COMMON HEALTH

PROBLEMS that DEVELOP

during INFANCY
INTUSSUSCEPTIONS
Is the invagination or telescoping of a
portion of the intestine into a adjacent,
more distal section of the intestine
causing mechanical obstruction .
It occurs in children
younger than age 3, most
commonly ages 5 to 10
months.
CAUSES:
The causes of intussusception
are not fully known.
Most cases in young children
are idiopatic.
Although some viral and
bacterial infections of the
intestine may possibly
contribute to intussusception in
infancy. Ex. Salmonella typhi
and Escherichia coli.
SIGNS and SYMPTOMS
Children with this disorder
suddenly draw up their legs and
cry due to severe pain.
Blood in stool, or later currant
jelly stools containing sloughed
mucosa, blood, and mucus.
Vomiting.
Increasing absence of stools.
SIGNS and SYMPTOMS
Abdominal distention, bowel sound
diminished, absent or high pitch.
Sausage like mass palpable in
abdomen (Dances sign).
Unusual looking anus; may look
like rectal prolapse.
Dehydration and fever
Shock like state with rapid pulse,
pallor, and marked sweating.
DIAGNOSIS:

The presence of the

intussusceptions are confirmed
by the ultrasound or a CT scan.
MANAGEMENT:
The initial treatment of choice is
nonsurgical hydrostatic
reduction by barium enema.
(The enema increases the pressure in the
child's intestine, which can often cause the
affected area to return to its normal
position)
If nonsurgical reduction is
unsuccessful, a surgical
reduction is indicated
NURSING
INTEVENTIONS:
Administer I.V. fluids as
ordered. If the patient is in
shock, give blood or plasma as
ordered.
A nasogastric tube is inserted to
decompress the bowel.
Replace volume lost as
ordered.
NURSING
INTEVENTIONS:
Prepare the patient for
hydrostatic reduction and
answer question to allay fears.
Monitor vital signs frequently.
Check intake and output and
watch for signs of dehydration
and bleeding.
Monitor amount and type of
drainage from the nasogastric
tube.
NURSING
INTEVENTIONS:
Explain what happens in
intussuseption to the
patient and his family.
If surgery is required, provide
preoperative teaching.
To minimize the stress of
hospitalization, encourage
patient to participate in their
childs care as much as
possible.
NURSING
INTEVENTIONS:
Be alert for respiratory distress due
to abdominal distention.
Monitor pain, distention, and general
behavior preoperatively and
postoperatively.
Observe infants behavior as
indicator of pain; may be irritable
and very sensitive to handling or
lethargic or unresponsive. Handle
the infant gently.
NURSING
INTEVENTIONS:
Explain cause of pain to parents,
and reassure them about purpose
of diagnostic tests and treatments.
Administer analgesic as
prescribed.
Maintain NPO status as ordered
Continually reasses condition
because increased pain and
bloody stools may indicate
perforation.
NURSING
INTEVENTIONS:
After reduction by hydrostatic
enema, monitor vital signs and
general condition especially
abdominal tenderness, bowel
sounds, lethargy, and tolerance
to fluids to watch recurrence.
Encourage follow up care.
Provide anticipatory guidance
for developmental age of child.
FAILURE TO
THRIVE (FTT)
Refers to inadequate weight
gain and physical growth in
children, usually <2 years of
age
 These are children whose current
weight or rate of weight gain is
significantly lower than that of other
children of similar age and gender.
A child that have also had a normal
growth pattern that began to slow
down.
Mainly diagnosed in children aged
<2 years old
80% of cases are diagnosed by 18
months of age
Poverty is a primary contributory
factor.
CLASSIFICATION:
I. ORGANIC FTT -
pathophysiologic cause that
reduces the availability of
nutrients for maintenance and
growth
II. NON ORGANIC FTT - is the
result of multiple psychosocial
factors, including disturbances
in parent-child interaction.
Causes

Inadequate nutrition ( Immediate

cause)
A. Inadequate caloric intake,
I. Psychosocial
II. Anatomic problems
B. Inability to utilize calories ingested,
I. Malabsorption
II. An inborn error of metabolism;
C. Increased metabolic demands from
chronic infections or illnesses.
A. Insufficient calorie intake

I. Psychosocial problems:
Poverty or financial stressors
leading to food shortage
Parental neglect
Behavior problems in the child,
e.g. misbehavior at meal times,
which can lead to power
conflicts and tension resulting in
inadequate feeding
 Food phobia, perhaps following
a choking episode
Parental mental health
problems, e.g. postpartum
depression
Parental eating disorders, such
as anorexia nervosa
II. Anatomic problems causing
mechanical feeding
difficulties:

Congenital anomalies, such

as cleft palate
Oromotor dysfunction from a
neurologic problem, such as
hypotonia, or neuromuscular
weakness
 Pain from dental caries
Severe gastroesophageal
reflux
Gastrointestinal obstruction,
such as pyloric stenosis
B. Inability to utilize
calories ingested

I.Malabsorption:
Cow's milk protein allergy
Cystic fibrosis
Other causes of pancreatic
insufficiency
 Celiac disease
Biliary atresia
Inflammatory bowel disease
Liver disease
Chronic diarrhea
II. Improper utilization:

Inborn errors in metabolism,

such as amino acidopathies
Storage disorders
Growth hormone deficiency,
which leads to failure to grow at
the correct rate
C. Increased metabolic needs

Prematurity
Recurrent infections
Chronic infections, such as
HIV or PTB
Endocrine disorders, such as
hyperthyroidism or growth
hormone deficiency
 Cardiac disorders, such as
congenital heart defects or CHF
Pulmonary disorders, such as
chronic lung disease,
bronchopulmonary dysplasia, or
poorly controlled asthma
Malignancy
Chronic liver disease
Rare causes

Child abuse
Diabetes insipidus
Rickets
Contributory or predisposing
factors

Poverty, homelessness, and

neglect
Inexperience in the parent
Overprotection by the parent
Underfeeding by the parent
Inattention from the parent
 Infants with special needs
Prematurity
Intrauterine growth retardation
Infants with difficult
temperaments
Irregular lifestyle in parents
Mothers with eating disorders,
such as anorexia nervosa, or
body image issues
Symptoms

1. Height, weight, and head

circumference do not match
standard growth charts.
2. Weight is lower than 3rd percentile
(as outlined in standard growth
charts) or 20% below the ideal
weight for their height.
3. Growth may have slowed or
stopped after a previously
established growth curve.
4. delayed or slow to develop:
a. Physical skills such as rolling
over, sitting, standing and
walking
b. Mental and social skills
c. Secondary sexual
characteristics (delayed in
adolescents)
Other symptoms

Constipation
Excessive crying
Excessive sleepiness (lethargy)
Irritability
EXAM and TEST

Conduct a physical exam and

check the child's height, weight,
and body shape.
Denver Developmental
Screening Test determines
delays in development
Other Test:

CBC
Electrolyte balance
Hemoglobin electrophoresis
Hormone studies (thyroid
function tests)
X-rays to determine bone age
Urinalysis
Treatment

Educate parents how to

provide a well-balanced diet.
Increase the number of
calories and amount of fluid
the infant receives
Correct any vitamin or
mineral deficiencies
 Identify and treat any
other medical conditions
Parents and children who
are having difficulty with
their relationship may
benefit from counseling.
Complications

1. Anemia, fatigue, hypothermia

2. Vulnerability to infection
3. Delayed healing
4. Behavior problems, poor
academic performance
5. Developmental, speech, and
language delays
6. Perceptual difficulties
COLIC
Colic is often defined as crying
more than three hours a day,
three days a week for more than
three weeks in an otherwise
well-fed, healthy baby.
Symptoms
Predictable crying episodes. A
baby who has colic often cries about
the same time every day, usually in
the late afternoon or evening. Colic
episodes may last from a few
minutes to three hours or more on
any given day. The crying usually
begins suddenly and for no clear
reason. Your baby may have a
bowel movement or pass gas near
the end of the colic episode.
 Intense or inconsolable
crying. Colic crying is intense
and often high pitched. Your
baby's face may flush, and he
or she is extremely difficult if
not impossible to comfort.
Posture changes. Curled up
legs, clenched fists and tensed
abdominal muscles are
common during colic episodes.
Colic usually starts a few
weeks after birth and
often improves by age 3
months.
CAUSES:
The cause of colic is unknown.
It can be associated with the
following:
a. Allergies
b. Lactose intolerance
c. An immature digestive system
d. Maternal anxiety
e. Differences in the way a baby
is fed or comforted.
RISK:

Mother who smokes.

Treatments and drugs

Gas-relief medication -
Simethicone
Probiotics - substances that
help maintain the natural
balance of "good" bacteria in
the digestive tract can soothe
colic.
COLIC REMEDIES
Feed the baby.
The baby may be hungry, try a feeding.
Hold the baby as upright as possible,
and burp the baby often. Sometimes
more frequent but smaller
feedings are helpful. If breast-feeding,
it may help to empty one breast
completely before switching sides. This
will give the baby more hindmilk, which
is richer and potentially more satisfying
than the foremilk, which is present at
the beginning of a feeding.
 Offer a pacifier.

For many babies, sucking is a

soothing activity. Even if
breast-feeding, it's OK to offer a
pacifier to help the baby calm
down.
 Consider dietary changes.

If breast-feed, see if eliminating

certain foods from own diet
such as dairy products, citrus
fruits, spicy foods or drinks
containing caffeine has any
effect on the baby's crying. If
bottle-fed, a new type of bottle
or nipple might help.
 Hold the baby.

Cuddling helps some babies.

Others quiet when they're held
closely and swaddled in a
lightweight blanket. To give the
arms of the mother a break, try
a baby sling, backpack or other
type of baby carrier. Don't worry
about spoiling the baby by
holding him or her too much.
 Rhythmic Motions

Rhythmic motions are said to

help the baby with colic relief.
Try rocking the child in a cradle
or rocking him in your lap in a
rocking chair. Taking them out
for a ride in a car is said to help
with the discomfort of colic.
 Sing to the baby.

A soft tune might soothe your

baby. And even if lullabies don't
stop your baby from crying, they
can keep you calm and help
pass the time while you're
waiting for your baby to settle
down. Recorded music may
help, too.
 Massage

Try stroking the baby in a

continuous movement from
head to toe using light strokes.
Also try massaging the babys
back and belly. This helps the
baby with the pain and also
promotes passing of gas.
 Turn up the background noise.

Some babies cry less when they

hear steady background noise.
When holding or rocking your
baby, try making a continuous
"shssss" sound. Turn on a kitchen
or bathroom exhaust fan, or play
a tape or CD of environmental
sounds, such as ocean waves, a
waterfall or gentle rain.
Sometimes the tick of a clock or
metronome does the trick.
 Use gentle heat or touch.

Give the baby a warm bath.

Softly massage the baby,
especially around the tummy.
 Give your baby some private
time.

If nothing else seems to work, a

brief timeout might help. Put the
baby in his or her crib for five to
10 minutes.
 Let someone else take over
for a time.

It's stressful to listen to the baby

cry for long periods, so give a
break. Arrange ahead of time
for someone who can call to
help with the baby so that the
mother can have a few
moments of relief.
TRISONOMY 21
 Down syndrome is a
congenital condition that
results in moderate to
severe retardation.
 Down syndrome describes a set
of cognitive and physical
symptoms that result from an
extra copy or part of a copy of
chromosome 21.

This form of Down syndrome is

called Trisomy 21.
 The extra chromosome causes
problems with the way the body
and brain develop.

It is typically associated with a

delay incognitive ability (mental
retardation) and physical
growth, and a particular set of
facial characteristics.
Common physical signs

Decreased or poor muscle tone

Short neck, with excess skin at
the back of the neck
Flattened facial profile and nose
Small head, ears, and mouth
 Upward slanting eyes, often
with a skin fold that comes out
from the upper eyelid and
covers the inner corner of the
eye
White spots on the colored part
of the eye (called Brushfield
spots)
 Wide, short hands with short
fingers
A single, deep, crease across
the palm of the hand
A deep groove between the first
and second toes
Delayed mental and social
development. Common
problems:

DELAYED LANGUANGE AND SPEECH

DEVELOPMENT
 IMPULSIVE BEHAVIOR
POOR ADJUSMENT
SHORT ATTENTION SPAN
SLOW LEARNING
CAUSES:

Trisonomy 21 is caused by
a random error in cell
division that results in the
presence of an extra copy of
chromosome 21.
This cell division errors occurs:

In more than 90% of cases, the

extra copy of chromosome 21
comes from the mother in the egg.
In about 4% of the cases, the
father provides the extra copy of
chromosome 21 through the
sperm.
In the remaining cases, the error
occurs after fertilization, as the
embryo grows.
DIAGNOSIS
Prenatal Screening
A. Blood test- the most accepted
approach to check for markers for likely
to have T21
B. Ultrasound - measurement of nuchal
translucency
Prenatal Diagnostic Testing
A. Amniocentesis
B. Chorionic villus sampling
C. Percutaneous umbilical blood sampling
(Done to test for extra chromosomes)
Treatment Therapies
 Physical therapy includes activities
and exercises that help build motor
skills, increase muscle strength, and
improve posture and balance.

Speech-language therapy can help

children with Down syndrome
improve their communication skills
and use language more effectively.
 Occupational therapy helps find
ways to adjust everyday tasks and
conditions to match a person's
needs and abilities.

Emotional and behavioral

therapies work to find useful
responses to both desirable and
undesirable behaviors.
CLEFT LIP
AND
PALATE
Cleft lip and palate are
birth defects that affect the
upper lip and the roof of
the mouth.
 It occurs as a result
of soft issue or bony
structure to fuse
during embryonic
development.

Defects involve
abnormal openings in
the lip/palate that
may occur unilaterally
or bilaterally and are
readily apparent at
birth.
 Cleft lip (with or without cleft
palate) occurs more frequently
in males,
Cleft palate is more frequent in
females.
 Combination of cleft lip and
palate occurs in approximately
50% of cases
Cleft lip alone occurs in about
25% of cases
and cleft palate alone occurs in
about 25% of cases.
CLASSIFICATION:
Cleft lip / pre alveolar cleft :
Varies from a notch in the lip
to complete separation of the
lip into the nose
Failure of maxillary process to
fuse with nasal elevations on
frontal prominence; normally
occurs during fifth and sixth
weeks of gestation
 Isolated cleft palate / postalveolar
cleft:
Cleft of uvula
Cleft of soft palate
Cleft of both soft and hard palate
through roof of mouth
Failure of mesodermal masses of
lateral palatine process to meet
and fuse; normally occurs
between seventh and 12th weeks
of gestation
 Submucous cleft:
Muscles of soft palate not
joined
Not recognized until child
talks; cannot be seen at birth
Cleft of hard and soft palate
CAUSES

1. Hereditary
A. chromosomal abnormalities
2. Environmental factors
A. Exposure to radiation
B. Rubella virus
C. Teratogenic factors
 Pierre Robin syndrome cleft palate,
glossoptosis (tongue lays back on
pharynx), and micrognathia
(underdeveloped mandible):
This causes feeding difficulties,
potential airway obstruction by
tongue, slow weight gain, and ear
infections.
By age 3 to 4 months, the
mandible has grown enough to
accommodate the tongue, and
respiratory difficulty is greatly
diminished.
Clinical Manifestations

Physical appearance of cleft lip

or palate:
Incompletely formed lip varies
from slight notch in vermilion
to complete separation of lip.
Opening in roof of mouth felt
with examiner's finger on
palate.
 Eating difficulty:
Suction cannot be created
for effective sucking.
Food returns through the
nose.
Nasal speech.
Diagnostic Evaluation

Prenatal UTZ enables many

cleft lips and some cleft palates
to be identified in utero.

Magnetic resonance imaging

(MRI) to evaluate extent of
abnormality before treatment.
 Photography to document the
abnormality.
Serial X-rays before and after
treatment.
Dental impressions for
expansion prosthesis.
Genetic evaluation to determine
recurrence risk.
MANAGEMENT:

General management is
focused on closure of the clefts,
prevention of complications,
habilitation, and facilitation of
normal growth and development
of the child.
 The cleft lip is generally repaired
before the palate defect.
Immediate repair several
hours to several weeks after
birth.
Intraoral or extraoral
prosthesis to prevent maxillary
collapse, stimulate body
growth, and aid in feeding and
speech development; may be
used before surgical repair.
 Later repair when infant is 6 to
12 weeks old, hemoglobin 10
g/dL, steady weight gain seen
10 lb (4.5 kg) or white blood cell
(WBC) count normal.
 Cleft palate repair may be done
any time between ages 6 months
and 5 years; it is based on degree
of deformity, width of oropharynx,
neuromuscular function of palate
and pharynx, and surgeon's
preference.
Repair at age 9 to 18 months
may be preferred because
speech patterns have not been
set, yet growth of involved
structures allows for improved
surgical repair.
 If repair is delayed to age 4 or
5, a special denture palate is
used to help occlude the cleft
and aid in establishing speech
patterns.
SURGERY
CHEILOPLASTY surgery to close cleft
lip; done as early as possible, using the
RULE OF 10
a. At least 10 weeks old
b. Weighing at least 10 lbs
c. Having at least 10 grms hemoglobin

PALATOPLASTY done not earlier than 10-

12 months nor too late
VELOPLARYNGEAL FLAP done at age 8-
9 to revise previous repair, correct nose
deformities and nasopharynx for speech
improvement
Nursing Assessment

If the patient has a cleft lip, assess

for cleft palate by direct visualization
and palpation with finger.
Obtain family history of cleft lip or
palate.
Evaluate feeding abilities.
Effectiveness of suck and swallow
Amount taken
Observe for other syndromic
features.
Ineffective Infant Feeding Pattern
related to defect
1. Administer gavage feedings if
nipple feeding is to be delayed
to prevent spread of a cleft lip.
2. If sucking is permitted, use a
soft nipple with crosscut to
facilitate feeding. Note that
nipples can be softened by
boiling them.
3. If sucking is ineffective use
preemie nipple, crosscut
nipple.
4. Avoid enlarging nipple holes
5. Feed infant in an upright, sitting
position
6. Feed slowly over approximately
18 to 30 minutes.
7. Encourages small frequent
feeding.
8. Burp frequently during feeding
to decrease amount of air
swallowed
9. Avoid repeated removal of
nipple due to fear of choking.
This may only frustrate the
infant, causing crying and
increasing chances of
aspiration.
10.Advance diet as appropriate
for age and needs of infant.
11. Encourage to begin feeding the
soonest possible time to strengthen
the oral structures needed later for
mastication and speech production.
12. Assist and support mother with
breast-feeding if this is preferred.
Suggest the use of a breast pump
before nursing to stimulate the let-
down reflex.
Hold the infant in a semi-upright,
straddle, or football hold position.
Risk for Infection related to open
wound created by malformation,
ear infections

1.Protect child from infection so

that surgery will not be delayed.
Use and teach good hand-
washing practice.
Avoid patient contact with
anyone who has an infection.
2. Change the infant's position
frequently.
3. Clean the cleft after each
feeding with water and a cotton-
tipped applicator.
4. Observe for fever, irritability,
redness, or drainage around
cleft, and report promptly.
5. Monitor vital signs; report
temperature greater than 38.3C.
Risk for Impaired Parent/Infant
Attachment related to
malformation and special care
needs
1. Show acceptance of the infant;
maintain composure, and do not
show negative emotion when
handling the infant.
2. Support parents when showing a
neonate for the first time.
Demonstrate acceptance of the
infant's and the parents' feelings.
3. Offer information and answer any
questions in a simple, matter-of-
fact manner.
4. Be aware that the normal
sequence of parental responses
may include shock, disbelief,
worry, grief, and anger, and then
proceed to a state of equilibrium
and reorganization.
5. Encourage parental involvement
in infant's care: frequent holding,
cuddling, and playing.
Risk for Aspiration related to
tongue and palate deformities in
Pierre Robin syndrome

1. When feeding the infant with

Pierre Robin syndrome,
consideration must be given to
respiratory effort, flaccid tongue,
and cleft palate. Generally,
feeding can be done with a
nursing bottle ( same as with
cleft)
a) Use orthopneic position --- vertical and
slightly forward; this allows infant to
push jaw forward to suck and allows
the feeder a clear view of the infant.
b) Use gentle finger pressure at
mandibular attachment to bring the
jaw forward.
c) Feed slowly.
2. Prevent respiratory obstruction
by the tongue, especially on
inspiration and when the infant
is quiet.
a. Place the infant in prone
position so tongue and jaw
fall forward.
b. Tilt head back as tolerated
by the infant, and slightly
elevate upper trunk.
 c. Place stockinette cap on
infant's head and suspend from
an overhead support to assist
the infant to maintain a position
for easy ventilation.
d. Suction nasopharynx as
needed.
e. If the tongue is sutured to pull
it forward, observe for slipping,
cut tongue, and infection.
3. Observe closely for respiratory
compromise.
Postoperative Care
1. Apply elbow immobilizers to
prevent hands from reaching
the mouth while still allowing
some freedom of movement.
a.Pad immobilizer, and place it
from the axilla to inner aspect
of the wrist.
b.Remove immobilizer
occasionally, one at a time, to
exercise the arms.
2. Butterfly-type adhesive, or
adhesive bandage placed
cheek-to-cheek across top of lip
to prevent lateral tension on
cleft lip incision.
a. Prevent wetting tape, or it
will loosen.
b. Observe for and report
bleeding.
3. Prevent the child from
crying, blowing, sucking,
talking, and laughing, which
increase tension on the
suture line.
a. Encourage the mother to
hold and cuddle the child.
b. Keep the child dry, fed,
and comfortable.
4. Position the child on back or
propped on side to keep from
rubbing lip on the sheets. An
infant seat may be useful for
variation of position, comfort,
entertainment, and to prevent
interference with suture line.
a.Provide for appropriate
diversional activity, hanging
toys, and mobiles.
b.If only cleft palate was repaired,
child may lie on abdomen.
c. Do not allow child to put
anything in his mouth, such
as straw, eating utensils, or
fingers. Instead paper cups.
5. Monitor respiratory effort after cleft
palate repair.
a.Be aware that breathing with a
closed palate is different from the
child's customary way of
breathing; the child must also
contend with increased mucus
production.
b. Provide for croup tent with mist to
decrease occurrence of
respiratory problems and provide
moisture to mucous membranes
that may become dry from mouth
breathing.
6. Clean suture line after every
feeding.
a.Gently wipe lip incision with
cotton-tipped applicator and
solution of choice, such as
water, saline, or hydrogen
peroxide. Gently pat dry, and
apply antibiotic ointment or
petroleum jelly if ordered.
b.Rinse the mouth with water,
or offer a drink of water after
each feeding.
c.Irrigate the mouth with normal
saline solution or water after
cleft palate repair. Direct a
gentle stream over the suture
line using an ear bulb syringe
with the child in a sitting
position with head forward.
d.Keep the mouth moist to
promote healing and provide
comfort.
7. Accomplish feeding without
tension on the suture line for
several days after lip repair.
a. Use dropper or syringe with
a rubber tip, and insert from
the side to avoid suture line
or to avoid stimulating
sucking.
b.Use side of spoon. Never put
spoon into the mouth.
c.Perform nasogastric (NG)
gavage if prescribed; usually
this is last treatment of
choice.
d.Advance slowly to nipple
feeding as directed. The
infant should be able to suck
more efficiently with the lip
repaired.
8. Check weight periodically
to see if adequate nutrition
is being maintained.

9. Administer an antibiotic as
prescribed because the
mouth and suture line are
constantly contaminated.
IMPERFORATE ANUS
An arrest in embryologic development of the anus at the
eighth week of embryonic life.
cause is UNKNOWN.
 Imperforate anus occurs when the anal
opening is absent or not in a normal
position.

It is a birth defect caused by the failure of

normal development of the anal area
ANORECTAL MALFORMATON

Sometimes an abnormal opening (fistula) is

present between the bowel and the vagina
In girls, or between the bowel and the
Urinary Tract in boys --- ANAL FISTULA
There are many possible
abnormalities As follows:
The absence of an anal opening.
The anal opening in the wrong place.
A connection, or fistula, joining the intestine and urinary
system.
A connection joining the intestine and vagina.
In females, the intestine can join with the urinary system
and vagina in a single opening, known as a cloaca.
CAUSES
Imperforate anus may occur in several forms. The
rectum may end in a blind pouch that does not
connect with the colon.

Or, it may have openings to the urethra, bladder,

base of penis or scrotum in boys, or vagina in
girls.

A condition of stenosis (narrowing) of the anus or

absence of the anus may be present.
 The problem is caused by abnormal development of the
fetus, and many forms of imperforate anus are
associated with other birth defects.
CLINICAL MANIFESTATION
NO anal opening
Anal opening very near the vaginal
opening in girls
Missing or misplaced opening to the anus
No passage of first stool within 24 - 48
hours after birth
Stool passes out of the vagina, base of
penis, scrotum, or urethra urethra may
appear as green-tinged urine.
 Thermometer, small
finger, or rectal tube
cannot be inserted into
the rectum.
Progressive abdominal
distention.
Fistula is likely to be
present.
Vomiting if infant is fed.
EXAMS & TEST
A doctor can diagnose this condition
during a physical exam.
Diagnosis is made at birth when the
anal
opening is checked during the
newborns
physical examination.
Imaging tests may be recommended.
X-ray films shows dilatations
throughout the intestinal tract
 Urine examination
for presence of meconium
and epithelial debris
indicates presence of
fistula.

Gentle insertion of a rectal

tube.
TREATMENT
The infant should be checked for other
problems, especially those affecting the
genitals, urinary tract, and spine.

Surgical reconstruction of the anus is

needed. If the rectum connects with other
organs, repair of these organs will also be
necessary. A temporary colostomy is often
required.
COMPLICATIONS
Infection
Intestinal obstruction
Loss of bladder or urinary sphincter control
NURSING INTERVENTIONS
Withhold feedings. Note any vomiting: color and amount.
Minimize energy expenditure due to altered nutritional
status.
Maintain NGT passed to decompress the stomach.
Measure abdominal girth.
Observe the patient carefully for any signs of distress,
and report. Check vital signs frequently.
 Use radiant warmer to maintain temperature stability.
Minimal handling; cluster procedures together to
encourage rest and sleep.
Keep fistula area clean.
Administer good oral care.
 Following anoplasty, do not put anything in the rectum.
Position the infant for easy access to perineum for
cleansing and minimal irritation to site (ie, place the
infant on his abdomen, possibly with hips elevated, to
prevent pressure on perineal surfaces; turn side-to-
side).
Expose the perineum to air.
Observe incision site for redness, drainage, poor
healing.
Apply antibiotic ointment to perineum as directed
 Following colostomy, observe wound and
stoma for redness, drainage, poor healing.
Monitor for return of peristalsis; NG tube
will be discontinued when bowel sounds
present
Start oral feedings as ordered
Anoplasty: usually within hours
Colostomy: when bowel sounds present
and colostomy has output
 Discontinue parenteral fluids when oral
intake is sustained
Report vomiting
Describe stool frequency, consistency,
and character. Report blood in stool, or
lack of stool output
Monitor urine output, particularly important
with urethral defects
 Assure the parents that colostomy is temporary (unless
complex surgery performed)
Encourage the parents to participate in care of the child
and to provide emotional security for the child.
Provide thorough teaching program for special care
needed at home.
Colostomy care
Anal dilatation to prevent a stricture at site of
anastomosis from scar tissue (after instructions by
health care provider)
 Encourage the parents to talk
about their concerns.
It is important that the family
understands the rationale and
technique for anal dilation as
follows:
Dilations prevent anal
strictures.
Usually begins 2 weeks
postoperatively.
 Surgeon passes the dilator first, then the family is
taught dilation technique:
Place child with knees flexed, close to the
chest.
Lubricate the tip of the dilator and insert into
the rectum 1 to 1 inches (3 to 4 cm).
Repeat twice daily for 30 seconds each time.
Advance to the next size dilator each week.
The desired size is reached after 6 to 8 weeks.
When the desired size is reached, the
schedule is weaned (eg, once daily for 1
month, then once every other day for 1 month,
two times per week for 1 month, and so forth.)
HIRSCHSPRUNG
DISEASE
(MEGACOLON)
Absence of parasympathetic ganglion cells
in a portion of the bowel, which causes
enlargement of the bowel proximal to the
defect.
 Hirschsprung's disease (congenital
aganglionic megacolon) is a form of
chronic intestinal obstruction affecting
primarily full-term infants.

Four times more common in males

than females
 Hirschsprung Disease occurs when
some of the nerve cells that are
normally present in the wall of the
intestine do not form properly during
fetal development.
NERVE CELLS
NORMAL NERVE CELLS MISSING
 During digestion, intestinal muscles move
food forward in a movement called
peristalsis. In order for this movement to
occur, special nerve cells called ganglion
cells are required. Because these nerve
cells are missing in children with
Hirschsprung disease, normal peristaltic
movement cannot occur.
 Consequently, stool backs up, causing
either partial or complete bowel
obstruction.
Eventually, a bacterial infection can
develop in the digestive tract, causing
serious problems. Severe worsening of
the obstruction can lead to a hole in the
bowel (perforation) and severe infection.
Classification

1. Length of involved bowel varies

from only internal sphincter to entire
colon.

2. Rectosigmoid colon the most

commonly affected site (short-
segment disease)
CLINICAL MANIFESTATION

Neonate symptoms appearing at birth or

within first weeks of life.

1) No meconium passed in the first 48

hours of life.
2) Vomiting - bile-stained or fecal
3) Abdominal distention
4) Constipation - occurs in 100% of
patients

4) Overflow-type diarrhea

4) Dehydration; failure to thrive

4) Temporary relief of symptoms with

enema
Older child symptoms not prominent at
birth. Short-segment disease commonly
presents later.

History of constipation at birth

Progressive abdominal distention
Peristaltic activity observable over
abdomen
 Absence of retentive posturing (ability to
contract the internal and external
sphincter to purposefully avoid
defecation)

Constipation - unresponsive to
conventional remedies

Absence of encopresis (common feature

of functional constipation)
 Ribbon-like, fluid-like, or pellet
stools
Failure to grow - loss of
subcutaneous fat; appears
malnourished, stunted growth
Presentation insidious or
catastrophic as with enterocolitis
Diagnostic Evaluation
1. Digital rectal examination
a. long-segment disease - reveals an anal
canal and a rectum that are narrow and
empty of stool
b. short-segment disease - rectal
impaction may be present; removal of
finger may be associated with a rush of
stool as the obstruction is relieved.
2. Barium enema
3. Anorectal manometry - demonstrates
failure of the intestinal sphincter to relax in
response to transient rectal distention.
Requires cooperation of the child.
4. Suction rectal biopsy - absence or
reduced number of ganglion nerve cells;
definitive diagnosis.
 Enterocolitis - consists of severe toxemia
and a proliferation of bacteria in the
colonic lumen.
Abdominal distention
Explosive diarrhea
Vomiting
Fever
Lethargy
Rectal bleeding
Shock
Therapeutic intervention
Surgical

1. Pull-through surgery ---Swenson

procedure-removal of aganglionic
portion of the bowel
2. Ostomy if necessary
Before surgery: The Step 1: The Step 2: The
diseased section is doctor removes healthy section is
the part of the the diseased attached to the
intestine that doesn't section rectum or anus.
work.
Colostomy and Ileostomy
Step 2: The doctor attaches
Step 1: The doctor takes the healthy part of the
out most of the diseased intestine to the stoma (a
part of the intestine. hole in the abdomen).
Complications
Preoperative

Enterocolitis - a major cause of

death
Hydroureter or hydronephrosis
Water intoxication from tap water
enemas
Cecal perforation
Postoperative

Enterocolitis: remains the major

cause of morbidity and mortality
(mortality 6% to 30%).
Diarrhea (69%)
Vomiting (51%)
Fever (34%)
 Lethargy (27%)
Leaking of anastomosis and pelvic
abscess
Stenosis, sudden inability to
evacuate colon
Long term: intestinal obstruction
from adhesions, volvulus,
intussusception
 Enterocolitis is a potentially life-
threatening event. Notify health care
provider immediately if change in
abdominal distention occurs in an
infant or child with Hirschsprung's
disease (whether preoperatively or
postoperatively), especially if
accompanied by fever, diarrhea,
vomiting, or lethargy.
NURSING CARE

A. ASSESSMENT

1. Thorough elimination history

a. Onset of constipation
b. Character of stools - ribbon like, foul
smelling
c. Nutritional/hydration status
2. Poor feeding habits; fussiness;
irritability

3. Abdominal distention

4. Current nutrition/hydration status

INTERVENTIONS
1) Monitor for respiratory embarrassment
that may result from abdominal
distention; watch for rapid, shallow
respirations; cyanosis; sternal retractions.
2) Elevate infant's head and chest by tilting
the mattress.
3) Administer oxygen, as ordered, to
support respiratory status
4) Note degree of abdominal tenderness.
Infant's legs drawn up
Chest breathing

5) Note color of abdomen and presence of

gastric waves; take sequential measurements
of abdominal girth for evidence of changes.

6) Assist in emptying the bowel by giving

repeated colonic irrigations.
7) Teach parents the correct procedure
for enemas if indicated (point out danger
of water intoxication)

8) Use only isotonic solutions

9) Prepare isotonic saline by using 1 tsp

table salt to 500 ml (1 pint) of tap water
10) Use the following suggested amounts of
fluid for enemas:

Age Amount (ml)

Infant 120 to 240
2 to 4 years 240 to 360
4 to 10 years 360 to 480
11 years 480 to 720
11)Administer medications (antibiotics)
to reduce the bacterial flora of the
bowel.

12)Obtain a dietary history regarding

food and eating habits.
This will contribute to planning dietary
alterations.
Explain to parents that eating problems are
common with Hirschsprung's disease.
13)Monitor I.V. fluids appropriately.
Measure all output.
14)Offer small, frequent feedings.
(Low-residue diet will aid in
keeping stools soft.)
Feed child slowly.
Provide as comfortable a position as
possible for child during feedings.
15) Control constipation
Education and Health Maintenance

Instruct the parents to serve small,

frequent meals to the child and be alert for
and eliminate foods that cause gas and
diarrhea, such as cabbage, spicy foods,
beans, Brussels sprouts, fruits, and fruit
juices.
 Advise parents that colds or viruses may
cause loose stools, which increases risk of
dehydration, especially in long-segment
disease, so to increase fluids.
 Alert parents of common
postoperative problems,
including bacterial overgrowth,
colitis or enterocolitis, and
lactose intolerance. Advise
parents to contact their health
care provider if persistent
diarrhea, abdominal distention,
abdominal pain, fever, vomiting
or constipation occur.
 Encourage parents to practice all
procedures long before the infant
is to be discharged.
Emphasize the importance of
treating the child as normally as
possible to prevent behavior
problems later.
Teach the basics of good nutrition
and diet. Involve the dietitian as
necessary.
 Encourage close medical follow-
up and general good health and
hygiene.
Safety
General growth and
development
Immunizations
Advise older children without
colostomies that fecal staining
may occur, but this will improve
with time.
SPINA BIFIDA
(Spinal Dysraphia)
Is a malformation of the spine in
which the posterior portion of the
laminae of the vertebrae fails to
close.
The most common developmental defect of the central
nervous system (CNS).
The most common site is the LUMBOSACRAL AREA.

Three are most common spina bifida

1. Spina Bifida Occulta

The defect is only in the vertebrae. The spinal cord and
meninges are normal.
2. Meningocele
The meninges protrude through the opening in the spinal
canal. This forms a cyst filled with CSF and covered with
skin.

3. Myelomeningocele or Meningomyelocele
The spinal cord and cord membranes protrude through
the defect in the laminae of the vertebral column. And
are covered by a thin membrane. Most serious type
SPINA BIFIDA
Associated defects include weakness or paralysis below
the defect, bowel and bladder dysfunction, clubfeet,
dislocated hip, and hydrocephalus

Arnold-Chiari syndrome: defect of the occipitocervical

region with swelling and displacement of the medulla into
the spinal cord
PATHOPHYSIOLOGY

1. Results from genetic predisposition triggered by

something in the environment.

Certain drugs, including valporic acid, have

been known to cause neural tube defects if
administered during pregnancy.
Women who have spina bifida and parents who
have one affected child have an increased risk
of producing children with neural tube defects.
2. Involves an arrest in the orderly formation of the
vertebral arches and spinal cord that occurs between the
fourth and sixth weeks of embryogenesis.

3. Theories of causation include:

There is incomplete closure of the neural tube during
the fourth week of embryonic life.
The neural tube forms adequately, then ruptures.
Clinical Manifestations
Spina Bifida Occulta
Most patients have no symptoms.
They may have a dimple in the skin or a growth of
hair over the malformed vertebra.
There is no externally visible sac.
With growth, the child may develop foot weakness or
bowel and bladder sphincter disturbances.
This condition is occasionally associated with more
significant developmental abnormalities of the spinal
cord, including syringomyelia and tethered cord.
Meningocele
An external cystic defect can be seen in the spinal cord,
usually in the midline.
The sac is composed only of meninges
and is filled with CSF.
The cord and nerve roots are usually
normal.
There is seldom evidence of weakness of the legs or
lack of sphincter control.
Myelomeningocele
A round, raised, and poorly epithelialized area may be
noted in the lumbosacral area.
Hydrocephalus with myelomeningocele due to
associated Arnold-Chiari malformation.
Degree of neurologic dysfunction directly related to level
of defect
Defective nerve supply to bladder affects sphincter and
muscle tone
Frequently poor anal sphincter control
DIAGNOSTICS:

A. Maternal serum alpha-fetoprotein

(MSAFP) test.
B. Ultrasound
C. Amniocentesis
THERAPEUTIC
MANAGEMENT
1. Multidisciplinary approach including
rehabilitation
2. Surgical repair of the sac to maintain
neurologic function and prevent
infection
Laminectomy and closure of the open
lesion or removal of the sac usually can be
done soon after birth.
 Purpose:
To prevent further deterioration of
neural function.
To minimize the danger of rupture
and infection, especially
meningitis.
To improve cosmetic effect.
To facilitate handling of the infant.
Complications

Hydrocephalus associated with

meningocele; may be aggravated by
surgical repair.
Scoliosis, contractures, and joint
dislocation.
Skin breakdown in sensory
denervated areas and under braces.
Nursing Care
A. Assessment

1. Condition of the myelomeningocele

sac
2. Level of neurologic involvement
3. Elimination
a. Urine: dribble or stream
b. Anal reflexes
4. Monitor head circumference and fontanels at
least daily
Analysis/Nursing Diagnoses

1. Altered family processes related to

the birth of a child with a physical defect
2. Risk for infection related to exposed
myelomeningocele sac
3. Risk for impaired skin integrity related
to paralysis, incontinence
4. Risk for trauma related to spinal cord
lesion
Planning/Implementation

1. Protect against infection because

breakdown of the sac leaves the spinal cord open to
the environment
a. Area must be kept clean, especially from
urine and feces
b. Diaper is not used, but sterile gauze with
antibiotic solution may be
placed over the sac
c. Avoid pressure on sac
2. Maintain function through proper
position:
place in prone position, hips slightly
flexed and abducted, and feet
hanging free of mattress, and a
slight Trendelenburg slope
to reduce spinal fluid pressure
3. Because of restriction in position,
feed child in prone position; establish
eye contact and encourage parents to
visit and feed the child
4. Foster elimination in the infant with a neurogenic
bladder:
a. Use the Crede method or slight pressure against the
abdomen for complete emptying of the bladder; may
need straight catheterization regimen
b. While the infant is prone, apply pressure to the
abdomen above symphysis pubis with the sides of the
fingers and counter pressure with the thumbs against the
buttocks
5. Postoperative nursing care

a. Measure head size to determine

whether hydrocephalus is occurring
b. Monitor for signs of increased
intracranial pressure
Children with spina bifida have a far
greater risk for latex allergy
Education and Health Maintenance
Prepare the parents to feed, hold, and stimulate their
infant as naturally as possible.
Teach the parents the special techniques that may be
required for holding and positioning, feeding, caring for
the incision, emptying the bladder, and exercising
muscles.
 Alert the parents to safety needs of
the child with decreased sensation,
such as protection from prolonged
pressure, the risk of burns due to bath
water that is too warm, and avoidance
of trauma from contact with sharp
objects.
 Urge continued follow-up and health
maintenance, including immunizations
and evaluation of growth and
development.
Advise parents that children with
paralysis are at risk for becoming
overweight due to inactivity, so they
should provide a low-fat, balanced diet;
control snacking; and encourage as
much activity as possible.
HYDROCEPHALUS

Is a condition of altered
production, flow, or
absorption of
cerebrospinal fluid (CSF).
 from the Greek words meaning hydro- water and
cephalo - head, is caused by excess cerebrospinal fluid
(CSF) in the spaces within and surrounding the brain.

result in a build up of fluid that can cause the pressure

inside of the head to increase and the skull bones to
expand to a larger-than-normal appearance.
CAUSES

Blockage of the CSF flow inside of the head

Problems with the body
absorbing the CSF
Overproduction of the
CSF
ACQUIRED HYDROCEPHALUS
Tumor
Infection
Prematurity
Bleeding inside the head
Birth injury
Abnormal blood vessel formation inside of
the head
Trauma
SIGNS & SYMPTOMS

A full or bulging fontanel (soft spot located on the top of

the head)
Increasing head circumference
Seizures
Bulging eyes and an inability of the baby to look upward
with the head facing forward
Very noticeable scalp veins
 Increased irritability
high-pitched cry
poor feeding
projectile vomiting
sleepiness or less alert than usual
developmental delays
Sunset eyes
DIAGNOSIS

X-ray
MRI
CT scan
TREATMENT
Goal :to reduce the pressure in the baby's head and to
properly drain the cerebral spinal fluid (CSF).
Occasionally, medications or procedures to draw off the
extra CSF may be used.
Ventriculoperitoneal (VP) shunt - removes excessive
cerebrospinal fluid from the ventricles and shunts it to
the peritoneum. A one-way valve is present in the tubing
behind the ear.
The shunt consists of three
parts:
a tube that is placed
inside of the ventricular
space
a reservoir and valve to
control the flow of CSF
tubing that is directed
under the skin to the
abdomen, or less
commonly to the heart or
lung area
 The shunt redirects the CSF out of
the head through the tubing to a
location elsewhere in the body where
it can absorbed. The shunt is usually
placed behind the ear and the tubing
is threaded from behind the ear,
under the skin to the area of the
abdomen, heart, or lung.
Components :

Ventricular tubing.
A one-way or unidirectional
pressure-sensitive flow valve.
A pumping chamber.
Distal tubing.
Shunt Complications

Infection

Shunt malfunction that results in under-

drainage or over drainage of CSF

Bleeding
Complications
Seizures
Herniation of the brain.
Spontaneous arrest due to
naturalcompensatory mechanisms,
persistent increased ICP, and brain
herniation.
Developmental delays.
Depression in adolescents is common.
 NURSING INTERVENTIONS

Observe for evidence of increased ICP,

and report immediately.
Assist with diagnostic procedures to
determine cause of hydrocephalus and
indication for surgical intervention.
Explain the procedure to the child and
parents at their levels of
comprehension.
 Observe closely after
ventriculography for the following:
Leaking of CSF from the sites of subdural
or ventricular taps. These tap holes should
be covered with a small piece of gauze or
cotton saturated with collodion.
Reactions to the sedative, especially
respiratory depression.
Changes in vital signs indicative of shock.
Signs of increased ICP, which may occur if
air has been injected into the ventricles.
 Hold the infant in a semi-sitting position
with head well supported during feeding.
Allow ample time for bubbling.
Offer small, frequent feedings.
Place the child on side with head elevated
after feeding to prevent aspiration.
Prevent pressure sores (pressure sores of
the head are a frequent problem) by
placing the child on a sponge rubber or
lamb's wool pad or an alternating-pressure
or egg-crate mattress to keep weight
evenly distributed.
 Keep the scalp clean and dry.
Turn the child's head frequently; change position at least
every 2 hours.
When turning the child, rotate head and body together
to prevent strain on the neck.
A firm pillow may be placed under the child's head
and shoulders for further support when lifting the
child.
Keep weight off incision during immediate
postoperative period.
 Provide meticulous skin care to all parts of the body, and
observe skin for the effects of pressure.
Give passive ROM exercises to the extremities,
especially the legs.
Keep the eyes moistened with artificial tears if the child
is unable to close the eyelids normally. This prevents
corneal ulcerations and infections.
 Avoid hypothermia or hyperthermia.
Provide appropriate blankets or covers, an
Isolette or infant warmer, or hypothermia
blanket.
Administer a tepid sponge bath or antipyretic
medication for temperature elevation.
Aspirate mucus from the nose and throat as necessary
to prevent respiratory difficulty.
Turn the child frequently.
Promote optimal drainage of CSF through the shunt
 Assess for excessive drainage of CSF.
Sunken fontanelle, agitation, restlessness (infant).
Decreased LOC (older child).
Assess closely for increased ICP, indicating shunt
malfunction.
Note especially change in LOC, change in vital signs
(increased systolic BP, decreased pulse rate,
decreased or irregular respirations), vomiting,
pupillary changes.
Report immediately to prevent cerebral hypoxia and
possible brain herniation.
 Prevent infection
Strengthen Family Coping
OTITIS MEDIA
Is usually an
infection and/or
inflammation of
the middle ear.
CLINICAL MANIFESTATION

Ear pain ( pulling of the ear)

and a feeling of fullness in the ear (fluid
buildup in the middle ear.)
Popping sensations in the affected ears
Decreased hearing
Signs of infection - fever, irritability, or
decreased appetite (Fussiness and
feeding problems in young children.)
 This inflammation often begins with infections that cause
:
Sore throats
Colds
Other respiratory problems, and spreads to
the middle ear.
Infections can be caused by viruses or bacteria(S.
pneumoniae, Haemophilus influenzae,Moraxella
catarrhalis)
 ACUTE OTITIS MEDIA (AOM)
- Fluid accumulation in middle ear
- Bulging eardrum accompanied
- Fever can be present
CHRONIC OTITIS MEDIA (COM)
- can cause ongoing damage to the middle ear and
eardrum, and there may be continuing drainage through
a hole in the eardrum.
- subtle loss of hearing
- Starts painlessly without fever
Otoscopy
Tympanometry
Acoustic reflectometry
DIAGNOSTICS

Otoscopic examination.
Tympanometry --- quick and simple way
to assess tympanic membrane mobility
Acoustic reflectometry --- useful in infants
older than age 3 months.
measures reflected sound waves from
the middle ear.
TREATMENT

Antibiotics for infection

Amoxicillin --- drug of choice
Amoxicillin-clavulanate (Augmentin) or
one of the cephalosporins. for treatment
failures
For recurrence --- Placement of ventilating
tubes by myringotomy (incision into the
tympanic membrane)
Pain management
Pain-relieving medicines
ibuprofen (Motrin)
acetaminophen (Tylenol),
or ear drops, such as Auralgan --- which
contain a numbing medicine, may be
used to reduce discomfort
COMPLICATIONS

Permanent hearing loss, perforations of the tympanic

membrane, scarring because of healed perforations, or
damage to the ossicles of the middle ear.
Delayed speech and language development.
Mastoiditis, meningitis, lateral sinus thrombosis, or
intracranial abscess; spread of bacterial infection.
PROMOTE COMFORT
Administer and teach parents to administer
antibiotics. Provide instruction in.
Measurement of correct dosage.
Time of doses.
Importance of administering all doses.
Proper storage and disposal of unused
medication.
Adverse effects.
Administer acetaminophen as directed for pain
or fever.
 Apply warm compresses to the external ear.
Administer analgesic otic drops, if prescribed; usually
indicated when no perforation of the tympanic membrane
exists.
Advise elevation of head to facilitate drainage of fluid
from the middle ear into the pharynx.
Teach older children to stimulate opening of their
eustachian tubes by yawning or performing Valsalva's
maneuver.
MINIMIZE HEARING LOSS

Teach parents to recognize early signs of

otitis and to seek prompt treatment.
Provide preoperative and postoperative
teaching if ventilation tubes are indicated
Stress the importance of the follow-up visit
to make sure that otitis has resolved.
FACILITATE VERBAL
COMMUNICATION

Assess hearing, speech, and language

development regularly.
Alert parents to immediately report signs
of hearing difficulty or delayed speech to
ensure early intervention.
Refer to a specialist for evaluation and
treatment, if necessary.
MENINGITIS
Is an inflammation of the
membranes that cover the
brain and spinal cord known
collectively as the meninges.
The meninges consists of the dura
mater, arachnoid and pia mater
CAUSES

I. VIRUS --- VIRAL MENINGITIS

II. BACTERIA --- BACTERIAL MENINGITIS

VIRAL MENINGITIS
It is also called aseptic meningitis.

In general, meningitis caused by a virus is less serious

than meningitis caused by bacteria.

Viral meningitis is most commonly caused by

enteroviruses.
BACTERRIAL MENINGITIS

Bacterial infection is more fatal than viral

infection.
Most cases are seen in children younger
than age 5.
 Most common causing bacterial meningitis in different
age groups:
Birth to age 3 months --- E coli,
Streptococcus, group B, Listeria
monocytogenes.
Ages 3 months to 6 years --- Streptococcus
pneumoniae, Neisseria meningitidis
(meningococcal meningitis), Haemophilus
influenzae.
Ages 6 to 16 --- S. pneumoniae, N.
meningitidis, Mycobacterium tuberculosis.
Early symptoms of meningitis broadly
include:
Vomiting
Nausea
Muscle pain
High temperature
Headache
Cold hands and feet
A rash that does not fade under pressure. Spread
rapidly and look like fresh bruises.
Diagnosis:
Glass test
a. Press the side of a drinking glass firmly against the
rash.
b. If the rash fades and loses color under pressure it is
not a meningitis rash.
c. If it does not change color you should contact a doctor
immediately.
Risk Factors
Age of 60 years or greater
Age of 5 years or less
Crowding (eg, military
recruits and college dorm
residents), which increases
the risk of outbreaks
of meningococcal
meningitis.
Signs and Symptoms of Bacterial
meningitis
Irritability
Lethargy
Vomiting
Lack of appetite
Seizures
High-pitched cry
Fever or hypothermia.
 Altered sleep patterns
Tenseness of the fontanelle
Nuchal rigidity
(+) Kernig's or Brudzinski's signs
Headache
Mental confusion
Photophobia or phonophobia
Petechiae or purpura
Petechial rash
Kernig's sign

Kernig's sign is typically assessed with

the patient lying supine, with one hip
flexed to 90 degrees and the knee
flexed to 90 degrees. If pain is elicited
when the knee is passively extended,
and it is not able to reach full
extension, this indicates meningism.
Brudzinski's sign

Brudzinski's sign is used in

infants, where forward flexion of
the neck may cause involuntary
knee and hip flexion.
Preventive measures for viral
infection
Conservative measures for mild cases:
Fluids
Bedrest
Analgesics
Antiviral drugs --- Acyclovir, but there are no clinical
trials that have specifically addressed whether this
treatment is effective.
Preventive measures for
bacterial infection

Ampicillin
Penicillin G
Cefotaxime
Gentamicin
RISK FACTORS

Age of 60 years or greater

Age of 5 years or less
Crowding (e.g., military recruits and
college dorm residents), which
increases the risk of outbreaks
of meningococcal meningitis
COMPLICATIONS

Brain damage
Deafness
Hydrocephalus
Epilepsy
LABORATORY TEST

Complete blood count (CBC)

Blood culture
Urine test
Chest X-ray
Biopsy of a skin rash
Computed tomography (CT
scan) or magnetic resonance image (MRI)
NURSING CARE

Maintain cerebral perfusion

Reduce fever
Relieve pain and irritability
Prevent infection
Prevent complications
Allay parental fear
Febrile Seizure
What is Febrile Seizure?
A febrile seizure, also known
as a fever fit or febrile
convulsion, is a convulsion
associated with a significant
rise in body temperature.
They most commonly occur
in children between the ages
of 6 months to 6 years.
What causes febrile seizure?
The direct cause of a febrile
seizure is not known; however,
it is normally precipitated by a
recent upper respiratory
infection, gastroenteritis. A
febrile seizure is the effect of a
sudden rise in temperature
(>39C/102F).
Types of Febrile Seizures

1. simple febrile seizure

2. complex febrile seizure
What is Simple Febrile
Seizure?

A simple febrile seizure is one in which

the seizure lasts less than 15 minutes
(usually much less than this), does not
recur in 24 hours, and involves the entire
body. (classically a generalized tonic-
clonic seizure).
Tonic-Clonic Seizure
 Tonic Phase

The person may also express

brief vocalizations like a loud
moan or scream during the tonic
stage, due to air forcefully
expelled from the lungs.
 Clonic Phase

The person's muscles will start to

contract and relax rapidly, causing
convulsions. The lips or extremities
may turn slightly bluish (cyanosis)
and incontinence is seen in some
cases.
What is Complex Febrile
Seizure?

A complex febrile
seizure is characterized by
longer duration, recurrence,
or focus on only one side of
the body.
Signs and Symptoms
During simple febrile seizures
the body will become stiff and the arms and legs
will begin twitching.
The patient loses consciousness, although their eyes
remain open.
Breathing can be irregular.
They may become incontinent (wet or soil
themselves); t
hey may also vomit or have increased secretions
(foam at the mouth).
The seizure normally lasts for less than five minutes.
 Risk factors

Young age
Family history
 Treatment

Application of a damp sponge can

help.
Anticonvulsants as prescribed.
Sodium valproate or
clonazepam are active against
febrile seizures.
AUTISM / ADHD
(Attention Deficit
Hyperactivity Deficit)
What is Autism?
Autism is when a person has poor or
underdeveloped social skills. In this
regard, the autistic person is not able to
clearly interpret or distinguish body
language. He is also unable to emphasize
other people. These characteristics are
said to be attributed to the absence of
mirror neurons in the central nervous
system.
Autism is a more complex developmental
disorder that affects many developmental
dimensions of the individual.
DIAGNOSIS:
Very early indicators that require evaluation by an
expert include:
no babbling or pointing by age 1
no single words by 16 months or two-word phrases
by age 2
no response to name
loss of language or social skills
poor eye contact
excessive lining up of toys or objects
no smiling or social responsiveness.
Later indicators include:
impaired ability to make friends with peers
impaired ability to initiate or sustain a conversation with
others
absence or impairment of imaginative and social play
stereotyped, repetitive, or unusual use of language
restricted patterns of interest that are abnormal in
intensity or focus
preoccupation with certain objects or subjects
inflexible adherence to specific routines or rituals.
 There is no cure for ASDs (Autism spectrum
disorder). Therapies and behavioral interventions
are designed to remedy specific symptoms and can
bring about substantial improvement. The ideal
treatment plan coordinates therapies and
interventions that meet the specific needs of
individual children. Most health care professionals
agree that the earlier the intervention, the better.

Educational/behavioral
interventions: Therapists use highly structured
and intensive skill-oriented training sessions to help
children develop social and language skills, such
as Applied Behavioral Analysis. Family counseling
for the parents and siblings of children with an ASD
often helps families cope with the particular
challenges of living with a child with an ASD.
 Family therapies. Parents and family members can
learn how to play and interact with their children in
ways that promote social interaction skills, manage
problem behaviors, and teach daily living skills and
communication.

Medications. No medication can improve the core

signs of autism, but certain medications can help
control symptoms. For example, antidepressants may
be prescribed for anxiety, and antipsychotic drugs are
sometimes used to treat severe behavioral problems.
Other medications may be prescribed if your child is
hyperactive.
 While ADHD(completely known as Attention
Deficit Hyperactivity Disorder)

- is when a person indulges in too much activity

to the point that he can no longer focus his
attention to a given object or task under
normal circumstances. There is a recurrent
feature of being impulsive, aside from the
common inattention to other things. Impulsive
and inattention are two of the most
identifiable characteristics of ADHD.
Symptoms:
The symptoms of ADHD fall into three groups:
Lack of attention (inattentiveness)
Hyperactivity
Impulsive behavior (impulsivity)
Some children with ADHD primarily have the
inattentive type. Others may have a combination of
types. Those with the inattentive type are less
disruptive and are more likely to not be diagnosed
with ADHD.
Inattentive symptoms
Fails to give close attention to details or makes careless mistakes
in schoolwork
Has difficulty keeping attention during tasks or play
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace
Has difficulty organizing tasks and activities
Avoids or dislikes tasks that require sustained mental effort
(such as schoolwork)
Often loses toys, assignments, pencils, books, or tools needed
for tasks or activities
Is easily distracted
Is often forgetful in daily activities
Hyperactivity symptoms:
Fidgets with hands or feet or squirms in seat
Leaves seat when remaining seated is expected
Runs about or climbs in inappropriate situations
Has difficulty playing quietly
Is often "on the go," talks excessively
Impulsivity symptoms:
Blurts out answers before questions have been
completed
Has difficulty awaiting turn
Interrupts or intrudes on others (butts into
conversations or games)
 Not all kids with ADHD are restless or hyper.
There are actually three types of ADHD:
Predominantly inattentive -- These kids have
problems focusing, are distracted easily, and have
trouble following directions or conversations.

Predominantly hyperactive-impulsive -- These

kids fidget, talk a lot, are impulsive and/or accident-
prone, and can't wait for their turn.

Combined -- These kids have traits from both types.

This is the most common.
Currently available treatments focus on reducing the
symptoms of ADHD and improving functioning.

Treatments includes:
Medication
-ADHD drugs sometimes have side effects. But these
usually occur when treatment is started and are usually
mild and short-lived. The most common side effects of
stimulants for ADHD include: decreased appetite/weight
loss, sleep problems, headaches, Jitteriness, social
withdrawal, stomachaches.
 Various types of psychotherapy
-A type of talking therapy, which means you or
your child will be encouraged to discuss ADHD and
how it affects you. It can help children, teenagers and
adults make sense of being diagnosed with ADHD,
and can help you to cope and live with the condition.
(eg. Family therapy, body psychotherapy)
or a combination of treatments.
 All in all, although both conditions are
classified as developmental disorders they
still differ in the following aspects:
1. Autism is a more complex problem
compared to ADHD.

2. Autism has hallmark characteristics of

repetitive behavior, language and sensory
problems, and social retreat. ADHD is seen
when the individual is impulsive, hyperactive,
inattentive and easily gets bored.
Intellectual Disability (ID)
 Once called mental retardation
Is characterized by below-average
intelligence or mental ability and a lack of
skills necessary for day-to-day living. People
with intellectual disabilities can and do learn
new skills, but they learn them more slowly.
There are varying degrees of intellectual
disability, from mild to profound.
SIGNS:
There are many different signs of intellectual disability in
children. Signs may appear during infancy, or they may
not be noticeable until a child reaches school age. It often
depends on the severity of the disability. Some of the most
common signs of intellectual disability are:
Rolling over, sitting up, crawling, or walking late
Talking late or having trouble with talking
Slow to master things like potty training, dressing, and
feeding himself or herself
Difficulty remembering things
Inability to connect actions with consequences
Behavior problems such as explosive tantrums
Difficulty with problem-solving or logical thinking
In children with severe or profound intellectual disability,
there may be other health problems as well. These
problems may include seizures, mental disorders, motor
handicaps, vision problems, or hearing problems.
The most common causes of intellectual disability are:

Genetic conditions. These include things like Down

syndrome and fragile X syndrome.
Problems during pregnancy. Things that can interfere
with fetal brain development include alcohol or drug use,
malnutrition, certain infections, or preeclampsia.
Problems during childbirth. Intellectual disability may
result if a baby is deprived of oxygen during childbirth or
born extremely premature.
Illness or injury. Infections like meningitis, whooping
cough, or the measles can lead to intellectual disability.
Severe head injury, near-drowning, extreme malnutrition,
exposure to toxic substances such as lead, and severe
neglect or abuse can also cause it.
 The primary goal of treatment is to develop
the person's potential to the fullest. Special
education and training may begin as early as
infancy. This includes social skills to help the
person function as normally as possible.
It is important for a specialist to evaluate the
person for other affective disorders and treat
those disorders. Behavioral approaches are
important for people with mental retardation.