Fecal incontinence

refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more
than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it
may be caused by psychosocial triggers (nonretentive type).
A reward system is one of the behavioral strategies used in the treatment of functional
incontinence (due to constipation). The reward is given to encourage the child's involvement in
the treatment to restore normal bowel function. Rewards are given for the child's effort and
participation, not for having bowel movements while sitting on the toilet.

Intussusception
an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into
another segment
The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a
sausage-shaped abdominal mass. However, it is more common for clients to have episodes of
sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal
behavior.
Reduction of intussusception is often performed with a saline or air enema.
The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception.
If this occurs, the HCP should be notified immediately to modify the plan of care and stop all
plans for surgery.
If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen
becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure.
Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This
condition can be fatal if it is not treated quickly.

Pyloric stenosis
results in recurrent projectile vomiting, which leads to dehydration and hypokalemic metabolic
alkalosis. Dehydration is manifested by hemoconcentration (elevated hematocrit) and elevated
blood urea nitrogen. Infants will be hungry constantly despite regular feedings, a palpable olive-
shaped mass in the epigastrium to the right of the umbilicus, and projectile vomiting (can be up to
3 feet).
The amount of milk consumed (particularly with bottle feedings) along with the mother's technique
(mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or
overfeeding as an etiology.

Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed.
Gastritis is a common cause of UGI bleeding in infants and toddlers.

Epistaxis, or nosebleed
Rarely serious and is usually due to mucosal irritation from dryness, local injury (eg, nose-
picking), a foreign body, or rhinitis. Most bleeding arises from a highly vascular network on the
anterior nasal septum. Epistaxis generally resolves spontaneously or with simple home
management.
The initial step in treatment is to tilt the client's head forward and apply direct, continuous
pressure to the nose for 5-10 minutes
Keeping the child quiet and calm may help provide the adequate time and pressure necessary for
clotting
Epistaxis can often be prevented by avoiding local trauma and maintaining hydration of the
mucosa with saline nasal spray or a humidifier.

Failure to Thrive
FTT in a child is characterized by a low weight/height ratio and/or falling below the 5th percentile
on the growth curve due to inadequate caloric intake, inadequate absorption of calories, or
excess caloric expenditure. Most children with a diagnosis of FTT have inadequate caloric intake
caused by multiple behavioral or psychosocial factors, including disturbances in child-parent
interaction. Risk factors for FTT include:

● Young parent age

● Unplanned or unwanted pregnancy
● Lower levels of parental education
● Single-parent home
● Social isolation
● Chronic life stresses/anxiety in the home
● Disordered feeding techniques
○ Prolonged breast or bottle feeding
○ Unstructured meal times
○ Negative or difficult interactions at meal time
○ Poor parental feeding skills
○ Negative attitudes toward food – fear of obesity or an overweight child
● Substance abuse
● Domestic violence and/or parental history of child abuse
● Poverty, food insecurity
● Parents who have a negative perception of the child

Hemophilia
A bleeding disorder caused by a deficiency in coagulation proteins. Clients with hemophilia who
are injured should be monitored closely for bleeding (eg, intracranial bleeds, bleeding into joints).
Signs of an intracranial bleed include lethargy, headache, irritability, and vomiting. An intracranial
bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first
order of action, followed by a CT scan.
Treatment consists of replacing the missing clotting factor and teaching the client about injury
prevention, including:
● Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties
● Avoid intramuscular injections; subcutaneous injections are preferred.
● Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging,
tennis) and use of protective equipment (eg, helmets, padding) are encouraged
● Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be
used.
● MedicAlert bracelets should be worn at all times
● The smallest gauge needle is used, and firm, continuous pressure is applied at the site
for 5 minutes
Clients with hemophilia are at risk for permanent joint destruction due to frequent bleeds into the
joint spaces. Assisting clients with decreasing the incidence of bleeding episodes and prompt
treatment when bleeding occurs can help minimize joint destruction.

Celiac disease (celiac sprue)

An autoimmune disorder in which the body is unable to process gluten, a protein found in most
grains.
Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats
(steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to
thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are
gluten free and are allowed in the diet
A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW).
Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from
malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease.

Kawasaki disease
a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries
are affected in KD, and some children develop coronary aneurysms. The etiology of KD is
unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. Kawasaki
disease (KD) is a systemic vasculitis of childhood that presents with ≥5 days of fever,
nonexudative conjunctivitis, lymphadenopathy, mucositis, hand and foot swelling, and a rash.
KD has 3 phases:
1. Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics.
The child becomes very irritable and develops swollen red feet and hands. The lips
become swollen and cracked, and the tongue can also become red (strawberry tongue).
2. Subacute - skin begins to peel from the hands and feet. The child remains very irritable.
3. Convalescent - symptoms disappear slowly. The child's temperament returns to normal.
Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma
oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large
quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased
urinary output, additional heart sounds, tachycardia, difficulty breathing).
treated with aspirin and IVIG to prevent coronary artery aneurysms.
Once children with KD are discharged home, parents should be instructed to check their
temperature every 6 hours for the first 48 hours following the last fever and then daily until the
follow-up visit. The health care provider should be notified if the child has fever as this may
indicate a need for further treatment.
KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet
and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye
syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with
coronary artery aneurysms.
Phenylketonuria (PKU)
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. 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 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.
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
● Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet
● Encouraging the consumption of natural foods low in phenylalanine (most fruits and
vegetables)

Esophageal atresia (EA) and tracheoesophageal fistula (TEF)

In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower
esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can
usually be corrected surgically. Clinical manifestations include frothy saliva, choking, coughing,
and drooling. Clients may also develop apnea and cyanosis when feeding.
Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants
with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating
the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from
the mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to
maintain a clear airway and prevent aspiration.
likely require parenteral nutrition prior to surgery. A gastrostomy tube may be placed to allow for
release of air and drainage of gastric contents to prevent aspiration; however, feedings or
irrigations through the tube are contraindicated until after surgical correction of the TEF.
Surgical correction is successful in most cases of EA/TEF. Infants diagnosed with extreme forms
or with additional congenital anomalies may require referral to palliative care services if surgical
correction fails.

Hirschsprung's disease.
occurs when a child is born with some sections of the distal large intestine missing nerve cells,
rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool
is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a
distended abdomen and will not pass meconium within the expected 24-48 hours. They
also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of
bowel is necessary.
a portion of the colon has no innervation and must be removed. Some children require
a temporary colostomy. The stoma created from the surgery should remain beefy red in the
immediate postoperative period. Any paleness or graying of the stoma indicates decreased blood
supply to that area.
A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which
can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-
smelling diarrhea; and rapidly worsening abdominal distension.
Thin, ribbon-like stool (congenital aganglionic megacolon)

Cystic fibrosis (CF)

a protein responsible for transporting sodium and chloride is defective and causes the secretions
from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug
smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block
pancreatic ducts, resulting in a deficient amount of pancreatic enzymes(amylase, trypsin, and
lipase) entering the bowel to aid in digestion and nutrient absorption. The result is malabsorption
of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is
of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal
cramping, ongoing diarrhea, and/or steatorrhea. Clients require multiple vitamin supplements and
supplemental pancreatic enzymes that are administered with meals. To meet the growth needs
of clients with CF, a diet high in calories, fat, and protein is required.
Nutritional therapy includes the administration pancreatic enzyme supplements with or just before
every meal or snack (not as needed). These enzymes are enteric-coated beads designed to
dissolve only in an alkaline environment similar to that of the small intestine. They must not be
mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule
contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH
<4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules
could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in
fibrosing colonopathy
Capsules should not be taken with milk as they can cause it to curdle.

Tooth avulsion
there is a limited amount of time (≤1 hour) before death of the affected tooth. These clients need
prompt treatment to save a permanent tooth.

snacks and meals for toddlers (age 1–3):

● Safety – small, hard, sticky and/or slippery foods pose a choking risk and should not be
offered to children under age 3. Examples include hot dogs, grapes, nuts, raw carrot
sticks, popcorn, peanut butter, hard candy, and raisins.
● Nutrient density (the nutrients a food provides relative to the number of calories it
contains). The snack should be of high nutritional value rather than "empty calories."
● Potential for food-borne illness – children are at higher risk for developing a food-related
infection if given raw, unpasteurized foods such as juice, partially cooked eggs, raw fish,
or raw bean sprouts.
Examples of healthy snacks for children under age 3 include pieces of cheese, whole-wheat
crackers, banana slices, yogurt, cooked vegetables, mini pizzas, and cottage cheese with cut-up
fruit.
Recommended that young children have no more than 4–6 ounces of fruit juice per day. It is best
to serve juice with a meal so the child does not become accustomed to snacking on sugary foods.

Infant formula
is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents who feed their
infants commercial formula should closely follow the manufacturer's recommendations for
preparation, particularly if the product requires dilution or reconstitution. Parents should also
adhere to basic guidelines for safe storage and handling. Key teaching points include:

● Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or
washing in the dishwasher
● Wash the tops of formula cans prior to opening to prevent contamination
● Prepared formula or opened cans of ready-to-feed or concentrated formula should be
kept in the refrigerator and discarded after 48 hours if unused. There is a risk of
bacterial growth after this time.
● Prepared bottles can be warmed by placing in a pan of hot water for several minutes
● Test temperature on the inner wrist before serving to the infant; formula should feel
lukewarm, but never hot
● Never microwave formula as it can cause mouth burns
Formula should never be diluted or concentrated. Dilution of the formula does not allow the
infant to receive the appropriate amount of calories, vitamins, and minerals needed for normal
growth and development. Overconcentration of the formula can cause excessive proteins and
minerals to be ingested that exceed the excretory ability of the infant's immature kidneys.
Any formula left in a bottle after a feeding should be discarded immediately because the
infant's saliva has mixed with it. This will encourage bacterial growth.
Water intoxication
(water overload) resulting in hyponatremia may occur in infants when formula is diluted to
"stretch" the feeding to save money. Hyponatremia may also result from ingestion of plain water
(eg, caregiver attempting to rehydrate an infant who has been ill). Infants have immature renal
systems with a low glomerular filtration rate, which decreases their ability to excrete excess water
and makes them susceptible to water intoxication. Symptoms of hyponatremia
include irritability, lethargy, and, in severe cases, hypothermia and seizure activity. Breast milk
and/or formula are the only sources of hydration an infant needs for the first 6 months of life.
Formula should be prepared per the manufacturer's instructions.

Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone
development in children and adolescents
To obtain the recommended 500 mg of daily calcium (for ages 1-3 years), the parents should
serve foods such as beans, dark green vegetables, and calcium-fortified cereals and
juices. Vitamin D, which enhances the absorption of calcium, is synthesized in the skin by
exposure to direct sunlight. Alternate dietary sources include fish oils, egg yolks, and vitamin D-
fortified foods (eg, orange juice).

Botulism
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.

Tonsillectomy
Postoperative bleeding is one of the biggest concerns after a tonsillectomy as the surgical site is
not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing.
Observe and notify the health care provider about signs of postoperative bleeding (frequent
swallowing or clearing of the throat, vomiting bright red blood)
Expected postoperative findings include ear pain when swallowing (ie, referred pain from the
throat), low-grade fever (<101 F [38.3 C]), and superficial infection at the surgical site causing a
white, fluid-filled area of exudate in the throat with halitosis (ie, bad breath). A superficial infection
at the surgical site is common and usually resolves spontaneously after 5-10 days.

Lead poisoning
Occurs from repeated lead exposure, either via ingestion of lead-based paints (eg, walls, toys),
glazes (eg, pottery) or water from lead pipes, or by inhalation of contaminated dust or soil found
around older homes. Elevated blood lead levels (BLLs) impair neural, blood, and renal
development. A BLL screening is recommended between ages 1 and 2, or up to age 6 if the child
was not previously screened. Clients with elevated BLLs (≥5 mcg/dL [0.24 µmol/L])
require follow-up blood work to ensure that levels decrease. Chelation therapy may be required if
levels remain elevated.
The priority intervention for clients with elevated BLLs is preventing continued exposure.
The home environment should be assessed for lead sources. Pediatric and pregnant clients
should not live in homes being renovated until the work is complete. Handwashing, especially
before eating, is important to remove lead residue.
Vacuuming spreads lead dust in the air, which increases inhalation exposure. Hard surfaces
should be wet-dusted or mopped at least weekly.
Hot tap water dissolves lead from older pipes; therefore, cold water should be used for
consumption if lead plumbing is present. Taps should be flushed for several minutes to clear out
contaminated water before use.

Allergic rhinitis
Symptoms include sneezing, nasal drainage, nasal congestion, and pruritus of the eyes or nose.
Clients and their families can help prevent these symptoms by identifying individual triggers (eg,
dust, mold, pollen, dander) and implementing strategies to reduce or avoid exposure to known
allergens.
Key measures to reduce exposure to household and environmental allergens include the
following:
● Installing high-efficiency particulate air filters in the home air conditioning system
● Keeping windows closed and staying indoors, particularly during times of heavy pollen
● Using hypoallergenic pillow and mattress covers to prevent exposure to dust mites
● Reducing or eliminating carpet and area rugs from the home
● Regularly mopping hard floors and damp-dusting furniture (at least weekly)
If the client is not allergic to animal dander, keeping a household pet may be acceptable.
However, to prevent pets from bringing environmental allergens into the home, further
precautions may need to be implemented, such as more frequent baths or additional doormats.
Open windows allow environmental allergens, such as pollen, to enter the home. To prevent
exposure to these particles, susceptible clients should keep exterior windows closed and avoid
spending long periods of time outdoors.

Sickle cell crisis

Laboratory results that support a vaso-occlusive crisis (pain crisis) in a client with sickle cell
disease include elevated reticulocytes, elevated bilirubin, and anemia(hemoglobin <.10.
Splenic sequestration crisis is a potentially life-threatening emergency of sickle cell disease. A
rapidly enlarging spleen and hypotension are the characteristic assessment findings.
A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the
occlusion of small blood vessels from increased red blood cell sickling.
Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain
management and bed rest. Nonpharmacologic measures to alleviate pain include distraction
(watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning,
and gentle massage.

HEART DEFECTS

Left-to-right shunting results in pulmonary congestion, causing increased work of breathing

and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis)
result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include:
● Tachypnea
● Tachycardia, even at rest
● Diaphoresis during feeding or exertion
● Heart murmur or extra heart sounds
● Signs of congestive heart failure
● Increased metabolic rate with poor weight gain

Left-to-right shunting - Patent ductus arteriosus (PDA)

acyanotic congenital defect more common in premature infants
The ductus arteriosus of a newborn should close spontaneously when fetal circulation changes to
pulmonary circulation. If the ductus arteriosus remains open, blood will shunt from the aorta to
the pulmonary arteries. The child will be acyanotic but will have a machine-like murmur heard on
both systole and diastole.
Commonly resolves within 48 hours and requires no intervention in full-term
newborns.Sometimes, the PDA will be treated with surgical ligation or IV indomethacin to
stimulate duct closure.

Left-to-right shunting - Atrial septal defect.

In a child with atrial septal defect, the nurse would expect to hear a heart murmur on auscultation
of heart sounds.
Left-to-right shunting - Ventricular septal defect
A cardiac abnormality, with a septal opening between ventricles, that may progress to congestive
heart failure (CHF). Clinical manifestations of VSD include a systolic murmur auscultated near
the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs (eg,
diaphoresis, tachypnea, dyspnea).

Coarctation of the aorta (COA)

an abnormal aortic narrowing that results in decreased cardiac output. The client will exhibit
elevated pulse pressure in the upper extremities and diminished pressures in the lower
extremities.

Tetralogy of Fallot (TOF)

Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg,
tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident
shortly after birth and during periods of physical exertion, manifested by signs of irritability and
clubbing of fingers due to oxygen saturation chronically remaining between 65-85% until the client
can undergo surgical repair.
The nurse should teach parents of an infant or child with a repaired congenital heart defect to
recognize and report signs and symptoms of heart failure to the HCP. These may include rapid
breathing rate; rapid heart rate at rest; dyspnea; activity intolerance (especially during feeding in
infants); pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the
eyes.
Hypercyanotic episode, or "tet spell,"
an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is
feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides
relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is
shunted through the overriding aorta and the ventricular septal defect.
Polycythemia (elevated hemoglobin levels)
Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism
due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at
risk for stroke or thromboembolism. Clubbing is another manifestation of prolonged hypoxia.
An infant with polycythemia must stay hydrated.

Physiologic anorexia
a normal period of decreased appetite that occurs in toddlers around age 18 months as a result of
decreased metabolic needs. Parents should be taught to provide multiple food options, set a
schedule for meals/snacks, and avoid watching TV or playing games during meal time; toddlers
should not be forced to eat.

Iron deficiency anemia

The most common nutritional disorder in children. Risk factors include premature birth, cow's
milk before age 1 year, and excessive milk intake in toddlers over 24 oz/day.
Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green
vegetables, fortified cereal) and supplementation.
Oral iron supplements should be given between meals and consumed with citrus juice to promote
absorption, and administered to the back of the mouth to prevent tooth staining. No more than a
1-month supply of supplements should be kept on hand to reduce the risk of accidental
poisoning. Oral iron should not be taken with milk.

Iron deficiency (ID)

A diet rich in iron can prevent iron deficiency anemia (hypochromic and microcytic) in children
and adolescents. The best sources of iron are those that contain heme iron, which has a higher
bioavailability; these foods include meat, fish, poultry, eggs, and legumes. Other dietary sources
of iron include dried fruits, nuts, green leafy vegetables, and whole grains. However, the iron
from these sources is not absorbed as completely as heme iron. Fruit and fruit juices high in
vitamin C may enhance the absorption of both heme and non-heme iron and should be included
in a meal.

Acute diarrhea
treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment
is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of
water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered
in small amounts at frequent intervals. Continuing the child's normal diet(solid foods) is
encouraged as it shortens the duration and severity of the diarrhea.
monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet
diapers, presence of sunken eyes, and the condition of the mucous membranes.
Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by
using skin barrier creams (eg, petrolatum or zinc oxide).

Appendicitis
acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood
cell count
a serious condition that usually requires emergency surgery due to the risk of appendix rupture.
The pain results from swelling and inflammation of the appendix. However, once the
appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and
sepsis.
The client will be placed NPO until surgery is performed to remove the appendix.

Immunization
Varicella - administered to prevent infection of varicella zoster, commonly known as chickenpox.
Side effects of the immunization include discomfort, redness, and a few vesicles at the injection
site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission
from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary.

MMR - Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first
dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site,
irritability, and restlessness.
Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is
important for the nurse to determine the child's temperature to evaluate the risk for a febrile
convulsion. It would also be important for the nurse to instruct the parent to monitor the child's
temperature and administer acetaminophen for a fever above 102 F (38.9 C).
Children with a history of seizures should be vaccinated with separate MMR and varicella
vaccines instead of the combination MMRV vaccine.

Measles, or rubeola, is a highly contagious disease that can affect people of all ages. Because
vaccination against measles is up to 99% effective, the incidence of measles has been reduced in
the United States. However, there has been a resurgence of disease due to increased
international travel and a rise in the number of unvaccinated children.
Measles is spread when infected persons cough or sneeze, sending the virus through the air
where it can remain for up to 2 hours. Hospitalized clients with measles are placed on airborne
precautions in a negative-pressure room. Postexposure vaccination within 72 hours of
exposure is recommended for persons who cannot show immunity, to decrease the severity and
duration of clinical symptoms.

**Common side effects of immunizations include a mild fever and soreness and redness at the
injection site. (Caregivers should be instructed to apply a warm compress to the injection site and
taught how to correctly calculate the dose of acetaminophen or ibuprofen needed for these
symptoms) Anorexia and fussiness can be present for the first 24 hours.
**The schedule of recommended routine immunizations for a 6-month-old client includes Hep B,
DTaP, RV, Hib, IPV, and PCV; a mnemonic is Be DR HIP (Hep B, DTaP, RV, Hib, IPV, PCV).
**MMR and varicella vaccines are given at age 12-15 months.
**Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG
administration as IVIG therapy may decrease the child's ability to produce the appropriate amount
of antibodies to provide lifelong immunity.
** Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS)
generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella,
rotavirus, yellow fever)

IMPORTANT:

**The nurse should report the presence of severe diaper rash to the HCP in an infant who has an
interventional catheterization procedure planned. If the rash is near the groin area, the procedure
may be delayed due to possible contamination at the insertion site.
Children are allowed nothing by mouth for 4-6 hours or longer before the procedure. Younger
children and infants may have a shorter period of NPO status and should be feed right up to the
time recommended by the HCP.

** Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported
immediately to the health care provider. This could indicate postoperative hemorrhage and
requires immediate intervention. Cardiac tamponade can develop rapidly in children and can be
life-threatening.
Urine output should be 1-2 mL/kg/hr.

** Solid foods are introduced at age 4-6 months, beginning with iron-fortified cereal and
progressing to soft fruits and vegetables. Five to 7 days should elapse before a new food is
introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months.
Cow's milk should not be introduced until after age 1 year. (whole milk - after 2 years - 2%fat)

Bacterial meningitis
is an inflammation of the membranes covering the brain and spinal cord (ie, meninges) caused by
a bacterial infection. The inflammatory process and bacterial growth within the meninges lead to
increased volumes of cerebrospinal fluid and, subsequently, increased intracranial pressure
(ICP). Without intervention, increased ICP may lead to nerve ischemia, permanent functional
impairment (eg, hearing loss, visual impairment, paralysis), brain damage, herniation, and
death.
Clinical manifestations of bacterial meningitis in infants age <2 include:

● Fever or possible hypothermia

● Irritability, frequent seizures
● High-pitched cry
 ● Poor feeding and vomiting
● Nuchal rigidity
● Bulging fontanelle possible but not always present
One common acute complication of bacterial meningitis is hydrocephalus, an increase in
intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP
can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense
fontanels and increasing head circumference are important early indicators of increased ICP
in children.
The initial priority of nursing care is protecting other clients and staff from exposure, as bacterial
meningitis is highly contagious and transmitted by droplets. After isolating the client, the nurse
should initiate prescribed antibiotics as quickly as possible, as bacterial meningitis can
progress rapidly and lead to death without treatment.
Clients with meningitis are at increased risk for seizures. Implementation of a low-stimulation
environment (eg, low lighting, minimal noise, uninterrupted rest periods) and seizure precautions
(eg, padded side rails) are important interventions.

Pediculosis capitis (head lice)

Treatment involves applying a pediculicide (usually permethrin 1% cream) to the head and
removing nits with a nit comb or by hand. After diagnosis, it is advised to use the nit comb at
least every 2-3 days for 2 weeks. Carpets, rugs, and upholstered furniture must be vacuumed
frequently to remove any lice or nits that might be present. The client's bedding should be
washed in hot water and dried on the hottest dryer setting. Non-washable items can be sealed in
a plastic bag for 2 weeks to kill lice. All hairbrushes, combs, and ornaments should be soaked in
boiling water for 10 minutes or lice-killing products for 1 hour

Developmental dysplasia of the hip (DDH)

a range of various hip abnormalities that may be present at birth or develop during the first few
years of life. There are many risk factors, including breech birth, large infant size, and family
history. Although all cases cannot be prevented, several interventions have been shown to help
reduce the risk of DDH development.
Key measures include:
● Proper swaddling technique - infants should be swaddled with their hips bent up (flexion)
and out (abduction), allowing room for hip movement
● Choosing infant carriers or car seats with wide bases - infant seats should allow for
proper hip positioning in an abducted manner
● Avoiding any positioning device, seat, or carrier that causes hip extension with the knees
straight and together
Nonsurgical treatment methods, such as a harness or cast, are most successful when initiated
during the first 6 months of life. After this time, surgery is frequently required.
A Pavlik harness, the most common tool used in treating early DDH, maintains the infant's hips
in a slightly flexed and abducted position, allowing for proper hip development. Pavlik
harnesses are typically worn for about 3-5 months or until the hip joint is stable. The straps are
adjusted periodically by the health care provider to account for infant growth.

Instructions on care for the infant wearing a Pavlik harness are as follows:
● Regularly assess skin for redness or breakdown under the straps
● Dress the child in a shirt and knee socks under the harness to protect the skin
● Avoid lotions and powders to prevent irritation and excess moisture
● Lightly massage the skin under the straps every day to promote circulation
● Only apply 1 diaper at a time as wearing ≥2 diapers (previous treatment practice)
increases risk of incorrect hip placement
● Apply diapers underneath the straps to keep harness clean and dry
The Pavlik harness is usually worn all the time, particularly during the first few weeks of
treatment. Some providers may allow the harness to be removed for a short bath once a day, but
it should be left in place for all other care activities, including diaper changes.
Erikson's stages of psychosocial development:
• Basic trust vs mistrust (0-18 mos)
• Autonomy vs. shame and doubt (18 mos-3 yrs)
• Initiative vs. guilt (3-6)
• Industry vs. inferiority (6-12)
• Identity vs. role confusion (13-19)
• Intimacy vs. isolation (20-39)
• Generativity vs. stagnation (40-64)
• Ego integrity vs. despair (65-death)
Developmental milestones that a 2-year-old toddler should meet include:
● Motor skills: Walks alone, builds block towers, draws lines, kicks a ball
● Language: Knows 300+ words, uses 2- to 3-word phrases, states name
Cognitive/social skills: Engages in parallel play, imitates others, exerts
independence

Autism spectrum disorder (ASD)

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they
may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A
calming environment with minimal stimulation should be provided; a private room away from the
nurses' station is the best location.
The nurse can also facilitate a calming environment by:
● Using a quiet or monotone voice when speaking to the child
● Using eye contact and gestures carefully
● Moving slowly
● Limiting visual clutter
● Maintaining minimal lighting
● Providing the child with a single object to focus on

Duchenne muscular dystrophy

X-linked recessive (carried by females and affecting males) disorder that causes the progressive
replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue.
The proximal lower extremities and pelvis are affected first. In response to proximal muscle
weakness, the calf muscles hypertrophy (pseudohypertrophy) initially and are later replaced by
fat and connective tissue. Children with Duchenne muscular dystrophy raise themselves to a
standing position using the classic Gower sign/maneuver (placing hands on the thighs to push
up to stand) and walk on tiptoes. Parents may also report frequent tripping and falling

Juvenile idiopathic arthritis

Joint pain that is worse in the morning is a symptom of juvenile idiopathic arthritis. Children with
this type of arthritis also experience symptoms of joint swelling and stiffness, high fever, and skin
rash.

Shaken baby syndrome (SBS)

type of abusive head injury and is defined by the Centers for Disease Control and Prevention
(CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms,
legs, or shoulders. The impact of the shaking causes bleeding within the brain or the eyes.
It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague
and nonspecific—vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable
crying. Usually, there are no external signs of trauma except for occasional small bruises on the
chest or upper arms where the child was held during the shaking episode.
The most common reasons that caregivers seek medical attention for children with SBS are
breathing difficulty, apnea, seizures, and lifelessness. Caregivers typically do not offer a history
of trauma nor do they report the episodes of shaking. By contrast, children who have sustained
unintentional head injury are typically brought for treatment out of concern by their caregivers
even when the children are asymptomatic.

Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of
infection but instead may have elevated temperature or be hypothermic. Subtle changes such as
irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine,
and cerebrospinal fluid cultures should be obtained immediately, and broad-spectrum antibiotics
started.

Hydroceles
Painless, new onset, bilateral testicular swelling
This infant has signs of a hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before
the first birthday and are not a medical emergency

Circumcision
Application of a blanket restraint or the use of a special board prevents injury during circumcision.
Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage
pain during circumcision.
Children who develop Reye syndrome often have had a recent viral infection, especially
varicella (chicken pox) or influenza. Clinical manifestations include fever, lethargy, acute
encephalopathy, and altered hepatic function. Elevated serum ammonialevels are an
expected laboratory finding. Acute encephalopathy manifests with vomiting and a severely
altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of
developing Reye syndrome increases if aspirin therapy is used to treat the fever associated with
varicella or influenza. As a result of this awareness, there has been a significant increase in the
use of acetaminophen or ibuprofen for fever management in children.

Acute glomerulonephritis (AGN) in children is an immune complex disease most commonly

induced by prior group A beta-hemolytic streptococcal infection of the skin or throat. A latent
period of 2-3 weeks occurs between the streptococcal infection (eg, pharyngitis) and the
symptoms of AGN. Clinical manifestations include periorbital and facial/generalized edema,
hypertension, and oliguria, which are primarily due to fluid retention (decreased kidney filtration).
The urine is tea-colored and cloudy due to the presence of protein and blood.
Although most clients recover spontaneously within days, severe hypertension is an anticipated
complication that must be identified early. Monitoring and control of blood pressure are most
important as they prevent further progression of kidney injury and development of hypertensive
encephalopathy or pulmonary edema.

Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from

the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue,
fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Treatment for
mononucleosis is management of symptoms and includes hydration, rest, control of pain, and
reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches.
Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph
nodes around the neck and severe abdominal pain (splenic rupture). These should be reported
to the health care provider (HCP) immediately.
Fatigue is a symptom of mononucleosis. Rest is very important in the care of a client with
mononucleosis. Mononucleosis may cause splenomegaly or hepatomegaly. Contact sports
should be avoided to prevent injury to the spleen or liver.

Parasites
Pinworm - The most common worm infection in the United States is pinworm, which is easily
spread by inhaling or swallowing microscopic pinworm eggs, which can be found on
contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines.
During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around
the anus, resulting in anal itching and troubled sleep. When the infected person scratches,
eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is
treated with anti-parasitic medications.
Hookworms (eg, Ancylostoma) are parasitic bloodsucking roundworms that are contracted from
larvae in contaminated soil. They can infect the intestines, causing intestinal bleeding and
anemia.
Tapeworm -Poor appetite, inadequate absorption of nutrients from food, and weight loss are
symptoms associated with tapeworm infection (eg, Taenia solium). Tapeworm larvae are
ingested when a person eats food that is contaminated with feces or undercooked meat from an
infected animal.
Ringworm is a skin infection caused by a fungus. It leads to red, scaly, blistered rings on the
skin or scalp that grow outward as infection spreads. The fungus is easily spread by sharing hair
care instruments and hats or via towels, linens, clothing, and sports equipment.
Otitis media (OM)
is the inflammation or infection of the middle ear resulting from dysfunction of the eustachian
tube. OM typically occurs in infants and children under age 2, sometimes following a respiratory
tract infection. The eustachian tubes in infants and young children are short, straight, and fairly
horizontal, which results in ineffective drainage and protection from respiratory secretions.
Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory
inflammation. OM risk is also higher with activities such as using a pacifier or drinking from a
bottle when lying down as these allow fluid to pool in the mouth and then reach the eustachian
tubes.
Key preventive measures include eliminating exposure to smoke, obtaining routine
immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6
months. Breast-fed infants have a decreased risk for OM, possibly due to the semivertical
position used when breastfeeding, which reduces reflux to the eustachian tubes.

Otitis externa (OE)

Excess water in the ears from bathing or swimming can alter the protective environment of the
external ear and contribute to otitis externa, known as swimmer's ear
Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human
parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions,
and the period of communicability occurs before onset of symptoms. The child will have a
distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash
spreads to the extremities and a maculopapular rash develops, which then progresses from the
proximal to distal surfaces. The child may have general malaise and joint pain that are typically
well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children
typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint
pains), they are no longer infectious. Isolation is not usually required unless the child is
hospitalized with aplastic crisis or immunocompromising condition.

Impetigo
is a highly contagious bacterial skin infection, most commonly occurring in children during hot,
humid weather. Impetigo is characterized by itchy, burning, red pustules that rupture to form
honey-colored crusts. When treated with antibiotic ointmentand/or oral antibiotics, lesions are
no longer contagious after 24-48 hours and typically heal within a week. Without antibiotics,
impetigo typically resolves within 2-3 weeks but remains highly contagious until lesions heal.
To care for and decrease transmission of impetigo, interventions include:

● Performing handwashing before and after touching the infected area

● Isolating the infected person's clothing and linens and washing them in hot water
● Keeping the infected person's fingernails short and clean to prevent bacteria from
collecting under them and to deter scratching
● Avoiding close contact with others for 24-48 hours after initiation of antibiotic therapy
● Keeping the infected area covered with gauze when in contact with others (eg, while at
school)
 ● Impetigo lesions should be soaked with warm water, saline, or Burow's solution (a skin-
soothing astringent) and gently cleansed with mild antibacterial soap before applying
antibiotic ointment. This helps remove infected crusts and reduce irritation. Alcohol is
irritative and should be avoided.

MARFAN SYNDROME

Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the
body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems.
Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and
fingers. Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta
and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may
require replacement or repair. Therefore, competitive or contact sports are discouraged due to
the risk of cardiac injury and sudden death.
The client may also experience crowding of the teeth from a very high-arched palate. Preventive
antibiotics prior to dental work may be needed to provide prophylaxis against infective
endocarditis, especially in clients with an artificial valve replacement.
These clients have an increased risk for scoliosis, especially during the adolescent years of
increased growth; therefore, the child should be monitored regularly for curvature of the spine.
Ocular problems (eg, lens dislocation [ectopia lentis], retinal detachment, cataracts, glaucoma)
can be common for the child with Marfan syndrome. Annual eye examinations with an
ophthalmologist are important to monitor for developing issues.

Pharyngitis
caused by group A β-hemolytic Streptococcus is a contagious bacterial throat infection that
can lead to renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated.
Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered
rather than solid foods. It is important to complete the full course of antibiotics to prevent
reinfection and complications. Toothbrushes should be replaced 24 hours after starting
antibiotics; the bristles can harbor the bacteria and reinfection may occur. Acetaminophen or
ibuprofen (liquid preparations) should be given for pain.
Young children may have minor cold symptoms and still be infected. The health care provider
should test siblings age <3.
Children with streptococcal pharyngitis may return to school or daycare after they have
completed 24 hours of antibiotics and are afebrile.

Hemolytic uremic syndrome

Hemolytic uremic syndrome results from the abnormal destruction of red blood cells, which start
to damage the kidneys. HUS is characterized by hemolytic anemia, thrombocytopenia (low
platelets manifest as petechiae or purpura), and acute renal injury.
• Most cases of hemolytic uremic syndrome develop in children after 2 to 14 days of (often
bloody) diarrhea due to infection with Escherichia coli.
• Bloody diarrhea and fever develops, followed by symptoms of hemolytic anemia such as fatigue
and low urine output due to acute renal injury, petechia
• Other signs and symptoms include hematuria, hypertension, edema, abdominal pain, and
encephalopathy.

Fetal Alcohol Syndrome

Fetal alcohol syndrome (FAS) is a leading cause of intellectual disability and developmental
delay in the United States. Diagnosis includes history of prenatal exposure to any amount of
alcohol, growth deficiency, neurological symptoms (eg, microcephaly), or specific facial
characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short
palpebral fissures). Asking about alcohol use during pregnancy can identify newborns and
infants who are at risk for FAS. Family support, early intervention, and prevention for subsequent
pregnancies are important for families with an infant with this diagnosis.
Down Syndrome

Cleft palate
 is a malformation of the roof (palate) of the mouth occurring from incomplete fusion of the
palatine bones and maxilla during fetal development. Cleft palate causes an opening (cleft) in the
mouth into the nasal cavity, which leads to difficulty in sucking and feeding.
Clients with cleft palate typically undergo surgical repair between age 6-24 months.
Postoperative nursing interventions for clients with a cleft palate repair include:

● Implementing pharmacological and nonpharmacological pain management (eg,

encouraging caregiver soothing), as uncontrolled pain leads to crying, which stresses
the surgical site and promotes hemorrhage.
● Positioning the child in an upright, supine position, particularly after feedings, to
prevent airway compromise and obstructionfrom secretions and/or feedings.
● Utilizing elbow restraints to prevent the child from disrupting the surgical site by placing
hands or objects into the mouth, and monitoring skin and neurovascular status by
removing elbow restraints per agency policy.
● Hard objects (eg, utensils, tongue depressors, pacifiers, straws) should not be placed into
the mouth as they may damage the surgical site, which can lead to hemorrhage.
Gastroesophageal reflux

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It

is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining
weight and meeting developmental milestones, treatment is aimed at controlling the symptoms.
Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in
cardiopulmonary resuscitation.
Burping the baby frequently helps expel trapped air before milk builds up over it. If there is milk
over an air pocket, the milk will come up with the burp.
Holding the baby upright for 20-30 minutes after feedings allows gravity to assist in keeping the
food in the stomach while the stomach settles.
Feeding the baby smaller but more frequent feeds prevents the stomach from becoming too full
and expelling extra milk and allows for more complete emptying before the next feed. It also
ensures that the child is getting the required ounces daily.
These infants should not be rocked or agitated by active play for at least 30 minutes after
feeding and should be kept calm and upright. Placing them on the stomach creates abdominal
pressure, which can aggravate the reflux. Infants should not be placed in a car seat after
feedings as this can increase intra-abdominal pressure and cause reflux.

Necrotizing enterocolitis
occurs predominantly in preterm infants secondary to gastrointestinal and immunologic
immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they
can proliferate excessively due to compromised immune clearance. This results in inflammation
and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes
congested and gangrenous with gas collections forming inside the bowel wall.
Measuring the client's abdominal girth daily is an important nursing intervention to note any
worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric
suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV
antibiotics are given.
Rectal temperatures should be avoided due to the risk of perforation of the gangrenous, friable
colon.To avoid pressure on the abdomen and facilitate observation for a distended abdomen,
clients are placed supine and undiapered.