Pediatrics

Question 1

Growth and Development

Answer 1

Growth is an increase in physical size while development is an increase in capability or function.
Development does not always follow growth and chronological age - chronological Age and development are two different things.

Question 2

Cephalocaudal development

Answer 2

The development that moves from the head downward through the body and towards the feet

Question 3

Proximodistal development

Answer 3

the Development that moves from the centre of the body outward to the extremities

Question 4

Infancy is birth to 12 months of age: Trust vs Mistrust (Erikson) : Basic Principles

Answer 4

Basic Principles:
This is a time when the primary source of activity is through the mouth; examples are rooting and sucking reflex, feeding, and pacifier.

Repeated use of reflexes develops experiences

Young infants are totally self-centered; they have little tolerance for delayed gratification

At 4-8 months they can perform a desired activity that will produce a result. Example: secures object by pulling on a string

Late infancy: develops the concept of object permanence understands parents are present even if not in line of vision,
works to get toy that is out of reach

Comprehends simple commands and meaning of words

Can say bye-bye and blow kisses

Begins to explore their surroundings

Infants trust that their needs will be meet (feedings, diaper changes, comfort, stimulation)

The trust developed during infancy is the foundation for all
relationships and for the progression of further development

The single most important element in developing trust is consistency in caregivers. Infants love routines! So do things like having a regular feeding schedule, bathe every night then give a bottle and go to bed.

Question 5

Infancy is birth to 12 months of age: Trust vs Mistrust (Erikson) : Assessment Guidelines

Answer 5

Important things to focus on when assessing an infant

Head control: should have no head lag by 4 months

Pincer grasp: should have established pincer grasp by 11 months of age. Remember up until 1 month of age, hands are closed, grasping at 2-3 months is a reflex.

By 5 months, infants can voluntarily grasp an object.

Rolling over: should be able to roll over from abdomen to back at 5 months of age. No your baby isn’t advanced if they rolled over at 2 months…..it was an ACCIDENT!!

Weight: gain 5-7oz weekly for first 6 months; at 2 weeks, the infant should have gained back to their birth weight, then weight should double around 5 months of age and triple by age 1

Posterior fontanel closes by 2 months of age anterior fontanel closes by 18 months of age

Verbal skills: should be able to imitate sound around 6 months, by 8 months combines syllables like dada but doesn’t know the meaning, 9 months responds to simple commands, comprehends no-no, 10 months says dada and mama with meaning attached,
12 months says 3-5 words

Question 6

Infancy is birth to 12 months of age: Trust vs Mistrust (Erikson) : Developmental milestones

Answer 6

Some important developmental milestones to remember:

By 2 months can try to pull up with some head control

By 7 months should bear weight on feet, can sit with support,
transfers object from one hand to the other

By 8 months can move from sitting to kneeling, sits without support

By 9 months can stand holding onto furniture, creeps on hands and knees 9-10 months takes deliberate steps

By 12 months walks with 1 hand held, can sit down from standing position without help

Question 7

Toddlers are age 12 months to 36 months: Autonomy vs. Shame and Doubt (Erikson) : Basic Principles

Answer 7

The primary source of activity is continued until about 18 months of age
and then the toddler transitions into a focus on elimination needs.

The child learns to control his bowels, but if this process doesn’t happen an “anal” fixation may develop and can lead to obsessive/perfection or
disorganized behaviors.

Cognitive development is characterized by EGOCENTRISM
Curious about their environment
Leaves parents for extended period of time
Searches for objects through hiding places
Imitates words and sounds and adult behavior
Engages in parallel play
LOVES ROUTINE!!!
Uses 2-3 words together
Possessive of their toys; uses the word MINE
Follows direction
Egocentrism is observed in the behaviors and play

The toddler has entered the world of NO NO NO NO NO!

Toddlers are aware of their will and control over others but they
are conflicted with exerting autonomy and relinquishing the much enjoyed independence on others

Holding on and letting go are evident in how the toddler uses his
hands, mouth, eyes: “No don’t touch”, spitting out food, etc.

NEGATIVEISM and RITUALISM are typical

Toddlers learn to behave based on the restrictions that are placed on their actions

If the child’s behaviors is punished they learn it is bad; if it is rewarded, it is positive

By 36 months you may see developmental aspects of a conscience

Question 8

Toddlers are age 12 months to 36 months: Autonomy vs. Shame and Doubt (Erikson) : Assessment Guidelines

Answer 8

Important things to focus on when assessing the toddler

Steady growth in weight and height

Development of body image; they learn to associate body parts with meanings

Gender identity is developed by age 3
– Developing self-image, avoid using negative terms like skinny legs or chubby legs.

Play is important so provide enough space for play; encourage pretend play

Permit child to help with adult tasks - they want to feel productive

Provide toys or activities that help with expression of feelings: language
skills aren’t developed enough to express all feelings

When assessing the child let them hold and touch equipment-this will greatly reduce their fear.

Question 9

Toddlers are age 12 months to 36 months: Autonomy vs. Shame and Doubt (Erikson) : Developmental Milestones

Answer 9

Some important developmental milestones to remember:

Gross motor: walks without help, creeps up stairs, kneels without support

Fine motor: builds tower of 2 cubes, holds 2 cubes in one hand, scribbles, uses cup well but struggles with a spoon

Language: says 4-5 words, including name, points and ask for objects, understands simple commands, says 10 or more words, uses 2-3 phrases, TALKS ALL THE TIME

Tolerates separation from parents

TEMPER TANTRUMS are normal

May develop a dependency on security item – like a special blanket or stuffed animal

Question 10

Preschool is ages 3-5 years: Initiative vs Guilt (Erikson) ; Basic Principles

Answer 10

This is a time when the primary source of activity is related to their sexual identity and relationship with parents.

Becomes rival with same sex parent, develops sexual desires for opposite sex parent. This is sometimes referred to as the Oedipus
Complex for boys and Electra Complex for girls

Develops a fear they will be punished for these feelings by same sex parent and this fear eventually leads the child to learn to identify
with the same sex parent

The preschooler’s thinking transitions from egocentric thought to social
awareness is often referred to as “magical thinking.” They believe their
thoughts are all powerful; for instance, if they wish their sister would die
and something happens and she dies, they think it is their fault

Literal thinkers- if you tell them they were bad for hitting a child, they literally think they are bad, they can’t understand it’s the behavior that was bad not THEM!

Poor body boundaries, they think when they have a cut all their blood is
going to come out. That’s why they always want a million Band-Aids.

Question 11

Preschool is ages 3-5 years: Initiative vs Guilt (Erikson) : Assessment

Answer 11

Important things to focus on when assessing the preschooler

Usual weight gain is 4-6 pounds per year; good rule of thumb:
4 years, 40 pounds, 40 inches. Average weight of 5 year old is 42.1 pounds.

The preschooler begins to move from parallel play to associative play.
This is group play that is similar but without rigid organization rules.
For example: everyone is sitting around playing with their blocks.

Imaginative and imitative play are also very important as a way for children to express their feelings when they don’t have the vocabulary
yet to describe what they are feeling.

Use drawing and pictures to help child express how they are feeling with procedures and interventions; allow them to help when safe for the child, such as with dressing changes or bandages.

Question 12

Preschool is ages 3-5 years: Initiative vs Guilt (Erikson) : Developmental Milestones

Answer 12

Some important developmental milestones to remember:

Gross motor: Rides tricycle, jumps off bottom step, Skip and hop on one foot, catch a ball, jumps rope

Fine motor: Builds a tower of 9 blocks, when drawing can copy circles, Use scissors usefully to cut out pictures, ties shoelaces

Vocabulary of 900 - 2100 words as they grow

Uses complete sentences starting with 3-4 words up to 6-8 words

Continues to talk all the time- even if no one is listening!!

Tells exaggerated stories and asks WHY, WHY, WHY?

Question 13

School Age is 6-12 years: Industry vs Inferiority (Erikson): Basic Principles

Answer 13

The child starts to place importance on privacy.
Plays mostly with same
sex peers. When caring for this age be sure to provide gowns and covers when performing procedures.
Always knock on the door before entering.

Has an increased need to understand the body and functions of the body.

One of the major tasks is mastering conservation. They learn that physical matter doesn’t change when its form is altered. They are no
longer magical thinkers. An example of this being achieved: They understand that if a girl cuts her hair short she doesn’t become a boy, their gender doesn’t change by having a haircut.

Does not reason logically, may use symbols or objects, either words or images. Understands relationship between things and ideas, allow the child to handle equipment-this will help increase
their understanding.

Children become more flexible. They are now able to see and
understand things from anothers point of view, no longer rigid
thinkers. They are no longer so egocentric. This is the beginning of logical thought formation which leads to the development of morality

They use cooperative play. They work hard in school, sports, and in
their family to fill a sense of accomplishment.

They want to be productive and successful!!

The goal of this stage of development is to develop a sense industry. This will help in building self-confidence. They continue to improve their social skills.

Eager to build skills and participate in meaningful and
socially useful work. They must balance this with the knowledge
that although they are improving and successful there is always more to learn.

If the child DOESN’T develop a sense of accomplishment this
may result is a sense of inferiority.

As children move from egocentrism to more logical thinking they are also developing a conscience and moral standards. These standards are
based on the teachings and beliefs of others such as teachers and
parents.

Question 14

School Age is 6-12 years: Industry vs Inferiority (Erikson): Assessment

Answer 14

Important things to focus on when assessing the school age child:

Height and weight gain slows, appears in bursts, can grow at least 2 inches in height per year

Question 15

School Age is 6-12 years: Industry vs Inferiority (Erikson): Developmental Milestones

Answer 15

Some important developmental milestones to remember:

Repeats activities in order to master them

Develops concept of numbers, knows when its morning or night, by age 8 gives similarities and differences between two things from memory, can repeat days of the week

Age 6 able to use knife to spread butter, by age 8 helps with routine housework, looks after own meals

Socially at age 6 can share and cooperate, likes to compete in games, enjoy spending time with others of the same age on projects and discussing the activities of the day, develops modesty: these are import ant consideration when they are in an acute care setting.

Question 16

Adolescents are age 12-18 years: Identity vs. Confusion (Erikson): Basic Principles

Answer 16

Adolescents primary focus is on peers and developing relationships out
side of the family.

Have the ability for mature abstract thoughts and ideas, can think
in hypothetical terms

As the adolescent physically matures and thought and ideas become more complex, a new sense of identity is developed.

This identity consists of a picture of oneself that includes past, present, and future.

Peer groups play a large role in developing a sense a self and self-esteem, with the key to identity achievement being based on interaction with others.

Barriers to developing identity would be lack of role models, inability to identify a meaningful sense of self, and lack of opportunities to explore alternative roles.

Establishes personal ethics on which to base decisions. Increase in reasoning and social cognition

Understands abstract thoughts and understands opinions of others.

Takes into account the opinions of others when making decisions

Question 17

Adolescents are age 12-18 years: Identity vs. Confusion (Erikson); Assessment

Answer 17

Physical changes related to sex and growth hormone effects; is varied in
rate and timing based on gender and family genetics/influences

Be clear, concise and honest when communicating with the adolescent, particularly with body and sexuality issues.

Nursing considerations: give both written and verbal instructions, give clear and complete information about disease process,
interventions, and hospitalization.

Question 18

Adolescents are age 12-18 years: Identity vs. Confusion (Erikson): Developmental Milestons

Answer 18

Some important developmental milestones to remember:

GIRLS develop more quickly than BOYS. Adolescents grow
stronger and more muscular.

Increased communication and time with peer group; enjoys
activities like movies, dances, driving, sporting events

Preoccupied with body image, very self-centered;
relationship with peers is the most important relationship

Feelings of “being in love” and dating forms stable
relationships and attachments to others

Emotional and physical separation from parents; becomes more independent

Question 19

Growth and Development and Toys

Answer 19

In addition to growth and development level, you must also think about the clients disease ( can they tolerate an increased oxygen demand, workload of the heart or stress of physical activity?)

Question 20

Safety and Toys

Answer 20

Don’t put stuff in croup tent - infection risk. You will have to keep bb in there and play with them - just make sure levels are built up.

Question 21

When does the anterior fontanel close?

Answer 21

12 - 18 months

Question 22

When does posterior fontanel close?

Answer 22

2 - 3 months

Question 23

Why are new foods introduced to babies one at a time?

Answer 23

Allergies and to give them time to get used to the food because that GI is immature

Question 24

How is the earlobe positioned in a child under 2 to view the auditory canal?

Answer 24

Down and Back

Question 25

How many cups of milk for the 15 month?

Answer 25

2 -3. you have to balance the diet

Question 26

Major causes of accidents in children up to 1 year

Answer 26

Falls, poisoning and burns

Question 27

Between 6 and 12, what major cause of accidents

Answer 27

MVA’s

Question 28

The Growth rate between 6 and 12 and How many calories a day

Answer 28

DECREASES and 2400

Question 29

Assessment

Answer 29

Start with observation. Then perform distraction techniques so that we get the most accurate set of vitals. TALK TO parent before child. LEAST INVASIVE FIRST.
Resps, HR, BP, Temp. Always cound HR and RR for a full minute because of irregularities. Record the beahviour if unable to get vitals.

Question 30

Temperature

Answer 30

Rectal: Recommended for children less than 2. Most reliable route.
Not for the immuno-suppressed or those with no rectum.

Auxillary - all ages, when oral route is not possible
Oral - 5 - 6
Tympanic - all ages

Question 31

Oxygen saturation

Answer 31

used to obtain a picture of the blood oxygen level through the skin

Check perfusion, skin temp and edema to determine the best location for the sensor probe
Common sites are the fingers and toes
Record what is going on at the time the pulse ox is measured
The pulse wave/intesity display on the oximeter machine should correlate with the childs radial pulse

Question 32

Communication: Children with Physical or Developmental Disabilities

Answer 32

If unable to communicate may feel helpless, fear or anxiety
Family may become anxious
Non-verbal - use gestures, picture boards and writing tablets
Communication - system of head nods and eye blinks

Question 33

Respiratory Asessemnt

Answer 33

Observable signs of respiratory dysfunction:
Accessory Muscle use
Nasal Flaring
Circumoral Pallor 
Sternal Retractions 
Cap refill more than 3 seconds

Question 34

Laryngotacheobronchitis (LTB)

Answer 34

The most common type of croup experienced by children admitted to the hospital Primarily affects children under 5 years. Caused by a viral infection

Slight to severe dyspnea
Barking or Brassy Cough
Increased Temp

Treatment:
Manage children at home with mild croup. At home, most episodes can be treated with judicious use of:

Steam and hot showers
Car rides with windows down at night
cool temp therapy assists by constricting edematous blood vessels

If symptoms worsen or there is no improvement, Hospitalization is required. Nebulized epinephrine is often used to constrict the edematous blood vessels - Rapid onset, and improvement is seen in 10 to 15 minutes , Observe for relapse. Corticosteroids to decrease inflammation of the airway.

Don’t confuse Epiglottitis with Croup. Key differences include absence of cough, presence of dysphagia, and the rapid progression to severe respiratory distress

SOUND WORSE THAN THEY LOOK

Question 35

Epiglottitis

Answer 35

is a serious obstructive inflammatory process that occurs in children 2 to 5 years of age.

absence of cough, presence of dysphagia, and the rapid progression to severe respiratory distress
LOOK WORSE THAN THEY SOUND

Question 36

Lower Respiratory Tract Disease - RSV

Answer 36

RSV - Respiratory Syncytial Virus - More dangerous for the very young

An Acute viral infection that affects the bronchioles and includes RSV, bronchiolitis and RSV pneumonia
Leading Cause of lower respiratory tract illness in children less than 2 years

Risk Factors 
Prematurity 
Congenital disorders 
Smoke 
Focus on Prevention; High Risk Children will get palivizumab 

Signs/Symptoms: 
URI
Nasal Discharge
Mild Fever
Dyspnea
Non-productive Cough
Tachypnea with flaring nares
Retraction and possible wheezing 
It is important to know the onset of signs and symptoms because the disease will become worse on days 2 - 3 

Treatment
Mild : Treat symptoms ( Supportive care - antipyretics)
Severe ; Suction, Oxygen: May need mechanical ventilation, IV fluids, Albuterol, Antipyretics

Question 37

Pneumonia

Answer 37

Disease marked by inflammation of the lungs

Causes
Viral: Common viral causes: RSV, Adenovirus or Parainfluenza
Bacterial: Usually Strep Pneumonia
Children <4 years have the greatest incident rate
Mycotic: Walking pneumonia (adolescents)
Aspiration Pneumonia: Occurs when something other air has gotten into the lungs

S/s
The same as generalized respiratory distress:
Fine crackles or rhonchi, with a cough that is either productive or non-productive 
Decreased or absent breath sounds 
Abdominal distention
Back pain
Fever, usually quite high 
Chest pain

Treatment
Depends on the type of pneumonia
ABC’s
Oxygen
Plenty of fluids to keep hydrated and keep secretions moving
Antibiotics for bacterial pneumonia
Supportive care: hydration, antipyretics and nebulizers

Question 38

Asthma

Answer 38

Inflammation and constriction of the airways, resulting in obstruction. Do an in depth through assessment.

S/s
Cough 
Shortness of Breath 
Audible Wheezing 
Prolonged expiratory wheezing 
Restless and cyanosis

Most important part of prevention is Asthma education and identifying triggers
A fish is a good pet for a person with asthma

Question 39

Cystic Fibrosis

Answer 39

The two body systems are affected by CF - Resp and GI - Thick secretions, does not absorb fat well.

What type of enzymes can be given to help improve digestion - Pancreatic enzymes. Take within 30 minutes of eating, and the beads should not be crushed or chewed as it can burn oral mucosa.

Diet:
Well balanced, high fat, high calories and high protein
They need water soluable vitamins ( A,D,E,K)

S/s
Steatorrhea - Fatty frothy stools
The sweat chloride test is the diagnostic test cystic fibrosis –> babies taste salty when you kiss them
High risk for hyponatremia
Newborn - Meconium ileus is the first sign of CF
Mucous secretions is thick and sticky.
It is an inherited disease but you must get the gene from both parents

Question 40

Down Syndrome

Answer 40

Down syndrome children are prone to developing Respiratory , because they have poor immune system.
Heart defects are the most common type of defect associated with Down syndrome
The primary aim in genetic counseling is to inform the parents of their risk

Question 41

Heart Failure in Peds

Answer 41

In children, HF is usually due to congenital heart defects.

S/s
Increased pulse at rest and with slight exertion
Increased respiratory rate
Scalp sweating
Fatigue
Sudden Weight Gain - more than 1 pound a day

Treatment 
Ongoing Assessment 
Listen to the lungs
Sit them up
Rest
Decrease Stimuli 
Cool humidified oxygen
Uninterrupted sleep 

Meds
Digoxin
Main signs of toxicity are bradycardia and vomiting
for infants, Hold dose if the pulse is less than 110
For Children, hold the dose if the <70
Infants rarely get more than 1 ml of digoxin per dose
(Normal Level is 0.8 - 2.0) Give one hour before or 2 hours after eating
Don’t mix with food or fluid
If you miss a dose and its 4 hours pass due, hold the dose and give the next dose on time
Don’t give more if the baby vomits
If two doses in a row are missed, call PHP
ALWAYS CHECK DOSE WITH ANOTHER NURSE

ACE inhibitors
Watch for decreased BP ( potential for hyperkalemia)
Kidney problems
A dry cough

Furosemide
Decreases the Volume

Question 42

Nutrition in the HF Peds Client

Answer 42

Well rested prior to eating
Small frequent feedings
increase Calories (formula has sodium in it)
Good feeding sced for heart baby is every 3 hours
Don’t prolong the infant feedings past 30 mins because they will be exhausted
Use a soft nipple with a larger opening, so baby won’t have to work so hard. Complete lavage feeding for resp distress
Breastfed babies will need additional supplements for calories

Question 43

Hypercyanotic Spells

Answer 43

known as blue spells
May be seen in infants with Tetralogy of Fallot ( A cogenital Heart Defect)

Treatment:
Put infants in knee chest position 
100% Oxygen (Blow by oxygen)
Morphine for sedation and Cardiac Output
Loose clothes
Loose diapers
Quiet Play
No stress
Respond to Crying Quickly 
Infections must be treated quickly because they can't handle fever

Question 44

Effects of Chronic Hypoxia

Answer 44

50% of brain growth occurs during the first year of life - hypoxia can lead to developmental delays

Polycythemia: Increased Red Blood Cells. The body senses it is hypoxic and makes more red blood cells to carry oxygen but there is no more oxygen to carry. So the blood gets very thick. Keep them hydrated to keep the blood thinned out. With this, there are so many RBC’s that there is no room for platelets/ this becomes a stroke and bleeding risk.
Clubbing (late sign of chronic hypoxia)
Poor growth development
Squatting

Question 45

Cogenital Heart Defects

Answer 45

A structural or functional defect of the heart or great vessels that is present at birth
In children, cardiac defects are classified by blood flow patterns such as:
Defects with increased pulmonary blood flow
Obstructive defects
Defects with Decreased Pulmonary Blood Flow

Question 46

Ventricular Septal Defect (VSD)

Answer 46

This is when there is an opening between the left and right ventricle (in
the septum)

This increases the volume on the right side of the heart. The right side
is having to pump harder so this can lead to right sided heart failure.

Many close spontaneously during the first year of life, but if not will have surgical repair.

Signs and Symptoms:

• Signs of heart failure
• Murmur

Question 47

Coarctation of Aorta

Answer 47

The aorta has a narrowing (pretend there is a tourniquet tied around the aorta). This makes it harder for the LV to pump so the client may wind up with left sided heart failure.

Signs and Symptoms:

Hallmark Sign: There is a BIG difference in the pulses and BP of the
upper and lower extremities. For example, you may have a pediatric
client with an Upper extremity BP = 100/60 and Lower extremity
BP = 70/40

The upper pressures are much greater than the lower pressures.
Treatment:
- Surgery
- Angioplasty in some

Question 48

Patent Ductus Arteriosus (PDA)

Answer 48

Normal fetal circulation: Blood goes Right Atrium….Right Ventricle….
Pulmonary Artery…doesn’t go to lungs….instead when blood leaves PA
it goes straight over to the aorta via the ductus arteriosis.

Why does the blood do this? Because in utero the baby’s lungs are collapsed, and the
baby gets oxygen through the placenta.

This ductus arteriosis is supposed to close when the baby is born and
takes their first breath. When it closes then blood flows from the
Pulmonary Artery to the lungs etc….just like in the adult. But when it
doesn’t……
This leads to increased workload on the left side of the heart and therefore
left sided heart failure.

Some blood is going like it’s supposed to, but some is going over to the right
side because the left side is pushing it to the right.

Signs and Symptoms:

• May be asymptomatic
• May be in heart failure
• They have a machinery - like murmur

Treatment:

• Indomethacin (Indocin®) (prostaglandin inhibitor) will close PDA
• May need surgery to close the ductus

Question 49

Transposition of the Great Vessels

Answer 49

Think about the normal blood flow in the heart (remember the square heart in your cardiac lecture?)

In transposition of the great vessels, the pulmonary artery and the aorta have swapped places. The aorta is still going to the right side of the heart and the pulmonary artery is going to the left but they never connect or cross.
So you wind up with 2 separate sets of circulation going in and out of the heart. Yes, some blood is getting out to the systemic circulation, or the client would be dead at birth. Instead, the baby is cyanotic at birth, but
alive. What’s keeping the baby alive?

Usually there is some other defect that is allowing that baby to get
just enough oxygen to stay alive. (often it is a PDA)

Signs and Symptoms: Usually cyanotic at birth
If not picked up on until older……decreased growth, poor feeding

Treatment:
- Surgery

Question 50

Tetralogy of Fallot

Answer 50

Consists of 4 defects:

a. Ventricular Septal Defect (VSD)
b. Pulmonary Artery Stenosis
c. Overriding Aorta
d. Right Ventricular Hypertrophy

Signs and Symptoms:
Infants may be cyanotic at birth: others may have mild cyanosis that progressively worsens during first year

Murmur
Acute cyanotic or hypoxic spells (blue spells/Tet spells)
*usually seen during crying, after feeding, during bowel movements
*at risk for sudden death, seizures

Older children: Squatting, nail clubbing, poor growth, exercise
intolerance

Treatment:
- Surgery

Question 51

Cleft Palate/Cleft Lip Clients top concern

Answer 51

Top concern is Nutrition! Use a syringe in the side of the mouth

Question 52

If both are present, which do you correct first?

Answer 52

The cleft Lip

Question 53

what do you have to do frequently for these clients?

Answer 53

Burp them because they swallow alot of air, risking abd distention, vomiting or aspiration

Question 54

Cleft Lip Repair

Answer 54

Position child on their back or side laying position following the repair.
The goal is to protect the suture line. Do NOT place int he prone position.

Post op:
Clean the suture line with saline. Elbow restraints.

Question 55

Cleft Palate Repair

Answer 55

Done before Speech develops, usually between ages 1 and 2 years
Avoid putting things into their mouth, especially hard things
We don’t want to do anything that will disrupt the suture line. So soft diet until well healed.
Speech defects are common afterwards

Question 56

GER, GERD

Answer 56

GER is the passage of gastric contents into the esophagus. GERD is chronic form of GER.

With GERD you have tissue damage to respiratory structures which can lead to pneumonia and bronchospasms. So it is worse!
Positioning is controversial.
Use upright position with feeding and at night, Elevated prone otherwise ( 30 degrees) Decreases reflux and improves stomach emptying and decreases the chance of aspiration
Provide small frequent feeding with thickened formula.

Question 57

Pyloric Stenosis

Answer 57

There is increased resistence on the smaller opening. It results in projectile vomiting after a feeding, patients are always hungry
Olive shaped mass in the epigastric region - it’s the enlarged pylorus

Pyloric ultrasound

Hydration/ I&O/Daily Weights/Monitor urine specific gravity

Question 58

Intussusception

Answer 58

When the bowel goes backwards on itself; forming an obstruction

Sudden Onset
Cramping
Intermittent Abd Pain
Inconsolability 
Drawing up of the knees
Currant Jelly stools

Monitor the stools closely!
Sometimes a barium or pneumatic enema can be done and the pressure will correct the bowel - others will need surgery. Keep for three days in hospital after resolution because it can come back

Question 59

Celiac Disease

Answer 59

Celiac Sprue is a genetic malabsorption syndrome where there is a permanent intestinal intolerance to gluten.

Lifelong disorder
No food with gluten ( a veggie protein)
NO BROW: Barley, Rye , Oats and Wheat
YES RCS: Rice, Corn, Soy

Question 60

Hirschsprung’s Disease

Answer 60

A congenital anomaly also known as aganglionic megacolon that results in mechanical obstruction, due to the lack of nerves in that part of the intestine = no peristalsis. Usually affects the sigmoid Colon.

Presenting symptom is constipation. Abd distention and ribbon like stool that has a foul smell.

Treatment:
Remove part of the bowel that is diseased
May require two surgeries to give the intestines time to heal

Question 61

UTI

Answer 61

Very common in children and can be potentially serious. usually at 2 to 24 months.

In newborns and children less than 2 years, symptoms will be non-specific - seen as a GI problem
Failure to Thrive
Feeding Problems
Vomiting and Diarrhea
If left untreated, attacks kidneys, tissue and destroyed and then scarring occurs. Then the kidneys could fail.
There is tendency for infections to reoccur

Predisposing Factors
Renal Anomalies
Constipation
Bubble Baths
Poor hygiene
Pin worms
Sexual activity 

Signs and Symptoms over 2
Classic symptoms!
Frequency
Dysuria
Fever
Flank Pain
Hematuria

Requires a properly collected urine specimen
Most accurate method is catheterization

Antibiotic therapy: PO or IV

Question 62

Sickle Cell Disease

Answer 62

When caring for a client with a hematologic disorder, always include protective isolation as part of their plan of care. High risk of infection - encourage good hand-washing. Always use sterile technique when working with any central lines because these are primary sources of infection.

A hereditary disorder in which the hemoglobin is partly or completely replaced with sickle cell hemoglobin. There is a reduced oxygen carrying capacity.

Sickle Cell Crisis: Decreased Blood flow = Decreased Oxygen = Pain

S/s
Pain in areas of involvement
Anorexia
Exercise intolerance

Treatment
Bed Rest
HYDRATION
Analgesics
Antibiotics
Blood transfusions 
Oxygen

Question 63

Hydrocephalus

Answer 63

A disturbance of the ventricular circulation of the cerebral spinal fluid in the brain. Increased Intracranial Pressure!

S/s
Bulging with palpitation of the anterior fontanel
Dilated scalp veins
Depressed eyes ( due to forehead protruding)
Irritability and changes in the LOC
High pitched cry
Setting sun sign - White around iris of eye

Treatment:
Insertion of a shunt
POst OP:
Measure the frontal occipital circumference
Fontanel and cranial suture line assessment
Monitor the temp
Supine position

Hydrocephalus is often associated with myelomeningocele. When an infant is born with spina bifida. protect the SACK. Do not let it rupture! The baby should be lying prone - cover sack with a moist sterile normal saline dressing so it won’t dry out waiting for surgery

Question 64

Scoliosis

Answer 64

Lateral curvature and rotation of the spine, seldom appears before 10, can be genetic

Heavy Backpacks, Bags and carrying children on hips can be contributing factors

Observation/Orthosis/Operations (Spinal Fusion with Rods)

Question 65

Head Lice

Answer 65

Itchy - Spread through personal contact

Question 66

Pin Worms

Answer 66

Spread Hand to mouth
Collect specimen through tape test
The whole family should be treated

S/s
Intense Rectal itching 
General irritability 
Restlessness
Poor Sleep
Bed Wetting
Distractibility
Short Attn Span

Treatment:
Mebendazole
Good hand hygiene
Keep fingernails SHORT

Question 67

Chicken Pox

Answer 67

Prevent infection of the lesions
Home remedies include oatmeal baths and baking soda paste
IT IS CONTAGIOUS - in adults it causes shingles

Question 68

Mononucleosis

Answer 68

Caused by Epstein Bar virus - kissing disease.
Spread through direct intimate contact

Rest/Analgesics and fluid
Spleen will be enlarged so you don’t want them to participate in contact sports.

Question 69

Tonsillectomy

Answer 69

Positioned on side with elevated HOB or prone after surgery
NO brown or red fluids
Hemorrhage = frequent swallowing
Risk for hemorrhage up to 10 days
Common complaints are sore throat and slight ear pain
Low grade temp
Bad Breath

Question 70

Otis Media

Answer 70

Middle ear is affected. Eustachian tubes are blocked. Usually follows an upper resp infection.

Tympanic membranes are bulging and bright red

Heat helps the pain
Avoid chewing / Eat soft foods
Lie on the affected side - promotes drainage
May not hear you
Avoid Smoke
May require tympanostomy tubes to keep middle ear drained - its ok if they fall out

Prevention:
Have bb sit up for feedings
No bottle propping
Non-aggressive nose blowing
Play blowing games
Avoid smoke
while tubes are in, wear ear plugs while bathing or swimming

Question 71

Parenting Styles

Answer 71

Authoritarian: highly controlling, expects to be obeyed, inflexible rules
Authoritative: Sets reasonable limits on behaviour, encourages growing autonomy of child, open communication
Permissive: A few or no restraints, unconditional love, much freedom, little guidance, no limit setting
Indifferent: No limit setting, lacks affection for the child, focused on own life.

Question 72

Why are peanuts so dangerous when aspirated?

Answer 72

They swell and crumble

Question 73

Why does a mentally challenged child often deliberately do things to displease?

Answer 73

For Attention.

Question 74

Why don’t we use ventrogluteal in children that have not been walking for at least a year?

Answer 74

Muscle is not developed.

Question 75

Post op position of child after perineal surgery?

Answer 75

On their side - Prone is contraindicated. When inserting an NG put them in sniffing position and then head down.

Question 76

Tracheoesophageal fistula

Answer 76

Tracheoesophageal fistula is an abnormal connection in one or more places between the esophagus (the tube that leads from the throat to the stomach) and the trachea (the tube that leads from the throat to the windpipe and lungs). Normally, the esophagus and the trachea are two separate tubes that are not connected.

Tracheoesophageal fistula is also known as TE fistula or simply TEF.

TE fistula is a birth defect, which is an abnormality that occurs as a fetus is forming in its mother’s uterus.

When a baby with a TE fistula swallows, the liquid can pass through the abnormal connection between the esophagus and the trachea. When this happens, liquid gets into the baby’s lungs. This can cause pneumonia and other problems.

Frothy, white bubbles in the mouth

Coughing or choking when feeding

Vomiting

Blue color of the skin, especially when the baby is feeding

Difficulty breathing

Very round, full abdomen

Question 77

What is esophageal atresia?

Answer 77

TE fistula often occurs with another birth defect known as esophageal atresia. The esophagus is a tube that leads from the throat to the stomach. With esophageal atresia, the esophagus does not form properly while the fetus is developing before birth, resulting in two segments; one part that connects to the throat, and the other part that connects to the stomach. However, the two segments do not connect to each other.

Since the esophagus is in two segments, liquid that a baby swallows cannot pass normally through the esophagus and reach the stomach. Milk and other fluids cannot be digested if the esophagus does not connect to the stomach.

If a TE fistula is also present, liquid that a baby swallows can pass through the connection between the esophagus and the trachea and go into the lungs. This can cause pneumonia and other problems.

Question 78

Phenylketonuria

Answer 78

Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur.

A low-phenylalanine diet is essential in the treatment of PKU (Option 1). Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL [120-360 µmol/L] for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health (Option 3).

Management of the client with PKU includes:

Monitoring serum levels of phenylalanine
Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet (Option 4)
Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2)
Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

Phenylketonuria requires lifetime dietary restrictions. Infants should be given special formulas (eg, Lofenalac). For children and adults, high-phenylalanine foods (eg, meats, eggs, milk) should be restricted and replaced with protein substitutes

Question 79

Infant botulism

Answer 79

Although more than one of these parent comments are concerning, the most concerning is feeding honey to a child under age 1 year. Honey (especially raw or wild) is not recommended for children under age 1 due to the risk for infant botulism. An infant under age 1 has an immature gut system that can allow Clostridium botulinum spores contaminated in honey to colonize the gastrointestinal tract and release toxin that causes botulism.

Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the neuromuscular junction. Infants often present with constipation, diminished deep tendon reflexes, and generalized weakness. Additional symptoms are lack of head control, difficulty in feeding, and decreased gag reflex, which can progress to respiratory failure. Isolation of the organism from the child’s stool can take several days; therefore, diagnosis is usually made by history, and treatment with botulism immune globulin is started before laboratory results are known.