Nursing Care of the Infant

1. . Nursing Care of the Infant

2. The first year Growth is VERY rapid gains 5-7 ounces (150-210g) qd x 6mths doubles by 6 months triples by 1 year Infants breast fed after 4 months grow slower than bottle fed Height Increases by 1 inch (2.5cm) every month for the first 6 months, slows down for the rest of the year. 50 increase in birth height by the end of the first year. Head circumference Rapid growth in HC – 0.6inches (1/5cm) a month for 1st 6 mths, then 0.2 inches (0.5cm) in second 6 months. By 1 year HC has increased 33%. Fontanels: Posterior: closes by 2 months Anterior: closes by 12-18 months * With every health care encounter HC & fontanels should be assessed.*

3. Respiratory system • Short Eustachian tubes encourage easy passage of bacteria/viruses/fluid to middle ear = increase in otitis media. • Very prone to upper airway infections due to short distance between structure (trachea/bronchi/lungs) • Cardiovascular System • Fetal Hgb present during the 1st 6 months HgF, after 5 months changes to adult Hgb, anemia is common at 2-3 mths when high levels of fetal HgF inhibit RBC production. Maternal Iron stores last for 5-6 months. • Renal system • Immature till about 18months with decreased filtration, this decrease can lead to toxic accumulation of meds, toxins. • Teething • First teeth are the lower central incisors. Teething is often accompanied by drooling, gumming, low grade fever, diarrhea, difficulty sleeping/eating. Use teething rings, baby Oragel, Tylenol • Sleep • By 3-4 months nocturnal pattern 9-11 hrs per night, total sleep 15 hrs/qd. • Most sleep problems are “Learned behavior” • BACK TO SLEEP • Crib is ideal spot for sleeping but many families use “family bed”

4. Nutrition • For the first 6 months the ideal food is breast milk if breast feeding is not possible - commercial baby formula. Parents must be taught to strictly adhere to instructions for preparation of formula. • 6mths-1 year breast milk/formula + iron fortified cereal +baby food fruits & vegetables. • First solid food at 5-6 months (when extrusion reflex disappears) • 1st food iron fortified baby cereal (rice/barley/oatmeal) mixed with BM or formula • Fruit juice should be diluted 50%-avoid large amounts, can cause diarrhea and fills child up with empty calories • Strained fruits, vegetables, meats • Yogurt • At 8-9 months junior foods,cherrios, zwieback toast, crackers, small pieces of fruit (banana, orange) NO Grapes, very well cooked vegetables • By age of 1 year can have table foods with appropriate texture and appropriate size. • Never use skim, 1%, 2%, condensed or evaporated milk in child under the age of 1. • Feed baby food first, then formula or BM • Never use honey in any food preparation – botulism spore • Never allow baby to fall asleep with bottle of juice or milk (H20 if absolutely necessary), causes severe dental carries & predispose infant to OM • Introduce 1 new food every 3-5 days to identify any potential allergies. Do not feed baby eggs or nuts (including peanut butter) for the first year • Home cooked baby foods should be made from fresh vegetables/fruits (canned/frozen high in Na)

5. . • GI System • Immature until 3 months. Decreased pancreatic and gastric enzymes. Solid foods passed almost unchanged in stools (corn, raisins), high fiber can cause diarrhea. By 1 year of age baby should be eating 3 meals /qd in addition to formula. Liver function also remains immature until 1 year. • Body composition is 75-80% water mostly extracellular, child can have rapid dehydration from V & D.

6. Prevention of Injuries • Aspiration of foreign bodies into respiratory tract is the leading cause of fatal injuries in children <1year. Infants aspirate toy parts, buttons, batteries, food. • Suffocation by covering airway or entrapment • MVA. Proper use of car seats Infants must be rear facing until 1 year of ageAND20lbs. (neck muscles) • Poisoning: medications, household cleaners, alcohol • Drowning • Burns (including sunburn)

7. Attachment , separation anxiety and stranger anxiety Attachment • Attachment begins at birth and continues throughout the first year. During the first few weeks infants respond indiscriminately or anyone. Between 8-12 weeks infants cry, smile and vocalize more to the mother than to anyone else but continue to respond to others . • About 6 months of age they begin to show distinct preference for their mother, following her more, crying when she leaves, playing with her more and feeling most secure in her arms. • Approximately 1 month after attachment to the mom, the infant begins attachment to other family members (most often dad)

8. . • Between 4-8 months infant begins to have awareness of self and mother as separate persons and object permanence begins. Infant is aware that parent can be absent and separation anxiety begins. Infant begins to protest when put in crib, when mom leaves and can anticipate her leaving and begin to protest. • About 6-8 months stranger anxiety and fear begin (healthy sign of attachment to parents)

9. Language development Children are born with the ability to develop speech and language skills if they have intact physiologic structure , intact CNS and hearing. But even with all of the above they must have stimulation, they must hear their language to begin to speak it. First means of communication is crying usually for physiologic needs to be met (hunger, cold, etc.). • They begin to vocalize by 5-6 weeks with throaty type sounds. • By the age of 2 months they make single vowel sounds like ah, eh, uh. • By 3-4 months they begin using consonants n/k/g/p/b, they begin to gurgle, coo and laugh out loud. • By 8 months they begin to imitate sounds adding t/d/w and begin to combine syllables, Dada is frequently the first “word” they make but do not know the meaning • By 9-10 months they comprehend the meaning of “NO” • By the age of 1 year they can say 3 or 4 word in proper context (dada , mama, cat, dog, up, down

10. Growth & development during infancy • 1 month • Physical: wt gain =150-210g (5-7 oz) wkly for 1st 6 mths, HC increases by 1/5cm wkly for 1st 6mths, flexed position. Breathes through nose • Gross Motor: primitive reflexes present and strong, can turn head from side to side, can lift head momentarily from bed, marked head lag, esp. when pulled from lying to sitting • Fine motor: hands closed, clenches when in contact with object • Sensory: able to fixate on moving object. Visual 20/100, follows light to midline, quiet when hears a voice. • Vocalization: cries when wet, cold, hungry, frightened, makes small throaty sounds, comfort sounds during feeding • Socialization/cognition: in Sensorimotor phase, trust vs. mistrust, watches parents face as they talk to infant • 2 months • Physical: posterior fontanel closes • Gross motor: less head lag when pulled to sitting, when prone can hold head also 45 degrees off table • Fine Motor: hands open • Sensory: Binocular fixation, visually searches to locate sounds. • Vocalization: vocalizes (different from crying), different types of cries noted, coo’s, vocalizes to familiar voice • Socialization/cognition: social smile begins

11. . • 3 Months • Physical: primitive reflexes fading • Gross Motor: able to hold head more erect (but still not steady), Slight head lag when pulled to sitting, regards own hand. • Fine Motor: holds rattle but will not reach for it, hands kept open (loosely), clutches hand, will pull at blankets and clothes. • Sensory: Follows objects 180 degrees, locates sound by turning head to side looking in same direction. • Vocalization: squeals with pleasure, coo’s, babbles, chuckles, vocalizes when smiling, “Talks”, less crying. • Socialization/cognition: very interested in surroundings, stops crying when parent enters room, can recognize familiar objects and faces, shows awareness of strange situations. • 4 months • Physical: Drooling begins, Moro, tonic neck and rooting disappear • Gross motor: almost no head lag when pulled to sitting, balances head well when" sitting”, back less rounded, begins rolling front to back • Fine motor: inspects and plays with hands, pulls blanket and clothes over face in play, tries to reach objects (but cannot), grasps objects with both hands • Sensory: binocular vision well established, beginning to have eye-hand coordination • Vocalization: : Makes constant sounds n/k/g/p/b, laughs aloud, vocalization based on mood.

12. . • 5 months • Physical: Tooth eruption, BW Doubles • Gross Motor: able to sit erect if propped, raises head in prone position to 90 degrees, Rolls from front to back, back to side • Fine motor: grasps objects voluntarily, palmer grasp-using both hands, plays with toes, objects into mouth, can hold a cube while looking at a second one. • Sensory: visually pursues a dropped object. • Vocalization: squeals, makes cooing vowel sounds with consonant sound ah/eh/oh/goo. • Sensory/cognition: smiles at self in mirror, can tell family from strangers, discovering parts of body, very playful • 6 months • Physical: growth rate begins to slow down- wt gain= 90-150g (3-5 oz) per week, HC 1.25 cm mth . Teething and to tooth eruption may begin, chewing and biting begin • Gross motor: when prone can lift head off surface bearing weight on both hands, when pulled to sitting position- lifts head, sits in high chair with back straight, rolls from back to abdomen, when held instancing position can bear wt. • Fine motor: rescues a dropped object, drops one cube when given another, can grasp and manipulate small objects, holds bottle, grabs feet – puts in mouth. • Sensory: adjusts posture to see something. • Vocalization: begins to imitate sounds, babbling sounds like one syllable words (ma/da/hi), vocalizes to toys, mirror, loves hearing own voice. • Socialization/Cognition: Recognizes parents, stranger anxiety beginning, holds arms out to be picked up, has like & dislikes, plays peek-a-boo, object permanence beginning, mood swings • .

13. 7 months • Physical: Eruption of “two front teeth”. • Gross motor: leaning forward on both hands, sits erect (for a second) bears full wt on feet • Fine motor: transfers objects form one hand to the other, rakes at small objects, can use both hands to grasp, bangs cube on table. • Sensory: can fixate on small objects, responds to own name, has taste preferences • Vocalization: vowel sounds and chained syllables: dada/baba/kaka, “talks” while others are talking to them. • Socialization/cognition: fear of strangers, imitates simple acts and sounds, attracts attention by coughing/snorting, plays peek a boo • 8 months • Physical: beginning of regular bowel & bladder pattern. • Gross motor: sits unsupported, bears wt on legs when supported may be standing holding on to furniture (or person), has pincer grasp using index finger, 4th & 5th finger , release objects, retains 2 cubes while observing third, pulls on strings, reaches for toys out of reach. • Vocalization: consonant sounds t/d/w,combines syllables (dada) but does not know meaning. • Socialization/cognition: increased separation anxiety, stranger anxiety, responds to word “NO”, does not like getting undressed, diaper changing

14. . • 9 months • Physical: eruption of upper lateral incisor may begin • Gross Motor : creeping begins, sits steadily on floor, can recover balance when sitting, pulls self to standing position when holding on to furniture/person recovers balance when leaning forwards (but not sideways) • Fine motor: Use thumb and index finger in crude pincher grasp, dominant hand not obvious, grabs third cube, compares to comes by bringing them together • Sensory: localizes sound by turning head • Vocalization :responds to simple verbal commands, comprehends “NO” • Socialization/cognition: mother extremely important, trying to please parents, beginning to show fears of going to bed/being left alone. covers face to avoid having it washed • 10 months • Physical: when prone or supine can lift head • Gross motor: can easily change from prone to supine position, stands holding on to furniture, sits by falling down on butt, recovers balance easily while sitting, when standing lifts one foot to take a step. • Fine motor: releasing of objects beginning (crude) • Sensory: can followed rapidly moving objects • Socialization/cognition: stops behavior on “NO”, waves bye-bye, imitates facial expressions, develops object permanence, repeats actions that attract attention/laughter, pulls others clothing, cries when scolded, Demonstrates independence is dressing, feeding, locomotion, looks at and follows pictures in a book.

15. . • 11 months • Physical: eruption of lower central incisors begins • Gross motor: cruises or walks holding on to furniture or with both hands held • Fine motor: explores objects, has Neat pincher grasp, puts one object into another, can manipulates small objects • Vocalization: imitates speech sounds • Socialization/cognition: experiences joy and satisfaction when a task is mastered, anticipates body gestures when a familiar song/nursery rhymes is told, plays games up-down, so-big, shakes head for “NO” • 12 months • Physical: BW tripled, HT increased by 50%, HC=chest circm , 6-8 teeth, anterior fontanel almost closed • Gross motor: walks with 1 hand held, cruises well, may attempt to stand alone for a moment, can sit from standing position without help. • Fine motor: releases cube in cup, tries to build 2 cube tower, can turn pages of a book (a few at a time) • Sensory: Can follow rapidly moving objects • Vocalization: recognizes object by name, comprehends the meaning of several words, imitates animal sounds, understands simple verbal commands • Socialization/cognition: shows emotion (jealousy, affection, anger, fear), may kiss on request, imitates facial expression, explores familiar surroundings (away from mom), fearful in nes situations may cling to mom, security blanket time, determined to perfect locomotion

16. Images .

17. Head lag

18. fontanels

19. Plantar or grasp reflex

20. Safety

21. Head control (prone)

22. G & D

23. Development of sitting

24. Development of locomotion

25. Crude pincer grasp 8-10 months

26. Fine motor development,Neat pincher grasp (10-11mths)

27. Developing Body Image

28. Dental caries

29. Inner ear

30. Measuring head circumference

31. Head control when pulled to sitting

32. . Health Problems of the infant

33. Failure to thrive Inadequate weight gain based on standardized growth charts. If growth ht/wt/hc falls below 5th percentile (or falls off child’s curve) Is divided into 2 categories: • organic failure to thrive- OFTT • Non- organic failure to thrive NFTT

34. Organic FTT • Identifiable cause for inadequate weight gain • Medical cause for inability to metabolize kcal • 2 most common causes: • Congenital Heart Disease • Cystic Fibrosis Other medical causes include: inherited metabolic disorder, endocrine disorder, neurological condition/lesion. HIV, GERD, Malabsorption syndrome.

35. Non-organic FTT No identifiable medical cause of inadequate growth, psychological cause. • 3 types of NOFTT • Accidental: inadequate nutrition as a result of a mistake (improper preparation of formula, not enough breast milk production, feeding an infant condensed milk) Watering down formula to make it last longer is very common • Neglectful: inadequate nutrition resulting from parent being overwhelmed (post-partum depression, other kids, financial reasons) not knowing how often a infant needs to eat etc… • Deliberate: deliberate withholding of food – child abuse

36. Physical assessment in FTT • Wt below 5th % • Sudden rapid decline in growth curve • Delay in developmental milestone • Decreased muscle mass • Abdominal distension • Hypotonic • Weakness

37. Behavioral findings in FTT • Avoidance of eye contact • Sleep disturbances • Apathy • Extreme irritability

38. Diagnostic testing in FTT • Developmental screening • Nutritional screening • Evaluation of growth curve • Urine Analysis (bladder infection/sepsis) • Sweat Chloride test (CF) • Stool Culture • T4

39. Nursing Issues • Nursing Diagnosis: • Altered nutrition • Altered G & D • Altered family process • Alteration in parental bonding • Nursing interventions • Carefully document feeding patterns (quality, quantity, suck, effort, interest) • Observe and carefully document parent/child interaction • Feed on demand & increase feeding s as tolerated • Strict I & O • Weight daily • Consistent primary RN

40. SIDSSudden infant death syndrome Sudden unexplained death of infant. Death unexplained after autopsy, review of history. Leading cause of death in infants, 90% of cases occur before 6 mths of age. Most common in 2-4 months olds, more frequent in males, in winter and spring.

41. SIDS, cont. Referred to as a syndrome because of many varied clincal findings on autopsy, autopsy does not identify one single cause of death. Child discovered after sleep dead, appears to be a struggles (in crib) upon examination (messy bedding) position may be changed from the position parents put child to sleep in, there may be frothy, blood tinged secretions around mouth& nares. Parents report no crying or disturbances during child’s sleep. Current thinking is that the etiology of SIDS is an abnormality in the brainstem that causes a delayed development of arousal with cardiac-resp or cardiovascular control. Other proposed causes include: H.pylori infection, prolonged QT syndrome

42. SIDS, cont. • It is believed that a very small % of SIDS are actually homicides (1-3%) but as no cause of death is found this makes this suspicion very hared to prove. • Despite much media attention there has been no link between DTaP & SIDS found.

43. Risk Factors • h/o ALTE or cyanosis, resp distress in neonatal period • Apnea of infancy • Preemie • Multiple birth • Exposure to passive smoke • Poor prenatal care • Poor wt gain of mom while pregnant • Brain stem defect • Prone sleeping • Mom smoking during pregnancy • Sibling with SIDS • Multiple pregnancies with short intervals between them • Soft bedding, use of pillows

44. Nursing interventions to prevent & educate about SIDS “BACK TO SLEEP” Educate, educate, educate No pillows, quilts under baby, firm approved bedding

45. Nursing interventions after death of child • Help them contact family members. • Referral to SIDS support groups. • Compassionate, empathetic care. • Family advocacy in ER when police are involved. • Reassure parents that they are not responsible for child’s death. • Immediate referral to compassionate friends. • If there are siblings, reassure them that this will not happen to them & it is not their bad thoughts about sibling that caused this. • Allow parents to hold child, take hand/foot prints, lock of hair, photos.