in vehicle, expiration dates, accidents 

hyperthermia : avoid overdressing; fever <3 months old needs evaluation 

Safe crib and changing table use 

Avoid use of baby walkers 

Safety in the home

• Safety gates 

• Outlet covers

Identify and avoid choking hazards (small toys, foods, toilets paper roll test)

Water safety less than 120

Colic rule of 3s

• Crying occurs in first 3 months 

• Crying at least 3 hours a day (not continuous) 

• 3 days/week for more than 3 weeks 

causes of colic

• Intrinsic

  • Gi spasms

  • Allergies

  • Gas buildup 

  • Immature nervous system 

• Extrinsic 

  • Tension in environment 

  • Anxiety of parents 

  • Inappropriate handling of baby 

  • Tobacco use in home

  • Breast feeding (avoid garlic, broccoli, cauliflower, chocolate, onions, cabbage)

  • Feeding problems

  • Maternal depression 

management of colic

• Parent journaling 

• Position (cuddle, swaddle, carriers, football hold) 

• Feeding - frequent burping; don't constantly change formula, Consider nipple size for infant , don't over feed, pacifier use, keep upright after feeding

• Environmental: peaceful, relaxed, car rides, no smoke exposure, chiropractor 

• Pharmacologic: tylenol, gripe water, 

Period of PURPLE cry  P

• Peak of crying: your baby may cry more each week, the most in month 2 less than 3-5M

Period of PURPLE cry U

• Unexpected: crying can come and go and you don't know why 

Period of PURPLE cry R

• Resists soothing: your baby may not stop crying no matter what you try 

Period of PURPLE cry P (second P)

• Pain like face: a crying baby may look like they are in pain, when they are not

period of PURPLE cy L

• Long lasting: crying can last as long as days or more

Period of PURPLE cry E

• Evening: your baby may cry more in late afternoon/evening 

Erickson 0-1

• Trust vs mistrust

•  relates to meeting child's needs (feeding, crying-  encourage parent to respond) 

Erickson 1-3

• Autonomy vs shame/doubt

• holding on vs letting go: protective view of environment; toileting training “NO” “myself”

erickson 3-6

• Initiative vs guilt

• exploration; pretend/dramatic play; choices

erickson 6-12

• Industry vs inferiority

• shaping feelings of self; identify what they are good at; school focus; learning skills of future 

erickson 12-18

• Identity vs role confusion

•  social relationships; fitting in with peers; experimentations (drugs, sex, alcohol, tattoos)

Infant developmental tasks across the life span

Developmental surveillance and early intervention are imperative in this stage 

Screen closely for language, motor, visual abilities, and communication patterns at every appointment 

• Use standardized screening tools, such as bayley scales of infant and toddler development (BSID ll or bayley-lll)

Promote skin-to-skin contact with caregivers 

Limit painful procedures 

Toddler developmental tasks across the life span

Standardized developmental assessment should be performed at 12,18, and 30 months of age

Provide extra emotional support to caregivers due to extra stress 

• Children often pull at tubes and equipment 

• Encourage medication, mindfulness, support groups, and other self-care activities 

Augmented-language intervention (ALI) can be used for children who have communication difficulties 

Encourage caregivers to allow limited choices and to promote autonomy 

Closely monitor height, weight, and nutritional status

Preschool developmental tasks across the life span

Highly dependent on caregivers for daily care and medication management 

• Screen caregivers for depression and stress levels and provide appropriate resources/referrals 

Carefully assess for school readiness and milestone achievement 

Continue supportive interventions to assist in milestone achievement 

Speech and language delays are very common

• Incorporate speech therapy services 

• Preschool programs can promote socialization 

• Inclusive classrooms increase positive gains in language

School age developmental tasks across the life span

Chronic illness impacts academic performances, school attendance, interactions with peers, and psychosocial health 

• If chronic illness, twice as likely to be absent from school 

Encourage caregivers to provide support for learning in school 

• Develop personalized attendance plan with the school 

• Encourage the use of personalized interventions, such as: assistive technology, individualized education plans, remote assignment completion, home-bound instruction, etc

Encourage socialization and continue support for mental health 

• Psychoeducation about illness, cognitive behavioral therapy, individual counseling, and peer support groups 

• Motivation interviewing and art therapies can also help with coping

Adolescent developmental tasks across the life span

• Developmental task of seeking autonomy may lead to transition to self-management of their illness 

• Screen for risky behavior and provide appropriate education 

• Commonly experience higher rates of poor body image and self-esteem, increased conflict with parents, and difficulties with interpersonal relationships

Emotional aspects of chronic illness 

Caregivers must manage all aspects of care 

Fragmented health care systems 

Must navigate speciality services 

• Health literacy level

Diagnosis of chronic illness/disability is upsetting 

• Experiences of uncertainty 

• Grief process

• Must adapt to the challenges of caring for a child with special needs 

Highest level of grief/uncertainty during diagnosis but may return as child faces challenges and transitions in life 

Nurses advocate and support patients and caregivers to minimize the emotional impacts

Normalize-ask-pause-connect (NAPC) model in chronic illness/diability

Four-step process to encourage active discussion of mental health needs 

• Normalize the conversation through emphasis that is difficult to care for someone with chronic illness 

• Ask a general question about how they are doing 

• Pause and actively listen without charting or distraction 

• Connect back by restating what was said and offering resources/referrals if needed 

Ensure privacy during the conversation 

• Some children will not openly share concerns when their parents are present 

• Parents may not freely express their concerns with their child present

Primary health care 

Consistent providers ensure continuity of care and helps patients and families build trust 

• Primary health care provides and specialists should opening communicate

• Interdisciplinary model to promote coordination 

• Coordinate network of speciality centers: often associated with major children's hospitals 

Medical home nurses can help coordinate services within the community promoting health equity 

Timely care and early recognition facilitates early intervention and improves outcomes  

Care coordination needs

Promote family-centered care 

• Involve caregivers in shared decision-making 

• Encourage open communication with schools, providers, caregivers, and patient 

Navigate financial costs of health care 

• Costs of health care can be stressful for caregivers 

• Coordination with insurance companies 

• Commercial policies vs medicaid or children’s health insurance programs 

Educate for caregivers and families 

• Education on medical skills (suctioning, parenteral feeding) to reduce exacerbation of disease, complications, and readmissions 

• Evaluate ability to learn, learning preferences, learning needs, and current health literacy level 

• Use visuals, videos, written materials, demonstration, and teach back method 

• Adequate education increases self-efficacy 

play of infants

• Play is an essential part of development, especially during the younger ages 

• Encourage family play for psychosocial engagement and to provide a way to cope with stress  

• Play promotes healthy growth and development, and children should actively play within the restriction of their disease 

• Play can also be used to  promote distraction and to assist with coping during hospitalization 

Use child life services to support children and their siblings through play services

pain management meds

Analgesics 

• Nonopioid and opioids: when combined offers greater pain control with fewer adverse effects 

Adjuvant 

• Benzos

• Anticonvulsants 

Anesthetics 

Preferred routs 

• Oral, rectal, intravenous, topical or local nurse block routes 

  • Choose least traumatic route for medication admin 

• Epidural administration and moderate sedation also can be used

Nurses role of pharmacological pain 

Adhering to the rights of medication administration 

Knowledge about the drugs pharmacokinetics and pharmacodynamics 

Assessment is crucial and ongoing 

Monitor physiological parameters 

• Levels of consciousness

• Vital signs

• Oxygen saturation 

• Urinary output 

• Monitor for signs of adverse effects (respiratory depression) 

Assess the child and parents emotional status 

Teach child parent about the drugs

Acetaminophen dosing

• 10-15 mg/kg/dose 

• Every 4-6 hours 

ibuprofen dosing

• 5-10 mg/kg/dose

• Every 6-8 hours 

• Don't use in kids less than 6 months

Nonpharmacologic pain management

• Relaxation 

• Distraction 

• Imagery 

• Biofeedback

• Through stopping

• Positive self talk 

• Nonnutritive sucking with sucrose 

• Heat and cold applications 

• Massage and pressure, chiropractor 

• Alternative medical: acupuncture, homeopathy 

• Energy based: reiki, magnetic treatment 

CRIES pain assessment tool

• Crying

• requires oxygen for saturation

• increased vital signs

• expression

• sleepless 

FLACC pain assessment tool

• Face

• legs

• activity

• cry

• consolability

• (2 months-7years)

FACES pain assessment tool age

• ages 3+

OUCHER pain assessment tool

• uses real faces

• age 3-13

Numeric rating skill

• Ages 8 and older 

• For non-verbal children: observe behavior for 20 mins 

  • 6 sub categories scores on scale 0-3

  • 6-10 mild pain, 11 or higher moderate to severe pain 

Health history data related to pain assessment 

• Location, quality, severity, and onset of pain, as well as the circumstances in which the child experiences the pain 

• Condition: if any , that precede the onset of pain and condition that follow onset of pain 

• Any measures that increase or decrease pain 

• Any associated symptoms, such as weight loss, fever, vomiting, or diarrhea, that may indicate current illness

• Any recent trauma, including interventions that were used in an attempt to relieve the pain 

• Functional assessment: sleep disruption, school functioning, emotional functioning 

Indicators of pain in children 

Behavioral 

• Facial expressions, body movements, crying, increased irritability, refusal to move, injured body part, interrupted sleep, guarding, thrashing 

Physiologic 

• Changes in heart rate, RR, oxygen saturation levels, vagal tone, plantar or palmar sweating 

• Limited value as a sole indicator of pain 

Verbal 

• Self report 

• Toddler : owww hirt owiw booboo

• Preschool: can identify location and severity of pain but may lack verbal skills to accurately describe 

• School age : communicate type 

Otitis media with effusion 

• More common than AOM-fluid behind the TM

• Usually caused by blocked eustachian tube from URL or allergies 

• May accompany viral URI, prelude or sequela of AOM

• Pain control and observations 

Acute otitis media - infection - causes and symtpoms

• Otitis media is caused by middle ear infection leading to pain, pressure, hearing loss, and irritability in children (bacterial and/or viral).

• otorrhea , a discharge from the ear, may occur and can appear yellow or green 

AOM risk factors and diagnosis/treatment

• Young age, daycare, secondhand smoke, bottle-feeding supine, allergies, and respiratory infections 

Diagnosis and treatment 

• Diagnosis is by otoscope exam; treatment ranges from observation to antibiotics and surgical tube placement (myringotomu- place the tube and tympanoplasty- repair the hole if needed) 

 Hearing loss and developmental impact 

Types and identification 

• Conductive, sensorineural or mixed

• Early screening is crucial to prevent delays 

Developmental challenges 

• Untreated hearing loss may cause speech delays, social isolation, and academic difficulties 

Treatment and support 

• Treatment (ideally within first 6 months) includes hearing aids, AS, cochlear implants and assistive communication devices 

Family education and resources 

Educating families on community resources and school accommodations

Strabismus

• Eye misalignment due to muscle imbalance- may lead to amblyopia 

• Present after 6 months of age is abnormal 

• Assessment-cover uncover test, corneal light reflex test 

• Patch the good eye, corrective glasses, eye exercise, atropine eye drops, surgery 

Amblyopia

• Reduced vision in one eye 

• Goal is prevention

Blindness and risk factors

• Blindness may be partial or complete - legal blindness is a 20/200 with corrective lenses 

• Risk factors include vitamin A deficiency, retinopathy or prematurity, eye injuries, diabetes, eye infections, genetics

Retinopathy of prematurity

Abnormal blood vessels grow in the retina (neovacularization) 

• Prematurity - gestation <30 weeks   

• LBW/VLBW < 1600 g (3 lb 8oz)

• Extended O2 therapy 

• Cerebral palsy 

• Multiples 

90% will improve and recover - visual loss varies greatly 

Increased chance of developing later in life: nearsightedness, retinal detachment, strabismus and amblyopia 

Eye trauma

• Penetrating, perforating, cut.scratch, or blunt 

• Requires urgent evaluation to prevent vision loss

Blocked tear duct (nasolacrimal duct stenosis)

• Mild eyelid redness and crusting 

• Very common in newborns/infants - 90% resolve by 6 months 

• Clean, warm, moist cloth with nasolacrimal duct message