Lecture 1

Question 1

what is the most common cause of death and disability in children in the US?

Answer 1

• childhood injuries

Question 2

what are the leading causes of mortality in those less than 15?

Answer 2

• unintentional injury
• violence
• accidents

Question 3

what accounts for 50% of acute conditions in children?

Answer 3

respiratory illness

Question 4

discuss the overarching goals of Healthy People 2020

Answer 4

• high quality, longer lives free of preventable dz, disability, injury, and premature death
• health equity, eliminate disparities, improve health of all groups
• create social and physical environment that promote good health for all
• promote quality of life, healthy development and health behaviiors across all life spans

Question 5

why are global health concerns important to address?

Answer 5

• inc travel–>inc incidence of bringing things to US
• effects of “war” on children
• inc in foreign adoptions–>new dz and concerns we aren’t used to
• supporting maternal and child health is an investment for all

Question 6

what contributes to 50% of deaths globally?

Answer 6

malnutrition

Question 7

explain “family centered care”

Answer 7

• recognize that the family is integral to a child’s life
  
  • family is essential part of health care team
  • family is expert in care of child
  • enable and empower the famiyl
  • meeting the families needs healps eet the child’s needs
    
    • may need social work, pastoral care, etc
  • the family IS the patient
    
    • you cannot separate out the family and the child

Question 8

explain “atraumatic care”

Answer 8

• use procedures and approaches to minimize trauma
  
  • physical and psychological trauma
• 3 principles:
  
  • prevent/minimize separation from family
  • promote a sense of control
  • prevent/minimize bodily injury and pain
• child’s bed needs to be a safe place–>try to minimize trauma in the bed

Question 9

what are the goals of pediatric hospital care?

Answer 9

• use developmentally appropriate approach and care (NOT always the same as chronological age)
• use important assessment and observation skills
• minimize distress
• honest, truthful approach
• use of play to interact, teach, assess, and to help with coping
  
  • play is the work of the child
  • hospitalization interrupts their development
• respect of family as experts of their child
• safety!

Question 10

how to correct for gestational age?

Answer 10

• example:
  
  • if normal gestation is 40 weeks, and the child is born at 25 weeks, if you plot that child on a developmental growth chart, then that child will always be below the bar
    
    • if child born at 25 weeks, subtract 40-25=15 weeks premature
      
      • if child is now 6 mos old–>~24 weeks, so then 24-15=9 weeks
        
        • so then the child has a corrected gestational age of 9 weeks
  • we will correct for gestational age up until 2 years old where it becomes obvious then if the child is going to be back on the normal growth chart or if they never will be

Question 11

explain “regression”

Answer 11

• return to an earlier developmental level or ability
• a coping mechanism
• occurs when there is a threat to autonomy–>often occurs when ppl/child admitted to the hospital
• common to occur in times of stress–>hospitalization, family stresses, etc.
• temporary
• best approach: ignore and praise appropriate behavior

Question 12

children and pain

Answer 12

• pain tends to be underestimated in children
• there are physiological and psychological effects when pain is not treated adequately
• myths:
  
  • infants do not experience pain
  • children are more prone to complications of pain mgmt
  • children are always honest about pain
  • if a child is sleeping or playing, they must not be in pain

Question 13

multiple ways to treat pain

Answer 13

• pharmacologic:
  
  • non-opioids and opioids
  • PCA
  • epidural
  • topical: have to make sure child can’t touch/take off/eat patches
• non pharmacologic:
  
  • sucking kangaroo care, distraction like music/tv
• CAM

Question 14

PCA

Answer 14

• must be physically able to push button and understand it
• advantages:
  
  • pain won’t spike b/c of basal rate
    
    • if it does spike, it requires more medication
    • if not on PCA, want pt on ATC pain meds NOT PRN b/c with PRN they are more likely to need breakthrough pain
    • if on PCA and have breakthrough pain, need to talk to provider and see if level is therapeutic

Question 15

WHO Analgesic Ladder

Answer 15

• Step 1:
  
  • Mild to Moderate Pain:
    
    • non-opioids–aspirin, NSAIDs, or paracetamol
• Step 2:
  
  • moderate to severe pain:
    
    • mild opioids (ie codeine) w/ or w/o non-opioids
• Step 3:
  
  • severe pain:
    
    • strong opoiods (ie morphine) w/ or w/o non-opiods

Question 16

explain “equianalgesic opioid dosing”

Answer 16

• tells you how much PO med you need to get the same effect as IV meds
  
  • must use this otherwise pt will be in tremendous pain b/c PO meds take so long to get into system and IV meds out of system almost immediately
  • ie. if on PCA and want to switch to PO, slowly titrate down on the PCA and inc PO–>don’t stop PCA w/o having PO in the system

Question 17

pain assessment in children

Answer 17

• pain is whatever person says it is
• ask parents: they often have good insight
• self report is the GOLD standard

Question 18

FLACC Tool

Answer 18

• use for children, if non-verbal, if sedated/under anesthesia
• score from 0 to 10
  
  • higher score–>higher pain
• stands for:
  
  • Face
  • Legs
  • Activity
  • Cry
  • Consolability
• Patients who are awake:
  
  • observe for 1-5 min
  • observe legs and body uncovered
  • reposition pt/observe activity
    
    • assess body for tenseness/tone
    • initiate consoling if needed
• patients who are asleep:
  
  • observe for 5 min
  • observe body uncovered
  • if possible, reposition patient
  • touch body/assess for tenseness

Question 19

FACES tool

Answer 19

• point to each face using words to describe pain intensity
  
  • ask the child to choose face that best describes own pain and record the appropriate #
• rating scale is recommended for persons 3 years and older

Question 20

Numbers/NRS/Visual Analogue tool

Answer 20

• most used tool
• 0-10: 0 being no pain, 10 being worst pain
• developmentally appropriate tool, meaning must understand numbers and their relationships to one another
  
  • so have to know that 5 is more than 0, and 10 is more than 5

Question 21

what are important concerns in newborns?

Answer 21

• temperature regulation
• hypoglycemia
• poor ability to fight infection–>immature immune system
• neonatal period: first 28 days

Question 22

infant vision

Answer 22

• eyes are fully formed, but vision and eyes muscles are immature
• bright or moving objects 8 in from face is easiest for them to focus on
• Strabismus (crossed eyes):
  
  • common until 4 mos of age
  • binocular vision is developed by 4 mos (seeing clearly out of both eyes)
  • patching or surgery needs to be used to treat if it continues
    
    • patch the strong eye

Question 23

thrush (oral candidiasis)

Answer 23

• white adherent patches on tongue, palate, and inner aspects of cheek
• painful–infant may refuse to suck
  
  • concerned about dec oral intake–>dec urinary output
• use oral nystatin over the patches 4x per day and continue beyond symptoms for at least 2 days
  
  • gentian violet may be used in chronic cases

Question 24

diaper dermatitis

Answer 24

• rash: caused by prolonged exposure to irritants
• mgmt is aimed at altering the pH, wetness, and irritants
  
  • change diaper as soon as wet
  • expose to air but no heat
  • use barrier ointments: OTC with zinc oxide and petroleum based preparations
• super absorbent diapers are helpful but also expensive
• no talcum powder: risk of respiratory distress

Question 25

diaper candidiasis

Answer 25

• common w/ prolonged diaper dermatitis, use of Abs, or immunocompromised state
• lasts longer than 72 hours, then usually candidiasis
• yeast like fungus with diarrhea, Ab use, and thrush as predisposing factors
• very confluent, red rash with “satellite lesions”
• treated w/ antifungal creams (such as nystatin)

Question 26

dental care of the infant

Answer 26

• starts when the teeth erupt usually around 6 mos
  
  • usually bottom, central teeth
  • very pain–>can use tylenol, cold rings
    
    • NO ibuprofen b/c liver immature
• fluoride–start after 6 mos if non-fluoridated water and maintain until 3 yrs
• dental visits: start no later than age 3
• teething:
  
  • cold is soothing
  • but should discourage oragel and numbing agents
• low sugar diet
• baby bottle caries
  
  • discourage baby bottles in bed
  • discourage use of baby bottle as pacifier

Question 27

why should you discourage baby bottles in bed?

Answer 27

• they don’t need bottle in bed and can use pacifer
• until 5 yo, eustachian tube is horizontal to throat, so if laying down drinking, milk goes into eustachian tube to middle ear and causes otitis media

Question 28

SIDS: what is it? cause? risk factors?

Answer 28

• unexplained, sudden death of an infant under age 1
• unknown cause
• risk factors:
  
  • maternal smoking during pregnancy and tobacco exposure during infancy
  • co-sleeping or soft bed surfaces
  • prone sleeping
  • pre term infants (LBW, low apgar), siblings of 2 or more with SIDS, male babies, recent viral illness

Question 29

education for SIDS

Answer 29

• back to sleep
• firm sleep surface w/ no loose bedding
• do not cosleep w/ infant
• avoid overheating/overbundling
• sleep w/ pacifier and breast feeding may be protective
• provide supervised tummy time to avoid flat occiput and help develop neck and shoulder muscles

Question 30

car seat safety

Answer 30

• most significant risk factor for death and serious injury in a car crash is the failure to use size appropriate restraint system
• use approved car seat for age and weight
• infants rear facing until at least 2 yrs and 30-40 lbs
  
  • when child reaches max height and weight recommendations, then can turn carseat around
  • convertible carseat w/ a weight limiit of 35 lbs can be used rear facing 2-4 yrs
• backseat is safest for all of those 13 yrs and younger
• toddler seating–appropriate harness placement and height of carseat
• proper lap belt placement for older children and those in boosters
  
  • should be down around hips/thighs–>not against abdomen b/c can destroy inner organs (splenic lac, etc)
• shouldn’t be in front seat until 100 lbs

Question 31

breast milk or formula

Answer 31

• prefer breast milk as complete diet for 6 mos
  
  • it can dec respiratory infections, asthma, otitis media, obesity, diabetes, SIDS, leukemia
• prefer iron fortified formulas
• no add’l H2O needed
• do not microwave breast milk b/c can cause hot spots and change the composition of breast milk
  
  • store breast milk in fridge

Question 32

what is necessary for an infant to start eating food?

Answer 32

• 6 mos of age
• dec tongue thrust
• can hold head up when sitting
• interested
• can signal refusal

Question 33

progression of food introduction

Answer 33

• rice cereal–>fruits/veggies–>meats–>eggs

Question 34

introduction of food to infants

Answer 34

• limit juice intake to less than 4 oz/day
• begin w/ rice cereal b/c least allergenic
• use single item foods only for 4-7 daus b/c want to look for allergic rxn and wait b/w to check for allergies
• no honey until after 1 yr–>b/c of risk of botulism

Question 35

juice recommendations

Answer 35

• should be 100% pasteurized fruit juice NOT fruit drinks
• should be less than 4 oz/day
• older children should be encouraged to eat whole fruits as opposed to drinking juice

Question 36

infant feeding concerns

Answer 36

• spit up vs vomit
  
  • spit up is a normal occurrence
  • reduce by frequent burping, minimal handling during and after feeding
• colic: paroxysmal abdominal pain
  
  • loud crying and drawing up of knees more than 3 hours per day more than 3x per week
  • usualy gains weight and thrives

Question 37

weaning from a bottle

Answer 37

• goal: to be weaned by 12 mos
• offer juice in cup, but limit
• switch to cow’s milk at 12 mos b/c need the fats
  
  • should use whole milk or 2%, not skim until 2 yo
• physiologic anorexia: stretch where child doesn’t eat, but need to make sure still gaining weight
• prefer no more than 20-24 oz of cow’s milk per day
  
  • risk of iron deficiency anemia if more thn 32 oz of milk/day