Common Problems That Develop During Infancy

Failure to ThriveFailure to thrive refers to children whose current weight or rate of weight gain is significantly lower than that of other children of similar age and gender.

Causes, incidence, and risk factorsMEDICAL CAUSES:Chromosomeproblems such as Down syndrome andTurner syndromeOrgan problemsThyroid hormone deficiency, growth hormone deficiency, or other hormone deficienciesDamage to the brain or central nervous system, which may cause feeding difficulties in an infantHeart or lung problems, which can affect how nutrients move through the bodyAnemia or other blood disordersGastrointestinal problems that make it hard to absorbe nurtients or cause the body to have a lack of digestive enzymesLong-term gastroenteritis and gastroesophageal reflux (usually temporary)Cerebral palsyLong-term (chronic) infectionsMetabolic disordersComplications of pregnancy and low birth weight

Other factors :Emotional deprivation as a result of parental withdrawal, rejection, or hostilityPovertyProblems with child-caregiver relationshipParents do not understand the appropriate diet needs for their the childExposure to infections, parasites, or toxinsPoor eating habits, such as eating in front of the television and not having formal meal timesMany times the cause cannot be determined.

AssessmentSymptoms of failure to thrive include:Height, weight, andhead circumferencedo not match standard growth charts.Weight is lower than 3rd percentile (as outlined in standard growth charts) or 20% below the ideal weight for their height.Growth may have slowed or stopped after a previously established growth curve.

Children who fail to thrive may have the following delayed or slow to develop:Physical skills such as rolling over, sitting, standing and walkingMental and social skillsSecondary sexual characteristics (delayed in adolescents)Babies who fail to gain weight or develop often have a lack of interest in feeding or a problem receiving the proper amount of nutrition. This is called "poor feeding."Other symptoms that may be seen in a child that fails to thrive include:ConstipationExcessive cryingExcessive sleepiness (lethargy)Irritability

DiagnosticsPhysical exam - child's height, weight, and body shape. Denver Developmental Screening Test will be used to show any delays in development. A growth chart outlining all types of growth since birth is created.The following tests may be done:Complete blood count (CBC)Electrolyte balanceHemoglobin electrophoresis to check for conditions such as sickle cell diseaseHormone studies, including thyroid function testsX-rays to determine bone ageUrinalysis

ManagementTreatment depends on the cause of the delayed growth and development. Delayed growth due to nutritional factors can be helped by showing the parents how to provide a well-balanced diet.Other treatment depends on the severity of the condition. Increase the number of calories and amount of fluid the infant receivesCorrect any vitamin or mineral deficienciesIdentify and treat any other medical conditionsThe child may need to stay in the hospital for a little while.Treatment may also involve improving the family relationships and living conditions. Sometimes, the parent's attitudes and behavior may contribute to a child's failure to thrive.

Cleft PalateA congenital failure of fusion between the right & left palate processNSG. GOALSPrevent aspirations/ InfectionPlace in Prone or side-lying positionProvide Nutrition - Feed with special nipple that fills cleft & allow suckingClean mouth with water after feedingBurp at each ounceThicken formula to provide extra caloriesProvide parental support

ASSOCIATED PROBLEMS1. Eating2. Nasal Speech3. Lack of Normal dental function or appearance4. Repeated bouts of otitis media with subsequent hearing lossCOMPLICATIONS1. Long term problems:a. Speech impairmentb. Hearing impairmentc. Improper tooth placementd. Recurring otitis media2. Faulty social adjustment

CLINICAL MANIFESTATIONPhysical appearance of cleft lip & palateIncompletely formed lipOpening in roof of mouth felt with the examiners finger on palateMANAGEMENTSurgery to close the cleft lip - CHEILOPLASTYdone as early as possible using rule of 10at least 10 weeks oldweighs = 10 lbshaving at least 10 grams Hbg

Cleft Palate surgeryIs not done very early (not earlier than 10-12 months because it can harm tooth buds) NOR;Too late (because the palate can become too rigid & the child may develop undesirable speech patternsVelopharyngeal flap operationat 8-9 years oldto revise previous repaircorrect nasal deformities

IntussusceptionBowden TextTelescoping of part of

intestine into an adjacent

distal portion.

IntussusceptionCommon cause of intestinal obstruction in children ages 3 to 25 monthsProximal segment of bowel prolapses or telescopes into the lumen of an immediately distal segment of bowel.The prolapse results in vascular compromise, edema and mechanical obstruction.Bleeding results in the passage of blood and mucous in the stool.

Assessment Child appears with intermittent pain which is colicky, severeChild will often draw legs upEpisodes occur 2-3 times / hourVomiting is prominent feature bile stained vomiting a late signBowel movements bloody / mucousClassic current jelly stool is a late sign

Clinical ManifestationMucous + blood =classic currant jellystool

Diagnostic X-ray

Diagnostics Contrast enema using air, barium, or water-soluble contrast may be used for diagnosis or a therapeutic treatment tool. This test typically follows nasogastric decompression and the administration of IV fluids.Electrolyte studies will reveal electrolyte loss relative to symptoms

Reduction of Intussusception

ManagementReduce the obstruction before the bowel becomes necrotic.Contrast Enema is diagnostic in 95% of cases and therapeutic curative in most cases.Surgical reduction is radiologic reduction is not achieved.

Surgical InterventionIV fluids + antibiotics pre-operatively.

Manual reduction is attempted.

If bowel perforation is noted during operative procedure a temporary colostomy may be needed.

Nursing managementPromote adequate hydration: monitor NGT drainage, clear liquids after surgeryPromote adequate nutrition according to childs age and nutritional requirementsMonitor bowel elimination: stool amount and characteristics, abdominal distension, bowel soundsMonitor for infection : wound redness, swelling, and drainage, temperature

Hirschsprung Disease

Hirschsprung Disease

Congenital megacolon is a congenital absence of ganglio cells (ganglia). This results in obstructed passage of stools causing the normal bowel to distend.

AssessmentIn the newbornNo meconium in the first 24 hoursBilious vomitingAbdominal distentionFever

Older infants / childrenHistory of chronic constipation or fecal massAbdominal distentionFailure to thrive

Diagnosis and TreatmentRectal biopsy Removal of the aganglionic portion of the colon.1st stage surgery is often a colostomy2nd stage is pull-through surgery to connect the working colon to a point near the anus.

Typical X-ray

Colostomy at Birth Goal is to close colostomy and do pull through surgery at 6 to 12 months.

Long Term ComplicationsAnal stricture

Incontinence of stool

Short bowel syndrome

Spina Bifida CysticaIncomplete fusion of one or more vertebral laminae, resulting in an external protrusion of the spinal tissue.

5 per 10,000 births

Other anomalies

Focused HistoryPoor maternal nutritionMaternal agePregnancy historyBirth orderSocioeconomic status

DiagnosisUltrasound

Elevated AFP

95% survival rate

Meningomyelocele / MeningoceleBowden & Greenberg

MyelomeningoceleA protruding saclike structure

containing meninges, spinal fluid and

neural tissue.

Myelomeningocele

Assessment at BirthSize, level, nature of tissue coveringNerve involvementLower limbs / bowel and bladder functionMonitor for signs of hydrocephalusHead circumferenceLeakage of CSFCranial sutures

Immediate InterventionsProtect from injury and infection

Rupture of the sac can lead to death

Sterile moist dressing on sac until surgery

Position to prevent pressure on back

Goals of Surgery

Provide a normal anatomic barrier

Control Infection

Control hydrocephaly

Community Care

Bladder and bowel problemsLatex allergies: due to in and out catheterizationProblems with self-esteemOrthopedic managementSchooling based on IQ

HydrocephalusGreek meaning water on the brainDilation of the ventricles Two primary causes:Congenital .5 to 1% Acquired:Lesion, tumors, infection, intracranial bleed, myelomeningocele

Hydrocephalus

Head Circumference

HydrocephalusBulging anterior fontanelle

Eyes deviated downward

Setting Sun signBates: Physical Assessment

Transillumination of SkullBates: Physical AssessmentAdvanced cases of

Hydrocephaly produces

a glow of light over

the entire cranium.

Severe Hydrocephalus

AssessmentBulging fontanelsSplit suturesIncreasing head circumferenceProminent scalp veinsSunset eyesIrritability high pitched cryPoor feedThe older child will complain of headache

InterventionsPlacement of shunt to

drain CSF from the

ventricles to another

part of the body.

Assessment of ShuntVomitingHeadacheIrritabilityFeverRedness along shunt lineFluid around shunt valve