unit ii - los angeles harbor · pdf file · 2014-08-13unit ii: the infant and...

Unit II:

The Infant and Congenital Malformations

Dehydration

Higher risk for dehydration than adults

• Babies have 5x greater surface area than adults

• Longer GI tract

• Metabolic needs are faster

- need for water

- excretion in GI tract

- heat production

• Immature kidneys

- babies cannot dilute or concentrate urine

• Evaluating Extent of Dehydration

• Interventions for Dehydration

• Hydrate

• Strict I&O; daily weight

• Pulse oximeter

• Check capillary refill

• Measure and weigh diapers

• Counting stools or weighing if liquid

• Check tongue for fissures

• Daily Maintenance Fluid Requirements

• Daily Fluid Calculation – Example #1

Child weighs 32 kg

• 100 x 10 for first 10 kg of body weight = 1000 mL

• 50 x 10 for second 10 kg of body weight = 500 mL

• 20 x 12 for remaining body weight = 240 mL

• 1000 + 500 + 240 = 1740 mL/24 hr

Daily Fluid Calculation – Example #2

Child weighs 8.5 kg

• 100 x 8.5 for first 10 kg of body weight = 850mL

• No further calculations

• 850 mL/24 hr

Daily Fluid Calculation – Example #3

Child weighs 14 kg

• 100 x 10 for first 10 kg of body weight = 1000 mL

• 50 x 4 for second 10 kg of body weight = 200 mL

No further calculations

• 1000 + 200 = 1200 mL/24 hr

STAGES OF THE THERAPEUTIC PLAN

1. Emergency Phase for severe dehydration

• Restore circulation rapidly (except in hypertonic)

• D51/4NS

• Checking for behaviors indicating hydration status

• Urine Specific Gravity - WNL1.010 to 1.015; Severely dehydrated 1.025

2. Repletion Phase

• Restore body fluids to volume that will permit adequate circulation and good renal

function

• IV solution given slower than in #1

• K+ is added to IV when renal function is

established. May add Na Bicarb if acidosis

MODEL FOR REHYDRATION

• Rehydration solution should consist of 75-90 meq of Na per liter

Give 40 to 50 mL/kg of rehydration solution over 4 hours

May need maintenance therapy (not to exceed 150 mL/kg/day of ORS

Late Recovery Phase

• Concerned with realimentation

• NO BRAT diet - Begin normal diet

Diarrhea

88-90% of all diarrhea is caused by rotavirus

Increase in November to May

Temporary lactose intolerance- don’t give milk

Acidosis

• Loss of bicarbonate – metabolic acidosis

• Impaired renal function

• Accumulation of lactic acid

• Ketosis

• Diarrhea – Nursing Interventions

Put in isolation (until stool cultures back)

I & O

Daily weights

Stool Cultures

Been out of the country? History

Cardiac

• Pediatric Indicators of Cardiac Dysfunction

• CHD

• Incidence: 5-8 per 1000 live births

– About 2-3 of these are symptomatic in first year of life

– Major cause of death in first year of life (after prematurity)

– Most common anomaly is ventricular septal defect

– 28% of kids with CHD have another recognized anomaly

Cardiac catheterization is a medical procedure used to diagnose and treat certain heart

conditions

• O2 saturation of blood in chambers and great vessels

• Pressure changes

• Changes in CO or stroke volume

• Detect anatomic abnormalities

Nursing Care

Prepare child and parent

Explain according to developmental level

- what they see, hear, and feel

- don’t say inject “dye” into arm

• NPO 4-6 hr (with babies 4 hr)

• Assess vital signs q15min x 4; then q1hr

• Check pulse distal to the site

• Take apical pulse for 1 minute

- dysrhythmias common

Nursing Care (cont)

• Check site for bleeding & phlebitis

• Assess for reaction to contrast media

• Check pulses for symmetry and equality

• Check legs for color, warmth, blanching, coolness, capillary refill

• Keep in bed for 24 hrs

• Keep extremities straight - 6-8 for arterial, 4-6 for venous

• Babies are at risk for hypoglycemia; start feeding right away

Fetal Circulation

• Changes in Fetal Circulation after Birth

1. Pulmonary Vascular Resistance

• Increases pulmonary blood flow to lungs; pulmonary artery pressure decreases

2. Foramen Ovale

• Functionally closes as a result of pressure changes in the right and left atrium

3. Ductus Arteriosus

• Closes as a result of increased O2 tension in arterial blood (10-15hrs after birth)

4. Ductus Venosus

• Closes as a result of the loss of blood flow from the placenta

5. Systemic Vascular Resistance

• Increases as a result of above

• Fetal Circulation

• Older Classifications of CHD

– Acyanotic:(left to right shunting)

• May become cyanotic

– Cyanotic: (right to left shunting

• May be pink

• May develop congestive heart failure (CHF)

• Newer Classification of CHD based on hemodynamic characteristics:

– Increased pulmonary blood flow

– Decreased pulmonary blood flow

– Obstruction of blood flow out of the heart

– Mixed blood flow

• Increased Pulmonary Blood Flow Defects

– Abnormal connection between two sides of heart

• Either the septum or the great vessels

– Increased blood volume on right side of heart

– Increased pulmonary blood flow

– Decreased systemic blood flow

Patent Ductus Arteriosus

Failure of Ductus Arterious to close after birth. Left to right shunt - Increased pulmonary blood flow

Acyanotic

Clinical Manifestations

• Machine type murmur

• Widened pulse pressure

• Cardiomegaly

• Bounding pulse

• Tachycardia

Ventricular Septal Defect


• Range in size from pinhead to no septum

• Increased pulmonary vascular resistance

• Large harsh murmur on left sternal border

• Easily fatigued

Complication

• CHF

Treatment

• Banding

• Large defects – Dacron patch

• Cardiopulmonary bypass

Pulmonic Stenosis


• Right ventricular hypertrophy - cardiomegaly

• decreased pulmonary blood flow

• Dyspnea and fatigue

• Cyanosis

Complication

• CHF

Treatment

• Infants – transventricular valvotomy (Brock procedure)

• Children – pulmonary valvotomy with cardiopulmonary bypass

• Balloon angioplasty

Coarctation of Aorta

Localized narrowing of aorta, near the insertion of the ductus arteriosus

Left to right shunt – Obstruction to blood flow from ventricles

Acyanotic


• High blood pressure and bounding pulses in the arms, weak or absent femoral pulses

• Cool lower extremities with lower blood pressure

• Dizziness, headaches, fainting, and epistaxis resulting from hypertension (older children)

Complication

• CHF – infants

• Cardiomegaly

• Hypertension, ruptured aorta, aortic aneurysm, and stroke

Treatment

• End-to-end anastomosis of the aorta

• Enlargement of the constricted section using a graph of prosthetic material or a portion

of the left subclavian artery

Post operative hypertension is treated with diuretic and ACE inhibitors or beta blockers

• Balloon angioplasty

Tetralogy of Fallot


• Infants are very cyanotic

• Poor feeding

• Babies have tet spells

• Children have increased hypoxia that cause clubbing, squatting, and poor growth

• Tachypnea & dyspnea

Complications

• Polycythemia

• Cerebral vascular disease

• Clubbing

Initial Treatment

• Put in knee-chest position

• 100% O2 by mask

• Morphine

Surgical Treatment

• Palliative shunt (temporary)

- May result in pulmonary artery distortion

• Complete repair – closure of the VSD and resection of the infundibular stenosis, with

placement of a pericardial patch to enlarge the right ventricular outflow tract

- Performed in the 1st year of life


• CHF

Therapeutic Management

• Digoxin

- increases force of contraction and decreased heart rate

- slows conduction through AV node, enhances diuresis

• Ace Inhibitors

- block conversion of angiotensin I into angiotensin II

- capoten, vasotec

- always check bp

• Diuretics

- Check potassium labs as K levels affect Digoxin absorption

Digoxin

Check pulse – babies < 100 bpm don’t give

Give at regular intervals

Give slowly, directing to the side of the mouth

Do not mix with foods or other fluids

Toxicity : vomiting and bradycardia

Elixir 50 mcg/mL; never give more than 1 mL

CHF

• CHF – Nursing Interventions

Neutral thermal environment

Treat infections

HOB up – reduce breathing efforts

decrease environmental stimuli to provide rest

Feed q 3hrs; give ½ hr to eat

Diuretics – strict I &O and daily weight

Kawasaki Disease (KD; Mucocutaneous Lymph Node Syndrome)

• An acute systemic vasculitis of unknown cause

• 75% of cases in children <5 yrs

• Three phases:

– Acute: sudden high fever, unresponsive to antipyretics and antibiotics

– Subacute: end of fever through end of all KD clinical signs

– Convalescent: clinical signs resolved, but laboratory values not returned to normal;

completed with normal values (6-8 weeks)

Risk for myocardial infarction

• Symptoms of MI in children

Abdominal pain

Vomiting

Restlessness

Inconsolable

Crying

Pallor to shock

Theraputic Management

• High doses of gammaglobulin or high doses of aspirin

- 1st 10 days of illness; single large transfusion over 10-12 hrs

- Aspirin 100mg/kg/q6hr; after fever 3-5mg/kg/day antiplatelet

Nursing Interventions

• Monitor cardiac status

• I & O

• Daily weights

• Mouth care

• Clear liquids, soft diet

• Promote rest

• Loose clothing

• Warm tub (arthritis)

• Teach parents to defer immunizations for 11 months

SIDS

http://www.youtube.com/watch?v=9Iu88-DaH0k&feature=related

• SIDS - Epidemiology

Higher percentage of males

Increased incidence in the winter

Greater incidence in African-Americans, Native Americans, and Hispanics

Lower socio-economic class

Pre-term infants

Low Apgar score

Birth order- highest in first borns

Lower incidence in breast-feed infants

Mother – young age, cigarette smoking, poor prenatal care, substance abuse

• SIDS – Nursing Implications

Teach parents

• Do not use soft bedding or fluffy pillows

• Do not sleep with infant

• Put babies on their backs

Death of a child

• Allow the parents to spend unlimited time with their baby

• Follow up

• Referrals – SIDS associations

Common grief response

• Denial

http://www.youtube.com/watch?v=9Iu88-DaH0k&feature=related

• Anger

• Hysteria

• Withdrawal

• Intense guilt

• No visible response

• Mourning period may take 1 year or more

RSV (respiratory synctial virus)

Between ages 2-12 months; rare after 2 years

Clinical Manifestation

• Bronchioles become inflamed & swollen; lumina filled with exudates

• Prolonged expiratory phase

• Obstruction in small air passages; patchy areas of atelectasis

• Dyspnea, irritability, tachypnea, nasal flaring, substernal intercostal retraction

• Fine rales and crackles

• Wheezing

• Emphysema with barrel chest

Diagnosis

• Nasal secretions

• ELISA

Treatment

• Rest

• O2 therapy

• Fluids (npo if tachypnea)

• Pulse ox

• Respiratory therapy – albuterol

• Corticosteriods (controversial)

• Suction

• Ribavirin (very controversial)

- 18-20hr/day for 7 days

- in isolation under hood

- teratogenetic drug

• Synergist (palivizumab)

- preemie with chronic lung disease

- $1400/shot once a month

• RSV immune globulin- neutralizes antibodies against RSV

Hydrocephalous

Non Communicating/Obstructive

• Obstruction to the flow of CSF through the ventricular system

Communicating/ Non Obstructive

• Impaired absorption of CSF within the subarachnoid space

• Malfunction of the arachnoid villi


• Infancy (early)

- Abnormally rapid head growth

- Bulging fontanels (especially anterior)

- Dilated scalp veins

- Separated sutures

- Cracked-pot sound

- Thinning of skull bones

• Infancy (later)

- Frontal enlargement, or bossing

- Depressed eyes

- Sun setting eyes

- Pupils sluggish, unequal response to light

Infancy (general)

- Irritability

- Lethargy

- Cries when picked up

- Early infantile reflex acts may persist

- Normally expected responses fail to appear

May display:

- Changes in LOC

- Opisthotonos (often extreme)

- Lower extremity spasticity

- Vomiting

Advanced cases:

- Difficulty in sucking and feeding

- Shrill, brief, high-pitched cry

- Hydrocephalus

• Childhood

- Headache on awakening; improvement following emesis or upright posture

- Papilledema

- Strabismus;diplopia

- Ataxia- Unsteady gait

- Irritability

- Lethargy

- Apathy

- Confusion

- Incoherence

- Vomiting

- Hydrocephalus

Treatment

• Ventriculoperitoneal (VP) shunt

- Spinal fluid drained into peritoneal cavity

- Need shunt revisions throughout their life

Complications

• Infection or malfunction

- 1-2 months after placement highest risk for infection

- Mechanical difficulties; kinking, plugging, or separation or migration of the

tubing

- Mechanical obstruction; tissue or exudate

Pre-op

• Head circumference

• Assess change in LOC

Post-op

• Position on unoperative side

• Keep flat (after 1st shunt)

• Check any drainage for glucose

• No sedation

• Shunt revision – HOB up

• Observe for ICP and infection

• NPO for 24-48 hr

• Teach parents signs of ICP

Spina Bifida


Spina bifida occulta

• Frequently no observable manifestations

• May be associated with one or more cutaneous manifestations:

- Skin depression or dimple

- Port-wine nevi, angiomas

- Dark tufts of hair

- Soft, subcutaneous lipomas

• May have neuromuscular disturbances:

- Progressive disturbances of gait with foot weakness

- Bowel and bladder sphincter disturbances

Spina bifida cystica

Sensory disturbances usually parallel to motor dysfunction

• Below second lumbar vertebra:

• Flaccid, partial paralysis of lower extremities

• Varying degrees of sensory deficit

• Overflow incontinence with constant dribbling of urine

• Lack of bowel control

• Rectal prolapse

• Below third sacral vertebra:

• No motor impairment

• Bladder and anal sphincter paralysis

• Spina Bifida – Nursing Implications

Position on their abdomen; frog-legs with hips abducted

Low trendelenburg (unless hydrocephalus)

Assess for hydrocephalus

Monitor sac

No diapers

No covers

Moist NS dressing over sac; change q2hr

Feeding – place in prone and nipple while head is turn to the side

• Latex Allergy

• Identified as serious health hazard when a child with spina bifida experienced

anaphylaxis due to latex allergy

• Spina bifida patients at high risk for latex allergy due to repeated exposure to latex

products from multiple surgeries and repeated urinary catheterizations

• Allergic Reactions to Latex

• Range from urticaria, wheezing, rash, to anaphylaxis

• Reactions tend to increase in severity when latex comes in contact with mucous

membranes, wet skin, bloodstream, or airway

• Cross-reactions with foods: banana, avocado, kiwi, chestnuts

Developmental Dysplasia of the Hip

Preluxation – (Acetabular Dysplasia)

• Shallow acetabulum

• Delay in acetabular development

• No dislocation of subluxation

Subluxation

• Incomplete dislocation; a dislocatable hip

• Femur in contact with acetabulum

– not displaced due to a stretch ligamentum teres and capsule

Dislocation

• Femoral head loses contact with acetabulum and is displaced posteriorly and superiorly

Galeazzi sign

• Asymmetry of gluteal and thigh folds with shortening of the thigh

Ortolani test

• Limited hip abduction, as seen in flexion

Allis sign

• Apparent shortening of the femur, as indicated by the level of the knees in flexion

Trendelenburg sign

• Pelvis tilts downward instead of upwards when weight is beared on affected hip

• Developmental Dysplasia of the Hip


Infant

• Shortening of limb on affected side

• Restricted abduction of hip on affected side

• Unequal gluteal folds (infant prone)

• Positive Ortolani test

• Positive Barlow test


Older Infant and Child

• Affected leg shorter than the other

• Telescoping or piston mobility of the joint

• Trendelenburg sign

• Greater trochanter prominent and appearing above a line from anterosuperior iliac

spine to tuberosity of ischium

• Marked lordosis (bilateral dislocations)

• Waddling gait (bilateral dislocations)


Treatment

• Bryant’s traction

- Loosens ligaments and muscles, easier to treat dislocation

Spica cast

Dennis Brown cast

Hypertrophic Pyloric Stenosis

Constriction of pyloric sphincter with obstruction of gastric outlet

Signs and Symptoms

Projectile vomiting; non bilious

Baby is always hungry

Signs of dehydration – Acid-base imbalance

Ph increases

Creatinine and BUN increase

Stools decrease

Visible peristaltic waves – see going left to right

Palpable – feels like an olive

Diagnosis – Upper GI or Ultrasound

Treatment - Fredet-Ramstedt procedure

• Minor procedure

• Post op vomiting common – keep IV

• Begin feedings 4-6 hr; 24 hrs give formula

• HOB in high fowlers

• Burp frequently

TEF


• Excessive salivation and drooling

• Three C’s of tracheoesophageal fistula

- Coughing

- Choking

- Cyanosis

• Apnea

• Increased respiratory distress after feeding

• Abdominal distention

Nursing Implications

• Immediately NPO

• HOB up to prevent reflux

• Suction frequently

• Begin antibiotics immediately

• Keep g-tube unclamped

Post-op

• Respiratory conditions

• G-tube feedings

• Tracheomalasia

Hirshprung’s

Pathophysiology

• Absence of autonomic parasympathetic ganglion cells in one section of the colon

• Problem in embryonic development

• Results in lack of propulsive movements (peristalsis)

• Accumulation of int. contents and distention of the bowel proximal to the defect causes

a large or megacolon

• Also internal rectal sphincter not relaxed prevent evacuation of solids, liquids, gas

• Most common site is rectosigmoid colon

• Intestinal distention and ischemia from distention of bowel wall cause enterocolitis—

leading cause of death


Vary according to age

Newborn

• Not pass meconium within24-48 hours

• Reluctance to drink

• Bile stained vomitus

• Abdominal distention if not treated- resp distress and shock

Infancy

• FTT

• Constipation

• Diarrhea and vomiting (explosive, watery diarrhea and fever signify enterocolitis)

Can have without diarrhea, but still have fever

Childhood

• Chronic symptoms of constipation - pass ribbon-like, foul smelling stools

• Abdominal distention; fecal mass palpable

• Visible peristalsis

Diagnostic Evaluation

• Newborn- fails to pass meconium

• Later childhood and infancy – history, rectum free of feces, sphincter tight, leakage of

liquids, gas and foul pale stool, chronic constipation, poor feeding poor weight gain

• Sometimes megacolon won’t develop until 3-4 weeks or months after birth

• *Need rectal biopsy

• *Anorectal mamometry- done NB and preemie. Insert cylinder with 3 balloons - test

reflex response of sphincters; internal sphincters don't relax

• Poorly nourished and anemic


• Most children are treated surgically. 2 stage repair- Remove aganglionic section of

colon and do colostomy. At approx . 20 lbs (in 2 mo to 1 year) will do sphincterotomy

and pull-down of functional bowel and close colostomy

• Lately, if diagnosed in neonatal period, will do a 1 stage repair. Resect aganglionic

section and pull down colon and anastomose to rectum

Also, laparoscopic-assisted pull thru(-thru anus- pull affected area of bowel out)

• Good results; no major abdominal surgery; less hospital stay; no colostomy care;

completion of treatment at earlier age

Nursing Considerations

Preoperative

• Depends on condition of child and age. If malnourished- will need high cal; high protein;

low fiber diet and isotonic enemas, until condition improves and can withstand surgery

• Preop will have NG GoLytely, antibiotics and rectal irrigations. Daily abdominal

circumference

• Psychological preparation for colostomy

Post-op

• NPO ; IV; abdominal dressings; perianal dsgs; may have NG tube; ostomy care

Intussusception

Most frequent cause of intestinal obstruction during infancy

50% occurs less than 1 year (most 3 mo to 12 mo)

Most others occur before 2nd year (Some books say 3 yrs)

3 X more in males

Pathophysiology

Telescoping of one portion of intestine into another; most common site is ileocecal

valve

This causes obstruction to passage of GI contents

2 walls of intestine press against each other edema, inflammation decreased

blood flow

Decreased blood flownecrosisresults in hemorrhage, perforation, peritonitis

Cause unknown. May have a viral origin. More in cystic fibrosis and Celiac’s Disease


Sudden acute pain with intervals where child is normal

Vomiting; may pass 1 normal stool

Stools become red-currant jelly (blood, mucous, and stool)

Abdomen tender and distended

Sausage shaped mass in rt upper quadrant

Dance’s sign- lower rt quadrant feels empty- bowel distal to obstruction less involved;

free of contents

Chronic picture may appear as diarrhea, vomiting, constipation and periodic colic

Diagnostic evaluation

• Rectal exam

Therapeutic management

• Nonsurgical hydrostatic reduction. Successful 75% of time. If not; manual reduction

and resection any non-viable intestine

• Barium enema- barium becoming less used Use water soluble contrast or saline under

ultrasound or pneumonic insufflation with air or O2.

Nursing Care

• Prepare parents- teach using glove with water

• Pre-op- watch for passage of normal stool. Report immediately- could mean

intussusception resolved

• After hydrostatic reduction- chance of recurrence within 36 hour.

• Observe stool patterns

• Child kept in hospital ???? Observe 12-24 hours at least

GERD

GE reflux is the passive transfer of gastric contents into esophagus

Affects 1 in 300 to 1000 children

Caused by inappropriate relaxation of lower esophageal sphincter

GE reflux is the passive transfer of gastric contents into esophagus

Affects 1 in 300 to 1000 children

Caused by inappropriate relaxation of lower esophageal sphincter

Could be problem with CNS or developmentally exaggerated enteric reflex

High risk- children with TEF or other esophageal repair, neurological disorders, scoliosis,

asthma, CF

Could be problem with CNS or developmentally exaggerated enteric reflex


• Most common is passive regurgitation or emesis

• Poor weight gain, anemia, irritability, gagging and choking, apnea, recurrent

pneumonias, heme-positive emesis or stools

• Esophagitis from acidic gastric contents- anemia, discomfort, poor weight gain

Diagnostic Evaluation

• Need a history of feeding habits

• Stool guaic; growth assessment; UGI

• Esophageal PH monitoring

• Endoscopy to assess for esophagitis

• Sometimes Scintigraphy – a radionuclide added to formula; gamma counter detects

presence of formula in lungs or esophagus

• Multiple respiratory abnormalities


• Controversy over thickened formula

• Better to combine with prone position, é 30°

• Position – prone with HOB elevated or flat

• Pharmacological treatment

• Antacids or H2 blockers – Tagament, Zantac, Pepsid (reduce acid in gastric contents)

• Prokinetic meds – Reglan, Urecholine; may decrease reflux

Nursing Interventions

• To keep elevated may need harness, wedge, elevated mattress

• Thicken feeding – 1 tsp to 1 tbsp of rice cereal per oz of formula. Enlarge nipple hole.

May need gavage feedings.

• Give pacifier – Increase sucking helps clear food from esophagus; keep quiet after

feeding

• If severe complications (ALTE’s; apnea) will do Nissen fundiplication. Also pyloroplasty;

g-tube

• Prognosis good for most. Most cured by 18 mo

• In severe cases- esophagitis; esophageal strictures; recurrent respiratory distress;

aspiration pneumonia

Cleft Lip and Palate

Diagnosis

• Obvious at birth

• Unilateral or bilateral

• Assessing a cleft palate

- Need thorough assessment of the mouth

- Put glove on and palpate for a cleft

- Suspect if infant is having trouble sucking

Treatment

• Repair lip first, then palate

• Z-shaped suture line

- protected by logan bow or butterfly suture

- don’t put them on their stomachs

- restrain arms and elbows

• Perform before faulty speech; before teeth

Long-term problems

• Speech impairment

• Otitis Media

Nursing Implications

• Feeding

- keep head upright

- watch when they eat

- large soft nipples

- encourage sucking

- frequent burping

- can breastfeed

Post-op Care after palate repair

• No tongue blades

• No straws

• No oral temperatures

• No forks; wide bowl spoon

• Discharge on soft diet

• Rinse mouth after feeding

• May have problems breathing

Classification of Anemias

• Etiology and physiology:

– RBC and/or Hgb depletion

• Morphology:

– Characteristic changes in RBC size, shape, and/or color

• Effects of Anemia on Circulatory System

• Hemodilution

• Decreased peripheral resistance

• Increased cardiac circulation and turbulence:

– May have murmur

– May lead to cardiac failure

• Cyanosis

• Growth retardation

• Iron Deficiency Anemia

• Failure To Thrive

Refers to a state of inadequate growth from inability to obtain and/or use calories required for

growth

It is a symptom, not a disease

No universal definition

Weight and sometimes height that fall below the 5th percentile for the child’s age

Must take into account cultural differences in build; plot on HT/WT chart

Failure To Thrive

Organic FTT (OFTT)

• Result of a physical cause (CHD,neuro prob, chronic UTI)

• Accounts for less than half of all FTTs

• Must be ruled out by physical assessment

Non-Organic FTT (NFTT)

• Definable cause that is unrelated to disease

• Psycho social factors

• Poor parenting skills/lack of knowledge

• Poverty, health beliefs, inadequate nutritional knowledge, family stress, feeding

resistance, insufficient breast milk

• Disturbance in mother/child attachment

Idiopathic or Mixed FTT

Diagnosis

• Plot on curve

• Dietary history

• Physical Examination

Characteristics of FTT Child

• Avoids eye contact (shows lack of bonding)

• Intense watchfulness

• Avoidance of contact – stiff or floppy

• Repetitive self-stimulating behaviors (rocking, head banging)

• Disturbed affect (irritability, apathy or extreme compliance)

• Sleep disturbances

• Lack of age-appropriate stranger anxiety

• Lack of appropriate preferences for parents

• Slow in social behavior – smiling

• Dietary “quirks” – turn away from food, regurgitation, etc.

• Failure To Thrive

Characteristic Behavior of Caregiver

• Substance abusers

• Inadequate support systems

• Poor parenting practices – lack of commitment to parenting

• No bonding due to lack of contact

• Making negative comments

• No name given to baby


• Goal is reversing the malnutrition – may need hospitalization or close home health

monitoring

• Structuring the environment for positive psychosocial interactions

• Multidisciplinary team to work with family

Prognosis – Uncertain, related to cause & controlling factors

ASSESSMENT, TEACHING, ROLE MODEL

unit ii - los angeles harbor · pdf file · 2014-08-13unit ii: the infant and...

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