Common health problems that develop during infancy

Imperforate anus

• Known as the stricture of the anus• Problems occur in 1:5000 live births• More common in males• Occur as an additional complication of Spinal

cord defects.

Assessment

• May reveal no anal formation• Abdominal distention is evident• No stool will pass• Absent of wink reflex

Diagnostic

• X- ray• Sonogram• Urinalysis

Therapeutic management

• Surgical repair• Post-op care- No rectal temp taking- Stool softener is given- Place a diaper under but do not put on- Side-lying position- May need rectal dilatation once or twice a day

- Instruct parents in care ofcolostomy

Nursing priority:- Record the first passage of meconium stool. If

infant does not pass stool within 24 hours, further assessment is required.

Cleft Lip

- A fissure of the upper lip to the side of the midline, which may vary from a slight notch to a complete separation extending into the nostril; may be unilateral or bilateral

- Caused by failure of the maxillary process to close in early fetal life; usually occurs during the 6th week of gestation

- Increased incidence in males; occurs in about 1:800 live births

Assessment:- Visible at birth an incompletely formed lip

Treatment:- Surgical repair is done early (2-6 months)

Nursing intervention

• Goal: To provide preoperative careA. Maintain Nutrition- Use a large-holed nipple or a modified nipple- Feed slowly- Burp frequently- Rinse cleft with water every after feeding - Elevate head of bed, put pillow under the

mattress

B. Prepare parents for newborn’s surgery- Encourage parents to position infant flat on

back or side- Encourage parents to place infant in arm

restraints periodically - Encourage parents to feed infant with the

same method

• Goal: To provide postoperative careA. Prevent trauma to suture line and maintain

patent airway- Observe for respiratory distress- Provide suction equipment at bedside- Position on side or back and elevate head of bed- Used soft elbow restraints- Cleanse suture line after each feeding: use

cotton-tipped applicator and roll along the suture line

- Prevent any crust or scab formation on lip and suture line

B. Provide for adequate nutrition- Feed in an upright position - Feed slowly ( burp at frequent intervals)C. Provide discharge teaching to parents- Encourage to cuddle and play infant to

decrease crying- Provide referrals to speech therapist

Cleft Palate

- Failure of fusion of the secondary palate; may involve the soft and hard palates along with the alveolar (dental) ridge.

- Generally associated with low birth weight infant, increased incidence of other malformations especially GI tract defects

assessment

• Opening in roof of mouth; usually associated with cleft lip

• Sucking difficulties• Breathing problems• Later problems:- Speech and hearing difficulties- Increased incidence of URTI and otitis media

Treatment

• Surgical: may be done in stages- Usually repaired around 18 months to allow

for bone growth; some are delayed until 4 years.

Nursing intervention

• Goal: To provide preoperative careA. Maintain nutrition- Use a modified nipple for feeding( lamb’s

nipple, brecht feeder, cup)- Feed child in semi-upright position- Cleanse mouth after feeding with waterB. Prevent infectionsC. Provide support and teaching to parents

• Goal: To provide postoperative careA. Maintain patent airway- Observe for respiratory distress- Position on side or abdomen to provide

drainage of mucusB. Prevent injury and trauma to suture line- Restraints: Elbow – infant, jacket – older child- Avoid use of straw, suction catheter, tongue

depressor, pacifiers or spoons- Decrease crying

C. Maintain nutrition- Give fluids initially, then advance to diet based

on age- Older child: not allowed to eat hard items

such as: crackers, potato chips- Cleanse mouth after each feeding with waterD. Provide guidance to parents- Provide emotional support- Provide referrals to speech and orthodontist

as needed

Spina bifida- Congenital anomaly of the spinal cord characterized by

nonunion between the laminae of the vertebrae.- A neural tube defects results in midline defects and

closure of the spinal cord- Most common site is lumbosacral areaTYPES 1. Spina bifida occultaa. Noncystic spina bifida- Results on failure of the spinous processes to join

posteriorly in the lumbosacral area, usually around L5 and S1

b. Neuromuscular disturbances may be apparent with foot weakness, bowel and bladder sphincter disturbance, and numbness and tingling of the extremities.

c. Infant may have no apparent clinical manifestations.

- Dimpling on the site2. Spina bifida cysticaa. Meningocele: a sac-like cyst of meninges

filled with spinal fluid that protrudes through a defect in the bony part of the spine.

b. Myelomeningocele: a sac-like cyst containing meninges, spinal fluid, and a portion of the spinal cord with its nerves that protrudes through a defect in the vertebral column; other defect most frequently associated with hydrocephalus.

- Paralysis of lower extremities- Musculoskeletal deformities- Neurogenic bladder and bowel

• Risk factors- Maternal Folic-acid def.- Previous pregnancy affected by neural tube

defect• Etiology- Combination of unknown

genetic/environmental factors- Advanced maternal age- High levels of AFP (alpha-feto protein)

Diagnostics

• Ultrasound• CT scan• Prenatal diagnosis: AFP elevated- Normal AFP level (>30 mg/dl)

Treatment

A. Occulta: no treatmentB. Meningocele/meningomyocele: - Surgical- Closure of defect with 24-48 hours to

decrease risk of infection, relieve pressure, repair sac, and possibly insert a shunt.

Nursing intervention

• Observe for irritation, CSF leakage and signs of infection

• Maintain asepsis; cover lesion with moist sterile dressings

• Position patient on the abdomen or semiprone with sandbags

• Provide optimum skin care, especially to perineal area

• Detect early development of hydrocephalus- Measure head and check circumference

frequently- Check fontanels for bulging and separation of

suture line• Check for abnormal movement of extremities,

absent or abnormal flexes, incontinence, fecal impaction, flaccid paralysis or lower extremities

• Observe for increased ICP• Observe for signs of meningeal irritation

• Provide parental bonding and education regarding proper positioning, feeding, skin care and exercises.

• Teach the parents “credes maneuver” to prevent urinary retention

Hydrocephalus• A congenital or acquired condition

characterized by anincrease in the accumulation of CSF within the ventricular system.

• Causes:- Neoplasm- Aqueductal stenosis- Spina bifida- Congenital cyst/ vascular malformations

Types

A. Communicating - Due to increased production of CSF or

impaired absorption of CSFB. Non-communicating- Due to obstruction/blockage of CSF

circulation between ventricles and subarachnoid space

assessment

• Fronto-occipital circumference increases at abnormally fast rate

• Split sutures and widened distended, tense fontanelles

• Prominent forehead, dilated scalp• Sunset eyes, nystagmus• Irritability, vomiting• Unusual somnolence

• Convulsion• High-pitched cry

Implementation• Operative managementa. Ventriculoperitoneal shunt- Connection between ventricles and

peritoneal cavityb. Ventricular atrial shunt- Connection between ventricles and right

atriumc. Ventricular drainage- Provides external drainage of fluid

• Observation of shunt functioning (not fnng well: dilated cerebral veins)

• Shunt needs to be modified as child grows• Continual testing for developmental

abnormalities/mental retardation• Discharge planning- Measure the head circumference: tape measure• Monitor for increased ICP- LOC earliest sign- Restlessness- Pupillary changes- V/S changes: Inc BP dec Pulse

Intussusception

• Telescoping of one portion of the bowel into another portion

• The condition results in an obstruction to the passage of intestinal contents

INCIDENCE:• Males affected two times more than females• Usually occurs between 3-12 months of age

Assessment• Colicky abdominal pain• Vomiting• Bile-stained fecal emesis• One or two normal stool then currant jelly-like

stools containing blood and mucus• Hypoactive or hyperactive bowel sounds• Tender distended abdomen• Palpable sausage-shaped mass in the upper

quadrant

Therapeutic interventions

• Medical reduction by hydrostatic pressure ( barium enema)

• Surgical procedure; sometimes with intestinal resection

Nursing interventions

• Monitor for signs of perforation• Insertion of NGT• Administer antibiotics• Start and IV line• Monitor passage of normal brown stool

Colic

• Paroxysmal abdominal pain or cramping• Baby cries for longer than 3 hours everyday for

more than 3 days a week• Extreme end of normal crying behavior• The condition is harmless though is can be

distressing to the parents or carers.• Is uncontrollable, extended crying in baby

Incidence

• About 20% of babies get colic• Boys and girls equally affected• Often occurs in 1st born child and those born

later• Appears around 2-4 weeks of age and can last

for 3 months or longer in some cases.

• Cause:- Unknown

ASSESSMENT- Characteristics of the cry- Diet of breastfeeding mother- When the attack occur in relation to feeding- Activity of caregiver around time of attack- Mother’s habit such as smoking

Treatment

• No single medicine or proven cure for colic• Different babies are comforted by different

measures• Parents who bottle-feed their babies may try a

new formula• Continue breatsfeeding• Carry the baby in front sling or back pack• Warp snugly in a blanket (swaddling)

• Take the baby for a car ride or a walk outside• Give a tummy or back rubs• Take a shower together – warm water may be

comforting

Hirschsprung’s disease

• Characterized by a congenital absence of ganglion cells in the myenteric plexus of the colon

• Congenital aganglionic megacolon• Most common site is the rectosigmoid colon

• Risk factors/ Etiology- Congenital, may be associated with Down

syndromeASSESSMENT

- Inadequate or absent peristalsis (Newborn)- Failure to pass meconium within 24-48 hours

after birth- Vomiting- Abdominal distention- Reluctance to take fluids

• Older infant- Passage of watery stools or diarrhea (ribbon-

like stools)- Failure to thrive- Lack of appetite- Persistent constipation, impactionsDIAGNOSTICS- Rectal biopsy- Barium enema

Treatment

• Surgical correction involves creation of a temporary colostomy, then a pull-through of the colon to a point near the rectum. After the reanastomosis has healed, the temporary colostomy is closed.

Nursing intervention

• Allow parents to ventilate feeling regarding congenital defect of infant

• Foster parent-infant attachment• Maintain a low residue diet: low fiber, high

calorie, high protein diet• Measure abdominal girth• Administer stool softener as ordered• Careful explanation of colostomy to parents

Care of colostomy

• Colostomy: opening of the colon through the abdominal wall, stool is generally semisoft and bowel control may be achieved.

- Maintain regular irrigations- Irrigate colostomy same time each day to

assist in establishing a normal pattern of elimination

Failure to thrive• Failure to thrive is a delay in physical growth and

weight gain that can lead to delays in development and maturation.

• Failure to thrive is a diagnosis given to children who are consistently underweight or who do not gain weight for unclear reasons.

• The diagnosis is based on a growth chart comparison, thorough examination, and parents' answers to specific questions about the child's health and environment.

• Normal growth:- Normal child usually 2x their weight by 4mos and

3x by 12mosCAUSE:1. Environmental and social factors- Parental neglect or abuse- Chaotic family2. Medical disorder- Cleft lip and palate - infections- HIV - intolerance to milk- GERD

• Diagnoses are made in infants and toddlers in the first few years of life.

• Use standard growth chart to plot weight, length and head circumference

• Failure to gain weight for 3 consecutive months during the first year of life.

Treatment

• High calorie diet to catch up growth• Treat the specific cause• Sometimes child may be hospitalized

Trisomy 21

• Down syndrome• Characterized by chromosomal abnormality

related to an extra chromosome 21. CAUSE:- Unknown- Associated with maternal age greater than 35

y. o

assessment

• Mental retardation• Marked hypotonia• Altered physical development• Large tongue• Simian crease• Slanting eyes• Low set ears• Usually associated with CHD

• Diagnostic test- AFP – usually decreased TREATMENT- Establish adequate nutrition- Provide parental education- Refer parents for genetic counselling

Meningitis

• Viral or bacterial infection affecting the meninges

• CAUSE:- Virus- Bacteria- Fungal

Assessment

• Headache• Fever• Photophobia• Signs of meningeal irritation- Nuchal rigidity - Kernig’s sign- Brudzinski’s sign- Opisthotonic position

• Changes of LOC• Seizures• Special symptoms in infants- Refuse feedings, vomiting, diarrhea- Bulging fontanelles- Vacant stare- High-pitched cry

Implementation

• Medications- Antibiotic – penicillin (DOC)- Antifungal – amphotericin- Mycobacterium – INH, streptomycinNURSING INTERVENTION- Implement strict isolation until first 24 hours

of antibiotic treatment- Refer to audiologist

Wilm’s Tumor

• Nephroblastoma• Most common intraabdominal tumor in

children associated with congenital anomalies especially in the genito-urinary tract

• Associated with genitourinary anomalies• Majority of children (80%) are younger than 5

years, peak incidence at 3 years

Assessment

• Swelling or mass on the abdomen• Painless abdominal tumor (first sign)• Abdominal pain as tumor enlarges• Fever• Nausea and vomiting• Blood in the urine• Hypertension

Diagnostics

• Biopsy• Ct scan• MRI• X-ray

Treatment

• A. Surgery- Is frequently scheduled within 24-48 hours

after the diagnosis.- Nephrectomy: Kidney is removed but the

adrenal gland may be spared, depending on the invasiveness of the tumor.

• If both kidneys are involved the less affected kidney is retained, bilateral nephrectomy is the last resort.

Nursing intervention

• Nsg. Priority: POST A SIGN ABOVE THE BED THAT READS: “DO NOT PALPATE ABDOMEN”

• Handle the child carefully to prevent trauma to the tumor site.

• Prepare the child for the surgery, including anticipation of a large incision and dressing.

• Assess V/S especially BP• Refer parents to a geneticist

Poisoning• Aspirin Poisoning• Lead poisoning• Tylenol poisoning

• Assessment:1. ABC rule- Treat the patient first then the poison2. Identify poison- Amount and time of ingestion

3. Diagnostics- Urine and serum analysis- Long-bone x-rays if lead deposits is suspected- CT scan and EEG

Implementation1. Preventiona. Child proofing - Store all potentially poisonous substances in

locked-out-of-reach areab. Increased awareness of precipitating factors- Growth and development characteristics –

under/overstimating the child’s capabilities- Changes in household routine- Condtions that increase family tension of

family members

2. Instructions for caretakers in case of suspected poison ingestion

a. Recognize signs and symptoms of accidental poisoning

- Change in child’s appearance/behavior; presence of unusual substances in child’s mouth, hands, play area, burns, blisters or suspicious odor.

b. Initiate step to stop exposurec. Save any substance, vomitus, stool and urine

d. Induce vomiting if indicated3. Ipecac – direct stimulation of vomiting center

and gastric irritant; a. dose:9-12months -10ml do not repeat1-2 years old – 15ml12 years and older – 30 mlb. Follow each dose with a clear fluids (4-8oz)c. Position child’s head lower than the chest to

prevent aspiration

d. Repeat once every 30 minutes for child over than 12 months

e. If no vomiting after 2 doses, transfer to ERf. Contraindications to inducing vomiting- When child is danger or aspiration- When substance is petroleum distillate or

strong corrosive substanceg. General considerations- Water may be used to dilute the toxin: avoid

giving large amounts of fluid when medication has been ingested

- Milk may delay vomiting4. Emergency carea. Basic life support- Respiratory- Circulationb. Gastric lavagec. Activated charcoal : 5-10gms for each g of toxin- Give within 1 hour of ingestion and after

emetic- Mix with water to make a syrup