Weeks 3 & 4 Babies and Beginnings Classroom topics

Weeks 3 & 4 Babies and BeginningsClassroom topics

Consider: Apgar Gestational age Humidity Hydration Hunger & digestion Heart Medications Physiology& Anatomy Respirations Sensory input & reflexive responses Sound & Light Substance withdrawal Touch – Painful stimuli Taste & Smell Temperature Control Changes to consider when assessing infants and young children for nutritional and feeding needs

Essential Variations in Infants to be considered for Feeding and Food Preparation • Mandatory/obligatory nasal breathers • Oral pharynx highly arched, glottis long and flexible facilitating sucking and swallowing with mouth full • Automatic reflexive glottis closing on swallowing • Extrusion reflex prevents tongue transfer of solids to back of throat • Eustachian tubes more horizontal and smaller venting allows for trickle back into inner ear • Higher demands as BMR higher for weight • Higher %TBW, increased need for liquefied food • No teeth to chew till about 6 mo. Some are born with vestigial teeth [genetic trait]

Enzymes and intestinal flora are absent or different inefficient metabolism of non-foods till 6 months or so • BMR supports protein metabolism and simple milk fats and milk sugars • Changes in body fat type(white and brown) and distribution occur within first few months • Stomach volume smaller and empties more quickly • Kidneys and Liver immature and not efficient. May have neonatal jaundice more frequently if breast fed and not exposed to ultraviolet light (sunlight) to assist in bilirubin breakdown. Temporary but may alter feeding • Dependent on adults for food source • Weight gain /loss indicates caloric sufficiency, health • If cold, burn more calories and build more by-products / wastes- Catabolism

Many variables contribute to the choice of feeding method; Vigour of infant General Health, Anomalies Formula or milk source/type Sensitivities / allergies Feeding patterns, amounts Developmental progress Growth outcomes Parenting approaches Cultural practices/ traditions Availability of food /formula All photos and diagrams from Wong’s Essentials of Paediatric Nursing Electronic Image Collection , 2001 < Mosby Inc. Feeding & nutrition

Physical assessment must be repeated frequently at subsequent well-child visits to monitor the infant’s health status and progress in healing of any health deficits - episodic or chronic and to assess parents’ abilities to cope and their stress levels and health Assess for Cues to family Bonadaptation or Maladaptation Birth trauma can alter ability to feed- Erb’s Palsy- damages to nerve pathway of face- may alter ability to suck: Brachial palsy, may deter ability to hold bottle

Comfort for babe and feeder 45-90’ angle, not flat when feeding, but back to sleep (or R. side) Breast is best, but bottle may help the rest; pump & freeze Teach Mom about safe meds & food choices for self- transfer to breast milk Consistency in feeders builds trust Prepare, anticipate schedule, Feed with positive relationships- hold/ bond, soothing language/ singing/ rocking, keep warm- covered, don’t rush Change diapers and cleanse perineum after feeds- about 20-30 min. Supervise siblings, praise gentle hands Prevent long pre-feed crying-Burping reduces gas pains Crying not always for food Feeding schedules must meet daily needs- holistic considerations

“En face” focus of babe on significant care – providers’ voice, face, body movement, schedule and routine & smell. Helps link cues to socialization, people, and relief of discomfort to comfort, consistency, and trust. Shared Feeding Experiencescan promote developmental progress & Family adaptation

When planning and selecting nutritional intake consider the future • Potential for Obesity has many contributing factors, many of which may begin in infancy. Research is demonstrating that breast fed babies have lesser incidence of obesity in later life. • Nurses can help educate parents about: benefits of breast feeding/EBP weaning and transitions ways to teach young children of healthy food choices quality of nutritional content daily requirements/supplements links to activity and growth fats needed for neural myelination

Suggested Schedule to meet daily intake- fluids and calories • On demand or scheduled feeds • Birth to 1 month: breast milk or formula: increase from 2-3 oz to 4 oz per feed, six times a day, usually 3-4 hours apart around the clock, interspersed by sleep and brief socialization periods • Age 2 months, 4 oz. 5 times daily, one night feed usually dropped • 5 months,5-6 oz five times daily, no night bottle • 6 months,4-5 oz five times daily if transition to solid food begins; Some families continue total breast milk feedings as nutritional source with slower introduction of solids. Importance of iron supplementation must be made.

Introduce between 5 & 12 months when infant developmentally and physically ready Sit upright with help or alone Extrusion reflex disappears Teeth erupt ^ desire to chew Tastebuds maturing for all sensations- sweet, sour, salty, bitter ; interested in learning different tastes and textures Digestive tract matures, enzymes begin to be secreted for a variety of foods Can wait a short time to eat Watch faces of caregivers and may make selections based on behaviours seen- modelling of choice-taking Introduce foods progressively, bland and low allergy first , meats vegetables, fruits- no nuts, wheat or eggs early Introducing solid foods

An assortment of medication administration tools. The variety allows the nurse to match the method and option to the health needs , capabilities, condition, developmental stage and skills,and growth. Do not confuse medicine with food

You can add Flavours and sweetener to the medicine instead. Avoid mixing medications into food at any age.WHY ???

Need to encourage safety proofing by everyone, including grandparents. With a new baby in the house, older children are often left alone more frequently. Distraction highpoints are at mealtimes for baby and family, bed time, or when infant crying. If alone, keep young children in sight, and supervised when looking after infant. Poisoning incidents increase when medications look like candy or pop and are easily available, and child can reach them.

Far left- assortment of self- care feeding utensils . OT helps to programme movement and skills so design will match capabilities. Promotes adaptation and rehabilitation. Top right- Brecht and Hummingbird Feeders and other assorted nipples and feeding syringes for cleft-lip / palate feeding till repairs are complete. Caution against dribbling formula down throat into lungs Bottom right- MIK-E G- tube a permanent feeding tube into the stomach. Some are also placed surgically into the jejunum- these are not removed unless problems arise: All need to be cleansed and irrigated pre and post feeds, Feeding devices are designed to maximize the nutritional intake while maintaining the developmental norms, or care-goals in a safe manner

Debates heighten when planning to wean or add solid foods • Need to understand the child, capabilities, health, • Know the cultural expectations for diet and feeding • Discuss how families make decisions and plan for change, link to change theory • Provide information to families to help them decide, clarify questions, refer to best practices evidence.

Debate on whether to introduce fruits & veggies first or meats Consider the following : • Rice Cereals easy to digest, hypo- allergenic, can make as thick or thin as desired. Do not put into bottle, infant needs to learn about differences and use of utensils ( spoon for infants and toddlers) • Pablum- With iron enriched additives comes now in flavours, finish box before going on to a new flavour • allow a week for each new taste and texture before adding another, do not mix up solids just to speed up meals. • Orange veggies can make skin orange if too much given Carotenemia, palms and soles of feet orange, urine & sclera not. Differentiate from jaundice- not harmful, will disappear when green veggies are given. • Normal physiological anaemia shift in infants to own RBC production and Haemoglobin. Maternal stores used up after120–180 days: needs Iron supplementation to prevent hypochromic and mycrocytic anaemia that prevents haemoglobin utilization.

Don’t forget the premies- • Premie babies need iron supplementation as they have missed the normal birthing infusion and have used what small stores of RBS’s/ iron were available.

Bottle Baby or Iron Deficiency Anaemiacommon in older infants and toddlers as No iron in most milk [unless added ]- overuse of the bottle for milk and juice [or breast exclusively some research shows] can cause iron-deficiency anaemia Hbg. < 9 g/dl.- baby cranky, fussy, restless, pale, low energy, sleeps poorly, seems unable to learn, memory poor,^ infections. • Give iron supplement in manner that does not contact teeth- stains. Some may put in mildly acid juice (in addition to Vit C), followed by sip of water or teeth brushing to help prevent discolouration. May cause cramps, tummy upset.

Meats have iron that is why some give first, save sweets as a reward as children/infants “love” dextrose sweet flavours-soothing • Don’t fight over foods presented and refused. Try a little at a time, use only washable surfaces, floor included- • Encourage hands in food and holding spoon, place small amounts of fluid in a sippy cup, refill after meal • allow play with dry foods ( crackers, O’s) at mealtime promotes self-feeding which will come later with utensils.

Families without food security may benefit from enablement activities such as: • Instruct about the benefits and cost effectiveness of breast feeding. • Provide listings of community-based agencies with food services for families- including assistance with other baby supplies such as diapers- second hand clothing and approved regulation child care items. • Warn against the use of powdered coffee creamers as a formula alternative for infants/ children- no nutritional value, high globule fats, not digestible by infant gut, no weight gain or growth.< %ile. • Avoid making commercial formulas half strength by diluting with water, not enough calories or supplements for growth and immunity. • Prevent overfeeding of distilled water to infants and young children- hypotonic, leads to electrolyte imbalances.

Instruct about how to make home-prepared blender foods for infants, how to freeze and use foods from the main nutritious sources for family. Save money on commercial baby foods. • Do not substitute juices for formulas or fruits, more sucrose and fructose than nutrients, empty calories. Watch junk foods- high salt and saturated fat • Encourage keeping infant and child dressed warmly- reduces caloric requirements for body heat- hat, socks, gloves, fleece, layers, warm bed.

Promote attendance at community parenting and baby support groups- weigh-in of parents and children. Keep growth chart to show progress. Developmental screening appraisals, free coupons for food and transportation, friendships with other new parents and nursing team, questions answered about behaviours, what to do and expect, access to free NP assessment and car for self as well as children, immunization information.

Don’t dip soother in sweeteners honey or alcohol-based solutions, should not use soother to substitute for food. Meant to be nurtrative, soothing self-calming activity, not feeding substitute. Ask parents about their preferences re starting and use of soothers, follow their family plan, explain possible need in the health-care context( NPO ). Avoid putting baby’s soother into other people’s or pet’s mouths and then back into baby’s without cleaning. Get good quality of soother so not sucking and leeching chemicals, carcinogens from plastics, latex etc. Buy new ones and interchange more than one, replace if getting too soggy, in bits, or have holes chewed in them. Wash as with dishes and rinse before reuse Soother Selection and Use: to have or not to have?

Do not allow to drag all over- safety issue with cord & contamination. Do not fight over “letting go” of soother before child understands or has other strategies or can handle the lack of sucking as a stress relieving activity. Don’t tease child about soother. Can set goals for weaning from soother but Not at same time as weaning from bottle or breast or when parent is resuming ‘work’ away from home. Child may need/ request soother again at times of worry, fear, and upset ( have one tucked away out of sight but for emergencies if requested). Sucking should be accompanied by comforting from care-provider as may be needed at time of physical and emotional trauma- post op- pain, parental separation, NPO.

Episodic and Long-term Conditions may require considerations in feeding practices, amounts and nutritional choices.Look at what cases are pictured and describe the alterations ,assessment findings , considerations, and nursing interventions associated with feeding and nutrition.

Pyloric Stenosis- progressive narrowing of the pyloric sphincter at the outlet of the stomach caused by hypertrophy of duodenal muscle. • Etiology unknown- some evidence of hereditary predisposition. Mostly male, caucasian, first-borns, one in 500 live births • Assessed by reports of increased spitting up, • to vomiting to projectile emesis of feeds in spite of • good appetite. Stools fewer, constipated, • Palpable painless olive-sized nodule RUQ, visible • reverse peristaltic waves over abdomen, <weight , • dehydration & electrolyte imbalances/ metabolic • alkalosis , hyponatremia, hypokalemia; • hemoconcentration • Diagnositcs- Gi series, Ultrasound • Surgical intervention- pylorotomy, high Fowler’s, • NPO to resume feeding in amount and concentration, • gradually, correct metabolic imbalances,hydrate, • Oral care, soother, parent support. Wound care, pain • relief , positioning,

Malabsorption Disorders: • Celiac Disease – sensitivity to gluten in grains- wheat, barley rye , oats. Creates a toxic colitis response to amino acid glutamine. Malabsorption crisis in small intestines, villi atrophy, weight loss, metabolic acidosis ^ and dehydration crises, bulky fatty stool that floats (steatorrhea), lots of offensive gas & cramps. Pendulous belly, shrunken buttocks, muscle wasting, infections increased,vomiting, abd. Pain,hemorrhages loss of vitK, Rickets and tetany due to lack of Vit D, and CALCIUM . Irritable, apathetic,pale, • Corrected by elimination of gluten in diet- no grains- substitute potatoes, rice, corn, soya: Add vitamin supplements & Calcium • Read all labels, know alternative chemical names for gluten and avoid those products. • Protect and prevent infections- precipitates a Celiac Crisis, • Should not receive anticholinergic drugs • May need Electrolyte and hydration per IV, bicarb calcium potassium • Give info re Celiac Associations

Inborn Error in Metabolism-Lactase deficiency=Lactose Intolerance • Common to many ethnic groups- due to lack of enzyme Lactase. Lactose must be metabolized in small intestine into glucose and galactose. • Variable ages of onset, usually 3-7 yrs. • May be secondary to other diseases- Cystic Fibrosis, Sprue, Kwashiorkor, giardiasis • Assessment- symptoms- abdominal pain, cramps, distension, bloating, diarrhea, a half hour after meal. • diagnosis by the positive breathalyzer test for hydrogen, gastric suction for enzymes, endoscopy, • Treat by eliminating Dairy and addition of replacement lactase tablets- alternative formulas from soya products • Add Calcium & Vit D to assure bone growth & density • Add probiotics such as lactobacillus in fresh yogurtare tolerated • Watch and teach about hidden sources of lactose ( med’s )

Various pathways are incomplete due to lack of enzymes, or faulty metabolites, Cord Blood analysis can now detect absent essential enzymes, variations, or metabolites. Dietary interventions are put into place if not, child will be mentally disabled, die from accumulation of metabolites that are incompatible with life. Alterations in hair, eye, skin pigmentation, urine colour and odour, bone formation, neural reflexes, hepatomegaly, drug sensitivities p. 335 ( PKU) and p. 338 ( Galactosemia) Galactosemia, Phenylketonuria,Maple Syrup Disease,life threatening malabsorptions /inborn errors in metabolism.

Special formulas • P. 337 • Drug manufacturers have created scientifically researched formulas and nutritional supplements to substitute for dietary restrictions. Calculations of calories and nutrients per unit of measure provide an opportunity for nutritionists to calcualate the requirements for each child depending on age, weight, height/length, Body surface area. Nurses are not responsible for making this calculation, but are accountable for making sure the mathematical calculation is correct and that the correct feeding is prepared and given. • Soya by-products- Isomil, Pro-Sobee, Similac, Enfamil, Phenyl-free, Lipid advance, etc. Read labels carefully and follow directions. Monitor vitals, weight, stool, urine, cognition, behaviour Help needed often to make meal planning a pleasure, not a challenge and chore. Difficult for School agers -Teens to follow special diets- want to be a part of the group. Must be assisted to keep dietary restrictions but to modify so could socialize and engage with others.

Feeding and Dietary challenges are associated with complex chronic conditions, birth injury, trauma, or congenital anomalies • Cerebral Palsy(pp.1806-1816) is a major cause of feeding and nutritional problems and concerns • Brain trauma and encephalopathy may minimize or negate normal swallowing, vocalization, head & breathing control, reflexes, sitting alone, upright posture ,and co-ordination, meeting milestones for age - from infancy onward, ability to relax muscles, • Prone to aspiration, seizures, sensory problems, communication impairment, • Require more high energy intake if ataxic, athetoid (diskenetic) or spastic or dystonic forms of CP- constant movement and muscle action, burns up caloric intake. • Speech, Audiology, Recreational, Occupational, and Physical Therapists assist with routine for helping with eating . Manual cuing, guiding swallowing , chewing, and training jaw control and movement with special exercises and games. Nutritionists create necessary dietary plans and physician and nurses assist with feeding tubes.

Various examples of challenging situations, & Aids in feeding and nutrition for the child with CP

Samples of assistive devices that encourage young children to maximize their strengths and promote their independence • Feeding children with swallowing difficulties is a • challenge right from the first days. It is essential • to teach and plan for the team approach . A • consistent team who know the child can modify • interventions quickly so the child does not lose • ground. Proper seating, posture supports, utensils • are vital to developmental progress and growth.

COLIC - Paroxysmal Abdominal Pain • This painful spasmodic abdominal pain can occur in up to a third of all infants. Multifactoral causes- feeding problems, formula, tension,too much fructose, too little lactose, environmental pollutants, CNS dysregulation. • Manifested by stiff board-like abdomen, legs drawn up kicking, LOUD and PROLONGED crying without relief in a baby under 3 mo.,for at least 3 hours,more than 3 times a week. Parents are upset and can not stand this any more- what is wrong? • Infant continues to gain weight, has normal temp, vitals, Resolves in about 12 weeks – without long term repercussions to the child. • Parents may have Self- doubting and angry thoughts- I must be a bad parent, infant getting back at me, not really my child, ungrateful little spoiled kid. May blame the other parent or grandparents. May lose control, need support and respite learn ways to manage it

Colic management strategies • Warm antispasmodic Herbal teas help • Investigate for CMA( Cow‘s Milk Allergy)- eliminate Dairy and use another formula but avoid soya types as may be sensitive to these too. • Place prone over a source of radiant warmth • Gently massage infant’s abdomen, do Infant Yoga • Attend to crying immediately, Colic carry • Swaddle tightly for warmth and comfort • Try rocking – automatic or personal • White noise, vibration- running motors • Heartbeat music- Beethoven • Smaller, warm, frequent feeds, well burped before during and after • Well fitted pacifier/ soother for extra sucking pleasure • Avoid gas –producing foods if mother breast –feeding- passes through • Air-free bottles, make sure a solid latch, not sucking air • Parenting contact with Public Health Nurse for support, allay anxiety, take history, find triggers • supportive literature, phone-in hotlines, e-health links, • ‘sleepovers’ for parents away from child/ Arrange for respite, babysitter and parents go out • Sleep routines eased into, but not stretched out- when trying to eliminate the night bottle, do not go into room immediately, do not put light on, resettle with the least intrusion, water not juice or formula • Lots of helpful booklets and suggestions through Health Canada, web information, materials.

Sometimes parental anxiety and anger get out of control. Displacement of emotions, power, seek to control - Act out on child. SBS may go undetected in infants under 6 mo – just slow. Subdural Hematoma or retinal hemorrhages without external trauma under 1 year are key signs Instruct new parents to avoid shaking infant to rouse, not to toss them in the air- “for fun” and not to shake them when angry Must protect infant if suspicious, Take stories separately Do thorough examination- radiography, CT. Check for signs of ICP, Dropping BP, delayed cap refill, bulging or depressed fontanel, chest sounds, injuries, bruises, fractures, soft tissue swelling- especially in rectum and perineum, black eyes, blood in urine, lacerations, burns inability to move head or body signs of decerebrate or decorticate posturing SBS can kill or paralyze for lifetime. Great costs to the system CAS and social work will need to be involved to investigate injuries, family integrity, tensions, protect child. Child may never be able to eat or drink normally again- alternate tube feeds. Child maltreatmentShaken Baby Syndrome p. 702

Observations of infants and children for recurring injuries, history in x-rays of sequential . Serial injuries, can be indicators of SBS or other maltreatment. Report concerns to CAS

Nursing skills associated with feeding

Anorexia and refusal to feed/eat is an early indicator of illness • Infants and children may not want to eat from time to time because they do not “feel well” . • May be unable to us words to describe symptoms so adult must be an acute observer of behaviour • Vitals ( PTR) can indicate if illness is affecting appetite, ability to swallow, respiratory and stomach distress, abdominal pain. • Drooling and Sore mouth may be from normal changes like teething, or from strep throat, Viral infections, or from an injury, or a foreign object.

Immature temperature control makes it difficult to maintain a median temp. Set points individualized, familial tendencies. need to have help e.g. more or less clothes, food, hydration, warm room, rest, antipyretic medication, cuddling. Pain relief as needed Fever is an indicator of illness Pain is another & change in behaviour

Safety essential in taking temp. no rectals in some agencies, dermal temp common tympanic variable Throat and mouth may be infected- smell breath, DO not probe throat/mouth with tongue blade Throat swabs may need to be taken or RSV mucous Specimen. Be careful not t force a gag reflex, may vomit and then aspirate. Use parent’s lap for non-intrusive vitals, do in treatment room, not own room or playroom Always consider dehydration and electrolyte imbalance with fever Take weight as may be in a negative and fluid calorie balance In addition to taking temperature, look

Febrile seizures are feared by parents • Teach parents about how to safely take temperature • Assess for diaphoresis, chills, flushing, rash, anxiety, lethargy, dehydration, reluctance to eat or void, diarrhea, emesis, • Know when a fever – 37.5-38.5 or above, pyrexia means fever, elevated temp. • know what their child’s fever-seizure threshold is. • give acetaminophen for weight when first signs of elevating temperature [no Aspirin] • Push fluids, keep calm, undress from many layers • No rubbing alcohol to tepid bath or as a wipe • Follow careful management of child in sponge bath( 20-30 min max) • Know how to reduce temperature by evaporation, radiation, convection, conduction. • light friction rub on limbs. • Careful of herbal cures, folk ceremonies (coining) and remedies(Lime juice rub) beliefs on foods – cold choices for hot illness to balance, or heat drives out heat, • Be careful of seizure, know seizure precautions, prevent anoxia, aspiration, injury. Place in recovery position when seizuring ended. Log time and descriptions, Get to clinic or ER ASAP. • Reassure parents that this does not mean the child has epilepsy but should be carefully monitored for cause- if related to pyrexia, then prevent by medicating early

Spinal tap/ Lumbar Puncture,may need to be done if fever high. Put into isolation- Need to protect children and others in case the cause is infectious, communicable. Be careful to hold child tightly, use “Numbing jelly” at least an hour beforehand. Fevers are a cue to infection & Neutropenia- Threat to children with cancer Fevers of concern to kids on medications such as steroids Fever in infant demands immediate attention- sepsis, needs prompt intervention- fluids, antibiotics, STAT Sudden onset of fevers is one indicator of illness .Must know pattern of highs and lows, if relieved with antipyrexic agents, if there are other signs & symptoms, Headaches, photosensitivity, neck pain , opisthotonus, rigidity, specific rashes.Patterns on the dermis- meningitis encephalitis urgent concern. • Meningococcemia rash • Spinal tap Rapid onset, act quickly.

Feeding is difficult for infants with respiratory distress and airways • Make sure that Positioning is in High fowler’s Feed small amounts frequently, Liquids should be pushed once kidney action is assured Do not allow to aspirate, may cover tracheal stoma if eating toast etc. • Make sure O2 is running and on trach or face and secure Clean stoma and tubing before eating/ feeding to allow for ease of intake, no shortness of breath Do not allow to become fatigued, monitor p & r Stop if apical is racing or gasping for breath, rapid respirations

Communicable diseases can cause anorexia • Some Communicable diseases are preventable –highly communicable contagious- so avoid contact. • Varicella- 4 strains, immunization only against selected strains so may not be totally possible to eradicate. Varicella immunization available. • Parents sometimes try to get chickenpox “overwith” in the season. Will attend varicella parties share toys and droplets with a child who has just come down with them the day before– not a good practice • Children can be very ill, encephalitis is possible. Pox can be internal as well as external. Uncomfortable, must stay home from school till pox dried( @10 days) Communicable I day before lesions erupt and 6 days after lesions/ vesicles- erupt as long as pox are moist and draining. Stages of resolution- macules to pustules to vesicles to crusts. • Know incubation period and profile of onset- pyrexia first then “bloom” of pox on chest, then gradually erupt all over body • Care with antipyrexic agents- no ASA, anti pruritis interventions, good oral care,cool clean cotton PJ’s, cut nails short, mitts, calamine lotion to lesions,Oatmeal baths, prevent infection of pox, keep calm, amused, and resting. Scabs may leave marks but temporary unless deep. Keep away from others with steroids, the elderly and immunocompromised.

Measles, Rubella ,Scarlet Fever • Every communicable disease will create a pyrexic pattern typical of the disease, Variable due to growth patterns of organisms, actions on healthy cells, endotoxins and pyogens. In addition to fever, look at the signs and symptoms of these diseases such as Koplik spots , rashes, pruritis, palms of hands and soles of feet, pain, concerns for pregnant women and damage to foetus,photosensitive,conjunctivitisstomatitis, arthralgia, malaise, anorexia,Coryza, cough • pp.664-678

Hearing and assessment of the infant and child’s ear placement is vital- link to kidney problems if anomalous, Hearing must be tested several times with infant who had a high bilirubin at birth.

Pinna positining to performOtoscopic examination, pull down for under three, pull up over 3 yrs. Be careful get help if needed to calm child and help. If child complaining of ear aches, not eating, has repeated infection, nurse should look at feeding patterns, bottle at bedtime(?).

Birth defects, congenital anomalies have a high morbidity and high mortality rate • Acute care is available for life support and corrective intervention. This allows for the increase of medically dependent as well as healthy children to live on . Nutrition, acidosis, infections, strokes, are common causes of mortality.

Weeks 3 & 4 Babies and Beginnings Classroom topics