Peds Lecture 3, Exam 1 January 21, 28, 2013

Physical assessment of children

Vital Signs Know the norms per a e for P, !!, "P infants hi her hr, #p, rr$ %ant to count for a min$ &' (') )*KE +,)*L- '.. )/E 0'(,)'! !! count 1 minute 1*uscultation +-$ +isual *pical pulse count 1 minute$ *#dominal #reathers til 2 ,f cryin , chart that$ !adial pulse not accurate measure until after a e 2$ 1)emperature3 !ectal, 'ral, *xillary -ometimes rectal contraindicated 4less than 1 month, #leedin concerns, etc$5 !ectal is the clinical 6old -tandard when in dou#t )emperature ran e 4 eneral5 37$8132$7 %e do a lot of axillary$ !ectal is old standard if in dou#t$ %e don9t routinely do it 1"P3 may use upper arm, lower le , upper le Hypertension in Children
HTN now affects up to 5% of all children. May be due to the increase in childhood obesity. Obese children are at a 3X higher risk of becoming hypertensive when compared to non obese children. In young children, HTN is more often secondary to an underlying pathological process. Make sure the BP cuff is the appropriate size

Screening for Hypertension

All children 3 years of age and older should be screened at all health care encounters. Children younger than 3 years of age with comorbid conditions should also be screened. Prematurity or NICU stay CHD, Kidney disease, GU abnormality Family history of congenital kidney disease Transplant or malignancy Meds associated with HTN side effects.

Treating Children for Hypertension -ta e 13 Lifestyle chan es

No evidence of organ damage, diabetes, and those who are asymptomatic After 6 months of lifestyle changes, need re evaluation and if still hypertensive then move to Stage 2. Whole family must adhere to lifestyle change. Children who are symptomatic, HTN secondary to medications, diabetes, or evidence of organ damage Many medications for HTN have not been tested long term in children.

-ta e 23 *ntihypertensi:e medications

Physical Assessment of Children (eurolo ical

Fontanels Posterior-2/3 months, Anterior- 18 mos. Can indicate dehydration or ICP Level of consciousness How much effort does it take to stimulate the child Following commands

Peds Lecture 3, Exam 1 January 21, 28, 2013

Motor milestones- Head control by 3 mos Cognitive and Social development Response to environment

Infant reflexeswhen do they disappear? 0oro, tonic1nec;, rootin , rasp, #a#ins;i, corneal, etc$ Infant Reflexes
Babinski Normal until approximately 2 years-of-age Moro Strongest during first 2 months. If present after 4 months, is indicative of brain damage Palmar Grasp Should disappear by 3-4 months Rooting Disappears by 3-4 months may persist for up to 12 months when the child is sleeping Absence of reflex is indicative of severe neurological disorder Sucking Reflex persists through infancy. Weak or absent reflex indicates developmental delay or neurological abnormality Startle Absence may indicate hearing impairment

Assessment of !C Assessment of Pain Assessment of "e#elopment

On-going as child grows Assessed often with well child visits Need to know the norms or major milestones to assess development Use Erikson for comparison Psychosocial and cognitive level

Standardi$ed tests
Many to choose from. Denver is broad screening tool used often. Use specific ones for concerns (ie M-CHAT (Modified Checklist for Autism in Toddlers)

<uestion=$ ,n what order should the followin routine assessments #e performed on a > month old child who is in the hospital? *$ )emp, !!, %ei ht, /!, "P "$ %ei ht, !!, /!, )emp, "P @$ /!, !!, )emp, "P, %ei ht &$ )emp, %ei ht, "P, /!, !! Assessment of %rowth 0easurement of 6rowth is central to e:aluatin health status *ll plotted on rowth charts
Height/length and weight On all visits Use centimeters and kilograms Up to 36 months The abdominal circumference, place a small mark at the same place. Check for ascites, abdominal distension, blockage, malabsorbtion

/ead circumference *t the top of the eye#rows, the pinnia of the earAA )E-) ?

Peds Lecture 3, Exam 1 January 21, 28, 2013 &ody 'ass Index
BMI is the best indicator of a healthy weight. Length for Height not as accurate BMI = kg/m-squared. Use decimals for fractions of pounds and inches Considered overweight if BMI is at or exceeds 85%

&'I ()estion *n 8 year old #oy wei hs 27 ; and is 128 cm tall$ %hat is his "0,? *$ 0$20 "$ 188$0 @$ 0$7 &$ 18$> &'I example *This will +e on the exam, "o not need cm-.in * B year old #oy wei hs 33 l#s B oC and is 32 8D8 inches tall B di:ided #y 17 E 0$28 l# F33$28 l#s 33$28 di:ided #y 2$2 F 18$1 ; 8 di:ided #y 8 E 0$728, F32$728 inches 32$728 G 2$8B F >8$7 cm "0, F 17$ 8 /is "0, is at the 28H mar; I how would you explain this to his parents? %rowth Chart .or Practice3 Plot the followin on the rowth chart at the #ac; of your text#oo;$ "oy 2 months old Len th 72 cms %ei ht 8$2 ; '.@ B8 cm % t for Len th Approximate %rowth Rate )he first year has rapid rowth$ 6rowth slows the second year of life$
Infants: Approximately 1 lbs. per month for first 5 months. Birth Weight doubles at 5-6 months Infants: Approximately lb. per month during second half of infancy Birth weight triples by 12 months

Childhood !+esity '#esity has tripled in *merican children since 1>80$ >$8H of infants and toddlers and a#out 12H of children and adolescents ' den, @$ L$ 420105$ /i h "0, remains steady in J$ -$ children, adolescents$ JAMA, 303, pp$ 2B212B>$ @hildren at or a#o:e "0, >8H are o#ese @hildren #etween 881>BH are o:erwei ht )hose with "0, K88th H should also #e screened for other comor#idities

Peds Lecture 3, Exam 1 January 21, 28, 2013 .ennoy, ,$ 420085$ @hildhood '#esity, Part ,3 %ei ht E:aluation an d@omor#idity -creenin $ @onsultant for Pediatricians$ &ecem#er$ 8081 811$ @hildren should #e mana ed for wei ht as early as a e 2

Childhood !+esity/ Comor+idities *sthma '#structi:e -leep *pnea /)( )ype 2 &ia#etes .astin #lood su ar for children 10 years or older if "0, K88th H with3 .amily history of )ype ,, &ia#etes !ace or ethnicity associated with an increased ris; of dia#etes @linical features of insulin resistance /yperlipidemia .astin lipid profile Childhood !+esity/ *ssessment
o o o o Measure and determine BMI Skin fold thickness and waist circumference has not shown evidence of usefulness Obtain diet history and activity history Obtain family and past medical history

-chuman, *$ J$ 420085$ *n o#esity action plan$ @ontemporary Pediatrics 284B5, 32181 Childhood !+esity/ Pre#ention @ounsel non o#ese patients to esta#lish wei ht friendly and healthy lifestyle "reast feed first 7 months and continue for at least the first year$ .i:e or more fruits and :e ies a day Limit su ar sweetened #e:era es Prepare more meals at home Eat at the ta#le as a family 817 times a wee; with )+ off$ /ealthy #rea;fast e:ery day ,n:ol:e the whole family in lifestyle chan es Parents should a:oid o:erly restricted feedin #eha:iors$ &iet rich in calcium Childhood !+esity/ )reatment
Weight management programs that involve the family and include frequent visits to the PCP. Physical activity recommendations Dietary instruction.

0edications (o wei ht loss meds are appro:ed for use in children youn er than 12 years$

Peds Lecture 3, Exam 1 January 21, 28, 2013 -ur ery Jnder in:esti ation for use in se:erely o#ese adolescents$ 0ail)re to Thri#e
Inadequate growth No universal definition Weight less than 5% for age Persistent deviation from growth curve

Types
Inadequate caloric intake Inadequate absorption (CF, hepatic disease, vit/mineral deficiencies) Increased metabolism (CHD, hyperthyroidism, immunodeficiency) Defective utilization (metabolic or genetic anomaly)

'anagement of 0TT
Diagnosisexam, growth charts, diet history, rule out organic causes, family assessment, home assessment Managementreverse the malnutrition, catch up growth, treat coexisting problems Prognosis o Related to the cause o Can we reverse the problem?

1)rsing Care of 0TT )he nurse

Feeding Assessment of weight, growth. Documenting food intake, feeding behavior, interactions b/w care givers Sufficient calories, feed on schedule, persistence, eye contact Quiet, non-stimulating feeding environment Positive, calm, structured feeding environment Supporting a positive family-child relationship Parent education Developmental stimulation between feeds (NOT during feedings)

)he Parent )he @hild

<uestion=$$ )he nurse is carin for a 3 month old with .))$ %hich of the followin feedin techniLues should #e tau ht? *$ .eed #a#y in a common room of the house$4may#e distractin 5 "$ Let the #a#y demand feed C2 "e#elop a str)ct)red feeding ro)tine &$ &ou#le concentrate the formula to increase caloric inta;e$ Phenyl3eton)ria 4P567 6enetic disease
Inherited autosomal recessive Inability to metabolize phenylalanine Lacks enzyme to metabolize phenylalanine

Peds Lecture 3, Exam 1 January 21, 28, 2013

Phenylalanine is an essential amino acid found mainly in proteins but also in grains and fruits/vegetables High phenylalanine levels can cause severe cognitive impairments and erratic behavior Degeneration of grey and white matter

P56--'anifestations
Growth failure, vomiting, irritability, erratic behavior, spasticity, seizures, cognitive impairments Best outcomes if treatment started before 3 weeks of age.

"iagnosis8screening mandatory in 9: states &ia nosis and treatment aimed at pre:ention of co niti:e disa#ilities )est close to new#orn dischar e #ut #efore 2 days old (eed sufficient exposure to Mmil;N to test 4at least 2B hours5 P568Treatment
Treatment o Low Phenylalanine Formula/Solution is only source of protein through adolescence (Minimize Protein intake) o Breast feeding MAY be OK if mothers intake is low in phenylalanine o Diet allows for 20-30 mg/kg/day of phenylalanine, (stay away from diet coke et) Maintain blood level of 2-8 mg/dlcognitive deficits occur at levels of 10-15 o Even with good control, could be some degree of intellectual impairment o Pregnant females must go back on the diet before the pregnancy to prevent fetal brain damage o Adults may experience mental decline if they do not continue the diet in adulthood.

<uestion=$$ %hich teachin is most important for a child with PKJ durin a well1child :isit? *$ )he child is a#le to eat a ham#ur er and mil;sha;e daily$ "$ ,f the child wants a soda, a diet soda is preferred o:er mil; or dairy$ @$ )he child may ha:e ice cream in any amount twice wee;ly$ "2 ow protein pasta and cereal are accepta+le ,mmuniCations
Dramatic decline in infectious diseases due to widespread use of immunizations Single most important health measure o Immunization status should be asked at each health care visit

!ecommended 4.lu5 :s$ reLuired :accines 4"TP; ''R etc227 -chedule

Contro#ersy with Vaccines

No association between vaccines and autism. Stems from a study that was funded by trial lawyers in 1998. o Study retracted by the authors in 2004.

Concern regarding Thimerosal o )himerosal is a preser:ati:e o !ates may ha:e e:en increased since the remo:al of )himerosal$ *t a reater ris; if not immuniCed for the illness$ Pertussis, Measles and Mumps are a result of vaccine refusal!

Peds Lecture 3, Exam 1 January 21, 28, 2013 Vaccine Ref)sal 0ost do not :accinate due parental concerns on :accine safety$ 0ost commonly cited concerns3 )himerisolF :ery few contain it (ot closely re ulated Fmonitored #y .&* and @&@ &iseases Mnot a ris;NF international tra:el increases this ris; !ecei:e too many :accines at once F actually, the loads of anti ens in a sin le :accine component ha:e decreased o:er time as technolo y impro:es Imm)ni$ation Sched)le @han es often 4yearly or e:ery few years5 Recommended #s2 Re<)ired2 !eLuired is determined #y the state for school attendance !ecommended is the entire schedule$$$recommended #y the **P 4*merican *cademy of Pediatrics5$ Hepatitis &
Hepatitis B infections can lead to cirrhosis or liver cancer Can become a Hepatitis B carrier Rapid rise in Hepatitis B incidence during adolescents Transmitted by blood and body fluids Given IM or SubQ Newer Oral Start by 12 wks of age Currently being expanded to 14 wks + 6 days First dose recommended 6-12 wks Final dose by 32 wks. Currently being expanded to 8 months + 0 days

Rota#ir)s Vaccine

"iptheria; Tetan)s; Pert)ssis 4"TaP7

Combination vaccine Given IM Common side effects to discuss: fever for 24-48 hours, localized pain at injection site, redness at injection site.

&iptheria3 #acterial infection can cause airway o#struction and se:ere seLuelae )etanus3 painful, muscular ri idity and often fatal Pertussis 4whoopin cou h53 can cause se:ere respiratory distress *cellular form of :accine with less side effects Haemophil)s infl)en$ae type + 4Hi+7
Given IM Protects against serious infections caused by Hib Bacterial meningitis Epiglottitis Pneumonia Sepsis

Inacti#ated Polio 4IPV7

Peds Lecture 3, Exam 1 January 21, 28, 2013 'P+ no lon er a:aila#le in the J-$
Polio can have neuromuscular, paralytic effects Given IM Used to be given orally, but now all doses given IM Live, attenuated vaccine. Given Subcutaneously Common Side effects to discuss include a rash (looks like measles) 7-10 days after the injection Do NOT give to pregnant women.

'easles; ')mps; R)+ella 4''R7

0easles 4!u#eola53 :iral and can ha:e complications of laryn otracheitis or encephalitis 0umps3 :iral and can ha:e complications such as encephalitis, deafness, sterility !u#ella 46erman 0easles53 :iralO#i est ris; is terato enic effects on the fetus$ Varicella 4Chic3en pox7
Highly contagious viral illness Live attenuated vaccine, given subcutaneously. Common side effect to discuss: Rash (like chicken pox) at the injection site 7-10 days after the injection Store frozen Not recommended for pregnant women Given due to complications of chicken pox that can include encephalitis and serious secondary infections. May get mild case of chicken pox if exposed

Pne)mococcal and 4PCV7 Pre#nar

Given IM Very helpful for conditions of immunosuppression Sickle cell, asplenia, transplant, HIV For prevention of strep pneumo strains of bacteria Often cause ear infections, sinusitis, and pneumonia PCV has decreased many cases of strep pneumo OM and a newer PCV vaccine that includes more serotypes of strep pneumo will decrease cases further. We will still be left with other causes of OM, however.

,f o:er 2B months, can use the older pneumoccocal :accine$ -ome increasin resistance to this :accine is #ein noted$ Infl)en$a
Given IM Dont give if allergic to eggs Give in early fall Administered yearly as the predicted strain changes Recommended for children > 6 mos and especially those with underlying conditions. Given IM in 2 doses Generally not required for school attendance Hepatitis A can cause serious liver complications Transmitted by fecal-oral route Required in some communities with a high rate of Hepatitis A Often required in food service

Hepatitis A

Peds Lecture 3, Exam 1 January 21, 28, 2013 'eningococcal 4'CV7

Given IM Recommended for those in crowded living conditions For the prevention of meningoccal meningitis Adolescents targeted for this.

Vaccine Administration
Site/equipment 1 inch, 25 gauge needle for IMnice place to start Vastus lateralis or Ventrogluteal for infant/young child Deltoidpreschool or older than 2 years of age

Safety
Good restraint Ok to give multiple injections, just use different sites Correct storage, reconstituation Do not combine unless it came as a combo vaccine

"e#elopmental Approach "oc)mentation

VIS, site, lot number, consent IM and SC injections IM Vastus lateralis, ventrogluteal, deltoid in older children

Imm)ni$ations and medications 4)s)ally anti+iotics7 -@ Arm for imm)ni$ations Jsed for insulin, hormone replacement, aller y shots, some :accines$ Contraindications for Vaccine Administration
Severe febrile illness (It is NOT a fever unless >38) Past SERIOUS adverse reaction to the vaccine or vaccine component Long-term (>2 weeks) use of SYSTEMIC steroids. Pregnancyno live vaccines Recent blood, plasma, or IgG for live virus vaccineswait a minimum of 3 months Seizure within several days of receiving a prior dose of vaccine. Immunosuppression Transplantation: Generally no live virus vaccines if undergoing immunosuppression therapy HIV: Can receive live virus vaccines if asymptomatic AIDS: Is not considered an asymptomatic state. Chemotherapy: wait 3 months usually to restart vaccination schedule Mild to moderate local reaction to past vaccine Mild, acute illness with or without low grade fever Current antibiotic therapy Prematurity Family history of seizure, SIDS, or adverse reaction to vaccine

!5 to gi#e a #accine when22

Peds Lecture 3, Exam 1 January 21, 28, 2013

TB test Breast feeding or household contact with pregnant woman CAN receive if HIV + and asymptomatic

<uestion=$ %hich is the nurse9s #est response to a mother of a 2 month old infant who is ettin an ,P+ 4inacti:ated Polio :accine5 and tells the nurse that the older #rother is immunocompromised? *$ Pour #a#y should not #e immuniCed today$ "$ Pour #a#y will recei:e an 'P+ instead of ,P+ then today$ 1(' @$ Pou should ;eep you #a#y and your son separated for 2 wee;s$ 1(' &$ =o)r +a+y can +e imm)ni$ed with IPV; he will not +e contagio)s2 1inacti:e %i#ing oral medications to children
Use the correct dosing device o Carefully measure it. Dont sneak medicine into food. o Do not put in a bottle. Administer into the cheek pocket. Mix in the smallest amount possible. o May need to crush it and make it a liquid o Can flavor it. Some meds you may repeat and others you may not. Do not always assume you repeat it if they spit it or vomit it.

0e#er 4neo nates ----hypothermia is common7 &efined as temperature K 38 @ or 100$B . /armful fe:er is a#o:e B1$2 @ or 102 . 0ost fe:ers are #rief with limited conseLuences and are :iral in ori in (either the rise in temperature nor its response to anitpyretics indicates the se:erity of the infection$ ,n the hospital settin , howe:er, notify physician for temps if not expected or follow floor uidelines$ >#al)ation of 0e#er in Children
Any infant less than 2-3 months old is evaluated immediately if febrile Less than 28 days usually receive a complete septic workup Up to 90 days of age the key is if they appear toxic Any child with fever > 105 is evaluated immediately A child that looks or acts very sick is evaluated immediately Fever 104-105, younger than 2 years, fever > 3 days, fever gone for 24 hrs and then returns, or parental concernsshould be evaluated in 24 hours. Tears stream only after 2 months. Aimed at relieving discomfort Medications to lower the set point Acetaminophen 10-15 mg/kg per dose Ibuprofen 5-10 mg/kg per dose (after 6 mos. of age) NO aspirin for fever reduction %% Home treatments

Treatment of 0e#er

Peds Lecture 3, Exam 1 January 21, 28, 2013

Light clothing, air circulation, sponging (be careful!) Oral intake

Parental s)pport Education

When to follow up, correct medication dosing, correct home care Jan 28, 2013:

0e+rile Sei$)re 4not all 0S leads to >pilepsy or stat)s epileptica 4shol)ld last for ?9 mins7
Affect about 3-5% of children and usually occur between the ages of 6 months and 3 years. Unusual after age 5 years. Cause is uncertain Temperature usually exceeds 38.8 C (101.8 F) Tonic Clonic seizure occurs during the temperature rise Initial episode should be evaluated by pediatrician Complicated episodes may need further evaluation by neurology. o Tell parents to turn the kids on the side

0ollow )p

Varicella @oster 4Chic3en Pox7

Transmitted: airborne and direct contact Incubation period: 14-21 days Communicable 5 days prior to rash onset and until last vesicle crusted over. Fever Malaise Headache Itching Vesicular rash

0anifestations3

Treatment of Varicella -upporti:e

Tylenol (No Aspirin) No benedryl till kids are 2 yrs old! Fluids Comfort for itching (baths) Immunization to prevent Treatment of secondary infections Cellulitis Meningitis Reye syndrome Illness more severe if on oral steroids Significant illness/death if immunocomprimised Monitor for complications Neurocomplications Infections Treatment of rash Comfort Fluids

(ursin ,mplications

/ome care

Peds Lecture 3, Exam 1 January 21, 28, 2013

OTC medications Monitor visitors as well

,solation if in /ospital >rythema Infectios)m 48th9s &isease5

Transmission: respiratory secretions and blood. Human Parvovirus B19 Headache, malaise, body aches Maybe low grade fever 1 wk later, slapped cheek rash 1-2 wks: lacelike maculopapular rash on trunk and limbs that comes and goes for 1-3 wks. Supportive Care Fluids Rest Keep out of sun with rash Avoid contact with pregnant women Contagious prior to symptoms Can cause aplastic crisis in children with hemolytic conditions

0anifestations3

(ursin ,mplications of 8th9s &isease /ome care for itchy rash 4usually not itchy5

<uestion=$$ )he mother9s child is dia nosed with 8th9s disease$ Pou o#ser:e the mother cryin and she says, M, am afraid$ %ill my un#orn #a#y die? , ha:e a planned @1-ection next wee;?N )he most therapeutic response for the nurse would #e? *$ Let me et the physician to come tal; with you$ "$ , understand$ , would #e afraid as well$ @$ %ould you li;e me to call your o#stetrician so you can #e seen as soon as possi#le? &$ , understand you are afraid$ @an we tal; a#out your concerns? Impetigo 4honey crusted lesions5 "acterial infection of the s;in$4staphylococcus aureus 5 'ften spread #y auto inoculation
Young children often affectedhand to mouth/nose Often seen around the nosecan be anywhere though Honey crusted lesions Handwashing Antibiotics Razors discarded Bleach kills it on surfaces

(ursin @are

Allergic Reactions
Can be: red, itchy, wheals, facial/tongue swelling, wheezing, difficulty breathing May be seen more in kids since they have first exposures to things There is a difference between food allergies and food sensitivities. Sensitivities may come and go in childhood

Peds Lecture 3, Exam 1 January 21, 28, 2013 %hat can cause it? (-*,&9s, anal esics, :accines, and anti#ioticsF most common causes P@( aller yFB18G more li;ely to ha:e cephalosporin rxn .oodsF peanuts, tree nuts, shellfish, e s, dairy, straw#erries most common Accident Pre#ention
Injuries are number 1 in childhood mortality Take a developmental approach to prevention Poor planning, top heavy, awkward, impulsive, curious Situations that lead themselves to injury: Weather extremes, Saturdays, overcrowded areas, tension in the home, alcohol/drug use

<uestion=$$ *n adolescent comes in for his yearly physical$ %hich would #e the most appropriate inQury pre:entionDsafety teachin for him? *$,nLuire which are his fa:orite sports and discuss his ;nowled e and application of appropriate safety principles$ " )ell him to #e careful performin sports acti:ities #ecause e:ery sport has the potential for inQury$ @$)ell him not to let his friends encoura e him to drin; or smo;e or ta;e any dru s$ &$*s; his mother what sports he plays and if he wears a helmet with contact sports$ Ingestions >0H of poisonin s occur in the home &e:elopmental characteristics predispose children to poisonin s$
Curiosity, oral experimentations, imitation Lock Poisons/Medications Up Keep out of sight Throw out old drugs, dont let young children see adults take, keep meds in safe area Keep in original containers Dont put in food containers, dont refer to meds as candy Poison control number handy

Pre#ention

Home Treatment of Ingestions *ssessment

What did they take?

/ow much? %hen?

1. 2. 3. Empty mouth Take child and container to the phone Call poison control

Treatments of Ingestions 0ay #e one in the E!Odepends on what was ta;en @harcoal
Absorbs compounds Poses risk for aspiration, intestinal obstruction, electrolyte imbalances

Peds Lecture 3, Exam 1 January 21, 28, 2013

Mix with diet soda as sweeteners reduce its absorption qualitiesthis may not be the case now. Stimulate evacuation of the bowel, decreasing intestinal absorption Use controversial Mucomist for tylenol, Narcan, etc

@athartics *ntidotes <uestion=$ * child who has swallowed paint thinner is #rou ht to the emer ency department #y her parent$ )he child is lethar ic, a in , and cyanotic$ %hat is the #est action for the nurse? *$ ,nduce :omitin with ipecac$ "$ ,nsert astric tu#e and i:e charcoal 4latter5 @$ Prepare for intu#ation with cuffed E) tu#e 4cyanotic =$ compromised airway 1st5 &$ *dminister chelation therapy usin &ELead Poisonin Known health haCard *#sor#ed #y in estion, inhalation, placental transfer *#sor#ed #y the #ody and not fully eliminated -ometimes can #e a part of cultural traditions The child Poun children a#sor# 80H of what they are exposed to while adults a#sor# 10H * es 118 years, pica, hi h fat diet, iron deficiency, de:elopmentally delayed, increased oral acti:ity Parent may #e distracted, unaware of pica Pathological >ffects of ead /ematolo y
Anemialead competes with iron in making hemoglobin Renal o Damage to renal tubules causes excretion of glucose, protein, amino acids and phosphate Fanconi Syndrome CNS o Cerebral edema, encephalopathy, increased ICP, seizures, MR, blindness, paralysis, death o Developing brain is especially vulnerable o CNS effects are nonreversible

&lood e#el Treatment Le:el R 10 !escreen in 1 year$ ,f exposure status chan es, do this sooner 1011> Education and rescreenin $ (utritional inter:entions 201BB /ome and medical treatment B817> -tart chelation within B8 hrs, remo:e from en:ironment K or E 20

Peds Lecture 3, Exam 1 January 21, 28, 2013 ,mmediate medical inter:ention Treatment )reatment of home en:ironment @helation starts around le:els of BB1B8$ "'SA
Oral agent used for lower levels Monitor for nephrotoxicity (UA daily), liver function tests and EKG Given in a monitored hospital setting Some pathophysiological effects are reversible Effects on CNS leave child with Cognitive Impairments, Behavior Changes, and Seizures Even low dose exposure may leave permanent effects of distractibility, impulsivity and learning disabilities Education Assessment of development Case coordination

Calci)m >"TA and &A ong term effects of ead

1)rsing Implications

Child A+)se
Physical Abuse Physical Neglect Emotional Abuse Emotional Neglect Verbal Abuse Sexual Abuse

%hat is *#use?
Deliberate maltreatment Deliberate withholding Shaming, ridiculing Emotional unavailability Exploitation Drug and ETOH abuse Psychiatric disorders Environmental stressors Poor parenting experiences Marital/partner stressors Social isolation Inappropriate expectations of the child Unexplained burns, bruises, fractures. Fading bruises or burns Bruises or welts in shapes or patterns Child shrinks in approach to adults Child is overly compliant Caretaker with conflicting story.

Ris3 factors of A+)se

Signs of Child A+)se

Peds Lecture 3, Exam 1 January 21, 28, 2013 1)rsing Implications Aith Regard to Child A+)se
Diagnosis History and physical Lab studies Reassurance of the child Does the history fit the evidence? Mandated reporter

(ursin implications (ursin assessment

Child 'altreatment - Physical

Non-Accidental Injury to a Child caused by a Caregiver Physical Indicators Red Flags Inconsistent Histories History and Exam Mismatch Withholding History No Knowledge of Circumstances Claims of Self-infliction Blaming of Siblings or Other Parent or Adult Delay in Seeking Care History of Other Injuries E.R. Shopping Inappropriate Rxn to Severity of injury Partial Confession

>arly 'otor 'ilestones A%> 'I >ST!1>S B months !aises /ead 817 months !olls ':er 81> months -its *lone 10112 months @rawls1%al;s 18 months %al;s *lone 18 months @lim#s -tairs 2212B months )hrows "all ':erhand 213 years )urns a /ot %ater Kno# 3 years *lternates .eet up the -tairs 8 years @atches "all "ounced -uspicious /istories

!uns %ell Pedals )ricycle

No explanation for injury Inadequate explanation Contradictory or changing history Injury attributed to a 3rd party (sibling, babysitter) If sibling, is that child developmentally mature enough to have caused the injury

Peds Lecture 3, Exam 1 January 21, 28, 2013 &r)ise Color Scale Color !eddish "lueDPurple &ar; "lueDpurple 6reen Pellow "rown !esolutionI@leared

Time 0rom InB)ry ,mmediate12B hrs 118 days 812 days 2110 days 1011B days 21B wee;s

Parental &eha#ior Patterns Seen in A+)se

Lack of concern or detachment about the injury Lack of response to child in pain Overly concerned about trivial injuries Demonstrates unrealistic expectations of the child Parents themselves may have a H/O Drug or Alcohol Addiction or Psychosis Lack of trust in health professionals

Consider the Possi+ility of Physical 'altreatment when the Child/

Has unexplained burns, bite, bruises, broken bones, or black eyes Has fading bruises or other marks noticeable after an absence from school Seems frightened of the parents and protest or cries when it is time to go home Shrinks at the approach of adults Reports injury by a parent or another adult caregiver

Consider the Possibility of Physical Abuse when the Parent or other Adult Caregiver: Offers conflicting, unconvincing, or no explanation for the childs injury Describes the child as evil or in some other very negative way Uses harsh physical discipline with the child Has a history of abuse as a child

S3in and Soft Tiss)e InB)ry

Bruises on face, lips, mouth, torso, back, buttocks and thighs Bruises in various stages of healing Degree of bruising is greater that expected for childs activity level Dating bruises by color scale

<uestion=$ * nurse is assessin the family of a child #rou ht in for se:ere inQuries$ %hich of the followin #eha:iors #y the parents indicates pro#a#le a#use? *$ &elay in see;in treatment for the child9s inQuries$ "$ &etailed description of the e:ents prior to the inQuries$ @$ *nxious, concerned attitude &$ Encoura in the child to explain the inQuries$ Child A+)se - sex)al
Incidence is increasing Child needs to be referred to Sexual Abuse Management (SAM) Team Will be seen in E.R. if immediate physical problems evident

Physical e:idence I 0ust #e collected :ery, :ery carefully Types

Peds Lecture 3, Exam 1 January 21, 28, 2013

Incest Between family members Not necessarily blood relatives Molestation Indecent liberties Touching, Fondling Exhibition Indecent exposure Child Pornography

Consider the Possi+ility of Sex)al A+)se when the Child/

Has difficulty walking or sitting Suddenly refuses to change for gym or to participate in physical activities Reports nightmares or bed wetting Experiences a sudden change in appetite Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior Becomes pregnant or contracts a venereal disease, particularly if < 14 years old Runs away Reports sexual abuse by a parent or another adult caregiver

Consider the Possi+ility of Sex)al A+)se when the Parent or !ther Ad)lt Caregi#er/
Is unduly protective of the child or severely limits the childs contact with other children, especially of the opposite sex Is secretive and isolated Is jealous or controlling with family members

Sex)al A+)se
Besides the obvious acts of Child Sexual Abuse, other behavior must be evaluated to determine if the act is designed to create sexual gratification Activities can include: Any conventional sexual activity with a child. Also included are acts such as touching the childs genitals or fondling with the intention of arousing sexual feelings Prolonged kissing, cuddling, French kissing, and excessive touching Looking at children either with or without clothes Photographing, videotaping, or filming children with the intent to create sexual stimulation May include exposure of a child to erotic material

Pedophilia 1 * form of child sexual a#use1 is an a#normal interest in children that is #ased on the intention #y the perpetrator to #e sexually aroused #y children ')ncha)sen +y Proxy
A mental illness that one person (usually the mother, who has some health care experience) fabricates or induces in another person May cause a child to undergo needless painful testing Parents should ask themselves the following questions to determine if this condition might exist o Are you overly concerned about the health of your child? o Do you remain concerned about minor problems that you have been told not to worry about? o Do you find yourself obsessing over possible medical problems that might affect your children? o Have you ever done an intentional act to make your child ill? o Do you have any motivation or will you derive any benefit if you make your child ill? o Parents that see this behavior in themselves should stop the medical attention-seeking behavior immediately and seek psychiatric help as soon as possible. Identification

(ursin !esponsi#ilities in @hild 0altreatment

o

Peds Lecture 3, Exam 1 January 21, 28, 2013

o o o Health professionals miss hundreds of cases of child maltreatment per year Nurses must perform excellent physical assessments and histories Somethings are not considered abuse o Coining (Cao Gio) Involves rubbing a coin along area to cause bad wind. If a redpurple discoloration appears, the treatment is considered successful. Performed by Vietnamese and other Asian-Pacific Groups

o o o o o o o

Care of the Child Depends on the injury Protection of the child Prevention of abuse Reporting Mandatory If written report is done, report must be in common terms, not medical terms. If a medical term is used, there must be an explanation Parents are told that a report is being made and that Social Service will want to interview them. Testifying in Court

1)rsing "iagnoses Associated with Child 'altreatment

o o o o o Knowledge Deficit (of Staff) of Hospital Child Maltreatment Policy Ineffective Family coping: compromised R/T Factors that Contribute to Child Maltreatment Altered Growth and Development R/T Inadequate Caregiving High Risk for Violence (Abusive Family Member): Directed at others R/T maladaptive Behavior Altered Parenting R/T the Abusive parents inability to Attach or Bond with the Child

CAR> 0!R TH> CAR>%IV>RS @arin for a#used children is :ery, :ery emotionally drainin $ /ealth care pro:iders need to remem#er that if they do not ta;e care of themsel:es they cannot ta;e care of the children$ (o#ody has to do this alone so #e sure to ;now what your resources are and use them$