316- midterm

infant mortality

the death of a baby before their first birthday

IMR

Indicator of the overall health of a population

\
IMR= # of infant deaths per 1,000 live births

Healthy people 2023 goal IMR

5

2020 IMR both national and state

5\.4 and 6.53

Leading causes of Infant death

1. Birth defects

2. prematurity

3. Sleep related deaths

Child mortality

• Number of deaths among children ages 1-19 per 100,000 children

• main cause is unintentional injury

  • MVC, guns, suffocation, drowning, burns poisoning

  • MVC are decreasing but overdose and suicides are increasing

Atraumatic Care

+The provision of therapeutic care by personnel that eliminates or minimizes the psychological and physical distress experienced by children/families in the healthcare system.

+Interventions include preparing children for procedures, providing accommodations for parents to room-in, providing choices to the child.

+3 principles:

• Minimize child’s separation from their family

• Promote a sense of control

• Minimize bodily injury and pain

Duvall’s Developmental Stages of the Family

• stage I- marriage and an independent Home: the joining of families

  • preestablish couple identity

  • Realign relationships with extended family

  • Make decisions regarding parenthood

• Stage II- Families with infants

  • Integrate infants into the family unit

  • Accommodate to new parenting and grandparenting roles

  • Maintain marital bond

• Stage III- Families with preschoolers

  • Socialize children

  • Parents and children adjust to separation

• Stage IV- Families with School children

  • children develop peer relations

  • Parents adjust to their children’s peer and school influences

• Stage V- Families with teenagers

  • Adolescents develop increasing autonomy

  • Parents refocus on midlife marital and career issues

  • Parents begin a shift toward concern for the older generation

• Stage VI- Families as Launching centers

  • Parents and young adults establish independent identities

  • Parents renegotiate marital relationship

• Stage VII- Middle-Aged Families

  • Reinvest in couple identify with concurrent development of independent interests

  • Realign relationships to include in-laws and grandchildren

  • Deal with disabilities and death of older generation

• Stage VIII- Aging Families

  • Shift from work role to leisure and semiretirement or full retirement

  • Maintain couple and individual functioning while adapting to the aging process

  • Prepare for own death and dealing with the loss of spouse and/or siblings and other peers

Family Systems Theory

• a change in any one part of a family system affects all other parts of the family system (circular causality)

• Family systems are characterized by periods of rapid growth and change and periods of relative stability

• Both too little change and too much change are dysfunctional for the family system: therefore a balance between morphogenesis (change) and morpho stasis (no change) is necessary

• Family system can initiate change as well as react to it

• Applicable for family in normal everyday life as well as for family dysfunction and pathology

• Useful for families of varying structure and various stages of life

• More difficult to determine cause and effect relationships because circular causality

• Mate selection, courtship processes, family communication, boundary maintenance, power and control within family, adolescent pregnancy and parenthood

Developmental theory

• families develop and change over time in consistent ways

• Family and its members must perform certain time-specific tasks set by themselves and by persons in the broader society

• Family role performance at one stage of family life cycle influences family’s behavioral options at next stage of disequilibrium

• Family tends to be in stage of disequilibrium when entering a new life cycle stage and strives toward homeostasis within stages

open family

external elements and situations influence the family system

closed family

isolated and self contained family

Family stress

• Stress is an inevitable part of family life, and any event, even if positive can be stressful for the family

• Family encounters both normative expected stressors and unexpected situational stressors over the life cycle

• Stress has a cumulative effect on family

• Families cope with and respond to stressors with a wide range of responses and effectiveness,

• Potential to explain and predict family behavior in response to stressors and to develop effective interventions to promote family adaptation

• Focuses on positive contribution of resources, coping, and social support to adaptive outcomes

• Can be used by many disciplines in health care field

• Relationships between all variables in framework not yet adequately described

• Not yet known if certain combinations of resources and coping strategies are applicable to all stressful events

• Transition to parenthood and other normative transitions, single-parent families, families experiencing work related stressors (dual-earner family, unemployment), acute or chronic childhood illness or disability infertility, death of a child, divorce, adolescent pregnancy and parenthood

traditional nuclear family

consists of a married couple and their biologic children

nuclear family

composed of two parents and their children

blended/ reconstituted family

contains at least one stepparent, stepsibling or half sibling

extended

includes at least one parent, one or more children and one or more members (related or unrelated) other than a parent or sibling

Single parent

one parent present

binuclear

parents continuing the parenting role while terminating the spousal unit

LGBT

there is a legal or common law tie between two persons of the same sex who have children

positive parenting practices

• Showing unconditional positive regard

• responding to child’s needs

• using active listening

positive parenting results

secure attachments, self-esteem and effective relationships with others

principles of discipline

• consistency

• timing

• follow through

• unity among caregivers

• flexibility

• planning

• behavior focus

• privacy

• clean slate

types of discipline

• reasoning

• ignoring

• time-out

• corporal punishment

corporal punishment yields

• short term change

• encourages violence

• physical and emotional harm

• interferes with moral development

Authoritarian Parenting

• High control/ Low warmth

• Highly controlling, issues commands and expects them to obey

• Little communication with child

• inflexible rules

• permits little independence

Authoritarian parenting outcomes

• Child may be fearful, withdrawn, and unassertive

• Girls often passive and dependent during adolescence

• Boys often rebellious and aggressive

authoritative parenting

• Moderately high control/High warmth

• Accepts and encourages growing autonomy of the child

• Open communication

• Flexible rules

Authoritative parenting outcomes

• Tends to be best-adjusted, self reliant, self-controlled, and socially competent

• Higher self esteem

• better school performance

Permissive parenting

• Low control/ High Warmth

• Few or no restraints

• Unconditional love

• Communication flows from child to parent

• much freedom with little guidance

permissive parenting outcomes

• May become rebellious, aggressive, socially inept, self-indulgent or impulsive

• May be creative, active, and outgoing

Indifferent Parenting

• Low Control/ Low warmth

• No limit setting

• Lacks affection for the child

• Focused on stress in own life

Indifferent parenting outcomes

May show high expression of destructive impulses and delinquent behavior

Growth

Increase in the number and size of cells. Results in increased size and weight

Development

Advancement from lower to more advanced stages of complexity

Infancy age periods

• 0-1 year

• Neonatal

  • 0-28 days

• Infancy

  • 1mo-12mo

Early Childhood age periods

• 1-6 years

• Toddlers

  • 1-3 years

• Preschool

  • 3-6 years

Middle Childhood age periods

• 6-11or12

• “school age”

Later Childhood age periods

• Prepubertal

  • 10-13 years

• Adolescent

  • 13-18 years

Cephalocaudal development

head to toe

proximodistal development

center out growth

Sequence and pace of development

• The sequence is definite and predictable

• The pace is variable

• There are sensitive periods for biological and psychosocial growth

Length or Height Growth measures

• stable measurements of general growth

• Active growth in length happens at the epiphyseal growth plate

• Height at 2 yrs is 50% of adult height

epiphyseal growth plate

hyaline cartilage plate at the metaphysis at each long bone

Weight Growth measurements

• The average newborn weighs 3175 to 3400 grams (7-7.5 lbs)

• Birth weight doubles by 4-7 months and triples by age 1 year

physiological changes: metabolism

• BMR is highest in newborns

• BMR determines caloric requirements

• Energy requirement of infants is 108 kcal/kg and decreases to 45 kcal/kg at maturity. Nutrition has largest influence on growth

• Each degree of fever raises the BMR 10%

Physiological changes: temperature

• Thermoregulation is critical in infants

  • hypothermia leads to hypoglycemia, metabolic acidosis, and elevated bilirubin

• Infants and young children are susceptible to temperature fluctuations

Physiological changes: Sleep

• Neonate sleep when not eating but wakefulness increases with age

• The lengthen with age

Temperament

The manner of thinking, behaving or reacting that is characteristic of a person

The easy child

• Even tempered, regular, predictable.

• They have a positive approach to new stimuli. Mild to moderate intensity of mood which is usually positive.

• 40% of children fall into this category

The difficult child

• Highly active, irritable, and irregular in their habits

• Mood expressions are intense and primarily negative

• Frequent periods of crying and frustration can lead to tantrums

• 10% of children

The slow-to-warm-up child

• Mild intensity, react negatively to new stimuli and adapt slowly.

• They are inactive and moody

• 15% of children

Freud- psychosexual

sensual pleasure and conflicts arise from body areas

Oral stage

* Birth-1 year

Anal stage

* 1-3 years

Phallic stage

* 3-6 years

Latency stage

* 6-12 years

Genial stage

* 12+ years

Erikson- psychosocial

Describes core conflicts that the child tries to master

Trust vs. Mistrust

• Birth to 18 months of age

• the infant is uncertain about the world in which they live and look towards their primary caregiver for stability and consistency

• If not met, mistrust, suspicion, and anxiety

• leads to the virtue of hope

Autonomy vs. Shame & doubt

• 18 months - 3 years

• focused on developing a sense of personal control over physical skills and a sense of independence

• Leads to the virtue of will and will have increased independence

• If not supported it can lead to feel inadequate in their ability to survive, may lead them to be overly dependent on others, lack self-esteem and feel a sense of shame or doubt in their abiliies

Initiative vs. guilt

• 3-5 years

• children assert themselves more frequently through directing play and other social interactions

• creates the virtue of purpose

• Failure results in a sense of guilt

Industry vs. Inferiority

• 5-13 years

• children will be learning how to read and write, to do sums, and to do things on their own

• virtue of competence

Identity vs. Role confusion

• 13-21 years

• adolescents search for a sense of self and personal identity, through an intense exploration of personal values, beliefs and goals

• virtue of fidelity

• no support can lead to unhappiness in the role they assume

Piaget- Cognitive

Intelligence enables child to adapt to environment and survive

Sensorimotor stage

• 0-2 years

• Six substages:

  • Use of reflexes (0-2 months)

  • Primary circular reactions (1-4 months)

  • Secondary circular reactions (4-8 months)

  • Coordination of secondary schemes (8-12 months)

  • tertiary circular reactions (12-18 months)

  • Mental combinations (18-24 months)

Preoperational stage

• 2-7 years

• children understand causality

• understand identities

• categorization

Concrete operations

• 7-11 years

• children are more capable of solving problems because they can consider numerous outcomes and perspectives

• All cognitive abilities are better developed in this age

• understand conversation

Formal Operations

• 11-15 years

• abstract thought

Kohlberg’s theory- mortal development

By using children's responses to a series of moral dilemmas, established that the reasoning behind the decision was a greater indication of moral development than the actual answer.

Preconventional Stage

• 4-7 years

• decisions are based on avoiding punishment

Conventional

• 7-12 years

• Conscience/ follow rules

Postconventional

• 12+ years

• Ethical standards are internalized

• social responsibility

onlooker play

child watches another play

solitary play

child’s interest is centered on their own activity

parallel play

Child plays besides, but not with, other children. Characteristic play of toddlers

Associative play

Children play together without cooperation towards a goal

Cooperative play

it is organized in a group with plans toward goal

Functions of play in development

• sensorimotor development

• intellectual development

• socialization

• creativity

• self-awareness

• therapeutic value

• morality

Variant forms of gene results

• No measurable or observable differences

• Susceptibility to a pathology under certain conditions

• A clinically recognized disorder (minor or severe)

• Advantage in a particular environmental context

Congenital anomalies

1. may occur as a single defect or multiple anomalies may occur together

2. Multiple anomalies may occur together

   1. syndrome

   2. association

   3. sequence

3. defect may be caused by a teratogen such as a drug (Accutane, cocaine, alcohol), virus (rubella), or physical agents (radiation or hyperthermia)

syndrome

a recognized pattern resulting from a single specific cause (e.g. Down syndrome or fetal alcohol syndrome)

Association

a nonrandom pattern of problems for which the cause is undetermined (VACTERL association which is vertebral defect/ anal atresia/ cardiac defect/ tracheoesophageal fistula/ renal defect/ limb defect)

Sequence

a pattern of defects that occurs when a single problem cascades into multiple anomalies (e.g. Pierre Robin sequence which is an underdeveloped mandible that leads to displaced tongue which obstructs the formation of the palate then other conditions develop)

Autosomal variants

account for a variety of syndromes characterized by cognitive deficits and dysmorphic facial features, unusual cry, feeding difficulties and poor muscle tone

Health history

• Categories:

  • Identifying information

  • Chief Complaint (CC)

  • History of present illness (HPI)

  • Past Medical History (PMH)

  • Review of Systems (ROS)

  • Family History

  • Sexual History

• Details

  • “informant”- person who gives the information should be documented including their reliability and any special considerations such as conflicting answers or use of an interpreter

  • “Sex”- Sex assigned at birth is abbreviated AFAB or AMAB. Transgender and gender diverse is abbreviated as TGD

  • “Illness”- Term used to denote any problem of a physical, emotional, or psychosocial nature for which the parents or child are seeking care

  • Information and documentation of allergies is essential

  • “Habits”- This topic includes sleep and use (or experimentation with) substances such as tobacco, alcohol or drugs

  • Family History- Assess for consanguinity of souses, genetic illness, chronic infectious diseases among first degree relatives of the patient

Family assessment

See textbook page 69

Review of systems

See textbook page 70

Nutritional Assessment

• Obtain a dietary intake history

• Perform an assessment through a lens of nutrition. Look for clinical signs of nutritional deficiency, “failure to thrive”, obesity or eating disorders

• record growth measurements on a growth chart over time to compare velocity of length/weight, head circumference, and weight gain

Age specific Physical Exam: infant

• position on crib or parent’s lab

• Auscultate if quiet

• Record RR and HR first

• Head to toe direction except perform traumatic areas last.

Age specific physical exam: toddler

• Position on parent’s lap

• Inspect through play & transitional object

• introduce equipment gradually

• perform traumatic procedures last

Preschooler

• They stand or sit close to the parent.

• Use head to toe sequence if cooperative

• expect cooperation

• Give choices

• Request self undressing

School-age child

• prefer sitting

• head to toe sequence.

• Examine genitalia last.

• Provide privacy, gown and underwear

• Give explanations

• Teach body functions and care

Adolescent

• offer option of parental presence

• provide privacy

• Matter-of-fact statements about sexual development

• Emphasize normalcy of development

Growth measurements

• Growth Charts

• Length/height

  • measure recumbent length using length board & 2 measures until 24 months. (if the growth chart used is birth -36 mo, then continue to use recumbent length until 36 mo). stature is height when standing upright with a stadiometer

• Weight & BMI

• Head circumference

  • Reflects brain growth

  • measure in children from 0-3 y or any child whose head size is questionable

  • Chest circumference = HC at 1 yr

Posterior fontanel

closes by 2 months

Anterior fontanel

closes by 12-18 months

Head lag

should disappear after 6 months

Torticollis

twisting of the neck that causes the head to rotate and tilt at an odd angle.

Kussumaul respirations

abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace