1. Hypoglycemic: Hypoglycemic is defined as a true blood glucose level of less then 40 mg /dl irrespective of period of gestation. If there are no symptoms, it should be confirmed on repeat analysis. The infant is born with a blood glucose concentration of 60-70% of the maternal level and it falls during first 3 days of life.
2. Dermatitis: Dermatitis of the ear usually associate with seborrheic dermatitis of the scalp or middle ear discharge. It may be due to allergic reaction, characterized itching, redness, papules, vesicles or red scaly macules or plagues.
3. Spine Bifida: Central nervous system defect that occurs as a result of neural tube failure to close during embryonic development. It is two types: a. Spine bifida occulate, b. Spine bifida cystia.
4. Delinguency: It is an antisocial behavior when a child or adolescent purposefully repeatedly does illegal activities such as theft, sexual assault, murdes, etc.
5. Apgar Score: A system of assessing infant's physical condition one minute after birth. The heart rhythm respiration, muscles tone, response to stimuli and skin color are assigned a score of 0, I or 2 total score is 10. Those with very low score require immediate attention.
6. Convulsion: It is a symptoms of neurological disorder paroxysms of involuntary muscles contraction and relaxation.
7. Fallots Tetralogy: Folloty tetralogy is most common cyanotic congenital heart disease. This condition is characterized by the combination of four defects.
   1. Pulmonary stenosis
   2. Ventricular septal defect
   3. Overriding or dextroposition of the aorta
   4. Right ventricular hypertrophy.
8. Hydrocephalus: Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the intracranial spaces. It occurs due to imbalance between production or absorption of or due to obstruction of CSF pathways. It results in the dilation of the cerebral ventricles and enlargement of head.
9. Encephalitis: This is an inflammatory process of the central nervous system producing altered function of various portion of the pain.
10. Hypospadiases: Hypospadias is the congenital abnormal urethral opening on the ventral aspect (under surface) of the penis. It is one of the commonest malformations of male children. It may found in females as urethral opening in the vagina with dribbling of urine.
11. Otitis Media: Infection of the middle ear occurring as a result of a blacked Eustachian tube which present normal drainage otitis media is a common complication of acute respiratory infection.
12. Hypothermia: It is defined when infant's body temperature is below then 36.5^oC or 97.7F. it may be in the newborn also.
13. Croup: It refers to the symptoms of complex characterized by barking cough, stridor and respiratory difficult usually due to formation of diphtheritic membrane and due to obstruction in the larynx.2
14. Dwarfism: The state of being short in stature arrest of growth of development growth is affected by abnormality in endocrine secretion.
    An adult men with a height below 130 cm and a female below 122 cm are designated a dewarfs or short stature.
15. Diphtheria: Diphtheria is an acute contagious disease in which there is a formation of fibrous pseudomembrane upon the mucosa of respiratory tract caused by corynebacterium diphtheria.
16. Rheumatic Fever: Rheumatic fever is an acute or chronic inflammatory disease affecting joints, heart, central nervous system and subcutaneous tissue. The process of disease is usually with fever, polyarthritis and carditis. It occur must commonly between the age of 5-12 years.
17. Mental Retardation: The term mental retardation refers to significantly sub average general intellectual functioning existing concurrently with deficits in adaptive behavior manifested during the development period.
18. Intussusception: Telescoping of one portion of the bowel into another portion. Results in an obstruction to the passage of intestinal contents.
19. Hypertrophic Pyloric Stenosis: 1 Hypertrophy of the circular muscle of the pylorus causes narrowing of the pyloric canel between the stomach of the duodenum. Usually develops in the first few weeks of life causing projectile vomiting, dehydration, metabolic alkalosis and failure to thrive.

 

• Emotional factors
• Environmental factors
• Organic causes
• Other factors:
  • Emotional Factors: Responsible for enuresis are hostile or dependent parent child relationship dominant parent punishment, sibling rivalry, emotional deprivation due to insecurity and parental death.
  • Environmental Factors: Like dark passage to toilet or cold or fear of toilet or toilet at distance from bedroom may cause bedwetting at night.
  • Organic Causes: May present, e.g. spine bifida, neurogenic bladders. Juvenile diabetes mellitus, seizures disorder, etc.
  • Other Factors: Include the child with emotional conflict and tension small bladder capacity, improper toilet training and deep sleep with mobility to receive the signals from distended bladder to empty it.

• Primary (Persistent Enuresis)
• Secondary (Regressive Enuresis)
  • Primary or Persistent Enuresis: Is characterized by delayed maturation of neurological control of urinary bladder, when the child never achieved normal bladder control usually due to organic cause.
  • In Secondary or Regressive Enuresis: the normal bladder control is developed for several months after which the child again starts bedwetting at night usually due to regressive behavior like illness and hospitalization or due to any emotional deprivation.3

• The home conditions, socioeconomic status, and habits of the family should be found out.
• Child-parent relations should be explored. Parent and child should be interviewed separately. Understanding the child's relationship with playmates, teachers and siblings is also important.
• Anlaysis of the time of bedwetting, frequency and relation to sleep should be done.
• The child and parents should be explained about the factors related to bedwetting.
• Parents should be explained about enuresis and asked to take precautions against scolding, shamming, threatening and punishing child.
• The child should be helped to get relief from the feeling of shame, guilt, and parental rejection. They should be encouraged to develop self-confidence. Modification in routine may be helpful.
• Restriction of fluids in the evening and helping the child in developing the habit of passing urine before going to bed.
• He/she may be woken up four hours after sleep and made to pass urine again.
• Drug therapy with tricylic antidepressant [IM ipramine] are useful.
• Condition therapy by using electric alarm bell mattress is a effective and safest method, when the child wakes up as soon as the bed is wet.
• Supportive psychotherapy is important for child and parents.
• Change of home environment to remove the environmental causes are essential.

Trisomy 21	Translocation 15/21	Mosaicism
1. IT is also called as Trisomy ‘G’ there are total 47 chromosomes instead of 46. The extra chromosome presents in 21st pair.	Translocated chromosome transmitted most often by mother who is a carrier age not a factor.	It may occur rarely. The affected child has two number of chromosome.
2. The origin of extra chromosome is either from mother or from Father.	In this type total number of chromosome remains normal (46) though one is large and a typical	It occur due to post conception error in chromosomal division during mitosis.
3. Frequently associated with advanced maternal age (older than 40 years of age) can occur in all age group.

1. Skin: Dry, cracked, mottling, excessive skin on back of neck.
2. Hair: Soft fine possibly sharse.
3. Head: Size in the third to 20th percentile, brachycephalia (a head that is short and wide) flat occiput possibly late closure of the fontanela.
   • Face: Flat facial profile.4
   • Eyes: Bilateral epicanthal folds, upward and outward slant to palpebral fissures, short scanty eyelashes, brushfiled spots, nystagmus severe myopia.
   • Ears: Low placement small short in length, anomalies of the cartilage over folding of the angulated upper helix possible hearing defect.
   • Nose: small, flat or depressed bridge.
   • Mouth: Oral cavity small narrow high palate hypoplastic mandible protrusion of tongue delayed eruption of teeth, small irregular teeth.
   • Neck: short perphaps.
   • Check: funnel or pigeon chest.
   • Abdomen: Protruding separation of recturs muslces, umbilical hernia.
   • Genitalia: Infantile genital development cryptorchidism.
   • Musculoskeletal: Muscle hypotonia, pronounced, hyperflexibility of joints.
   • Hands: Short and broad hands. Little fingers are short incurved due to hypoplasia of middle fingers. There is single transverse crease (simian crease) in the palm inspite of 3 major creases.
   • Feet: Short and broad hand - stubby fingers. Clinodoctylism. In the feet there is wide gap between the big and second toes (sandle gap) a deep crease is found on the sale starting between the big and second toes and extending towards heel.
   • Reflexes: More reflex absent.
   • Height, length and weight: Growth in height and weight after the neonatal period depends on adequate nutrition and the prompt control of infections.
   • Neonatal period: Length within normal range between shorter than average weight possible below normal.
   • Childhood: Growth in height slows to below normal wt normal for ht but below normal.
   • Adolescence: Adult height reached at about 15 years final height for males-approximately 5 feet (180 cm) final height for females – a few inches shorter than that of males.
   • Other associated and potential prob all visual defects, hearing problems speech and communication disorders, hypothyroidism, short stature obesity growth and retardation recurrent respiratory infections. The mydriatric effect of atropine instilled into the eye of a child with down's syndrome tis exaggerated.

• Physical characteristic of the child with down's syndrome sufficient to diagnose the condition.
• The confirm diagnosis is done with the help of chromosomal study, dermatoglyphic findings and radiological finding of bony abnormalities.
• Antenatal diagnosis can be done is suspected causes by amniocentesis.
• HCG and estriol assay.
• USG can be helpful to reveal the bony.
• Femur, Humerus abnormalities nuchal thickening.

• Both parents should be informed together of the defect as soon as the diagnosis is made.
• Provision of physical care: Aspects of the physical care of infants with down syndrome that require particular attention include nutrition and skin care.
• In children who have down syndrome nutritional requirements are based on the length and wt not on the chronologic age, bec these infant's are generally smaller than normal hypotonic and inactive if too much food is given obesity may result feeding are scheduled in small amount and are given slowly and at frequent intervals to allow for adequate digestion and rest.

• Infants and children with down syndrome are prone to repeated respiratory infection including colds, otitis media and pneumonia. These infections may occur because of persistent mouth breathing, which dries the mucous membranes of the oral cavity and pharynx lack of normal physical activity, which leads to pooling of secretions and lack of adequate tone in the respiratory muscles.
• The nurse can assist the parents in the prevention of these infections by teaching them to use a bulb syrings to clear secretion from the nostrilas to change the infant's position frequently to use a mist vaporizer in order to keep the mucous membrane of the respiratory tract moist.
• Therapy should be given.
• Physiotherapy, speech therapy, special educational facilities, occupational training can be helpful for some children. According to the IQ level the child can be trained in self care or parents should provide daily routine care for health maintenance.

• Preventing rapid rise in serum bilirubin level
• After an exchange transfusion
• How serum protein
• Prophylactic phototherapy.

• Baby is undressed completely out diaper is kept on to protect the gonads.
• Eyes are convered with eye patched to prevent damage to retina.
• Nude baby is kept under the light source at a distance of 45 cm.
• The baby is turned every 2 hours or after each feed to expose maximum area of skin to light.
• Baby should be given frequent breastfeedings but no supplements of extra water or milk is required.
• Phototherapy is stopped when serum bilirubin return to a safe value as per unit protocol.
• Nurse should monitor the following parameters during phototherapy.
• Temperature every 2 hours.
• Ensure adequate breastfeeding so that baby passes urine 6-8 time day.
• Daily wt record.
• Serum bilirubin as per unit protocol.
• Side effects of phototherapy include skin rash, loose greenish stools, hypothermia or hyperthermia, (dehydration excessive wt loss) bronze baby syndrome skin of the baby becomes bronze calored when a baby with conjugated hyper bilirubinemia is placed under light.

• Sclera appeal yellow
• Lethargy
• Refusal to food
• Dark urine and stool6
• Jaundice is a relatively common physical abnormality a newborn baby during the first week of life, clinical jaundice manifests as yellowness of the skin of the face when the serum bilirubin level exceeds 5 mg/dl. As the degree of jaundice increase, there is progression of yellowness of the skin from face towards trunk, limbs and finally palms and soles.
• When the trunk of the baby is distinctly yellow stained the serum bilirubin level is likely to vary between 10 to15 mg/dl.
• The yellow staining of the palms or soles is aminous and indicates that the serum bilirubin level has excessed 15 mg /dl.

• Decreased bilirubin conjugation:
  • The liver may not cope-up with conjugation due to inadequate enzyme glucuronyl transferase.
  • Inadequate bilirubin binding proteins
• Increased bilirubin load:
  • Hemalysis due to Rh incompatibility
  • Structural abnormality of the red blood cells.
  • Physiological rapid destruction of RBC
  • Extravascular blood, such as cephalhematema
• Polycythemia:
  • Small for gestation age
  • Babies of diabetic mothers
    Mixed factors: There may be increased bilirubin load and decreased ability of the liver to clear the bilirubin.

• Details history of illness and physical examination help to detect the causes.
• Laboratory investigation to exclude the exact case of jaundice include estimation of direct and indirect bilirubin.
• Hemoglobin percentage, blood grouping and typing, reticulocyle count, coomb test stool examination.
• Liver function test and other specific test for suggestive etiology.

• Management of a child with jaundice primarily directed toward to etiology, special supportine Nursing care is very important and includes rest, skin care, directory restriction of fat, spices and fried food, intake of more carbohydrates.
• Maintance of hygienic measures, care of bladder, bowel, prevention of injury of bleeding, emotional support and health education.
• Phototherapy: It act as photooxidizing with change fat soluble bilirubin to water soluble bilirubin.
• Phenobarbitone: It induces glyconal transference for motion by liver cells.
• Exchange transfusion: It is done to remove bilirubin mechanically about 180 ml of blood/kg body wt should be exchanged.

• Leukemia is a disease characterized by abnormal proliferation and maturation of bone marrow. The leukemic process in the bone marrow interferes with the production of normal red cells, white cells and platelets. The leukemic cells can occur in any cell in the white cell line in the form of a young undifferentiated blast cell.7
• About 95 to 98 percent of childhood leukemias all acute type mostly the cases all acute lymphocytic leukemia (70-75) other variety in acute non-lymphocytic leukemia about 20 chronic myelocytic leukemia and other varieties account for about 4 percent of all cases chronic lymphocytic leukemic is very rare in children.
  
• Acute lymplocytic leukemic: All is a primary disorder of the bone marrow in which the normal bone marrow elements are replaced by immature or undifferentiated blast cells. It is characterized by anemia, thrombocytopenia and neutrophenia specially granulocytopenia.
  The incidence of All is about 1 in 2,000 live birth peek age of onset is 3 to 7 years. The male children are more affected than females, All can be classified on the basis of cell morphology as three subtypes, g L₁ and L₂ L₃

• Fever, anorexia, malaise, weakness petechiae purpura, ecchymosis and bleeding.
• The child may present with progressive pallor, decreased activity level, wt loss and muscle wasting.
• The child may complain abdominal pain, bone pain, joint pain and sternal tenderness.
• Hepatosplenomegaly, hematemesis, melena, hematuria, oral infection are common associated features.
• Excessive bleeding from nose prick or minor injury or minor operation like tooth extraction may be the first features.
• CNS involvement or meningeal leukemia may be manifested with headache, vomiting drowsiness, unconsciousness, convulsions, cranial nerve involvement, blurred or double vision.

• Complete blood count physical examination. Bone marrow study slows large numbers of lymphoblasts, lymphocytes with hypercellular condition of bone marrow.
• Chest X-ray helps to diagnose Meduastinal mass.
• CSF study determines CNS involvement with presence of leukemic cells.

• Remission Induction Chemotherapy: It is administered for 4 to 6 weeks with vincristine, prednisolone, astarginase and adriamycin. These drugs given 95 to 98% to remission with recommended dose by intensive systemic chemotherapy. This Rx can be carried out for two additional weeks, if normal bone marrow is not achieved. No response at 8 weeks indicates poor prognosis.8
• Maintanance therapy or Systemic Continuation: It is given for 2.5 to 3 years with 6 MP (Mercaptopurine) and MTX (Methotrexate) as per recommended dose.
• Late Intensification or Reinforcement Therapy: It is provided with vincristive and Prednisolone every 4 weeks.
• CNS Prophylaxis: In case of CNS involvement triple therapy is administered in intrathecal route as antileukemic drugs do not penitrate into the CSF. Methotrexate, hydrocortisone and cystosine arabinoscale are administered one a week during induction and then every 8 weeks for 2 years, cranial irradiation can be given in combination with the above drugs.

Ml	M2	M3	M4	M5	M6	M7
Acute	Myelocytic	Promyolocytic	Myclomonocytic	Aucte	Erythroblastic	Mage
Myelocytic	leukemia	leukemia	leukemia	nonocytic	leukemic	karyocytic
Leukemia				leukemia		leukemia

• Chronic infection, fatigue, lymphodenopathy, bone and joint pain, pallor and frequent bruising, hepatosplenomegaly.
• Pallor, bleedy, fever and pain
• CNS headache, blurred vision, fundal hemorrhage.

• ANLL is managed with chemotherapy using cystosine arabinoside continuous IV infusion for 7 days and IV daunorubicin for 3 day.
• Heparin therapy may be needed in case of fetal hemorrhage and nursing management in these situations must include astote clinical observations, through assessment development and implementation of an individualized plan of are and evaluation of the child and family supportive Rx with blood platelet transfusion and IV antibiotic thereby may be required.

• CML is characterized by increased number of myeloid calls in all stages of maturation both in the blood and bone marrow.
• CML is equite rare in children accounting for 2 to 3 of all leukemia. It presents in children as adult and juvenile type, adult type is most commonly found.

• Weakness and progressive massive enlargement of spleem and liver which may reach into the pelvis.
• Most cases are found in about 10 to 12 years of age.9
• Arthritis, priapism, retinopathy.
• Skin infiltration and unexplained fever.

• Blood examination slows anemia, thrombocytosis and excess leukocytic count with remarkable eosinophilia and basophilia.
• Bone marrow study help to confirm the diagnosis and slows hyperplasic.

• Occur in children below 2 years of age. It present with eczema lymphadenopathy, recurrent bacterial infection and hepatosplenomegaly WBC count is usually less than 100,000/-cmm. Thrombocytopenia is frequently present bone marrow study slows monoplastic cells philadelphia chromosome is negative Rx is done same as ANLL. Response to chemotherapy is discouraging. Bone marrow transplantation gives good result.
• Nsg management of a child with Leukemia.
• Providing psychological and emotional support to parents to reduce parental anxiety.
• Encouraging the parents to express their feeling of answering their questions honestly.
• Preventing infection and hemorrhage: Maintaining aseptic technique, hygienic measure general cleanliness handwashing practice, restriction of visitor and taking proper precautions during any invasive procedures.
• Administering antibiotics as prescribed oral IV route to be used. IM injection should be best avoided.
• Take proper precautions during blood transfusion.
• Avoiding injury such as soft toothrbrush can be used for dental care, soft jelly to be applied for dry lips. Non irritating mouth wash to be used. No alcohol or H₂O₂ to be used. Breaking skin and mucous membrane to be avoided.
• Monitor proper VS intake output, findout signs of infection bleeding and other complication.
• Given proper best rest to prevent pain.
• Maintaining normal body temp by tapid sponge in high fever air environment adequate fluid intake avoiding overclothing and hot environment, administering antipyretics and other prescribed drugs.
• Recording VS 4 hourly. Avoiding use of rectal thermometer and provide adequate nutritional intake with high nutritions diet and small frequent feed. Avoiding high salty food when steroids are given. Antiematics to be given to present vomiting, diet should be attractive and tasty to promote intake of more amount.
• Explaining about the change of body image, especially in case of alopecia due to chemotherapy, ensuring about future change and contacting with people having new hair following alopecia.
• Reducing fear the children by allowing parents with them during procedure, improving IPR and allowing play materials.
• Teaching the parents about health maintenance regarding regular blood testing, chemotherapy or other mode of management possible complication and their warring signs, necessary medical help and following up.

• An inflammatory autoimmune disease that affects the connective tissues of the heart joints, subcutaneous tissue or blood vessels of the CNS.
• The most serious complication is rheumatic heart disease, which serious complication is rheumatic heart disease, which affects the cardiac values.
• Presents 2 to 6 weeks following an untreated or partially treated group a beta hemalytic streptococcal infection of the upper respiratory tract.
• Joints criteria are utilized in determining the diagnosis.

• Aschoff Bodies (lesions): Found in the heart blood vessels brain and serovs surfaces of the joints and pleura.
• Signs of Carditis: Shortness of breath edema of the face, abdomen or ankles and precordial pain.10
• Signs of Polyarthritis: edema, inflammation of large joints and joint pain.
• Erythema Marginatum: erythematous mascular rash on the trunk and extremities.
• Subcutaneous modules found in crops over the bony prominences.
• Chorea: Sudden, aimless, irregular movements of the extremities involuntary facial grimaces, speech disturbances, emotional lability muscles weakness.
• Fever: Low grade fever that spikes in the late afternoon.
• Elevated antistreptolysin 0 titer.
• Elevated sedimentation rate.
• Elevated C-reactive Protein.

• Chest X-rays slows cardiomegaly and heart failure
• Electrocardiography
• Blood test for ESR, ASO titles, WBC count (leukocyte)
• Artificial subcutaneous nodule test.

• Bedrest is important in the management of children with reheumatic fever. It is needed for at least 6 to 8 week till the rheumatic activity is disappeared.
• Nutrition diet to be provided with sufficient amount of protein vitamins and micronutrients, self restriction is not necessary unless CCF is present. Avoid rich spicy food.
• Antibiotic therapy, penicillin is administered after skin test to eradicate streptococcal infection, initially procaine penicillin 4 lacks units deep IM twice a day is given to 10 to 14 days. Then the long acting benzathine penicillin 12 mega units every 21 days or 0.6 mega unit every 15 days to be given oral penicillin 4 lacks units (250 mg) every 4 to 6 hours for 10 to 14 days can be also given erythromycin can be used in penicillin sensitive patient.
• Aspirin is administered as suppressive therapy to control pain and inflammation of joints. The dose of aspirin is 90 to 120 mg/kg/day in 4 divided doses. It may be needed for 12 weeks.
• Aspirin should not be given in empty stomach antacid to be given just prior to or with the aspirin.
• Steroid (Predniosolone) therapy is given as suppressive therapy along with aspirin the initial dose is 40 to 60 mg/ day or 2 mg/kg/day in 4 divided doses for 7 to 10 days. Then the dose is reduced to 1mg/kg/day. It should be tapered off gradually over 12 weeks period and used for patient having carditis with or without CCF. Good nursing care with emotional support to the child and parents in an important as the medication.

• Primary prevention can be achieved by educating the people to avoid streptococcal sore throat and elimination of predisposing factors of the disease Rx of streptococcal pharyngitis with penicillin or other medications can be useful measure to prevent primary attack of rheumatic fever.
• Secondary prevention of the disease can be done by early detection, adequate treatment and prevention of recurrences of rheumatic fever long acting penicillin therapy should be continued every 15 days of 21 days for wt least 5 years from the last attack of rheumatic fever or up to 18 the birthday whichever comes earlier parents should be made aware about the continuation of Rx medical help follow-up.

• Cleftlips: Incomplete fusion of maxillary and premaxillary processes fusion should be completed between 5 to 8 weeks of fetal life.
• Cleft Palate: Incomplete fusion of palate structure may involve soft or hard palate and may extend into nose, forming an oronasal passageway fusion should be completed between 9 to 12 weeks of fetal life.11

• Cleft Lip: Difficulty feeding infant cannot vacuum with mouth to suck, may be able to breastfeed (breast may fill cleft, making sucking easies).
• Mouth breathing dries mucos membrane, predisposing infant to infection.
• Cleft Lip: closure of cleft lip defect procedes that of the palate is performed usually during the first weeks of life.
• Cleft Palate: Repair is performed sometime between 12 to 18 months of age to allow for the palatil changes that take place with normal growth; a cleft palate is closed before the child develop faculty speech habits.

• Cleft lip can range from a slight notch to a complete separation from the floor of the nose.
• Cleft palate can include nasal distortion, midline or bilateral cleft, and variable extension from the uvula and soft and hard palate.

1. Assess the ability to suck, swallow, handle normal secretions of breathe without distress.
2. Assess fluid and calories intake daily and monitor weight.
3. Modify feeding techniques; plan to use specialized feeding techniques, obturators, and special nipples and feeders.
4. Hold the child in an upright position and direct the formula to the side and back of the mouth to prevent aspiration, feed small amounts gradually and burp frequently.
5. Position on side after feeding.
6. Keep suction equipment and bulb syringe at bedside.
7. Encourage breastfeeding if appropriate.
8. Teach the parents special feeding or suctioning techniques.
9. Teach the parents the ESSR (enlarge, stimulate sucking swallow rest) method of feeding and, e.g. enlarge the nipple, stimulate the suck reflex swallow rest to allow the child to finish swallowing what has been placed in the mouth.
10. Encourage the parents to describe their feelings related to the deformity.

• Cleft Lip: Repaired in first few week after birth further modification may be necessary, Aids infant's ability to suck helps parents with visible aspects of the defects.
• Cleft Palate: surgical intervention and repair may occur as early as the neonatal period but not later than between 12 to 18 months done before speech is fully developed.

• The mother should be explained about the proper breastfeeding the bottle feeding to help the infant gain weight.
• The infants should be encouraged to lie on its back to practise for postoperative essential positioning especially with the arm restraints.
• prevent infection from irritation of the lip.12
• Parents should be motivated to provide love and affection to develop an attachment.
• Feed slowly burp frequently bec of swallowed air.
• Instruction should be given the last feed six hours before the surgery.
• Prevent infection from irriation of the lip.

• Maintain patent airway because of edema and infant's habit of mouth breathing, keep Laryngoscope, endotracheal tube and suction equipment nearby.
• Cleanse suture line to prevent crust formation and eventual scarring.
• Minimize crying because of pressure on suture line, encourage a parent to stay with child.
• Place infant in supine position with arm or elbow restaints, change position to side or sitting up to prevent hypostatic pneumonia remove restraints only what infant is supervised.
• Support parents during healing process.

• Cleft Palate Repair
• Child is allowed to lie on the abdomen
• Feeding are resumed by bottle, breast or cup
• Oral packing may be secured to the palate (removed in 2 to 3 days)
• Do not allow the child to brush his or her teeth.
• Instruct the parents to avoid offering hard food items to the child, such as toast or cookies.
• Avoid contact with sharp objects near the surgical site.
• Avoid the use of oral sucion or placing objects in the mouth such as tongue depressor, thermometers, straws, spoons, forks or pacifiers.
• Provide analgesics for pain.
• Instruct the patient in feeding techniques and in the care of the surgical site.
• Instruct the parents to monitor for signs of infection at the surgical site, such as redness, swelling or drainage.
• Encourage the parents to hold the child.
• Initiate appropriate referrals for speech impairment or language based learing difficulites.
• Soft elbow or jacket resptraints may be used [Check agency policies and procedures to keep the child from touching the repair site; remove restraints at least every 2 hours to assess skin integrity and allow for excercising the arms.]

 

1. Growth: It is the process of physical maturation resulting an increase in size of the body and various organs. It occurs by multiplication of cells and an increase in intracellular substance. It is quantitative changes of the body which can be measured in inches/centimeters and pounds/kilograms. It is progressive and measurable phenomenon.
2. Development: It is the process of functional and physiological maturation of the individual. It is progressive increase in skill and capacity to function. It is related to maturation and myelination of the nervous system. It includes psychological, emotional and social changes. It is qualitative aspect of maturation and difficult to measure.13

• Genetic Factors Heredity: Heredity decides size and shape of the body therefore, family members bear resemblance. The characteristics are transmitted through genes that are responsible for family illness, for example diabetes.
• Sex: The sex of children influences their physical attributes and patterns of growth. Sex is determined at conception. A birth, male babies are heavier and longer than the female babies. Boys maintain this superiority until about 11 years of age. Girls mature earlier than boys and bone development is more advanced in girls. But mean height and weight are usually less in girls than boys at the time of full maturity.
• Race and Nationality: Growth potential of different social group is different in varying extent. Physical characteristics of different national groups also vary. Height and stature of Americans and Indians are usually differ because of the differences in growth patterns.

• Maternal Malnutrition: Dietary insufficiency and anemia lead to intrauterine growth retardation. Low birth weight and preterm babies have poor growth potentials. In later life, those children are usually having disturbances of growth and development.
• Maternal Infections: Different intrauterine infection like HIV, HBV, STORCH, etc. may transmit to the fetus via placenta and affect the fetal growth various complications may occur like congenital anomalies, congenital infections, etc. which ultimately affect the growth and development in extrauterine life.
• Maternal Substance Abuse: Intake of teratogenic drugs [thalidomide, phenytoinetc] by the pregnant women in the first trimester affects the organogenesis and lead to congenital malformations which hinder fetal growth. Presence of congenital anomalies in later life influence childhood growth and development. Maternal tobacco intake and alcohol abuse also produce fetal growth restriction.
• Maternal Illness: Pregnancy-induced hypertension, anemia heart disease, hypothyroidism, Diabetes mellitus, chronic renal failase, etc. have adverse effect on fetal growth. Iodine deficiency of the mother may lead to mental retardation of the body in later life.

1. Growth Potential: Growth potential is indicated by the child's size at birth. The smaller the child at birth, the 14smaller she/he is likely to be in subsequent years. The larger the child at birth, the larger she/he is likely to be in later years, low birth wt babies have various complication in later life which retard child's growth.
2. Nutrition: Balanced amount of essential nutrients have great significant role in growth and development of children both quantitative and qualitative supply of nutrition [e.g. protein, fat, carbohydrates, vitamins and minerals] in the daily diet are necessary for promotion of growth and development. Adequate food intake helps the child in body building, energy production/protection from infections. The nutritional requirements during growth period depend upon age, sex, growth rate, level of activity and health status of the child.
3. Childhood Illness: chronic childhood diseases of heart, (congenital heart disease rheumatic heart disease), chest (tuberculosis, asthma) kidney (nephrotic syndrome) liver (cirrhosis) malignancy malabsorption syndrome, digestive disorders, endocrinal abnormalities, blood disorder, worm infestations, metabolic disorders, etc. generally lead to growth impairment. Acute illness like ARI, diarrhea, repeated attack of infection result in malnutrition and growth retardation. Congenital anomolies, accidental injury and prolong hospitalization usually have adverse effect on growth and development.
4. Physical Environment: Housing, living conditions safety measures, environmental sanitation, sunshine, ventilation and fresh air, hygiene safe water supply, etc. are having direct influence on child's growth and development.
5. Psychological Environment: Healthy family good parent child relationslip and healthy interaction with other family members, neighbors, friends, peers and teachers are important factors for promoting emotional, social, intellectual development, Lack of Love, affection and security leads to emotional disturbances which hinders emotional maturity of personality development. Broken family, inappropriate school environment have poor effect on psychological development.
6. Cultural Influences: Growth and development of an individual child are influenced by the culture in which he or she is growing up. The child rearing practices, food habit, traditional beliefs, social taboos, attitude towards health, standard of living, educational level, etc. influence the child's growth and development.
7. Socioeconomic Status: Poor socioeconomic groups may have less fevorable environment for growth and development than the middle and upper groups. Parents of unfortunate financial condition are less likely to understand and adopt modern scientific child care.
8. Climate and Season: Climate variation and seasonal changes influence the child health weight gains is greatest in late summer, rainy season and autumn. Maximum gains in height among children occur in the spring. These variations may be due to difference in activity level.
9. Play and Exercise: Play and exercise promote physiological activity and stimulate muscular development, physical physiological, social, moral, intellectual and emotional development, etc. enchanced by play and exercise.
10. Intelligence: Intellegence of the child influences mental and social development. A child with higher intelligence adjust with environment promptly and fulfil own needs and demands, whereas a child with low level of intelligence fail to do that. Intelligence is correlated to some degree with physical development.
11. Hormonal Influence: Hormones are the important aspect of internal environmental which have vital role in growth and development of the children. All hormones in the body affect growth in some manner. The important three influencing hormones are somatotropic hormone, thyroid and adrenocorticotropic hormone that stimulate to secrete gonadotropic hormone other hormones that less directly influence the process of growth and development include insulin, parathomone, cortisol and calcitonin.

• In Hypotonic Dehydration: The depletion of solutes in ECF is much more than the water losses. Hypotonicity of ECF leads to shift of water from ECF to ICP (Intracellular Fluid). Causing further contraction of ECF and shock.
• Isotonic Dehydration: Isotonic dehydration with proportionate loss of water and solutes from ECF. The ICF volume remains intact as there is no redistribution of fluid.
• Hypertonic dehydration: Excess loss of water proportionate to the solutes causing movement of water from the cells in the ECF (Extracellular fluid) leading to intracellular dehydration.

1. Mild 2. Moderate and 3. Severe Dehydration
   Sign according to the classification are following:

Sign	Mild	Moderate	Severe
Appearance	Normal	Restless	Semicoma
Eyes	Normal Lustrelass	Suken Eyes	tears absent.
Anti fontanella	Normal or slightly	Moderately sukence	well depressed.
(when open)	Suken	Depressed
Skin turger	normal	Moderate loss	Cranial sutures standard
Tongue and mouth	Moist	Moist	Very dry and coated lips
Pulse and heart rate	Normal 130/140/mint	160/180/mint	180/mint.
Extremities	Warm	Warm	cold and clammy
Urine output	Normal	Oliguria	No urine for 12-24 hrs.
Muscle tone	Normal	Normal and increased	flaccid.
Thirst	Thirsty	Extreme thirst	refuse drinks
a. Respiration	Normal	Mild	Deep slighing
b.  Acidosis Alkalosis
Wt Reduction	2.5-5 %	5-10 %	10-15 %

Assessment	Isonatremic dehydration proportionate loss of water and sodium	Hyponatremic dehydration of sodium in excess of water	Hypernatremics loss of water in excess of sodium
Extracellular fluid volume, intracellular fluid volume areas of assessment	Marked decreased maintained	Severely decreased increased	Decreased
Psyche behavior	Lethargic	Coma	Hyperirritable
16
Assessment	Isonatremic dehydration proportionate loss of water and sodium	Hyponatremic dehydration of sodium in excess of water	Hypernatremics loss of water in excess of sodium
Physical signs: loss of body weight.	Infant's mild dehydration up to 5% loss of body wt	Moderate dehydration 5-10% loss of wt and severe −10% loss body wt.	Other child up-to 10 3% to up to 6%
Skin
color +	Gray	Gray	Gray
temp	Cold	Cold	Cold or hot
tugert + +	Poor	Very Poor	Fair
Feel	Dry	Clammy	Thickened, doughy
Mucous membrances	Dry	Slightly moist	Parched
Eyeball	Sunken and soft	Sunken and soft	Sunken
Fontanel	Sunken	Sunken	Sunken
Pulse +	Rapid	Rapid	Moderately rapid
Blood present	Low	Very low	Moderately low
Blood chemistry	BUN: increase	(Blood Urea Nitrogen)	BUN:(Blood Urea Nitrogen)
	Na Decreased	BUN increase	increased
	C1 decreased	Na Decreased
	K Normal or increased	C1 decreased K varies or is increased
			Na decreased or increased CI low during correction
			K decreased

• The successful management of dehydration is infants and children can be possible by accurate assessment of degree of dehydration and initiation of rehydration thereby according to the child's condition.
• Clinical history and physical examination all the major aspects of assessment of hydration status. Details history should include the amount of urine output, vomitus and diarrheal losses physical examination should be done to exclude the signs of dehydration which include dryness of mucous membrane (mouth tongue eyes) absence of tears, sunken eyes, presence of thirst, lethargy or unconsciousness and cold extremities CNS sign sings of shock should be detected for early intervention.

• Laboratory Investigation all essential for further assessment of fluid and electrolyte deficits and to guide the subsequent therapy in severely dehydration patient. These are not essential for starting the management. The most helpful investigation are serum electrolytes, blood urea and creatinine, acid base status plasma, osmolality hematocrit valves and urine specific gravity.17

• “Dehydration to be managed promptly after accurate assessment of hydration status.
• In severe dehydration and shock rapid expansion of intra vascular volume is required to maintain vital functions. This is achieved by rapid intravenous infusion of 100-120 ml of istonic, Isoosmotic solution (ringer's locate) or normal salive or plasma.
  • The goal is to achieve normal urine output correction of potassium deficit and acidosis and to enable the patient return to oral rehydration as early possible.
  • Correction of total fluid deficit by rehydration therapy very important aspect to management by intravenous fluid oral rehydration therapy (ORT)
  • Total correction of fluid and electrolyte deficit can be achieve safely and rapidly through ORT in most of cases with dehydration.
  • In patient with severe dehydration, once the intravascular volume deficit has been corrected and urine flow is established, rest of the deficit can be corrected by ORT.
  • In diarrheal dehydration rapid ORT is superior to conventions slow or rapid intravenous rehydration therapy.
  • Intravenous rehydration is recommended if there is severe dehydration or if there is persistent vomiting, paralytic ileus or child is unconscious or too sick to drink ORS.
  • There should be provision of maintenance fluids and electrolytes balance and replacement of ongoing losses and to monitor the child's hydration status for effective outcome therapy.
  • Mother should be involved during rehydration therapy, especially in ORT.
  • Hydration should be reassessed at regular interval to determine whether rehydration therapy is essential further more or not.
  • Maintenance of intake/output record is vital responsibility of nursing during rehydration therapy.

• Inflammation of the alveoli caused by a virus, mycoplasmal agents, bacteria, or the aspiration of foreign substances
• The causative agent is usually introduced into the lungs through inhalation or from the blood steam.

• Mild fever, slight cough, and malaise to high fever, severe cough
• Nonproductive or productive cough of small amounts of whitish sputum
• Wheezes or fine crackles.

• Fever chills anorexia, headache Malasie, and muscle pain.18
• Rhinitis, sore throat, and dry cough.
• Cough and is nonproductive initially then produce seromucoid sputum that becomes mucopurulent or blood streaked.

• Acute onset fever, toxic appearance
• Infant: irritability, lathargy, poor feeding, abrupt fever (may be accompanied by seizures); respiratory distress (air hunger, tachypnea, and circumoral cyanosis)
• Older child: headache, chills, abdominal pain, chest pain, meningeal symptoms (meningism)
• Hacking, nonproductive cough
• Diminished breath sounds or scattered crackels
• As the infection resolves, coarse crackles and wheezing are heard and the cough becomes productive with purulent sputum.

• Increasing cough and fever with foul smelling sputum
• Deteriorating result on chest X-rays and other signs of airway involvement.

• Affects one or more lobes. Is caused by pneumoncoccuss is seen between the ages of 5 to 15 years.
• Assessment of Lobes Pneumonia.
• Typical breath sound along with the coarse crepitus can be ausculted.

Bacterial	Funal	Viruses	Other
• Pneumococcus	• Cryptococcosis	• Influenza	Aspiration of food, fluid vomitus chemical, etc.
streptococcus	• Histoplasmosis	chickenpox
• Staphylococcus		Measles.
• H. Influenzatuberculosis

1. Antimicrobial therapy is initiated as soon as the diagnosis is suspected.
2. Administer oxygen (via hood, mist tent, or nasal cannula) for respiratory distress as prescribed.
3. Place the child in a mist tent as prescribed; cool humidification moistens the airways and assists in temperature reduction.
4. Suction the infant to maintain a patent airway if the infant is unable to handle secretions.
5. Administer chest physiotherapy and postural drainage every 4 hours as prescribed.
6. Promote bedrest to conserve energy.
7. Encourage the child to lie on the affected side (if pneumonia is unilateral) to splint the chest and reduce the discomfort caused by pleural rubbing.
8. Provide liberal fluid intake (administer cautiously to prevents aspiration) IV fluid may be necessary.
9. Administer antipyretics for fever as prescribes monitor temperate frequently because of the risk for febrile seizers.
10. Institute isolation precautions with pneumococcal or staphylococcal pneumonia (according to agency policy)
11. Administer antitussives as prescribed before rest times and meals if the cough is disturbing.
12. Continuous closed chest drainage may be instituted if purulent fluid is present. [Usually notes in staphylococcus infections].
13. Fluid accumulation in the pleural cavity may be removed by thoracentesis, thoracentesis also provides a means for obtaining fluid for culture and for instilling antibiotics directly into the pleural cavity.
14. Adequate fluid intake should be maintained. The accrued intake and output record should be maintained, if children are in respiratory distress they should not be given anything by mouth. The should be observed for vomiting and distension IV fluid may be prescribed and it should be maintained.
15. Gradually nutritional status should be maintained the adequate proteins, calories vit c all needed to the body resistance sufficient fluids are required to prevent dehydration and help to liquify the secretion.
16. Children should not be disturbed unnecessary.
17. Psychological support should be provided by allowing the parents to be with the children material will help to divert patient's mind and prevent loneliness.

• Pulmonary stenosis
• Ventricular septal defect
• Overriding or dextroposition of the aorta
• Right ventricular hypertrophy.

• Due to structural defects, there is right to left heart shunt causing cyanosis.
• The most vital abnormalities are pulmonary stenosis and VSD.
• Obstruction of blood flow from the RV due to pulmonary value stenosis results in shunting of deoxygenated blood through the VSD into the left ventricle. Then to the aorta causes cyanosis.
• RV hypertrophy develops due to the obstruction.
• The condition is complicated by persistent arterial unsaturation, poor pulmonary vascularity, polychythemia to compensate cyanosis and increased blood viscosity resulting thrombophlebitis and formation of emboli.
• Minimum right do left shunt in small obstruction causes mild from of TOF and termed as pink or acyanotic tetralogy of fallot.20

• Clinical features of TOF depend upon size of VSD of degree of right ventricular outflow obstruction.
• Blue baby or cyanosis of lips nailbeds with dyspnea is found initially with crying and exertion in neonates especially when the ductus arteriosus begins to close.
• As the infant grows, others presenting features are observed, e.g. hypoxic anoxic or blue spells, which occur due to cerebral anoxia. The spell consists of irritability, dyspnea, cyanosis, flacidity with or without unconsciousness. The spell is also termed as Tet-spell and found in the morning soon after awakening, during, or after feeding and painful produces.
  • The child feels comfortable in squatting posture or in lying down position.
  • Slow wt gain and mental slowness are found. By the age of two years, the child usually develops clubbing. CCF is unusual in infants and children suffering from TOF.

• Details history of illness and through clinical examination are important diagnostic approach. Ascultation of soft or systolic ejection murmur heard best at the upper left sternal border in third space P₂ usually single.
• Chest X-ray slows poorly vascularized lung fields a small boot-shaped heart and cancavity of the pulmonary artery segment. There may be right aortic arch.
  • ECG shows right axis deviation and RVH and help to detect ventricular hypertrophy and other changes in cardiac activity.
  • Cardiac catheterization demonstrates the location and size of defects and cardiac changes.

• The child with TOF should be managed for cyanosis, hypoxic spell and other associated complication.
• Oxygen therapy correction of dehydration anemia antibiotic therapy, supportive Nursing care and continuous monitoring of child's condition are very important measures.
• Hypoxic spells should be managed by placing the body in knee chest position, sedatives, oral propranolol therapy, IV fluid, treatment of acidosis, oxygen therapy and administration of IV vasopressors [phenylephrine methoxamine.]
• Oxygen therapy during the spells has limited value. Planning for surgical correction of defects should be done as soon as the child starts having.
• Parents should be taught about the immediate care at home during the spells and necessary medical help.
• Neonate with severe TOF, may be benefited from prostaglandin E, [IV] which causes dilatation of the ductus and allows adequate pulmonary blood flow. It should be administered immediately on diagnosis of cyanotic (CHD).

• Surgical interventions can be planned as palliative surgery or definitive correction in one stage repair may be contraindicated in abnormal coronary artery distribution, multiple VSDs hypoplastic branch of pulmonary arteries and small infant with less than 2.5 kg body wt.
• Palliative surgery is performed by different techniques as modified Blalock-Taussing [BT] shunt. Potts operation or watersen's operation.
  • Blalock: Taussing anastonosis is done to create a communication between the right or subclavian artery and lateral pulmonary artery. This communication improves the blood flow to the long through the pulmonary artery for oxygenation. This is beneficial for children with cardiac failure in early childhood.
  • Waterstone Cooley Shunt: This is the anastomosis between the right pulmonary artery and aorta. Total correction of the defects is carried out at the age of fine to six years.
    • Survived child may slow complete disappearance of cyanosis, clubbing and improvement in growth and development. Specialized nursing care is essential for those children before and after surgery.21

• Hypoxic spells Tet spell polycythemia and CCF may develop in children with TOF.
• Postoperative complication include sudden death due to cardiac arrhythmias, exercise disability complete heart block and operative complications.

• A set of clinical manifestations arising from protein wasting secondary to diffuse glomerular damage defined as massive proteinuria hypoalbuminemia hypelipemia and edema.
• The primary objective of therapeutic management is to reduce the excretion of urinary protein and maintain protein free urine.

• Minimal change nephropathy
• Masangial proliferation
• Focal glameurulo sclerosis
• Immune complex glomerulonephritis
• Membranopriliferative glomerulonephritis.
• Acute poststreptococcal
• Membranous nephropathy
• Congenital nephrosis.

• Infection
• Toxins-Mercurials, bismuth, trimethadione, renographic medium, pencilline, amine, gold, probene acid.
• Allergies-Poison, oak, bee sting serum sickness, fool allergy.
• Cardiovascular-Sick cell disease, renal vein thrombosis, passive congestive heart failure.
• Malignancies: Hodgkin disease, leukaemia carcinoma.

• Pale, irritable and fatigues child
• Child gain wt
• Decrease urine output
• Dark frothy urine, hematuria may be present
• Abdominal ascities
• Waxy pallor of the skin
• Hypertension
• Anorexia anemia
• Amenorrhea or abnormal menses22

• Providing care during hospitalization
• Administering medication
• Maintaining proper fluid balance and assessing edema
• Providing a nutritious diet.
  (See September, 2005 ten year and write down complete nursing care)

1. Causes of meningitis
2. S/S of Meningitis
3. Nursing Management of meningitis

• Meningitis can be classified as:
  1. Pyogenic or bacterial meningitis
  2. Tuberculous Meningitis

• Sudden with high fever, headache, malaise, vomiting restlessness, irritability and convulsions.
• The neonates may present with insidious onset of refusal of feeds, high-pitched shrill cry, hypothermia, seizures, jaundice, lethargy and bulging fontanel.
  • Mental confusion with varying degree of alteration of level of consciouses, marked photophobia, generalized hypertonic and marked neck rigidity.
  • An examination meningeal signs are found as neck stiffness, positive kernig's sign, positive brudzinski's signs and papilledema.

• Clinical manifestations are important diagnostic clue. The diagnosis is confirmed by lumber puncture and CSF study.
• CSF examination shows turbid appearance, with increased cell count mainly poly morphonuclear leukocytes. There is increased protein level (more than 100 mg/dl) and decreased sugar (below 40 mg/dl/) in CSF.
• Causative organism can be identified form CSF examination and culture. There is elevation of CSF pressure more than normal.
• Other diagnostic approaches are CT scan, Rapid diagnostic tests, (counter current immune electrophoresis latex agglutination, etc.)
• Routine examination of blood, urine analysis, X-ray skull and chest may help to exclude associated pathology.

• Pyogenic meningitis should be considered as medical emergency and following measures should be initiated promptly.23
• The specific antibiotic therapy is the important aspect of management. The commonly used drugs are: penicillin 4 to 5 lac units/kg/day 4 hourly or cefotaxime 200 mg/kg/day 8 hourly I/V or ceftriaxone 150 mg/kg/day BD.
• Ampicillin, gentamycin, amikacin, or chloramphenical can also be used depending upon the causative organisms, combination of two antibiotics can be administered. Antibiotics can be given intrathecal in neonatal meningitis and in advanced cases.
• Corticosteroids dexamethasone, 0.15 mg/kg every 6 hrs. IV is administered in severely ill patient with shock and to prevent neurological complications.
• Osmotic diuretic therapy is given with mannitol (20%) 0.5 mg/kg every 4 to 6 hours IV for maximum 6 doses to reduce the increased intracranial pressure.
• Anticonvulsive drugs, diazepam 0.3 mg/kg is given to manage convulsions other anticonvulsive like phenoberbitone or phenytoin can be also be used or phenytoin can also be used.
• Vasopressors (dopamine) may be required in case of hypotension.

• Nursing management should be performed based on subjective and objective data to formulate Nursing diagnosis, to plan and implement Nursing Interventions.
• In general the nursing management should be provided with rest comfortable position in rail cot bed with calm quiet dim lighted noise free environment.
• Important nursing measures include change of position, clearing of airway by removing oropharyngeal secretion, oxygen therapy.
• Tapid sponge in case of fever for reduction of body temperature.
• Maintenance of IV fluid therapy.
• Nasogastric tube feeding, dietary support and administration of prescribed medications.
• Maintenance of personal hygiene (skin care, mouth care, eye care) and bladder bowel functions are also significant.
• Prevention of injury continuous monitoring of patient condition care during convulsion, emotional support and teaching the parents about continuation of care after discharge are also important nursing responsibility.

• Pyogenic meningitis can be complicated with several neurological systemic complication.
• The complications include shock, myocarditis, status epilepticus SIADH (Syndrome of inappropriate ADH secretions), subdural empyema or effusion, ventirculitis, arachnoditis, hydrocephalus, brain abscess convulsive disorders, mental retardation neurological deficit. (like hemiplegia, ocular palsies, blindness, speech problems deafness) obesity and precocious puberty.

• Prodromal stage: It is the first stage of illness and the stage of invasion. It is presented with vague features like, low grade fever, anorexia, drowsiness apathy, headache, vomiting, irritability disturbed sleep, restlessness, constipation, loss of wt photophobia, and sometimes with convulsion.
• Transitional stage: It is the second stage of illness and also termed as stage of meningitis. In this stage the child is manifested with features of increased ICP and meningeal irritation. The presenting features are positive24 kernig's sing, neck rigidity along with fever bradycardia, drowsiness delirium, headache, vomiting respiratory disturbance and even unconsciousness. Increased muscle tone and convulsions are usually present. Neurologic deficits like monoplegia, hemiphegia, loss of sphincter control may develop. In infant anterior fontanel may be found bulging. Cranial nerve involvement ocular paralysis, nystagmus and contracted pupils are common findings. Papilledema may present.
• Terminal and third stage: It the stage of come. This stage is manifested with paralysis and come. The child present with fever irregular respiration and bradycardia, pupils are dilated and fixed often unequal with nystagmus and squint. Ptosis and ophthalmoplegia are common. This condition may become fatal if left untreated for 4 weeks. Hydrocephalus develops in small children and infants, if the treatment is delayed or done inadequately.

• History of illness in details along with family history of illness and history of contact with TB cases are important for diagnosis. The most important diagnostic procedure is CSF study by lumber puncture.
• Increased CSF pressure, clear or slight turbid appearance of CSF, increased cell count with presence of lymphocytes and cobweb formation in CSF (when kept in test tube for 12 hrs) are dependable information to diagnose TBM.
• Other supportive investigation are chest. X-Rays to detect primary focus X-ray skull, CT scan, Mantoux test, routine blood examination especially ESR and newer diagnostic approach like biochemical markers serodiagnosis and molecular diagnosis.
• Test for HIV infection should be performed in all suspected and at risk patient.

• Prompt management of TBM with adequate treatment for prolonged period should be provided.
• Antitubercular drugs should be given for 12 months, initially four drugs are given with INH, rifampicin, pyrazinamide mid and ethambutol or streptomycin for two months. Then, continuation phase, three drugs are given with INH, rifampicin and ethambutal for 10 months.
• Adverse effects of the AT drugs should be monitored, specially auditory and vestibular nerve toxicity of streptomycin and ocular complication of ethambutol specific instruction for the AT drugs should be followed.
• Parenteral corticosteroid therapy with dexamethasone for one to two weeks is useful to reduce cerebral edema and prevention of arachnoiditis with fibrosis, after wards, oral steroids should be continued with prednisolone for 6 to 8 weeks and then gradual tapered off.
  Other symptomatic management includes mannitol (or glycerol or hypertonic glucose therapy) to reduce increase ICP, anticonvulsive drugs (diazepam, phenobarbitone) to control convulsions and IV fluid therapy to treat dyselectrolytemia and to maintain fluid electrolyte balance.
• Pyridoxine (20 mg) orally once a day to be given to prevent side effects of INH.
• Supportive nursing care, maintenance of nutritional requirements (NG tube feeding or oral feeding) and monitoring of features of complications, especially measurement of head circumference, daily, to detect hydrocephalus are important measures.
• Ventriculo peritoneal shunt may be indicated in some cases with hydrocephalus.

• Hydrocephalus is most common complication of TBM, other complication include mental retardation, spasticity, cranial nerve paralysis, convulsive disorders, neurological deficits (hemiplegia, quadriplegia) endocrinal disturbance, bladder bowel dysfunction, optic atrophy and visual complication.25

• Dietary: Overfeeding, Indigestion. Imbalance diet deficiency of diasaccharides.
• Infective: Bacterial E.coli, shigella, Salmonella
  • Viral: Enterovirus
  • Palasitic: Protozoa.
• Parasites: E Histolytica, G lambia, H nana, malaria, etc.
• Fungal: Candide albicans
  • Parenteral: due to infections outside the gastroenteral tract such as urinary tract infection, otitis media and upper respiratory infection.
  • Noninfectious causes of diarrhea: congenital anormalies of G1 tract, malabsorption syndrome inflammatory bowel disease, inappropriate use of laxative and purgatives, emotional stress and excitement.

• Secretary Diarrhea
• Osmotic Diarrhea
• Motility Diarrhea

• The clinical presentation of diarrhea disease may very with severity, specific cause and type of onset.
• Dehydration is the important life threatening feature which is usually associated with diarrhea.
• Diarrhea stool are usually loose or watery in consistency. It may be greenish or yellowish green in color with offensive smell. It may contain mucus pus or blood and may expelled with force, preceded by abdominal pain. Frequency of stools varies from 2 to 20 per day or more.
• The child may have low-grade fever.
• Thirst, anorexia with intermitted vomiting and abdominal distention.26
• Behavioral changes like irritability, Restlessness, weakness, lethargy, sleepiness, dilirium, stupor and flaccidity are usually present.
• Physical changes like loss of wt, poor skin turgor, dry mucous membranes, dry lips, pallor sunken eyes, depressed fontanelles are usually found.
• The vital signs are changed as low blood pressure, tachycardia, rapid respiration cold limbs and collapse.
• There is decreased or absent urinary output.
• Convulsions and loss of consciousness may also present in some children with diarrhea diseases.

• Physical examination with through history of illness and assessment of degree of dehydration are important diagnostic criterias for prompt initiation of management.
• Stool examination can be done for routine and microscopic study and identification of causative organisms.
• Blood examination can be performed to detect electrolyte imbalance acid base disturbances, hematocrit value TC, DC, ESR, etc. the suspected associated cause should be ruled out for adequate management.

• Rehydration therapy: The management of diarrhea in a vast majority of children is best done with ORS (Oral rehydration Salts) solution and continued feeding.
• Replacement of fluids by rehydration therapy is the principal measure.
• It can be provided by ORT (Oral rehydration therapy) or IV fluid therapy shows standard formation of ORS as recommended by WHO and approved by government of India.
• Ingredients of oral rehydration salts.

Component	Content per litter water
Sodium chloride	3.5 gm
Potassium chloride	1.5 gm
Sodium citrate	2.9 gm
Glucose anhydrous	20.0 gm

• To be diluted in one litter of potable water
• Mix entire content of the packed in one litter of water
• ORS solution to be used within 24 hours of preparation or means drinking of solution of clean water sugar and mineral salts to replace the water and salt lost from the body during diarrhea, especially when accompanied by vomiting, e.g. gastroenteritis, ORT is beneficial in three stages of diarrheal disease, e.g.
  • Prevention of dehydration
  • Rehydration of the dehydration child. Maintenance of hydration after severely dehydrated patient has been rehydrated with IV fluid therapy. ORT is provided with ORS solution have available fluid, e.g. fruit juices, tender coconut water, dal soup sarbat (with sugar and salt and lemon) weak tea, etc.

• Monitor the character, amount and frequency of diarrhea.
• Monitor skin integrity
• Monitor electrolyte level
• For mild to moderate dehydration provide oral rehydration therapy; avoid carbonated bevarages and those containing high amount of sugar.
• For severe dehydration maintain NPO status to place the bowel at rest and provide fluid and electrolyte replacement by IV as prescribed if potassium is prescribed by IV ensure that the child has voided prior to administering.27
• Reintroduce a normal diet once rehydration is achieved.
• Provide enteric isolation is required.
• Instruct the parents in good handwashing technique.
• Provide proper rest to the children.
• Change diapers as soon as soiled, avoid use of plastic pants.
• Cleans buttocks with warm water after each stool apply protective ointment to provide skin barrier (remove before applying heart to area).
• Prevent spread of infection protect surrounding area from contamination by use of a pad in bed or caregiver's lap.
• Antimicrobial therapy may or may not affect the course of the diarrhea depending on the causative agent
• Enterotoxigenic E.coli responds to oral rehydration therapy with tatracycline being used in infant who are several ill. Enterpathogeni E.coli is treated with neomycin enteroinvasive as well as shigella may respond to ampicillin when therapy is indicated.
• Antibiotics especially ampicillin, amoxicillin and chloramphenicol may be given to young infant who have salmonella.

• The important preventive measures are improvement of food hygiene, personal hygiene and environment hygiene.
• These include safe water, adequate sewage disposal handwashing practices clean utensil, avoidance of exposures of food to dust and dirt, fly control.
• Washing of fruits and vegetable, etc.
• Avoidance of bottle feeding is most significant practice needed for prevention of diarrhea.
• Boiling or filtering to be practiced for safe drinking water.

• Primary Caregiver: Pediatric nurse should provide preventive promotive curative and rehabilitative care in all level of health services, as therapeutic agent. She/he acts as care finder and compassionate skilled caregiver as needed by the today's society. In hospital are of the sick children, e.g. comfort, feeding, bathing, safety, etc. are the basic responsibilities of the pediatric nurse. Health assessment, immunization, primary health care and referral are basic responsibilities at the community level as quality care provider.
• Health Educator: Important role of the pediatric nurse is to deliver planned and incidental health teaching and information to the parents, significant others and children to create awareness about health lifestyle and maintenance of health.
• Nurse Counselor: Problems solving approach and necessary guidance in health hazards of children to minimize or to solve the problem to help the parents and family members for independent decision –making in different situations are essential role of the pediatric nurse in the present health care delivery system.
• Social Worker: Pediatric nurse can do case work especially for children and try to alleviate social problems related to child health she/he can participate in available social services or refer the child and family for necessary social support from the child welfare agencies.
• Manager: The pediatric nurse is the manager of pediatric care units in hospital, clinics and community, she/he should organize the care orderly for successful outcome with better prognosis and good health.
• Child Care Advocate: Child or family advocacy is basic aspect to comprehensive family centered care. As an advocate the pediatric nurse can assist the child to obtain best care possible from the particular units.28
• Nursing Consultant: The pediatric nurse can act as consultant to guide the parents and family members for maintenance and promotion of health and prevention of childhood illness. The nurse can promote self-care within the family and prepare self care agent for the children who are unable to take care of their own health. The nurse can help the older children to become responsible for their own lives. The nurse assess the children's ability to do self-care activities and assist them in developing the ways of self care and self responsibility.
• Coordination: The nurse play an important role in the health team by coordinating activities related to patient care, which are interdependent on various health team workers and department. The communication and coordination may be direct or indirect depending on health care system.
• Researcher: Nursing research is and integral part of professional nursing. Pediatric nurse should participate or perform research projects related to child health. Clinical and applied research provide the basis for changes in nursing practice and improvements in the health care of children.
  In brief, the pediatric nurse can provide comprehensive care to the infant and children including guidance to the parents about their role in the child care.

Criteria	0	1	2
1. Respiration	Absent	Slow, irregular	Good crying
2. Heart Rate	Absent	slow (Below 100)	More than 100
3. Muscles Tone	Flaccid	Some flexion of extremities	Active body movement
4. Reflex Response	No Response	Grimace	Cry
5. Skin Color	Blue Pale,	Body pink extremities blue	Completely Pink

Total score	–	10
No depression	–	7 to 10
Mild depression	–	4-6
Severe depression	–	0-3

• 1 to 2 months: Able to lift the chin momentarily on prone position. Able to regard bright colored object at 20 cm distance. Cries when hungry or at discomfort. Able to turn hard toward sound and smiles back to the mother or caregiver.
• 2 to 3 months: Able to lift head and front part of the chest by supporting wt on extended arms. Can fallow moving object with steady eye movement and able to focus eyes. Produce cooing sound and enjoy people taking with her/him able to recognize mother and turn head to sound.
• 4 to 5 months: Can held head steadily in upright position able to hold a rattle and bring to mouth can reach a thing and grasp it crudly with palm. Make coos, gurgles and respond by making sounds. Join hands together in play enjoy people and lough out loudly.
• 5 to 6 months: Able to sit with support can hold with cube and transfer from one hand to other. Try to immitate sound and enjoy own mirror image.
• 7 to 8 months: Can sit without support and roll in bed from back to side than back to abdomen. Produce bubles and say ‘aam’, ‘da’, ‘da’ recognize unknown person and show anxiety resists toys to be taken from him/her.
• 8 to 9 month: Able to crawl on abdomen speak Da-Da and Ma-ma combrining syllables without meaning.
• 9 to 10 month: Able to creep on hand and knees can stand with support and cruiser around furniture. Able to pick-up a pallet with thumb and index finger understand emotions like anger, anxiety, wave-bye-bye and want to please caregiver, say ba-ba ma-ma with meaning.
• 10 to 12 months: Can stand without support and walk holding furniture. Able to feed himself/herself with spilling. Pick-up small bits of food and take to mouth able to push toy can alone and play simple ball game can speak 3-5 meaningful words and understand meaning of several words respond for affection by kiss.
  • Toddles: 15 months: able to walk alone, can walk several steps sidewise and few steps backward can feed himself or herself without spilling. Able to turn 2-3 pages at a time.
  • 18 Months: Can creep upstairs able to feed from cup-take shoes and socks off. Want potty, point the parts of body, if asked, build tower of two blocks and stop taking toys to mouth use 6 to 20 words copy mother's action.
  • 2 years: Able to run and try to climb upstairs by resting on each step and then climbing upon next put shoes and socks on can remove pants, build tower of six to seven blocks can copy and draw a horizontal and ventrical line. Control bladder at day time speak simple sentences without use of verb.
  • 3 years: Can walk on tip toes and stand on one leg for second. Jump with both feet. Climb upstairs by co-ordinated manner. Ride tricycle can dress and undress. Brush teeth with help can drawer a circle build tower of nine blocks has vocabulary of about 250 words. Repeat three numbers (once in three times) know own name and sex. Achieve bladder control at night (dry by night) fear dark. Interact and play simple games with peers.
  • Pre Schooler 3 to 6 years: Can jump and hop. Able to draw a cross (+) by 4 years and titled cross (x) by 5 years of age can draw a rectangle by 4 years and a triangle by 5 years. Able to copy letter, can tell stories and describe recent experience. Become independent, impatient, aggressive physically and verbally. Jealous of sibling but gradually improve in behavior and manner.
  • School Age: 6 to 8 years: Able to run, jump hop and climb with better coordination. Able to write better and take self care. Able to use complete sentence to express feeling and follow commends. Play in group learn discipline. Appreciate praise and recognition.
  • 8 to 10 years: Play actively with different physical skill. Improved writing skill and speed. Use short and compact sentences. Participate in family discussion. Peer group involvement and increased awareness about sex role.
  • 10 to 12 years: Develop more coordinated, skilful manipulative activities and games. Able to use parts of speech correctly. Accepts suggestion and instruction obediently. May slow short burst of anger.30

• The breastfeeding provides close physical contact between the neonate and the mother which provides satisfaction. It provides an opportunity for infant mother attachment.
• Human milk is available at the required temperature in required strength is fresh and free from contamination as it directly comes in he baby's mouth.
• Human milk contains more lactalbumin, a more complete protein then case in because of its high percentage of amino acids. It is more easily digested because of safe curds. Therefore, stomach emptying is rapid and thus requires frequent feeding.
• Extra lactose helps in synthesis of certain vitamins. It also contains a high amount of cystine, an amino-acid that may be essential during the neonatal period.
• Human milk contains high amount of lactose, a disaccharide, that is converted into monosaccharide glucose and galactose. Lactose is essential for the growth if the central nervous system unsaturated fatty acids in the human milk help absorption of fat and calcium in the neonate. Iron in human milk is absorbed better in the neonate.
• The human milk contains increased amount of antibodies immunoglobulin A (IgA) which gives immunity to the neonate against certain disease. These antibodies are present in a high amount in the colostrum than in mature milk, in the intestines, it acts against bacteria and viruses lactoferin also inhibits the growth of bacteria.
• It contains lactalbumin bifidus which help in suppressing E-coli lactobacillus bifidus help to produce lactic acid, to prevent bacterial growth and make the stools acidic.
• Breastfeeding help the mother in rapid involution of the uterus and lesser chance of breast cancer.

1. The mother's desire to feed is the first requirement for successful lactation. She should be psychologically prepared to feed she should drink milk juice or water before feeding.
2. She must wash her hands before feeding.
3. She should be physically and emotionally relaxed and comfortable.
4. She can sit comfortably with a support at the back. It is advisable to hold the baby in her lap.
5. If she is unable to sit, she may feed by lying on her side with a pillow under the shoulder.
6. She must check whether the baby has soiled the linen. If required the baby should be cleaned and dried to make the baby comfortable, before feeding.
7. The baby's head should be supported and slightly raised. The baby may be held in a semi-sitting position with his/her head close to the breast and supported with one arm.
8. The cheek of the baby should touch the nipple so that by rooting reflex the baby can get to the nipple and letdown reflex is encouraged.
9. If the breast is firm and full, it should be pressed with the first finger to prevent pressing of the baby's nose. Both breasts should be fed at each time, alternately, using each breast first if possible one breast (which is given first) should be completely emptied at the alternate feeding.
10. During the first few days most of the babies fall asleep after taking a few sucks. They should be aroused by gently tickle behind the ear or on the sale of the foot.
11. Before removal of the baby from the breast, it is necessary to break sucking by putting a little finger into the corner of the baby's mouth.
12. Every baby swallows some air during the feeding and should be held upright and patted on the back until the air is belched. If too much air is swallowed and not removed, the baby may have vomiting, colic, or fretfulness. After feeding, if required, the diaper should be changed.
13. After feeding, the baby must be positioned on right side or on the abdomen.31

• Psychological Factor: A shock strong pain, anger, anxiety or worry can affect the “let down” refax. The mother should be encouraged and given support by a calm and positive attitude to develop a confidence that any difficulties may be overcome. She should be explained the proper technique of relaxation and feeding. She should make sure that the neonate is sucking and should be encouraged to feed more often to increase sucking stimuli. In a case of severe anxiety sedative may be ordered by the doctor for a short time.
• Early Breast Engorgement: During the early period after delivery, breast may be felt full and uncomfortable. Some mothers get hard engorged breasts with the pain. This problem can be solved by application of warm compresses to the breast and then expressing the excess milk, later, the milk production gets adjusted according to demand of the baby.
• Flat and Inverted Nipple: If nipples are flat and it is difficult for the baby to get hold of the nipple and pull it into the mouth stimulation of the sucking reflex may be interrupted. A flat or inverted nipple may be pulled outward with the fingers to stimulate erection. After making the nipple erect, the baby can be gently put to the breast. If it is not successful, the nipple shield may be used some babies who get accustomed to the nipple shield may be reluctant to return to the mother's nipple. Therefore, wearing a specially prepared plastic cup between the feeding may be helpful.
• Score Nipple: Nipples may be sore because of faulty sucking techniques such as the baby takes an insufficient amount of areola surrounding the nipple into the mouth, while nursing. Also, it may be sore due to the long period of vigorous sucking, sucking in a bad position, engorged breast fissures, and oral thrush of the baby sore nipples are very painful.
  Sore nipples can be prevented by proper antenatal care decreasing the length of the feeding time and increasing the frequency of feeding may also help. The use of soap on the breast should be avoided as it cause drying. The cream may be used by the doctor's advice or any edible oil can be applied on the nipple between feed.

11. Withdrawn National Immunization Schedule.

Beneficiaries	e g A	Vaccine	Dose	Route
a. Infant	• at birth	BCG OPV	• Single zero dose	Intradermal oral	0.5 ml 2 drops
	• At 6 weeks	• BCG if not given at birth	Single	Intradermal	0.1 ml
		DPT-1	1st	Intradermal	0.5 ml
		OPV - 1	1st	Oral	2 drops
		Hepatitis B-1	1st	IM	0.5 ml
	At 10 weeks	• DPT-2	2nd	Intramuscular	0.5 ml
		• OPV-2	2nd	oral	2 drops
		• Hepatitis B-2	2nd	Intramuscular	0.5 ml
	At 14 weeks	• DPT-3	3rd	Intramuscular	0.5 ml
		• OPV-3	3rd	Oral	2 drops
		• Hepatitis B-3	3rd	Intramuscular	0.5 ml
	At 9 months	• Measles	Single	S/C Subutaneous	0.5 ml
b. Children	• At 16-24 months	• DPT	Booster	IM	0.5 ml
		• OPV	Booster	Oral	2 drops
	• At 5-6 years	• DT	Single	IIM	0.5 ml
		• DT	Second dose if not given	IM	0.5 ml
	• At 10-16 years	• TT	Single	IM	0.5 ml
		• TT	Second dose of TT should be given if not vaccinated previously	IM	0.5 ml
Pregnant women	Early in pregnancy	TT-1	1st	IM	0.5 ml
	One month after	T-T-2	2nd	IM	0.5 ml

• Prevention of accidents requires three things. That is forethought, time and discipline first is the forethought that is the anticipation of possible risk of accidents to the child. Second is time which is needed sufficiently to supervise and watch the child and his activities. Third is the discipline, which need to be well balanced to present the accidental hazards.
• Parents play a major role in prevention of accidents and safety precautions. Family members also need to contribute to follow the safety measures to prevent this hazards. In hospital, nursing personal are responsible to maintain safety precautions to prevent accidents.
• The safety precautions according to various age groups are follows.
  For Infants:
  • Never leave an infant alone on clot or table or in unprotected place to prevent fall.
  • Never give very small things to the child.
  • Toys should not have removable small parts which can be aspirated or put into the ear or nose.
  • Never feed solids which are difficult to chew, e.g. groundnut.
  • Coins, buttons, breads, marbles must not be left within child's reach.
  • Keep the shave or fire source and hot things far way from the child.
  • Electrical appliances should be kept out and reach.
  • Never leave the light near water tub or pond and never allow to go out alone.33

• Never use negative statement for any activities, e.g. don't do ‘that’, don't go theres, etc.
• Give proper directions for activity.
• Provide constant supervision.
• Protect stairs by gate and keep doors closed.
• Keep harmful substance like hot things, drugs, poisons, kerosine oil, electrical appliances, sharp object, etc. out of child's reach.
• Give adequate instructions to the care taker to look after the child and to follow the precautions.
• Provide safe playmaterials and toys.
• Floor should not be slippery.
• Furniture should be placed firmly to prevent fall and the child should not be allowed to climb over it.
• The child should not be allowed to climb over it.
• The child must not be allowed to wear inflammable synthetic materials which may catch fire easily.
• Mother should not hold the baby in lap when drinking tea of coffee or during cooking.
• Children must not be allowed to stand in a car when in motion.
• Electric switch should be out of child's reach.

• Teach safety precautions with fire, fire works, match box, electricity, sharp instruments, etc.
• The child should be taught swimming as soon as he/she is old enough.
• Encourage playing in safe places and supervise game wherever needed to present sports injury.
• Discourage the children from kite flying from rooftops and playing door banging games and from closing the doors with eat lot of force.
• Children must not be allowed to play on streets, they should be taught about road safely, use of zebra crossing and cautions in bicycles or tricycles riding.
• Never left the child alone in the car unless it has been ensued that the keys all not “in”.

• Health education is considered as vaccination for preventions of accidents. The significant role of nursing personnel is to improve the level of knowledge and awareness about the safety precautions.
• Parents should be taught to anticipate the risk, to maintain discipline and to provide time to supervise children. Anticipatory guidance should be provided to the parents, family members, school teacher, grown up children and general public about prevention of accidents.
• Provision of safe environment to eliminate or reduce the hazardous conditions for the children. It should be arranged at home, school community and hospitals.
• Safe child care should be organized and provided to prevent accidental hazards. Assessment of child's characteristics for accidental liability is important. Parents should be involved in safety program of child care. Elimination of consative factors need to the emplasized through health education.
• Assisting in medical care to prevent disabilities and handicapped condition is an important responsibility of the nurse.
• Emergency care at comprehensive trauma care unit improves the survival rate. Rehabilitation facilities should be organized with necessary referral.
• Public health measures regarding prevention of accidents should be implemented. Traffic rules restriction of speed, use of helmets, avoidance of alcohol while driving, regular checking of vehicle, etc. must be strictly enforced. Nurse should make the people aware about the strict implementation of rules.
• Participate in policy making and research activities related to accidents prevention and changing behavior for controlling accidents.34

 

1. Define the following:
   1. Patient ductus arteriosis
   2. Spina Bifida
   3. Delinquency
   4. Hypospadias
   5. Apgar Scoring

2. A seven years old child admitted in hospital, diagnosed as Nephrotic Syndrome.
   1. What are the causes of Nephrotic Syndrome?
   2. Enlist the clinical features of Nephrotic Syndrome.
   3. Write its Nursing management.

3. Write down the four (4) Clinical Manifestations of the following:
   1. Marasmus
   2. Rheumatic fever
   3. Megaclon
   4. Glomerulonephritis
   5. Tonsillitis

4. Write short notes on any three (3) of the following:
   1. Advantages of Breastfeeding
   2. Phototherapy
   3. Fallot's Tetralogy
   4. Immunization Schedule
   5. Factors affecting growth and development.

 

1. Patient ductus arteriosis
2. Spina Bifida
3. Delinquency
4. Hypospadias
5. Apgar Scoring

• Spina bifida occulta
• Spina bifida Cystic
• Meningocele
• Meningomyelocele

1. What are the caused of nephrotic syndrome?
2. Enlist the clinical feature of nephrotic syndrome.
3. Write its nursing management.

Primary renal causes	Systemic causes
• Minimal change nephropathy	1. Infections
• Mesangial Proliferation	2. Toxins: mercurial, bismuth, trimethadione, renographic, medium, penicillamine, Gold, probenecid.
• Focal Glomerulosclerosis	3. Allergies: Poison oat, Bee sting, serum sickness, fool allergy.
• Immune complex glomerulonephritis	4. Cardiovascular: Sick cell disease, renal vein thrombosis, congestive heat failure.
• Acute post streptococcal glomerulonephritis	5. Malignancies: Hodgkin disease, leukemia, carcinoma.
• Membranous nephropathy	Other: amyloidosis, multiple myeloma, systemic lupus
• Congenital nephrosis.	erythematosus, anaphylactoid purpura.

• Pale, Irritable, and fatigued child
• Child gain weight
• Decrease urine output
• Dark, frothy urine, hematuria may be present
• Abdominal ascites
• Waxy pallor of the skin
• Hypertension
• Anorexia
• Anemia
• Amenorrhea or abnormal menses.

• Defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema.
• The primary objective of therapeutic management is to reduce the excretion of urinary protein and maintain protein-free urine.
  The Goals of Nursing Management Include:
• Providing Care during hospitalization
• Administering medications36
• Maintaining proper fluid balance and assessing edema
• Providing a nutritious diet
• Preventing infection
• Preventing skin breakdown
• Promoting optimal psychosocial growth
• Providing emotional support and education for all family members.

• Sodium restriction is prescribed during period of massive edema.
• Normal protein intake is usually prescribed.

1. eumatic fever

3. Megacolon
4. Glomerulonephritis
5. Tonsillitis

• The drawn features, wrinkled skin and hollow temples of the children give them and appearance of an old man.
• Skin loos dry, scalp and prominent loose folds and having reduced mild-upper arm circumference.
• Superadded Infection: are common, skin infections and diarrhoea and vomiting and abdominal distention usually occur.
• Gross wasting of muscle and subcutaneous tissue.
• Psychomoter changes usually prevent and irritability, apathy and miserable appearance.
• Feature of mineral deficiency (anemia) and vitamin deficiencies all usually found.

• Aschoff bodies [Lesions] Found in: The heart, blood vessels, brain and serous surface of the joints and pleura.
• Signs of Carditis: Shortness of breath, edema of the face, abdomen or ankles.
• Signs of polyarthritis: Inflammation of large joints and joint pain.
• Elevated sedimentation rate.
• Chorea: Sudden, aimless, irregular movements of the extremities, involuntary facial grimaces, speech disturbances, of muscle weakness.

• Abdominal distension
• Vomiting may be bile stained/fecal strained.
• Constipation
• Overflow type diarrhea
• Anorexia.

• Child is pale, irritable and weak.
• Gross hematuria or dark, smoky, cola-colored or red-brown urine.
• Proteinuria that produces a persistent and excessive foam in the urine
• Oliguria and anuria
• Urine debris, moderate to high specific gravity low urinary pH.
• Increased blood urea nitrogen and creatinine38
• Azotemia
• Abdominal or flank pain
• Edema in the face and per orbital area, feet or generalized
• Hypertension and headache.

• Painful swallowing and fever.
• Mouth breathing and an unpleasant mouth odor.
• Enlarged bright red tonsils that may be covered and white exudate.
• Persistent or recurrent sore throat.
• Child feel uncomfortable due to persistent cough.

1. Advantages of Breastfeeding
2. Phototherapy
3. Fallot's Tetralogy
4. Immunization Schedule
5. Factors affecting growth and development

• The Breastfeeding Provides Close physical contact between the neonate the mother which provides satisfaction. It provides an opportunity for infant-mother attachment.
• Human milk is available at the required temperature in required strength and is fresh and free from contamination as it directly comes in the baby's mouth.
• Human milk contains more lactalbumin, a more complete protein than casein because of its high percentage of amino acids. It is more easily digested because of soft curds. Therefore, stomach emptying is rapid and thus requires frequent feeding.
• Extra, lactose help in synthesis of certain vitamin. It also contains a high amount of cysteine, an amino acid that may be essential during the neonatal period.
• Human milk contains higher amount of lactose, a disaccharide that is converted into monosaccharide glucose and galactose. Galactose is essential for the growth of the central nervous system unsaturated fatty acids in the human milk help absorption of fat and calcium in the neonate, Iron in human milk is absorbed better in the neonate.
• The human milk contains increased amount of antibodies immunoglobulin A [IGA] which gives immunity to the neonate against certain disease. These antibodies are present in a high amount on the colostrum then in mother milk. In the intestines, it acts against bacteria and viruses lactoferin also inhibits the growth of bacteria.
• It contains lactalbumin bifidus which help in suppressing E.coli Lactobacillus bifidus help to produce lactic acid, to prevent bacterial growth and make the stools acidic.
• Early breastfeeding helps the mothers in rapid involution of the uterus and lesser chance of breast cancer.

• Preventing rapid rise in serum bilirubin level
• After and exchange transfusion
• Low serum protein
• Prophylactic phototherapy.

• Baby is undressed completely but diaper is kept an on to protect the gonads.
• Eyes are covered and eye patches to prevent damage to retina.
• Nude baby is kept under the light source at a distance of 45 cm.
• The baby is turned every 2 hours or after each feed to expose maximum area of skin to light.
• Baby should be given frequent breastfeedings but no supplements of extra water or milk is required.
• Phototherapy is stopped when serum bilirubin returnes to a safe valve as per unit protocol.

• Temperature every 2 hours
• Ensure adequate breastfeeding so that baby passes urine 6-8 time/day
• Daily wt record
• Serum bilirubin as per unit protocol
• Side effects of phototherapy include skin rash, loose greenish stools, hypothermia or hyperthermia, dehydration, [excessive wt loss] bronze baby syndrome, skin of the baby becomes bronze colored when a baby and conjugated hyperbilirubinemia is placed under light.

• Pulmonary stenosis
• Ventricular septal defect
• Overriding or dextroposition of the arota
• Right ventricular hypertrophy.

• Cyanotic episodes: Spells may occur while crying and after feeding. After cyanotic spells, there may be limpness, fatigue and fainting.
• Blue baby or cyanosis of lips and nailbeds and dyspnea is found initially and crying and exertion in neonates especially when the ducts arteriosus begins to close.
• The child feel comfortable in squatting posture or in lying down position.
• Slow weight gain and mental slowness are found.
• By the age of two years, the child usually develops clubbing.
• CCF is unusual in infants and children suffering from TOF.
• Pansystolic murmur may be heard at the middle to lower sternal border.
• Clubbing of the fingers and toes.

• Details history of illness and through clinical examination are important diagnostic approach.
• Auscultation of soft or- harsh systolic ejection murmur heard best at the upper left sternal border in third space, P2 is usually single.
• Chest X-Ray shows poorly vascularized lung fields, a small boot-shaped heart and small size of pulmonary artery.40
• ECG shows evidence of light ventricular hypertrophy.
• Blood examination, Red blood cells and hemoglobin are increased.
• Cardiac catheterization demonstrates the location and size of defects and cardiac changes.

• Medical Management: The child and TOF should be managed for cyanosis, hypoxic spells and other associated complication oxygen therapy, correction of dehydration, anemia, antibiotic therapy, supportive nursing care and continuous monitoring of child's condition all very impotent measures.
• Hypoxic spells should be managed by placing the baby in knee-chest position, sedatives oral propranolol therapy, I/V fluid treatment of acidosis, oxygen therapy and administration of IV vasopressors [phenylephrine methoxamine]. Oxygen therapy during the spells has limited value. Planning for surgical correction of defects should be done as soon as the child starts have spells, parents should be taught about the immediate care at home during the spells and necessary medical help.

• Surgical interventions can be planned as palliative surgery or definitive correction in one stage repair, one stage repair may be contraindicated in abnormal coronary artery distribution multiple VSDs, hypolastic branch of pulmonary arteries and smell infant with less then 2.5kg body wt.
• Palliative Surgery is performed by different techniques as modified blalock - Taussing shunt potts operation or waterson's operation.
• Definitive correction is performed by direct vision open heart surgery for patch close of VSD and relief of right ventricular obstruction total correction carries a mortality of 15. Long term follow-up of the survived cases is very essential to monitor child's conditions and early detection of complication.
• Survived child may slow complete disappearance of cyanosis clubbing and improvement in growth and development.
• Specialized nursing care is essential for here children before and after srgery.

Beneficiaries	Age	Vaccine	Dose	Route	Amount
(a) Infants	a birth	BCG	Single	Intradermal	0.05 ml
		OPV	Zero dose	Oral	2 drops
	At 6 month	BCG (if not given at birth)	Single	Intramuscular	0.1 ml
		DPT-1	1st	Intramuscular	0.5 ml
		OPV-2	1st	oral	2 dorps
		Hepatitis-B-1	1st	Intramuscular	0.5 ml
	At 10	DPT	2nd	Intramuscular	0.5 ml
		• OPV	2nd	oral	2 drops
		• Hepatitis B-2	2nd	Intramuscular	0.5 ml
	A to 14	DPT-3	3rd	Intramuscular	0.5 ml
	Weeks	OPV	3rd	oral	2 drops
		Hepatitis B-2	3rd	Intramuscular	0.5 ml
	At 9 month	Measles	Single	Subcutaneous	0.5 ml
41
Beneficiaries	Age	Vaccine	Dose	Route	Amount
(b) Children	At 16-24	DTP	Booster	Intramuscular	0.5 ml
	month	OPV	Booster	Oral	2 drops
	At 5-6 year	DT	Single	Intramuscular	0.5 ml
	At-10 to 16	TT	Single	Intramuscular	0.5 ml
Pregnancy	Early in pregnancy	TT-1	Ist	IM	0.5 ml
	One month After	TT-2	2nd	IM	0.5 ml

• Immunization schedule should be planned according to the needs of community. It should be relevant with existing community. It should be relevant with existing community health problems. It must be effective, feasible, and acceptable by the community. Every country has its own immunization schedule.
• WHO, lunched global immunization programs in 1974, knew as expanded program Immunization to protect are children of the world against six killer disease. In India, EP1 was lunched in January 1978.
• The EPI is now renamed as universal child immunization, as per declaration sponsored by UNICEF. In India, it is called as Universal Immunization program was lunched I n 1985. November, for the universal Coverage of immunization to be eligible population.

• Heredity: Heredity decides size and shape of the body. Therefore family members bear resemblance. The characteristics are transmitted though genes that are responsible for family illness for example-diabetes.
• Race: Similar physical characteristics are seen people belonging to same race.
• Sex: A male infant is longer and heavier then female.
• Intrauterine development: Maternal nutritional deficiencies, drugs, and infections during pregnancy can have effect on the growing fetus.
• Illness and Injury: Illness may reduce the wt and cause hindrance in the child's progress.
• Nutrition: Quality and Quantity of food consumed by the child have effect on his/her body building and resistance.
• Environment: Better sunshine, clean surrounding, fresh air and socioeconomic status can affect parenting, thus children's development. Emotionally sound, warm and caring environment which promote parent child positive interactions enhance the development.
• Emotions: Lack of parent-child attachment, lack of love and security in children can distort the personality. The disturbed children neither sleep nor eat well as one who is happy.
• Exercise: Exercise stimulate physical activity and muscular development.

 

1. Define the following:
   1. Convulsion
   2. Fallots tetralogy
   3. Hydrocephalus
   4. Intussusception
   5. Croup

2. Write down the four signs and symptoms of the following:
   1. Scabies
   2. Small Pox
   3. Anemia
   4. Fracture
   5. Nephritis42

3. A 9 years old child admitted in hospital, diagnosed as a case of pneumonia:
   1. What are the causes of pneumonia
   2. Enlist signs and symptoms of Pneumonia
   3. Discuss in detail the nursing management

4. Write short notes on any two of the following:
   1. Difficulties in breastfeeding
   2. Bedwetting
   3. Fractures and accidents in Children
   4. Growth and development form 1 to 5 years

 

1. Convulsion
2. Fallots tetralogy
3. Hydrocephalus
4. Intussusception
5. Croup

• Convulsion: It is a symptom of neurological disorder. Paroxysms of involuntary muscle contraction and relaxation.
• Fallots tetralogy: Follots tetralogy is most common cyanotic congenital heat disease. This condition is characterized by the combination of four defect.
  1. Pulmonary stenosis
  2. Ventricular Septal defect
  3. Overriding or dextroposition of the aorta
  4. Right ventricular hypertrophy.
• Hydrocephalus: Hydrocephalus is the abnormal accumulation of cerebrospinal fluid itn the intracranial spaces. It occurs due to imbalance b/w production or absorption of or due to obstruction of the CSF pathways. It results in the dilatation of the cerebral ventricles and enlargement of head.
• Intussusception: Telescoping of one portion of the bowel into another portion. Results in and obstruction to the passage of intestinal contents.
• Croup: It refers to the symptom of complex characterized by barking cough, stridor and respiratory difficulty usually due to formation of diphtheritic membrane and due to obstruction in the larynx.

• Q.2. Write down the four sign and symptoms of the following.
  1. Scabies
  2. Smallpox
  3. Anemia
  4. Fracture
  5. Nephritis

• Burrows [Fine greyish red lines that may be difficult to see] on the skin. Between fingers, in the wrist and axillary or buttock folds.
• Skin lesions as papules and vesicles.
• The skin lesions may also found along the belt line, on the male genitatia and female breast, on the knees, elbows and ankles, or may occur in any part of the body, even face, neck and scalp.
• Excoriation of skin and watery exudate.43

• General malaise,
  • Sudden onset o fever
• Papulovesicular lesions on skin
• Vomiting
• Headache
• Backache
• Typical rashes appears which are centrifugal.

• Late symptoms may include: Pallor [skin nail bed, mucous membrane] weakness, vertigo, headache, malaise and drowsiness.
• Other features: Sore tongue, G1 problems, tachypnea, palpitations, stortness of breat on exertion, tachycardia, etc.

• Pain or tenderness over the involved areas
• Loss of function
• Obvious deformity
• Crepitation
• Ecchymosis
• Edeme
• Muscle spasm.

• Fever
• Hypertension
• Oliguria
• Edema
• Backache
• Urine looks smoky, bloody.

1. What are the causes of pneumonia
2. Enlist signs and symptoms of pneumonia
3. Discuss in detail the nursing management.

Bacterial	Funal	Viruses	Others
Pneumococcus	Crytococcosis	Influenza	Aspiration of food, fluid vomits chemicals
Streptococcus	Histoplasmosis	Chickenpox
Staphylococcus		Measles
H. Influenza
Tuberculosis
44

• Viral pneumonia mild fever, slight cough and malaise to high fever severe cough
  • Wheezes or fine crackles.
  • Nonproductive or productive cough of small amount of whitish sputum.
• Primary atypical pneumonia:
  • Fever, chills, anorexia, headache, malaise and muscles pain.
  • Rhinitis, sense throat, and dry hackling cough.
• Bacterial pneumonia: Acute onset fever, poor feeding, older child headache, chills, abdominal pain, chest pain.

• Administer oxygen (via hood, mist tend, or nasal cannale) for respiratory distress as prescribed.
• Place the child in a mist tent as prescribed cool humidification moistens the airways and assists in temperature reduction.
• Suction the infant to maintain a patient airway is the infant is unable to handle secretions.
• Administer chest physiotherapy and postural drainage every 4 hours as prescribed.
• Promote bedrest to conserve energy.
• Encourage the child to lie on the affected side [If pneumonia is unilateral] to splint the chest and reduce the discomfort caused by pleural rubbing.
• Provide liberal fluid intake [administer cautiously to prevent aspiration] IV fluid may be necessary.
• Administer antipyretics for fever as prescribed monitor temperature frequently bec of the risk for febrile seizures.
• Institute isolation precautions and pneumococcal or staphylococcal pneumonia (according to agency policy).
• Administer antitussive as prescribed before rest times and meals if the cough is disturbing.
• Continuous closed chest drainage may be instituted if purulent fluid is present [Usually noted in staphylococcus infections].
• Fluid accumulation in the pleural cavity may be removed by thoracentesis, thoracentesis aslo provides a means for obtaining fluid for culture and for instilling antibiotics directly into the pleural cavity.

• Q.4. Write short notes on any two of the following:
  1. Difficulties in breastfeeding
  2. Bedwetting
  3. Fractures and accidents in children
  4. Growth and development for 1 to 5 years

• Psychological Factors: A shock, strong pain, anger, anxiety or worry can affect the “Let-down” reflex.
• Early Breast engorgement: During the early period after delivery, breasts may be felt full and uncomfortable, some mothers get hard engorged breast with the pain.
• Flat and inverted nipple: If nipples are flat and it is difficult for the baby to get hold of the nipple and pull it into the mouth. Stimulation of the sucking reflex may be interrupted.
• Sore Nipple: Nipples may be sore because of fault sucking technique, such as the baby takes an insufficient amount of areole surrounding the nipple into the mouth. While nursing, also it may be sore due to long period of vigorous ‘sucking’. Sucking in a bad position, engorged breast, fissures, and oral thrush of the baby, sore nipples are very painful.45

• Premature babies and weak babies.
• The baby may have a blocked nose and be unable to suck properly.
• Respiratory infection.
• Congenital defects such as cleft lip and palate.

• Emotional Factors: Responsible for enuresis are hostile or dependent parent-child relationship, dominant parent, punishment, sibling rivalry, emotional deprivation due to insecurity and parental death.
• Environmental Factors: Like dark passage to toilet or cold or fear of toilets or at distance from bedroom may cause bedwetting at night.
• Organic factor: May present, e.g. spina bifida, neurogens bladder, juvenile diabetes mellitus, seizure disorder, etc.
• Other Factors: Include the child with emotional conflict and tension, small bladder capacity, improper toilet training and deep sleep and inability to receive the signals from distended bladder to empty it.

• Primary
• Secondary

• Primary or persistent enuresis is characterized by delayed maturation of neurological control of urinary bladder, when the child never achieved normal bladder control usually due to organic cause.
• In Secondary or regressive enuresis: The normal bladder control is developed for several months after which the child again starts bedwetting at night usually due to regressive behavior like illness and hospitalization or due to any emotional deprivation.

• The home conditions, socioeconomic status, and habits of the family should be found out.
• Child-parent relations should be explored. Parent and child should be interviewed separately. Understanding the child's relationships and playmates, teachers and siblings is also important.
• Analysis of the time of bedwetting, frequency, and relation to sleep should be done.
• The child and parent should be explained about the factors related to bedwetting.
• Parents should be explained about enuresis and asked to take precautions against scalding, shamming, threatening and punishing the child.
• The child should be helped to get relief from the feeling of shame, guilt, and parental rejection. They should be encouraged to develop self-confidence. Modification in routine may be helpful.
• Restriction of fluids in the evening and helping the child in developing the habit of passing urine before going to bed.46
• He/She may be woken up four hours after sleep and made to pass urine again.
• Drug therapy and tricyclic antidepressant [Imipramine] are useful.
• Condition therapy by using electric alarm bell mattress is a effective and safest method, when the child wakes up as soon as the bed is wet.
• Supportive psychotherapy is important for child and parent.
• Changes of home environment to remove the environmental causes all essential.

• Fracture: A break in the continuity of the bone as a result of trauma, twisting, or bone decalcification.
• Fractures in children usually result from increased mobility and inadequate or immature motor and cognitive skills.
  Fractures in children may result from trauma or bone disease. The most frequently seen fracture in children is located in the forearm.

• Pain or tenderness over the involved also
• Loss of function
• Obvious deformity
• Crepitation
• Ecchymosis
• Edema
• Muscle Sperm.

• Open fracture: It is a type of fracture in which a wound though the adjacent or overlying soft tissues communicates and the site of the break, it is also termed as compound fracture.
• Closed fracture: The fracture that does not produce on open wound in the skin.
• Plastic deformation (Bending): A bending of the bone occurs in such a manner as to cause a microscopic fracture line that does not cross the bone. It is unique to children and commonly found in the ulna.
• Buckle [torus fracture]: A fracture occurring on the tension side of the bone near the softer metapyseal bone. It crosses the bone and buckles the harder diaphyseal bone on the opposite site causing a bulge. The bone cortex is not broken but is buckled.
• Green stick fracture: A fracture in which the bone is partially bent and partially broken, as a green stick breaks. The bone is bent and the fracture begins but does not entirely. Cross through the bare.
• Complete fracture: A fracture in which the bone is completely broken, neither fragment is connected to the other. This fracture can be spiral, oblique transverse and epiphyseal.

• Initiate care of a fracture:
  • Assess the extent of injury and immobilize affected extremity.
  • If compound fracture exists, splint the extremity and cover the wound and a sterile dressing.
• Immobilization of the fractured part by plaster cost, splint or brace:
  • Closed reduction followed by a period of immobilization in the cost of splint.
  • Closed reduction: Accomplished by manual alignment of fragments, followed by immobilization.
  • Open reduction: Required the surgical insertion of internal fixation devices such as rods, wires or pins, the help maintain alignment while healing occurs.
  • Retention: The application of traction or a cost to maintain alignment until healing occurs.47
  • Most childhood fractures usually heal within 12 weeks or less, presence of wound needs special attention and aseptic precautions.
  • Care of the child and plaster cast and tractions are the most important nursing responsibility.
  • Provide proper nutrition for early healing.

• Common Accidental Injury in Different Age Groups:
• Infant: Falls, burns, cuts and injury, suffocation, foreign body [aspiration, infection in ear, nose, etc.]
• Toddlers and preschoolers: Falls, burns, cuts and injuries, infection and aspiration foreign bodies, drowning and near drowning poisoning, electrocution, suffocation and strangulation, bites and stings, vehicle or road-traffic accidents, sports injury, etc.
• School age children and adolescents: Sports injury, falls, electrical or instrumental injury, road-traffic accidents bites and stings, drawing, etc.

• Health education is considered as vaccination for prevention of accidents. The significant role of nursing personnel is to improve the level of knowledge and awareness about the safety precautions, parents should be taught to anticipate the risk, to maintain discipline and to provide time to supervise children.
• Provision of safe environment to eliminate or reduce the hazardous conditions for the children, It should be arranged at home, school, community and hospitals.
• Safe child care should be organized and provided to prevent accidents hazards.
• Assisting in medical care to prevent-disabilities and handicapped condition is an important responsibility of the nurse.
• Participate in policy making and research activities related to accidents prevention and changing of believes for centrally accidents.

• 12 months: Can stand without support and walk holding furniture, able to feed himself/herself and spilling pick-up small bits of food and take to mouth. Able to push to by car alone and play simple ball game. Can speak 3-5 meaningful words and understand meaning of several words, respond the affection by kiss.
• 15 to 18 month: Able to walk alone, can walk several steps sidewise and few steps backwards. Can feed himself or herself without spilling. Able to turn 2-3 pages at times 18 month can creep upstairs. Able to feed from cup. Take shoes and shocks off. Want potty point the parts of body, if asked. Build tower of two blocks and stop taking toys to mouth use 6 to 20 words copy mother's action.
• 2 Years: Able to run and try to climb upstairs by resting on each step and then climbing up on next. Put shoes and socks on can remove pants, build tower of sex seven blocks, can copy and draw and horizontal and vertical line. Control bladder at day time [dry by dry]. Speak simple sentences without use of verb.
• 3 years: Can walk on tip-toes and stand on one leg for second. Jump and both feet, climb upstairs by coordinated manner. Ride tricycle, can dress and undress brush teeth with help can draw a circle, build tower of nine blocks. Has vocabulary of about 250 words. Repeat three numbers [Once in three times] know own name and sex, achieve bladder control at night, fear dark, interact and play simple games and peers.48

 

1. Define the following terms:
   1. Growth and development
   2. Hypospadiases
   3. Encephalitis
   4. Apgar score
   5. Croup

2. Write in detail the growth and development of a child up to 5 years of age:
   1. Normal important milestones up to 5 years so °356/128 PD.
   2. Write the factors affecting growth and development of child.

3. 1. Define diarrhea
   2. Enlist the causes of diarrhea in a child up to 5 years of age
   3. Write the management of 5 years child who has developed diarrhea.

4. Write Short notes on any two of the following:
   1. Breastfeeding
   2. Nursing responsibility during steam inhalation
   3. Role of play and toys
   4. Phototherapy

 

• Q.1. Define the following terms:
  1. Growth and development
  2. Hypospadiases
  3. Encephalitis
  4. Apgar score
  5. Croup

1. Normal important milestones up to 5 years.
2. Write the factors affecting growth and development of child.

• By the age of 5 years, he or she can jump and hop.
• Able to tilted cross [×] by 5 years of age.
• Can tell stories and describe recent experience.
• Become independent, impatient, aggressive physically and verbally.
• Psychosocial development: The schoolers are interested in the meaning of relations. They talk to imaginary friends.
  • They project in imaginary play what is bad in themselves.
  • They learn the social norms.
  • They like to take responsibility.
  • Their aggression in turned toward their parents. By five year, they are cooperative, sympathetic and usually generous with their toys.
  • The preschoolers are interested in stories and they like outside world.
  • Preschooler's emotional tone may change suddenly. They watch adults and attempt to innitate their behaviors. They are imaginative and creative.
  • Their temper tantrum is and decrease. They are understand better. They are less rebellious then before. They may be afraid of darkness and loneliness.

a. 6 to 8 weeks b. 3 months c. 5 to 6 months d. 5 to 6 months e. 6 to 7 months f. 7 to 8 months g. 9 months h. 10 to 11 months i. 10 to 12 months j. 12 to 15 months k. 18 months	• Social smile • Head holding • Sitting with support • Reaches out to an object and holds it • Transfers object from one hand to other • Sitting without support • Holding small object b/w index finger and thumb • Creeping • Standing without support and says two words with meaning • Feeding self with spoon and walking without support • Running, says ten words with meaning.
50
l. 20 to 24 month m. 24 month n. 36 month o. 2 years p. 3 years q. 3 to 4 years r. 5 years	• Climbing up stairs, says simple sentence • Puts shoes and socks on • Tell story • Controls bladder and bowel at day time • Controls bladder and bowel at night time • Dresses self fully, Rides a tricycle, Know full name and sex. • Can play games, and tilted cross [×] by 5 years of age and triangle by 5 years.

1. Dietary:
   1. Overfeeding
   2. Indigestion
   3. Imbalanced diet
   4. Deficiency of diasaccharides.
2. Infective:
   1. Bacterial: Ecali, shigella, salmonella
   2. Viral: Enterovirus
   3. Parasitic: Protozoa
   4. Fungal: Candida albicans.
3. Parenteral: Due to infections outside the gastroenteral tract such as urinary tract infections, otitis media, or upper respiratory infection.
4. Noninfectious caused of diarrhea: Congenital anomalies of GI tract, malabsorption syndrome, inflammatory bowel disease, inappropriate use of laxative and purgatives, emotional stress and excitement.

• Monitor vital signs.
• Monitor the character, amount, and frequency of diarrhea.
• Monitor I/o and for signs of dehydration.
• Monitor electrolyte levels.
• For mild to moderate dehydration, provide oral rehydration therapy. Avoid carbonated beverages and those containing high amounts of sugar.
  1. For sever dehydration, maintain, NPO status to place the bowel at rest and provide fluid and electrolyte replacement by IV as prescribed, if potassium is prescribed by IV, ensure that the child has voided prior to administering:51
     • Reintroduce a normal diet once rehydration is achieved.
     • Provide enteric isolation as required.
     • Instruct the parents in good handwashing technique.
     • Provide proper rest to the children.
     • Change diapers as soon as soiled, avoid use of plastic pants.
     • Clean buttocks and warm after each stool apply protective ointment Vaseline to provide skin barrier [remove before applying heat to area]
     • Prevent spread of infection protect surrounding area from contamination by use of a pad in bed or on caregiver's lap.
     • Antimicrobial therapy may or may not affect the course of the diarrhea depending on the causative agent.
     • Enter toxigenic E. coli responds to oral rehydration therapy with tatracycline being used in infant who call several ill.
     • Enteropathogenie E. Coli is treated and neomycin, enteroinvasive E. Coli as well as shigella may respond to ampicillin when therapy is indicated.
     • Antibiotics, especially ampicillin, amoxicillin, and chloramphenical may be given to young influant who have salmonella.
     • ORS: Provide oral rehydration solution to 5 years old child in amount of 1000 ml solution/24 hours parent education.
     • The parents of these seriously ill infant and young children are anxious about their child condition.
     • Their anxiety may frequently be verbalized as concern about the use of isolation technique.
     • The parents should be supported especially when their children cannot have anything by mouth and when they are on IV fluid.
     • The parents should be explained about.
       • Use of boiled and cooled water for drinking.
       • Parents should be explained about the early signs of diarrhea and dehydration.

1. Breastfeeding
2. Nursing responsibility during steam inhalation
3. Role of play and toys
4. Phototherapy.

• The breastfeeding provides close physical contact b/w the neonate and the mother which provides satisfaction. It provides an opportunity for infant mother attachment.
• Human milk is available at the required temperature in required strength and is fresh and free from contamination as it directly comes in the baby's mouth.
• Human milk contains more lactalbumin, a more complete protein than casein because of its high percentage of amino acids. It is more easily digested because of self curds, Therefore, stomach emptying is rapid and thus requires frequent feeding.
• Early breastfeeding helps the mother is rapid involution of the uterus and less chance of breast cancer.
• It contains lactalbumin bifidus which help in suppressing E-coli lactobacillus bifidus help to produce lactic acid, to prevent bacterial growth and make the stools acidic.52

• The mother's desire to feed is the first requirement for successful lactation. She should be psychologically prepared to feed. She should drink milk, juice or water before feeding.
• She must wash her hand before feeding.
• She should be physically and emotionally relaxed and comfortable.
• She can sit comfortably with a support at the back. It is advisable to hold the baby in her lab.
• If she is unable to sit, she may feed by lying on her side and a pillow under the shoulder.
• She must check whether the baby has soiled the liner. If required the baby should be cleaned and dried to make the baby comfortable before feeding.
• During the first few days most of the babies fall asleep after taking a few sucks. They should be aroused by gentle tickle behind the ear or on the sole of the foot.
• Every baby swallows same air during the feeding and should be hold upright and patted on the back until the air is a belched.
• After feeding, the baby must be positioned on a right sick or on the abdomen.

• Psychological factors
• Early breast engorgement
• Flat and inverted nipple
• Sore nipple

• Explain the procedure to the parents to win their confidence and cooperation.
• If the patient can understand, explain him and if he cannot then make his parents understand that the pt has to remain in the bed for one to two hours after inhalation.
• Help the pt to empty bowel and bladder before procedure.
• Place the child in comfortable position, possible in the lap of his mother and cover and blanket.
• Close the doors and windows and put off the fan to prevent draught.
• Always remember the danger involved of scalding the pt either with steam or water. Instruct the mother never let the child touch the inhaler.
• When jug or kettle is used, fill it only 2/3 with boiling water to prevent scalding of the pt.
• Have the water in the jug method at a moderate temperature. It should not be too hot or too cold.
• When volatile drugs all used, warms the patient's mother to keep the eyes of the child covered to prevent the drug irritation of conjunctiva.
• Water the pt closely throughout the procedure for any adverse effects.

• Play is universal for all children. It is work for them and ways of their living. It is pleasurable and, e.g. enjoyable aspect of child's life and essential to promote growth and development.
• Play help in development of children in various aspects, e.g. physical, intellectual or educational, emotional, moral and social.
• Toys: These are the things to play and especially for a child or made in the limitation of the specified things and used for playing with, e.g. housekeeping toys that work doll accessories, paper doll sets, simple sewing machine, needle work, building toys:
  • Simple word, number, and card games that require increase skill.
  • Physically active games such as hopscotch, jump rope, bicycle riding toy car or toy gun, etc:
    1. Physical development: enhanced during play. Muscular and ability developed at the time of running, climbing, riding cycle and in other active play. These activities help to strengthen muscle and to learn 53coordinated movement and skills. The young children learn to differentiate the sensations by visual, auditory and tactile, stimulations through the use of play materials.
    2. Intellectual and education development: Promote during play, children, lear color, size, shape, number, distance, height, speed, name of the objects, etc. While playing and various toys and play things, creative activity, problem-solving, abstract thinking, imagination communication speech development occur during play. It helps them to experience thrill of achievement.
    3. Emotional development: Play improve emotional development. Children express their fear, anxiety, anger, joy, etc. during play. It reduces stress and strain and removes irritability and destructiveness, thus enhance the coping abilities.
    4. Moral development: Play is the means of moral development. Children learn morality from parents, teachers, and other adults during play with peers, child's behaviors will reflect the right and wrong things, honesty, and behaviors will reflect the right and wrong things, honesty, sportsmanship and value system. They learn norms of moral behavior and responsibility. They become creative and independent through play they learn sex-role behavior in play.
    5. Social Development: Children develop the capacity to cooperative and their peer. Group play provides opportunities to develop skills and social interactions to realize the consequences of behavior on other children become a social being through play. Play help in socialization.

 

1. 1. Discuss the role of pediatric nurse for child care.
   2. Explain the immunization schedule.

2. 1. Write the importance of breastfeeding.
   2. How a nurse can contribute for promotion of breastfeeding

3. 1. What are the causes and types of anemia in children?
   2. Discuss the nursing care of child having anemia.

4. What is Fallot's tetralogy? Write the nursing care of a child having fallot's tetralogy.

5. What is spina bifida? What is the nursing care of a newborn having spina bifida.

6. Write short notes any five of the following:
   1. Marasmus
   2. Prevention of home accidents
   3. Psychiatric Nursing
   4. Vitamin deficiency disease
   5. Rheumatic fever
   6. Pyloric stenosis
   7. Nursing care of child having diarrhea
   8. Hemophillia54

 

• The role of the pediatric Nurses is both caring and curing caring is a continues process in both wellness and illness. It refers as helping, guiding and counseling
• Curing refers to the act of diagnosis and management, usually during illness. Pediatric nurse have the responsibilities of providing nursing care in hospital, home, clinic, school and community where children and their parents health and counseling needs:
  • Primary caregiver: Pediatric nurse should provide preventive, promotive, curative, rehabilitative care in all levels of health services, as therapeutic agent. She/he act as case finder and compassionate skilled caregiver as needed by the today's society. In hospital, care of the sick children, e.g. comfort, feeding, bathing, safety, etc. are the basic responsibilities of the pediatric nurse. Health assessment, immunization, primary health care and referral are basic responsibilities at the community level as quickly care provided.
  • Health education: Important role of the pediatric nurse is to deliver planned and incidental health teaching and information's to the patients, significant others and children to create awareness about healthily lifestyle and maintenance of health change in health behavior and attitude and to develop healthful practice regarding child care should be initiated by Pediatric nurse as change agent, teacher and health educator.
  • Nurse-counselor: Problem-solving approach and necessary guidance in health hazards of children to minimize or to solve the problem and to help the parents and family members for independent decision-making in different situations are essential role of the pediatric nurse in the present health care delivery system.
  • Social-worker: Pediatric nurse can do case work especially for children try to alleviate social problems related to child health. She/he can participate in available social services or refer the child and family for necessary social support from the child welfare agencies.
  • Team coordinator and collaborator: Pediatric nurse should work together and in combination and other health team members towards better child health care. She/he should act as liaison among the member and maintain good interpersonal relationship. The nurse interprets the objectives of health care to the family and coordinates nursing services and other services necessary for the child. Cooperation and good communication among term members should be promoted by the nurse.
  • Manager: The pediatric nurse is the manger of pediatric care units in hospital, clinics and community. She/he should organize the care orderly for successful outcome and better progressive and good health.
  • Child care advocate: Child or family advocacy is basic aspect to comprehensive family centered care. As an advocate, the pediatric nurse can assist the child to obtain best care possible from the particular units. Advocacy can range from consulting dietary department for special food to arrange team meeting to discuss plan of care.
  • Researcher: Nursing research is an integral part of professional nursing. Pediatric nurse should participate or perform research projects related to child health clinical and applied research provide the basis for changes in nursing. Practice and improvement in health care of children.

• Immunization schedule should be planed according to the needs of the community. It should be relevant and existing community health problems. It must be effective, feasible and acceptable by the community. Every country has its own immunization schedule.
• The important asped in the child care, is to protect children against specific preventable disease. There are a few common dangerous infections in the childhood which are preventable by immunization, such as poliomyelitis, diphtheria, pertussis, measles, rubella and hepatitis B.
• The immunization against these diseases, stimulate the child's body to produce immunity against specific infections.55

• Interval b/w 2 doses should not be less than one month.
• Minor cough, colds and mild fever or diarrhea are not a contraindication to vaccination.
• In same states hepatitis ‘B’ vaccine is given as routine immunization.
• Interruption of the schedule with a delay b/w does not interfere and the final immunity achieved. There is to basis for the mistaken belief, that if a second or third dose in an immunization is delayed, the immunization schedule must be started all over again so, if the child missed a dose, the whole schedule need not be repeated again.

• There are the some following points to discuss with the mother to promote breastfeeding:
  • The mother should be encouraged and given support by a calm and positive attitude to develop a confidence that any difficulties may be overcome. She should be explained the proper technique of relaxations and feeding, she should make sure that the neonate is sucking and should be encouraged to feed more often to increase sucking stimuli. In a case of severe anxiety, sedative may be ordered by the doctor for a stort time.
  • Early beast engorgement: During the early period after delivery, breast may be felt full and uncomfortable. Some mothers get hard engorged breasts with the pain. This problem can be solved by application of warm compresses to the breast and then expressing to excess milk. Later, the milk production gets adjusted according to demand of the baby.
• Flat and inverted nipple: If nipples are flat and it is difficult for the baby to get hold of the nipple and pull it into the mouth. Stimulation of the sucking reflex may be interrupted. A flat or inverted nipple may be pulled outward and the fingers to stimulate erection. After making the nipple erect, the baby can be gently put to the breast. If it is not successful, the nipple-shield may be used. Some babies who get accustomed to the nipple shield may be reluctant to return to the mothers’ nipple; therefore, wearing a specially prepared plastic cup b/w the feeding may be helpful.
• Some nipples can be prevented by proper antenatal care. Decreasing the length of the feeding time and increasing frequency of feeding may also help. The use of soap on the breast should be avoided as the causes drying. The cream may be used by Doctor's advice or any edible oil can be applied on the nipples between feed.
• Diet of the mother should be well balanced and extra protein calcium and iron.
• The nurse should tell the mother that with the stimulus of sucking by newborn, the production of milk start.

• Inadequate iron storage during intrauterine period.
• Prematurity, twin baby.
• Maternal anemia and inadequate iron intake in diet due to prolonged breastfeeding or feeding and cow's milk.
• Delayed weaning, ignorance about child care, poverty, etc.

• There are several possible causes, including chronic exposure to myelotoxic agents, viruses, infection, autoimmune disorders, and allergic states.
• Acquired aplastic anemia: May occur due to viral infection, or bacterial or parasitic infection. It may develop due to infiltration of malignant, chemicals, (DDT) and drugs (chloramphenical antimetabolites).
• Congenital: It is inherited as an autosomal recessive condition.

• Inheritance of a gene for a structurally abnormal portion of the hemoglobin chain.
• Hgbs is sensitive to changes in the oxygen content of the RBC.
• Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstruction capillary blood flow.

• Folic acid deficiency: It is almost always found along with vit C deficiency and or iron deficiency.
  Caused by:
  • Dietary deficiency of nutrient.
  • Use of goat milk for infant feeding
  • Malabsorption syndrome
  • Prematurity diarrheal disease and in association with hemolytic anemia and drug therapy and anticonvulsant and antifolic acid agent.
• Vitamin B₁₂Deficiency
  Vit B₁₂ deficiency may develop due to dietary inadequacy, lack of intrinsic factor in the stomach, inhibition of B₁₂ and intrinsic factor complex malabsorption and infants of B12 deficient mothers.57

• Nursing care of a child with IDA should include rest, diet containing iron and protein rich food.
• Improvement of dietary intake, specially iron and protein containing food should be emphasized.
• Iron therapy can be administered in oral route, IM or IV route as single total dose infusion, depending upon the child's condition, oral iron therapy is given with elemental iron dose. 3 to 6 mg/kg/day in divided doses in b/w meals.
  The duration of Rx may vary from 3 to 6 months, side effects should be observed and necessary modification may be done as needed.
• Parental iron therapy is indicated in oral intolerance defective absorption and poor compliance.
  • Blood transfusion is indicated only in severe case of anemia, where Hbs to need to be increased quickly.
  • Increasing awareness about prevention of IDA is essential measure that need to be promoted by health education.

• Management of the condition includes mainly supportive care, bone marrow transplantation and immunotherapy.
• Treatment of infections and bleeding are important.
• Blood transfusion and steroid therapy to be given.
• Children with mild to moderate aplastic anemia can be treated and androgens for 3 to 5 moths or more.

• Nursing are by blood transfusion, parenteral fluid therapy.
• Treatment of infections, analgesics, correction of acidosis and other symptomatic and supportive care.
• Folic acid and other vitamin supplementation are given.
• Newer treatment modalities include red cell Hbg concentration reduction agent, membrane active agent and bone marrow transplantation.

• Administration of deficient folic acid and or vit B12 in oral or parenteral route. Vitamin C also need to be administered.
• Associated causative factors to be managed accordingly, dietary improvement is very essential.

• Adequate antenatal care for prevention of maternal anemia and iron-folic acid supplementation to all antenatal mother.
• Prevention of preterm delivery or low-birth weight and control of infections in prenatal, natal and neonatal period.
• Introduction of semi-solid and solid foods from 4 to 6 months of age as complementary feeding.
• Universal immunization to all children and adolescent girls.58
• Adequate Rx of parasitic infestation, chronic illness and IDA.
• Improvement of living condition by avoidance of open air defection, practicing environmental sanitation, hygienic measures, wearing of shoes, balance diet and preventive measures of nutritional deficiencies.

• Spina bifida also called neural tube defects. It is a congenital malformations of the CNS resulting from a defective closure of neural tube during early embryogenesis b/w 3rd and 4th week of intrauterine life.
• It occur in about 1 to 5 per 1000 line birth.

• Prevent local trauma: To covering over the spina bifida is thin and therefore the neonate should be handled carefully. The baby should be placed in prone position. The soft protective covering should be applied over the lesion and padding should be applied around the sac. The routine nursing care of the neonate may be modified to prevent injury and provide comfort.
• Prevention of local infection: According to the doctor order the meningomyelocele should be cleansed with aseptic precaution by using sterile normal saline or hydrogen peroxide and cotton and sterile dressing should be applied. The site should be observe for abrasions, tears or infection. If any change is observed it should be reported.

• The antibiotics should be administered in time.
• The head circumference must be measured daily for detection of hydrocephalus. Also other signs of hydrocephalus should be notified should as high pitched cry, irritability, and difficulty in taking feeds.
• Prevention of urinary tract infection: Contamination with stool should be prevented.
  • The urinary bladder should be periodically emptied by compressing.
  • The fluid intake may be increased to dilute the urine.
  • Prevention of the skin sores: The position should be changed 2hrs on the abdomen or lateral.
  • Slight rub on the skin to stimulate the circulation.
  • Avoid under pressure on the soft area and joints to prevent skin sores.
• Prevention of deformities of the lower extremities: The body alignment should be maintained in each position.
  • Positive range of motion exercises should be provided for the affected muscles and joints.
  • The hip should be maintained in slightly abduction and flexion to prevent dislocation.

• Anxiety about the recurrence of defect in the next child can be relived by referring the parents for genetic counseling.
• Explain the parents about long-term care
• The development of abilities such as normal infants of children achieve for their age levels is encouraged.
• The child should also be helped to develop abilities in self care and a reasonable level of self-esteem before the adolescent years.
• The nurse encourages and supervises the demonstration of such care including: bathing, feeding, positioning skin care, manual expression of urine, infant stimulation techniques, and rang of motion exercises.
• The nurse can help the parents by explaining each new procedure that is necessary and the goals to be achieved.
• The nurse may also make home visits to determine a further need for referral to other agencies.
• Allow express their feeling and assist to plan development activities.59

1. Marasmus
2. Prevention of home accidents
3. Vitamin deficiency disease
4. Rheumatic fever
5. Pyloric stenosis
6. Nursing care of child having diarrhea
7. Hemophilia

• Insufficient breast milk, prolonged feeding with the diluted milk and starvation.
• Chronic infections: Such as tuberculosis, respiratory infections.
• Chronic vomiting: In cases of pyloric stenosis, diaphragmatic hernia.
• Congenital disorders: Such as cleft-lip, palate, hydrocephalus congenital renal disorder.
• These factors may cause the insufficient nutritional intake, especially protein and calories, in relation to the requirement of the children for the age.
• Gastroenteritis, measles, and acute infectious diseases are the predisposing causes.

• Grade– I – loss of fat in the axillae and groins
• Grade – II –Loss of fat in the axillae, groins, the abdomen and the spine
• Grade – III – Loss of fat in the chest and spine in addition to sign of grade I and grade II
• Grade – IV– In addition to above three grades, the buccal fat is loss.

• Wrinkled skin and hallow temples of the children given them an appearance of old men.
• Skin loss dry, scalp with prominent loose folds and having reduced mild –upper arm circumference.
• Superadded infection are common, skin infections and diarrhea with vomiting, and abdominal distention usually occur.
• Gross wasting of muscle and subcutaneous tissue.
• Psychomotor changes usually present with irritability, apathy and misearable appearance.
• Feature of mineral deficiencies [anemia] and vitamin deficiency are usually found.

• The collection of history regarding diet, intake, feeding habits previous illness and common complains is important, specific cause, if known, should be treated.
• In sever malnutrition and the subnormal body temperature, the body temperature should be maintained using measure to provide warmth.
• Daily weighing and recording helps to assess the progresses.
• The caloric intake can be increase gradually.
• In Grade I. and grade II, when the children are hunger, they should be offered adequate diet containing calories and proteins, if digested well, the calories should be increased with the balance diet.
• In severe case when the children refuse to eat, they should be fed with the nasogastric tube. Gradually oral feeding can be increased with tube feeding can be stopped, children may be provided about 200 calories/kg/day.60
• Diet may contain nutritious food such as milk, egg, pulses, cereals, groundnuts, oils, butter, vegetable, banana, oranges, fish meat and other items that are liked by the children.
• In brief, the total caloric and protein intake should be calculated according to the requirement for an expected wt of children for their age.
• The detection of early signs of complications can be done by the observation for the oral thrush, bronchopneumonia, pyelonephritis pressure sores or septicemia.

• Parents play a major role in prevention of accidents and safety precautions. Family members also need to contribute to follow the safety measures to prevent this hazards.
• The safety precaution according to various age groups are as follows:

• Never leave an infant alone on cot or table or in unprotected place to prevent fall.
• Never give very small things to the child.
• Toys should not have removable small parts which can be aspirated or put into the ear or nose.
• Never feed solids which are difficult to chew, e.g. groundnut.
• Coins, buttons, beads, marbles, must not be left within child's reach.
• Keep the stove or fire source and hot things for away from the child.
• Electrical appliances should be kept out of reach.
• Never leave the infant near water tub or pond and never allow to go out alone.

• Give proper directions for activity.
• Provide constant supervision.
• Protect stairs by gate and keep doors closed.
• Keep harmful substances like hot things, drugs, poisons, kerosine oil, electrical appliances, sharp object, etc. out of child's reach.
• Give adequate instructions to the caretaker to look after the child and to fallow the precautions.
• Floor should not be slippery.
• Furniture should be placed firmly to prevent fall and the child should not be allowed to climb over it.
• For school children and adolescents.
• Teach safety precautions with fire, firework, matchbox, electricity.
• Sharp instruments, etc.
• Discourage the children from kite flying from roof tops and playing door banging games and from closing the doors with lot of force.
• Children must not allowed to play on streets.
• Never left the child alone in the car unless it has been ensured that the key all not ‘in’.

• Night blindness: In this a person is unable to see in dim light especially when he comes into a dark room after seeing bright light.61
• Xerophthalmia: It is softening of the entire or a part of whole of cornea. The process is rapid one and may lead to necrosis, ulcerations and destruction of the eye ball.
• Bitot's spots: These are triangular, foamy, rough and raised patches seen on conjunctiva not interfering the vision. These are generally bilateral.
• Keratomalacia: The cornee becomes soft and loses its transparency.
• Vitamin D: The deficiency diseases of vitamin D are most common between the age group of 6 moths to 2 years.

• Bone tenderness and muscular weakness.
• Difficulty in climbing stairs or getting out of a chair.

• Beriberi: It is a nutritional disorder. The onset is insidious. There is anorexia and malaise associated with heaviness and weakness of the legs. They may complain of pins and needles and numbness in the legs, Beriberi exists in there forms.
• Wet Beriberi: Edema is a most notable feature, palpitations are marked and there may be pain in legs after walking.
• Dry Beriberi: The essential feature is a polyneuropathy. The muscles became progressively week and wasted and walking becomes difficult and pt may become bedridden.
• Infantile Beriberi: It occurs in breast feedinfant usually b/w the second and fifth month. The child become restless, often cries, passes less of urine and shows signs of puffiness.
• The infant may suddenly become cyanosed with dyspnea and tachycardia and dies within 24 to 48 hours.
  1. Wernicke's encephalopathy.
  2. Indigestion may occur in children:
     • Vitamin B₂(Riboflavin): The deficiency disease of vitamin B₂ is ariboflavinosis:
     • Ariboflavinosis: It is a condition arising from a deficiency as riboflavin in the diet. The main features includes.
     • Lesions on the lip, angular stomatitis, cheilosis, later fissures in the angles of the mouth, seborrhea around the nose and vascularization at the cornea and dermatitis.
     • Vitamin B₆(Pyridoxine): The deficiency of pyridoxine cause skin lesions, cheilosis, glossitis and convulsions in children.
     • Vitamin B₁₂(Cyanocobalamin): Deficiency disease of Vitamin B₁₂ is megaloblastic anemia, pernicious anemia characterized by marked decrease in the red blood cells.

• Pellagra is characterized by diarrhea, dermatitis, dementia, etc. other characteristic features includes soreness of tongue and pigmented scaly skin. Pellagra can develop in only 6 to 8 weeks on diets deficient in niacin. Patient is generally poor and under weight. Pellagra has been called the disease of the three dermatitis, diarrhea and dementia.62
• Skin: Characteristically there is erythema resembling sever sunburn appearing over the parts of the body expose to sunlight.
• Diarrhea: It is common but not always present. There may be anorexia, nausea, dysphasia and dyspepsia. Tongue appeals red, swollen and painful, Diarrhea is usually watery and sometimes blood and mucous is noted.
• Nervous System: In severs cases, delirium is the most common mental disturbance in the acute from the disease and dementia in the chronic form.
• Folic Acid: Its deficiency results in anemia, which is common in pregnant women.
• Vitamin (c) [Ascorbic Acid]: The deficiency disease of vitamin C is scurvy:
• It is characterized by pains in extremities and joints, anemia, bleeding gums, loosening of teeth, subcutaneous hemorrhages and hemorrhages from mucous membrane and delayed wound healing.
• Vitamin E: Its deficiency is associated with habitual abortion, testicular and myocardial degeneration.
• Vitamin K: Its deficiency is associated with improper clotting of blood.

• An inflammatory autoimmune disease that affects the connective tissues of the heart, joints, subcutaneous tissues, and/or blood vessels of the CNS.
• The most serious complication is rheumatic heart disease, which affects the cardiac valves.
• Presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract.
• Joints criteria are utilized in determining the diagnosis.

• Aschoff bodies [lesions]: Found in the heart, blood vessels, brain and serous surfaces of the joints and pleura.
• Signs of carditis: Shortness of breath, edema, of the face, abdomen or ankles, and precordial pain.
• Signs of polyarthritis: Edema, inflammation of large joints and joint pain.
• Erythema Margination: Erythematous mascular rash on the trunk and extremities.
• Subcutaneous nodules found in crops over the bony prominence.
• Chorea: Sudden, aimless, irregular movements of the extremities involuntary facial grimaces, speech disturbances emotional liability and muscle weakness.
• Fever: Low grade fever that spikes in the late afternoon.
• Elevated antistreptolysin O titer.
• Elevated sedimentation rate.
• Elevated C- reactive protein.

• Chest X-Ray shows cardiomegaly and heart failure
• Electrocardiography
• Blood test for ESR, ASO-titls, WBC counts (leukocytes)
• Artificial subcutaneous nodule test.

• Bedrest is important in the management of children with rheumatic fever. It is needed for at least 6 to 8 week till the rheumatic activity is disappeared.
• Nutritious diet to be provided and sufficient amount of protein, vitamins and micronutrients, sufficient amount of protein, vitamins and micronutrients, self restriction is not necessary unless CCF is present. Avoid rich spicy food.
• Antibiotic therapy, penicillin is administrated after skin rest to eradiate streptococcal infection, initially procaine63 penicillin 4 lacks unit deep IM, twice a day is given for 10 to 14 days. Then the long-acting benzathine penicillin 1.2 mega every 21 days or 0.6 mega unit every 15 days to be given oral penicillin 4 lacks units [250 mg], every 4 to 6 hours for 10 to 14 days can be also given. Erythromycin can be used in penicillin sensitive patients.
• Aspirin is administrated as suppressive therapy to control pain and inflammation of joints. The dose of aspirin is 90 to 120 mg/kg day in 4 divided doses. It may be needed for 12 weeks. Aspirin should not be given in empty stomach. Antacid to be given just prior to or with the aspirin.
• Steroid [prednisone] therapy is given as suppressive therapy along and aspirin. The initial dose is 40 to 60 mg/day or 2 mg/kg/day in 4 divided doses, for 7 to 10 days. Then the dose is reduced to 1 mg/kg/day. It should be tapered off gradually over 12 weeks period and used for pt having cardites and or without CCR Good nursing care with emotional support to the child and parents is an important as the medication.

• Primary prevention can be achieved by education the people to avoid streptococcal sore throat and elimination of predisposing factors of the disease. Rx of streptococcal pharyngitis with penicillin or other medications can be useful measure to prevent primary attack of rheumatic fever.
• Secondary prevention of the disease can be dose by early detection, adequate treatment and prevention of recurrences of rheumatic fever long acting penicillin therapy should be continued every 15 days or 21 days for at least 5 years from the last attack of rheumatic fever or up to 18th birthday whichever comes earlier. Parents should be made acute about the continuation of treatment, medical help and follow-up.

• Inflammation and edema can cause total obstruction.
• Usually develops in the first few weaks of life causing projectile vomiting, dehydration, metabolic alkalosis and failure to thrive.

• Palpable olive shaped mass in right upper quadrant vomiting progressively projectile non-bile-stained vomits.
• Dehydration wt loss failure to thrive, electrolyte, acid-base imbalance.
• Constipation, hunger and irritability.
• Electrolyte imbalances.
• Metabolic alkalosis.

• Monitor vital signs.
• Monitor I/O and wt.
• Monitor for signs of dehydration and electrolyte imbalance.
• Prepare the child and parents for pyloromyotomy if prescribed.

• Monitor hydration starts by daily wt I/O and urine for specific gravity.
• Correct fluid and electrolyte imbalances; administer IV fluid as prescribe for rehydration.
• Maintain NPO status.64
• Monitor the number and character of stools.
• Maintain patency of the NG table placed for stomach decompression.

• Monitor I/O
• Maintain IV fluids until the infant is taking and retaining adequate amounts by mouth.
• Begin small, frequent feedings of glucose, water or electrolyte solution 4 to 6 hours postoperatively as prescribed advance the diet to formula 24 hours postoperatively as prescribed.
• Gradually increase amount and interval between feeding until a full feeding schedule is reinstated, usually by 48 hours postoperatively.
• Feed the infant slowly, burping frequently handle the infant minimally after feedings.
• Monitor for abdominal distention.
• Monitor the surgical wound and for sign of infection.
• Instruct the parents about wound care and feeding.

• Hemophilia is an inherited abnormality of blood coagulation characterize by a tenency of hemorrhage from a trauma. It is due to deficiency of plasma factor VIII [Antihemophilic globulin] factor IX [Christmas disease] and factor XI.
• Hemophilia is an Inherited as a sex linked recessive trait, it is transmitted by a female but appears only in a male.

• Hemophilia A [Classical Hemophilia]
• Hemobhilia B [Christmas Disease]
• Hemophiliac

• They may have bleeding after any injury or surgery.
• In server hemophilia excessive bleeding may occur in neonates from umbilical cord, but usually the condition is diagnosed when the child becomes active.
• The history of illness includes prolonged bleeding after circumcision or tooth extraction or any injury.
• The child may present with easy brushing, spontaneous soft tissue hematomas, prolonged bleeding from locations in the nasal mucosa or oral cavity.
• Spontaneous hematuria, G1 bleeding.

• Clinical symptoms, laboratory data, and genetic history are used to differentiate hemophilia from other bleeding conditions.
• Laboratory test for hemophilia include a complete blood count, platelet function test, and clotting studies.
• X-Ray if the affected joints help to detect the severity complications of hemarthrosis.

• The care of child with hemophilia involves a health care term of physicians, nurses, social water, laboratory personal physical therapists, and child-life workers, laboratory personal physical therapists, and child-life worker, preventing and controlling bleeding are integral aspects of the day-to-day care of a child and hemophilia.65
• Replacement preparation of factors VIII and IX are available in the form of cryoprecipitate made from fresh plasma.
• One unit of plasma (250 ml) provides one bag of cryoprecipitate which is 75 to 125 U of coagulation factor.
• Fresh or frozen plasma can also be used to correct factor deficiency plasma is readily available and simple to transfuse.

• Nursing care of the hemophiliac child includes preventing and controlling bleeding and education and supporting the pt and family.
• The nurse must provide a safe environment, understand the coagulation process and need for factors replacement perform the tasks involved and replacement therapy, e.g. [Intravenous management, administrations of transfusion] and assist the family to be safe and competent caregivers at home.
• Administering drugs as prescribed and necessary precautions missing factors or blood should be given slowly to minimize transfusion reaction [2-3 ml/min] packet should be checked for negative test of hepatitis ‘B’ HIV, etc.
• Provide protection against injury and bleeding.
• Providing emotional support to cope and the problem and involving parents in routine care of the child.

 

1. Define the following terms:
   1. Hypothermia
   2. Sepsis
   3. Exclusive breastfeeding
   4. Tonsillitis
   5. Otitis media
   6. Anorexia nervosa

2. 1. Define dehydration
   2. Classify the types/degree of dehydration
   3. Describe the management of a child who has severe dehydration

3. 1. Define low birth weight baby
   2. Enumerate physical characteristics of LBW babies
   3. Describe the nursing management of LBW babies

4. 1. Physiological and pathological jaundice in newborn
   2. List the causes of convulsions in children and describe nursing management of a convulsive child

5. Write short notes on any five of the following:
   1. Nutritional programs for children
   2. Neonatal jaundice
   3. Hypothermia and KMC (Kangroo Mother Care)
   4. Methods of oxygen administration in children
   5. Prevention of worm infestation in children
   6. (f)Cleft lip and palate66

 

1. Hypothermia
2. Sepsis
3. Exclusive breastfeeding
4. Tonsillitis
5. Otitis media
6. Anorexia nervosa

• In hypotonic dehydration, the depletion of solutes in ECF is much more than the water losses. Hypotonicity of ECF leads to shift of water from ECF to ICF causing further contraction of ECF and short.67
• Isotonic dehydration and proportionate loss of water and solutes from ECF and ICF volume remains intact as there is no redistribution of fluid.
• Hypertonic dehydration: Excess loss of water proportionate to the solutes causing movement of water from the cells in the ECF leading to intracellular dehydration.

Signs	Mild	Moderate	Severe
1. Appearance	Normal	Restless	Semicoma
2. Eyes	Normal	Lusterless	Suken eyes tear absent
3. Ant Fontanella	Normal or slightly	Moderately sunken's	Well depressed cranialsutures
(When open)	sunken	depressed.	stand out
4. Skin turgor	Normal	Moderate loss	Severe loss
5. Tongue and mouth	Moist	Moist	Very dry and coated
6. Pulse and heart rate	Normal 130/140/m/s	160-180 /mint	180/mint
7. Extremities	Warm	Warm	Cold and clamming
8. Urine output	Normal	Oliguria	No. urine for 12-24 hrs
9. Muscle tone	Normal	Normal and increased	Flacid
10. Thirst	Thirsty	Extreme thirst	Refuse drinks
11. Respiration	Normal 2.5 - 4	Mild 5-10.0	Deep sliging 10-150

1. Dehydration to be managed prompt after accurate assessment of hydration status. In severe dehydration and shock repaid expansion of intravascular volume is required to maintain vital functions.
2. This is achieved by rapid intravenous infusion of 100-120 ml /kg of isotonic, isosmotic solution [Ringer's locate] or normal saline or plasma.
3. The goal is to achieve normal urine output, correction of potassium deficit and acidosis and to enable the pt to return to oral rehydration as early as possible.
4. Correction of total fluid deficit by rehydration therapy is very important aspect of management by intravenous fluid or oral rehydration therapy (ORT). Total correction of fluid and electrolyte deficit can be achieved safely and rapidly through ORT is must of cases and dehydration.
5. In pt and sever dehydration, once the intravascular volume deficit has been corrected and urine flow is established, rest of the deficit can be corrected by ORT.
6. In diarrheal dehydration, rapid ORT is superior to conventional slow or rapid intravenous rehydration therapy.
7. Intravenous rehydration is recommended if there is severe dehydration or if there is persistent vomiting, paralytic ileus or child is unconscious or to sick to drink ORS.
8. There should be provision of maintenance fluid and electrolytes balance and replacement of on-going losses and to monitor the child's hydration status for effective outcome of therapy.
9. Mother should be involved during rehydration therapy especially in ORT. Hydration should be reassessed at regular interval to determine whether rehydration therapy is essential further more or not.
10. Maintenance of intake and output record is vital responsibility of nursing personnel during rehydration therapy.68

• Low birth wt baby is small in size with relatively large head.
• General activity of the baby is poor and spoggit or incomplete neonatal reflexes such as more, sucking and swallowing reflex.
• Skin in shiny, thin, delicate and pink and little vernix caseosa and plenty lengugo hair. There is less subcutaneous fat.
• Wt 2.500 grams or less.
• Length 44 cm or less.
• Head is larger then body, stall bones are soft, sutures are widely separated and fontanelles are large.
• Eyes remain closed and protruding due to shallow orbits ears are soft, flat and cartilage is not fully developed.
• Genitalia- in male baby, tests are undescended.
• In female baby, labia minora is exposed due to poorly developed and widely separated labia major clitoris is hypertrophied and prominent.
• Poor muscle tone.

• Care of LBW babies of birth: Efficient resuscitation and prevention of hypothermia are important aspect of care at birth. Delayed cord clamping may improve the iron stores and reduce the incidence of hyaline membrane disease. It should be done according to baby's condition. Continuous breathing support may be support may be necessary warmth should be maintained by heat source, vitamin ‘K’ 0.5 mg should be administered intramuscularly. Then after stabilization of condition the baby should be transferred to neonatal intensive care unit fro special care with all precaution.
• Care at neonatal intensive care unit: Neonatal intensive care unit should provide as like as intrauterine environment for the LBW neonates. The NICU should be warm, free from excessive sound and have smoothing light, protection from infections should be ensured by aseptic measures and effective handwashing. Rough handing and painful produces should be avoided. Baby should be placed on a soft-comfortable, ‘nestled’ and cushioned bed. Continuous monitoring of the baby's clinical status are vital aspect of management which depends open the wt of the baby.
• Maintenance of breathing: Respiratory distress is the commonest problem in LBW baby. Baby should be positioned with neck slightly extended and air passage to be cleared by gentle suctioning to remove the secretion if needed. Oxygen therapy should be administered only when indicated. Head box to be used for oxygen therapy. Baby's respiratory rate, rhythm, signs of distress, chest retraction nasal flaring, apnea, cyanosis, oxygen saturation, etc. to be monitored at frequently interval.
• Maintenance of stable body temperature: Environmental temperature should be maintained according to baby's weight and age. Baby's skin temperature should be maintained 36.5 to 37.5°C. Baby with birth weight of less than1200 gm should be cared in the intensive care incubator and 60 to 65 percent humidity, oxygen [if needed] and thermoneutral environment for better thermal control and prevent heat loss. Kangaroo mother care can be provided when the baby's condition stabilizes. Baby should be clothed with frock, cap, socks, and mittens, constant monitoring of temperature is essential with low reading thermometer. Bathing should be delayed. All measures to be taken to prevent heat loss. External heat source to be used for thermal protection of those neonates, whenever needed.69
• Maintenance of nutrition and hydration: Caloric needs of non-growing LBW babies during first week of life are 60 Kcal/kg/day. Fluid requirements of LBW babies all given in following.

Day	<100 gm	1000-1500 gm	>1500 gm
1st and 2nd	100 - 120	80 - 100	60 - 80
3rd and 4th	130 - 140	110 - 120	90 - 100
5th and 6th	150 - 160	130 - 140	110 - 120
7th and 8th	170 - 180	150 - 160	130 - 140
9th on wards	190 - 200	170 - 180	150 - 160

• Requirement of all nutrients should be maintained and adequate feeding should be initiated early: These babies who have good sucking and swallowing reflexes should start breastfeeding as early as possible.
• Prevention of infections: LBW. Babies are prone to infections due to poor immunity measures to be taken to prevent nosocomial infections. Through handwashing, separate baby care articles restriction of visitor, strict aseptic technique to be followed of all invasive procedure.

Pathological Jaundice	Physiological Jaundice
1. The important causes of pathological jaundice in newborn babies are idiopathic, prematurity, septicemia breast milk, jaundice, hypothyrodism, metabolic disorder, neonatal hepatitis [intrauterin infections]. Rh-isoimmunization, ABO - hemolytic disease of the newborn	1. The important causes of physiological jaundice under anxiety to the parents. As the neonates has immature liver and rapid destruction of fetal red blood cells.
2. About 5 percent of newborn babies develop pathological jaundice or hyperbilirubinemia	2. About 60 to 70 percent of healthy newborn babies are likely to develop physiological jaundice.
3. The onset of jaundice within 24 hrs of age staining of the palms and soles and its persistence beyond two weeks of age all suggestive of pathological jaundice requiring appropriate laboratory investigation.	3. Physiological jaundice appears b/w 36 to 72 hours of age.
4. Its marked intensity as evidenced by yellow s/s Presence of pallor Hepatosplenomegaly Peripheral blood smear raised reticulocyte count [>8 to] rapid rise of bilirubin [>5mg/dl in 24hrs >0.5/dl/hr.	4. Its maximum intensity is seen on the 4 th day of life and the peak serum bilirubin level does not exceed 15 mg/dl. This type of jaundice usually disrappers b/w 10 to 14 days life and does not any specific therapy, clinical manifestation Sclera appears yellow before skin belt becomes yellow Lethargy Refused of feeds Dark urine Dark stools
• Presence of lethargy, poor feeding, failure to thrive.	• Intensely staining the trunk or causing yellow discoloration of the plans and sales.
Diagnostic Work-Up in Such a Newborn Includes:	Diagnosis:
1. Investigations to rule out cholestasis [Stool color, urine color, direct and indirect bilirubin levels]	The diagnosis of physiological jaundice cannot be made by examining the baby at point of time because it depends upon a characteristic timetable of jaundice taking into consideration the time of onset of jaundice, maximal limits of intensity and age of disappearance besides the exclusion of pathologic causes. Physiological jaundice occurs due to relative polycythemia with reduced life span of neonate red blood cells.
2. Investigation to rule out on-going hemolysis, G-6 screen.
3. Investigations to rule out hypothyroidism.
4. Investigation to rule out urinary infection
70
Nursing Management It is treated and blood transfusion. The prognosis is fair. Phototherapy has been found to be effective in treating jaundice in neonates. Babies with serum bilirubin > 20 mg/dl and those who require exchange transfusion.	Nursing Management The parents should be explained about the benign nature of jaundice. The mother should be encouraged to breastfeed frequently. The newborn should be exclusively breastfeed with no top feeds, water or dextrose water. Mother should be told to bring the baby to the hospital if the baby looks deep yellow or palms and soles also have yellow staining. Any newborn discharged period to 72 hours of life should be evaluated again in the next 48 hours for assessment of adequacy of breastfeeding and profession of jaundice.

• Birth asphyxia, hypoxia, birth injury, intraventricular hemorrhage.
• Hypoglycemia, hypocalcemia, hypo-or hypernatremia hypomagnesemia.
• Narcotic drug withdrawal, accidental injection of local anesthetic drug into fetal scalp.
• Septicemia, kernicterus, meningitis, tetanus neonaterum.
• Congenital malformations – microcephaly, porencephaly, arteriovenous fistula.
• Pyridoxin deficiency, inborn errors of metabolism.
• Intrauterine infections such as STORCH infections.

• Febrile convulsions.
• CNS infections: Meningitis, encephalitis, cerebral malaria, tetanus, Reye's syndrome and intrauterine infections.
• Post-infectious and post-vaccinal encephalopathy: Following acute viral infections [mumps encephalopathy measles encephalopathy] pertussis vaccination.
• Metabolic disturbances: Dystectralytemia, dehydration, alkalosis, hypocalcemia, hypoglycemia, inborn errors of metabolism, glycogen storage disease.
• Traumatic: Accidental and non-Accidental injury.
• Space-occupying lesions in the brain: Brain tumor, brain abscess, tuberculoma, cysticercosis.
• Vascular: Intracranial hemorrhage, DIC, arteriovenous malformations hypertension.
• Drug and poisons: phenothiazine, Diphenylhydantin salicylates piperazine.
• Miscellaneous: Heat stroke, cerebral anoxia acute cerebral edema, poisoning, allergy, renal disease, breath holding spells degenerative discarders.
• Idiopathic epilepsy.

• Ensure adequate vitals systemic and cerebral oxygenation:
  • Terminate seizures activity.
  • Prevent recurrence.
  • Establish the diagnosis and treat the underlying disorder.71
  • Emergency Supportive treatment
  • Emergency management of convulsing pt focuses on securing the airway, maintaining oxygenation, ensuring perfusion by obtaining intravenous access the protecting the pt from injury.
  • Head and neck should be positioned to keep the airway open. An oral or nasal airway may need to be inserted if necessary airway should be suctioned.
  • Oxygen should be administered by nasal cannula or mask.
  • Anticonvulsive drugs are indicated in prolonged convulsions. Diazepam 0.3 mg/kg IV or 0.5 to 1 mg/kg per rectum or phenobarbitol 5 mg/kg IM can be administered.
  • Antipyretics [Paracetamol, mefanamic acid] and tepid sponge should be given to treat fever. Hydration and nutrition status to be maintained.
  • Clearing of airway and oxygen therapy may be needed for some children.
  • Rest, comfortable position and hygienic measures to be provided. Explanation and emotional support to the parent are important along with necessary health teaching.
  • Investigations to be done to ruled out other possible cause of convulsions and treatment to be planned accordingly.
  • Provide preventive measures to protect the child from injury by removal of hard objects, sharp things or toys from the child and placing child on floor or beds.
  • Side rails of the bed or crib to be padded.
  • Preventing respiratory arrest and aspiration.
• Avoid restraining the child and not give anything in b/w teeth or in the mouth, when the teeth are clenched during convulsions.
• Clear airway, remove secretions, turn head to one side during seizures and on sidelying position in postictal stage.
• Record the events in details:
  • Diet therapy: Ketogenic diet may be given to raise the seizure threshold with calculated amount of proteins and fats without carbohydrates. This diet makes the child ketotic as fat is used for energy production rather than carbohydrate. It seems that ketones may inhibit the seizure.
  • The child should not be given IV fluid and dextrose strict fluid restriction to be maintained.
  • Providing health teaching: Necessary related health teaching to be given with special emphasis on continuation of medications, care during convulsions, diet therapy restricted activities, misconception regarding the disease and follow-up.

1. Nutritional programs for children
2. Neonatal jaundice
3. Hypothermia and KMC [Kangroo mother care]
4. Methods of oxygen administration in children
5. Prevention of warm inspiratiion in children
6. Cleft lip and palate

• This program was started in the year 1960 in a few states and then gradually implemented throughout the country. The program is assisted by international Agencies like WHO, UNICEF and FAO. The program was designed to meet the nutritional needs of vulnerable segments of our society like preschool children pregnant and lactating mothers. The program aims at achieving self sufficiency by increasing food production. The production by popularizing kitchen gardens, poultry unit and development of fisheries, etc. Nutrition education is being imparted fro efficient utilization of locally produced foods and increased consumptions of green leafy vegetables, seasonal fruits and protein rich foods. The program has lost its initial enthusiasm and commitment.72
• Nutrition supplements are being provided as snacks and mid-day meals to preschool children in several government and public sector school in the country. It is being done at the state level and there is universal national policy.
• The Govt of India have initiated several nutrition programs throughout the country to prevent central major nutritional problems. They includes the followings.
  • Vitamin ‘A’ prophylaxis program.
  • Prophylaxis against nutritional anemia.
  • Central of iodine deficiency disorders.
  • Applied nutrition program.
  • Special nutrition program.
  • Balwadi nutrition program.
  • Mid-day meal program for school children.
  • Integrated child development services scheme.
• The overall objectives of those programs are to improve nutritional status, to overcome specific deficiency conditions and malnutrition. In future, we can hope that improvement of nutritional status of Indian children can be achieved by the improvement of socioeconomic status of our community so that each family will be able to offered balanced diet to their children toward optimum health.

• Sclera appear yellow
• Lethargy
• Refusal to food
• Dark urine
• Dark Stool

• Decrease bilirubin conjugation:
  • The liver may not cope-up with conjugation due to inadequate enzyme glucuronyl transferase.
  • Inadequate bilirubin binding proteins.
• Inadequate bilirubin load:
  • Hemolysis due to Rh incompatibility.
  • Structural abnormality of red blood cells.
  • Physiological rapid destruction of RBC.
  • Extravascular blood, such as cephalhematoma.
• Polycythemia:
  • Small for gestational age.
  • Babier of diabetic mothers.

• Jaundice is a relatively common physical abnormality in a newborn during the first week of life, clinical jaundice manifests as yellowness of the skin of the face when the seem bilirubin level exceeds 5 mg/dl. As the degree of jaundice increase, There is progression of yellowness of the skin from free towards, trunk, limbs and finally plans and soles.
• When the trunk of the baby is distinctly yellow stained, the serum bilirubin level is likely to vary b/w 10 to 15 mg/dl.
• The yellow staining of the palms and soles is ominous and indicates that the serum bilirubin level has exceeded 15 mg/d.

• Details history of illness and physical examination help to detect the causes.
• Laboratory investigations to exclude the exact cause of jaundice include estimation of direct and indirect bilirubin.
• Hemoglobin percentage, blood grouping and typing, reticulocyte count, coomb's test, stool examination.
• Liver function test and other specific test for suggestive etiology.

• Management of a child with Jaundice primarily directed toward the etiology, special supportive nursing care is very important and includes rest, skin care, dietary restriction of fat, spices and fried food, intake of more carbohydrate.
• Maintenance of hygienic measures, care of bladder and bowel, prevention of injury and bleedings, emotional support and health education.
• Phototherapy: It act as photo oxidizing with change fat soluble bilirubin to water soluble bilirubin.
• Phenobarbitone: It induces glyconal transference formation by liver cells.
• Exchange transfusion: It is done to remove bilirubin mechanically. About 180 MI of blood/kg body wt should be exchanged.

• Control Stress: Temperature b/w 36.0° C 36.4°C The difference b/w the core and peripheral skin temperature is more then the 1.5°C and extremities all cold and pale
• Moderate hypothermia: Temperature b/w 32.0°C – 35.9°C.
• Severe hypothermia: Temperature of less then 32.0°C
• The hypothermic baby is uncomfortable, restless and cries to generate heat by muscular activity. If unattended at this stage, bay becomes sluggish and inactive.
• The vital functions are depressed with slow breathing, Bradycardia and full in blood pressure leading to poor tissue perfusion.
• The wt gain is unsatisfactory because food is wasted for heat production and denied for physical growth.
• Even brain growth may be adversely affected as evidenced by slow increase in head size.
• The immunologic system is also depressed and increased susceptibility to develop septicemia, sclerema and disseminated intravascular coagulation.

• Severe asphyxia74
• Extensive resuscitation
• Delayed crying at birth
• Respiratory distress
• Hypoglycemia
• Sepsis
• Preterm or small for gestational age

• Hypothermic baby should be immediately transferred to an incubator or open care system and slowly warmed to achieve normal skin or core temperature within 4 – 6 hours.
• Oxygen and glucose should be administered to meet the increased demands and correct hypoxia and Hypoglycemia if it present.
• In the event of hemorrhagic manifestations 0.5 – 1.0 mg of vitamin K is given IV.
• Antibiotics are given to treat associated septicemia.
• Exchange blood transfusion is given when DIC is suspected.
• Hydrocostisone is indicated in babies with sclerema, where in skin become taut and stretched like the hide of and animal.
• In babies and severe hypothermia and clod injury, prognosis is generally poor and a case fatality rate of 25 to 50 percent.
• The presence of bleeding manifestation and scalene are associated and poor outcome.

• Skin-to-skin contact: Direct, continuous and prolonged skin-to-skin contact is provided b/w the mother and her baby to promote thermal control.
• Exclusive breastfeeding: Skin-to-skin contact promotes lactation and feeding interaction with exclusive breastfeeding for adequate nutrition and to improve desired wt gain.

• KMC helps in thermal control and metabolism prolonged, continuous and direct skin-to-skin contact b/w mother and neonatal provides effective thermal control and reduce risk of hypothemia.
• KMC results in increased duration and rate of breastfeeding.
• During KMC, the baby has more regular breathing and less predisposition to apnea
• KMC protects against nosocominal infection and reduces incidence of severe illness including pneumonia during infancy.
• Daily wt gain is slightly better with KMC, thus duration of hospital stay may be reduced. LBW baby receiving KMC could be discharge from the hospital earlier then conventional care.
• KMC facilitate better mother-infant bondage due to significantly less stress during kangarooing than the incubate care of the baby.
• Mother feels increase confidence, self-esteem, sense of fulfilment and deep satisfaction and KMC father feels more relaxed, comfortable and better bonded.
• KMC does not require additional staff compared to incubator care.75

• Noninvasive method by
  • Oxygen mask which can be simple face mask, venturi mask or partial rebreathing mask.
  • Oxygen hood or face tent.
  • Oxygen tent or conopy.
  • Isolate incubator or other closed incubator.
• Invasive method by
  • Orotracheal or nasotracheal or tracheostomy route and
  • Nasopharyngeal catheter or nasal canule or nasal prong.

For Infant	1 liter/mint
For Young Children	2 liter/mint
For old children	4 liter/mint

• Vegetables and fruits must be washed in running water before using them.
• Use boiled water for drinking.
• Educate people about:
  • Avoid defecation in fields, near river tanks and any water source.
  • Wasting hard thoroughly before meals and after defecation.
  • Avoid eating raw vegetables.
  • Avoid pollution of water and soil.
• Pin Warm infestation: This is very common parasite in intestine of children. These are mostly found in smell intestine, colon and rectum. The females parasite migrate to perineal region and lay eggs on the skin, which are infective.

• Maintain clean facilities defecation, practice personal hygiene of the toilet, hand washing properly.
• Bathing frequently to keep the body clean, use clean clothing.
• Habits of nail biting and scratching anal area should be discouraged.
• Hookwarm infestation: This a chronic infestation of small intestine by “Ancylostoma Duodenale” or “Necator Americansus” It involves skin, lungs, and small intestine.
• It withdraws blood from the gut and causes anemia in host. Hemorrhage may also occur which may result in bloody stool. Women may have sterility abortions and impaired lactation. This is characterized by weakness, puffiness of face, flatulence, constipation, edema of legs, anemia, slight fever loss of appetite. It may also lead to mental retardation.

• Maintain personal hygiene.
• People should have habit of wearing chappals and should not go out barefoot and wash their feet after coming from outside.
• Provisions for adequate latrines.
• Vegetables and fruits must be washed before use.
• Guinee Worm infestation: It is acquired by drinking contaminated water containing infected cyclops. It is caused by “Dracunculus Medinensis”.

• Preventing pollution of water and soil.
• Disinfect or purify water and calcium oxide or potassium permanganate or lime.
• Use boiled or filtered water for drinking.

• Cleft lips: Incomplete fusion of maxillary and premaxillary processes; fusion should be completed b/w 5 to 8 weeks of fetal life.
• Cleft palate: Incomplete fusion of palatal structure may involve soft or hard palate and may extend into nose, forming an oronasal passageway fusion should be completed b/w 9 to 12 weeks of fetal life.
• Involves abnormal opening in the lip and palate that may occur unilaterally and bilaterally and are readily apparent at birth.77

• Genetic
• Hereditary
• Environmental factors, exposure to radiation or rubella virus, chromosome abnormalities and teratogenic factors.

• Cleft Lip: Difficultly feeding-infant cannot form vacuum with mouth to suck, may be able to breastfeed (breast may fill cleft, making sucking easier)
• Mouth breathing dries mucous membranes, predisposing infant to infection.

• Prone to infection, especially otitis media.
• Altered speech: Complete palate needed to trap air in the mouth.
• Malposition of teeth and maxillary arch, extensive orthodontic and prosthodontics, needed to correct.
• Hearing problems caused by recurrent otitis media.

• Cleft lip: Repaired in first few weeks after birth, further modification may be necessary: Aids, infant is ability to suck; helps parents with visible aspects of the defects.
• Cleft palate: Surgical intervention and repair may occur as early as the neonatal period but not later then b/w 12 to 18 months, done before speech is fully developed.

• The mother should be explained about the proper breastfeeding and the bottle feeding to help the infant gain wt.
• The infants should be encouraged to lie on its back to practize for postoperative essential positioning especially with the arm restraints.
• Prevent infection from irritation of the lip.
• Parents should be motivated to provide love and affection to develop an attachment.
• Feed slowly, best frequently bec of swallowed air.
• Instructions should be given to give the last feed six hours before the surgery.
• Prevent infection from irritation of the lip.

• Maintain patent airway bec of edema and infant's habit of mouth berathing, keep laryngoscope, endotracheal tube be and suction equipment nearby.
• Cleanse suture line to prevent crust formation and eventual scarring.
• Minimize crying bec of pressure on suture line, encourage a parent to stay with chid.
• Place infant in supine position and arm or elbow restraints, changes position to side or sitting up to prevent hypostatic pneumomia remove restraints only what infant is supervised.
• Support parents during healing process.

• Child is allowed to lie on the abdomen.
• Feeding are resumed by bottle breast or cup.78
• Oral packing may be sucured to the palate [removed in 2 to 3 days]
• Do no allow the child to brush his or her teeth.
• Instruct the parents to avoid offering hard food items to the child, such as toast or cookies.
  • Soft elbow or jacket restraints may be used [checked agency policies and procedure] to keep the child from touching the repair site, remove restraints at least every 2hrs. to asses skin integrity and allow for exercising the arms.
  • Avoid contact with sharp objects near the objects in the mouth such as tongue depressor, thermometer, straws, spoons, forks or pacifiers.
  • Provide analgesics for pain.
  • Instruct the parents in feeding techniques and in the care of the surgical site.

 

1. Define the following terms:
   1. Hypoglycemia
   2. Toddler
   3. Dermatitis
   4. Preterm baby
   5. Pica
   6. Dysmenorrhea

2. 1. Define growth and development.
   2. Enlist factors affecting growth and development of a child.
   3. Why the knowledge of normal growth and development is essential for nurses working with children?

3. 1. Define physiological jaundice.
   2. Classify neonatal jaundice.
   3. Describe the management of neonatal jaundice specific of phototherapy.

4. 1. Enumerate common communicable vaccine preventable diseases (VPDs).
   2. Chalk out immunization schedule up to 3 years.

5. Write short notes on any five of the following:
   1. Bedwetting.
   2. Prevention of accidents during infancy and toddlerhood.
   3. Physical and physiological changes during adolescent period.
   4. Gastrostomy feeding.
   5. Juvenile delinquency.
   6. Play and toys for children.

 

1. Hypoglycemia
2. Toddler
3. Dermatitis
4. Preterm baby
5. Pica
6. Dysmenorrhea79

• Genetic Factors:
  • Age
  • Sex
  • Race
  • Nationality80
• Prenatal factors:
  • Maternal malnutrition
  • Maternal infections
  • Maternal substance abuse
  • Maternal illness
  • Hormones
  • Miscellaneous: Malpresentation, Malfunction, Maternal emotion during pregnancy, Inadequate prenatal Care.
• Postnatal Factors:
  • Growth potential
  • Nutrition
  • Childhood illness
  • Physical environment
  • Psychological environment
  • Cultural influences
  • Social-economic status
  • Climate and season
  • Play and exercise
  • Birth order of the child
  • Intelligence
  • Hormonal Influence.

• The nurse knows what to expect of a particular child at a given age: Knowledge of growth of development is essential for nurse to know the needs of every child according to their age group.
• The nurse can judge each child: Whether he/she is normal for specific level of development every child have own different development needs which is necessary to fulfil other wise it may cause many emotional problems in children. That's why knowledge about normal growth and development is essential for nurse to know or judge the specific level of development.
• The nurse can understand the season of illness at a particular age: The knowledge of normal growth and development help the every nurse to know the disease problems of every child at a particular age group.
• The nurse can understand the need of a particular child: Knowledge of growth and development process help the nurse to understands the basic needs of children.
• The nurse can plan the total care of the child.

• Physiologic jaundice
• Kernicterus jaundice81

• Sclera appeasers yellow before skin becomes yellow
• Lethargy
• Refusal of feeds
• Dark urine
• Dark stools.

• It is the bilirubin encephalopathy due to effect of high concentration of indirect bilirubin on brain and basal ganglia during the neonatal period.
• Hypoglycemia and hemolytic disease may increase the susceptibility of the neonate for kernicterus.

• Neonate looks very week and lethargic
• Refusal of feeds
• Tremors or Convulsions
• Dehydration
• A high pitch cry
• Dark urine and stools
• Opisthotonos position.

• Bilirubin level: Total bilirubin
• Peripheral blood smear for structural abnormality of RBC
• Blood group and Rh factor of the mother and the baby. Combe's test
• Total serum albumin
• pH of blood
• Hb level
• Stool examination
• MRI
• Hepatic imaging, etc.

• Phototherapy: Phototherapy is the use of fluorescent light for breakdown of the bilirubin. Phototherapy acts by photo-oxidizing tissue bilirubin and changing yellow lipid bilirubin into colorless, nontoxic water soluble bilirubin which can be easily excreted in the urine and bile. The length of time the neonate needs phototherapy depends on the level so serum bilirubin and clinical condition of the neonate.
• Care of Baby In Phototherapy: It is a specially designed, electronically based instrument which has an effective light source for the therapeutic purposes.

• Fluorescent lamp as a light source
• Side rails
• Platform to keep the baby
• Mattress
• Power cord for connecting with power supply
• On /off switch of light source
• Adjusting screw for light source.

1. Check the physician order and instructions
2. Wash the hands and clean the phototherapy unit with cotton swab properly.
3. Check the phototherapy machines working condition.
4. Advice the mother to feed the baby to prevent dehydration while exposed to phototherapy.
5. Remove the cloth of baby and make the baby naked.
6. Place the baby in phototherapy unit
7. Apply the eye shield properly which cover the both eyes.
8. Apply the napkin to cover the genitalia which protects the test as from the lights.
9. Side rails should be raised.
10. Switch on the fluorescent lights and note the time.
11. Continuous changing of position about every 2 hrs to reaches the lights at all areas of the body.
12. Do the recording and reporting
    Note: Time of phototherapy care depends on the severity of jaundice.
13. Give the feeding at regular interval to maintain the fluid level.
14. Change the napkin regularly
15. Do not give the pressure over the eyes with eye shield.
16. Continuously observe the skin for rashes, dryness, etc.
17. Do not apply oil to the skin of the baby because it can interfere the effect of fluorescent lights.
18. Keep the observation for side effects such as–greyish brown discoloration of skin and urine, skin rashes, loose green stool due to increase in the bile flow.

• Phenobarbitone: Phenobarbitone acts on the liver including glucuronyl transferase formation by the liver cells and help bilirubin metabolism.
• Exchange blood Transfusion: Sometime it is necessary to remove the excessive serum bilirubin mechanically by exchange blood transfusion. About 180 milliliters of blood per kg of body weight is required to be exchanged. It is a slow process and only 10 milliliters of blood is exchanged at a time. The whole process may be continued over an hours. To avoid shock nd toxic effect of the donor blood, after milliliter of calcium gluconate is injected a every 20 milliliter of blood exchange.
• Salt free albumin: Salt free albumin may be prescribed about one gram per kg of body weight. The salt free albumin increases bilirubin binding capacity.

• The nurse should frequently observe and detect any early changes.
• Vital signs also should be monitored.
• The skin color is observed for the increase or decrease in yellowness.
• The urination is checked for the frequency amount and color.
• Any behavior changes, convulsion should be noted and reported.
• The normal Temperature should be maintained especially when the baby is under phototherapy.83
• Adequate fluid intake is necessary to help in the excretion of bilirubin and to prevent dehydration.
• The neonate is removed for a short while from the phototherapy, for breastfeeding, eye contact with the mother emotional support and for tactile stimulation.

1. Tuberculosis
2. Chickenpox
3. Measles
4. Mumps
5. Poliomyelitis
6. Diphtheria
7. Pertussis (Whooping Cough)
8. Tetanus
9. Infective hepatitis
10. Typhoid fever (Enteric fever)

• General symptoms are low grade fever loss of weight, anorexia and fatigue.
• Specific symptoms may be related to the site of infection such as in the lungs, brain, bone or kidney.

• Tuberculin test (montoux)
• X-Ray of the chest
• Examination of the smear from the sputum
• Cerebrospinal fluid is examined for diagnosis tuberculosis meningitis.

• Antituberculosis Drugs:
  • Streptomycin
  • Isonicotinic acid hydrazide
  • Pyrazinamide
  • Ethionamide
  • Rifampin
  • Ethambutol
  • Duration of treatment depend on the age, health status of children and severity of the disease.
• Corticosteroids: Corticosteroids may be used in the early part of the disease.
• Surgical Treatment: Some time necessary to for removal of the affected part.84

• Pulmonary Tuberculosis in children is noninfections so there is no need for isolation.
• Rest and comfort may be necessary in the case with a fever and severe illness fresh air and sunshine helps in the recovery.
• Nutrition: High protein, high caloric diet with the vitamin C and calcium should be encouraged.
• Periodical weighing and check-up are necessary.
• Administration of the drugs at proper time and parents should be explained about the side effects of the drugs used over a long period and about regular use of the drugs.

• The infection can be transmitted by a direct contact with the patient and indirect contact with clothes/fomites.
• Incubation Period: 14-21 days.

• Prodromal Phase: Older children may have short period of fever, headache and generalized malaise.
• Eruptive Phase: There is a rapid evolution of lesions with a superficial, polymorphic having tear or due drop appearance with an erythema around the lesions.
  • After the scabs separate, and scars of the skin occur due to scratching by the children.
  • Treatment: Antihistamine drugs may be prescribed to control itching.
  • Secondary infection may be treated with the antibiotics.

• Gamma globulin may be given 0.4 ml/kg body weight
• The advice should be given to avoid the contact with the infected cases.

• It is viral disease spread by droplet infection.
• Incubation period: 7 to 14 days:

• Catarrhal Stage
• Eruptive Stage
• The convalescent Stage.

• There is no specific drug to use
• Acetyl salicylic acid or paracetamol may be prescribed for treating the fever.
• Cough may be treated with linctus.
• Antibiotic give for secondary infection.85
• Prevention: Active immunization should be administered. A single dose of attenuated line virus vaccine for all children, around the age of one year is recommended.

• Fever
• Sore throat
• Earache
• Pain on chewing and tenderness beneath the angle of the jaw.

• Aspirin may be administered to relieve the pain.
• Bedrest advise until the fever and swelling subside.
• Fomentation to the swollen part helps to reduce the swelling and pain.
• Liquid diet given because patient unable to chew and swallow.

• Active immunization, in the form of MMR can be given at the age of nine month.
• Passive immunization of gamma globulin may help to reduce complications.

• Asymptomatic stage: In this stage no symptoms are seen.
• Abortivel: The children may get sore throat, moderate fever, vomiting and low headache.
• Non-paralytic: The children may get a headache, fever, stiff neck, pain in the extremities, hypersensitivity of the skin, children look drowsy but can be easily aroused.
• Paralytic stage: In this stage, the paralysis is seen in relation to the destruction of the nerve cells of anterior horn cells of the spinal cord are destroyed, legs, arms and diaphragm may be paralyzed.
• Bullbar Polio: Nuclei are affected. It can cause facial and pharyngeal paralysis. The speech and respiration may get affected.

• The Treatment depends on the Severity of the symptoms.86
• Ventilator may be required for respiratory paralysis.
• Retention of urine may be treated by indwelling catheter.
• Analgesics may help to reduce fever.
• Laxatives may be prescribed for the constipation.
• Antibiotics may be for secondary infections.

• Vaccination-Polio vaccine is of two types
• Sabine – orally
• Salk– Injectable
• Children should be vaccinated at the age of six weeks – nine months and oral polio drops up to 5yrs of age
• Orofacial infection should be prevented
• Each children with history of polio should be advised to get immunized with the polio vaccine.

	e g A	Vaccination
1.	At birth, with in 72 hrs.	BCG Vaccine, dose of OPV
2.	1 V months	DPT + OP + Hep B
3.	2 V months	DPT + OPV + Hep B (2nd dose)
4.	3 V months	DPT + OPV (3rd dose)
5.	4 V months	OPV
6.	5 V months	OPV
7.	7 V months	Hepatitis B
8.	9 months	Measles + Syp vit A
9.	15 months	MMR
10.	18 months	DPT, OVP
11.	5 yrs	DPT + OPV
12.	10 yrs	TT
13.	16 yrs	TT

1. Bedwetting
2. Prevention of accidents during infancy and toddlerhood.
3. Physical and physiological changes during adolescent period.
4. Gastrostomy feeding.
5. Juvenile delinquency.
6. Play and toys for children.

• If toilet training very early it may produce confusion and resistance
• Some emotional disturbance
• Parents may be dominating nature such as punished or scolded, the feeling of jealousy that cause internal tension which may reflect in disturbed bladder control
• Anatomical defect of urinary tract
• UTI
• Neurological deficit
• Diabetes insipidus.

• The home conditions, socioeconomic status, and habits of the family should be found out.
• Child parent relations should be explored parent and child should be interviewed separately.
• The parents-child should be explained about the factors related to bedwetting.
• The child should be helped to get relief from the feeling of guilt, shame parental rejections.
• Modification in routine may be helpful.
• Restriction of fluids in the evening and helping the child in developing the habit of passing urine before going to bed.
• Some drugs are prescribed for 6 to 8 weeks to decrease the output.
• Toilet training should be given to the child to increase capacity of the bladder.

• Providing safe child care
  • Parents needs to know about a safe environment for their children from early infancy.
  • Parents must have and understanding about the children's developmental. Changes and capabilities at different ages.
  • Parents must know about the potential dangers of accidents related to the child's age and various situations.
• Providing Safe Environment: According to level of children's development, age, and capabilities, children are attracted toward certain hazardous environment which may lead to accidental injuries. The steps should be taken to prevent such injuries by providing safe environment at home, school and in the community.
• Health Education: As a responsibility of nurses it is important to help the parents and community to be aware of accidental injures in children and their relation to the growth and development of their children. It should be stressed that children need the positive and clear instruction to protect themselves from the accidents. Provision of a safe environment is also important.

• Development of identity is the major need of the adolescent, before development of an intimate relationship. During this period adolescents try to achieve autonomy from the family, hope to have group identity and try to develop a sense of personal identity.
• Adolescents are egocentric, therefore lack the ability to differentiate, their opinions from that of others. Because of their egocentrism, the lack understanding empathy and cooperation.88
• During early, adolescent have concrete thinking. Gradually concrete functioning develops into obstruct during middle adolescence.
• Adolescents find it difficult to form satisfactory identity from the various aspirations, roles and identifications.

• Adolescents do not like parental restraints, but they are afraid to be independent when they think of the responsibilities along with think of the responsibilities along with their independence adolescents need acceptance from friends few close friends, and supportive family for interpersonal maturity.
• They spend more time outside the family, with the pear group. Their behaviors fluctuate according to their mood. Adolescents become more competent and feel the need for more autonomy. At this stage beginning of puberty, starting to date and attending a new school. Adolescents have a fear that they may not be able to cope with the expected role and responsibilities as an adult.

• For infants with esophageal atresia requiring a temporary gastrostomy feeding purpose.
• For infants with an esophageal stricture due to ingestion of corrosive solution or fibrosis or and anastomosis.
• For infants requiring prolonged artificial feeding.

• The dressing around the tube is checked to see that is no leakage and the tube is in the position wile feeding the receiver is kept under the end to the gastrostomy tube and the spigot or clamp is removed. The gastric residue will drain into the receiver. It the residue contains the bile, duodenal intubation should be suspected and reported to the physician.
• The food should be warm. As crying and restlessness causes and increase in the intra-abdominal pressure, the food will be forced back into the funnel. Therefore the funnel should be filled half with the food and the air should be expelled from the apparatus, by releasing the clamp and allowing some food to run through into the container.
• The tube should be clamped. The funnel should be held 20 to 25 cm above the level of the stomach, to allow the food to run slowly, The funnel is filled again.
• At the end of the feeding, when the food leaves the funnel a small amount of water is instilled to wash the tube. The tube is then damped.
• Alternatively the gastrostomy tube is left open to allow the reflux of the gastric contents into the funnel and tubing which is secured 10 cm above the level of the stomach. The child is made comfortable.
• Changing of gastrostomy tube.
• A non irritating polyvinyl, self-retaining balloon or malecot's catheter may be changed every two to three weeks.89 The rubber catheter is changed more frequently. This procedure is done just before feeding, while, removing the tube, the balloon of the catheter is deflated and gastrostomy tube withdrawn. Then it is quickly replaced by inserting the tip of the new catheter 2.5 to 5 cm beyond the last aperture or balloon bag, depending on the nature of the catheter and size of the child.
• The balloon is then, inflated and the introduced malcots catheter is withdrawn. The catheter is held in position with strips of adhesive lapse applied around the catheter and crossed over the abdominal wall.

• When children are under stress, they should be helped to relive the stress by providing an opportunity to vent out their emotions.
• Play facilities and friends keep the children happy.
• Delinquent children need to come out of their stress. The history of their socioeconomic status, environment, child parent relationship and teacher relationship should be explored.
• They can be helped by child guidance clinic.
• A sympathetic but firm approach may be helpful.
• Parents should be taught to provide love and security, and to encourage to develop their skills.
• It is necessary to reform the child. This can be done with team work or with Cooperation of parents, teacher, social workers and psychologists and police person.
• A delinquent child is taken to the court for their antisocial acts. The court orders are given mainly, to improve the child's behavior and not only to punish the child.

• Early detection of children's maladjustment at home, in the school, or with the friends should be alone.
• Social services such as recreational facilities educational facilities and health centers should be made available to the children.
• Healthy relationships between parents and child, teacher and child as well as other social members and children are important to prevent delinquency in children. Children should be explained about the discipline when the tantrum subsides, parents should show control as well as security to the child.
• The causative factor in the environment should be found out and attitude related to those factors should be corrected.
• The parental education about children's need is important.

• Physical Development: The play encourages muscles activity and muscle tone. It also, help to develop skills and balancing in various positions.
• Psychological Development: The play provides a place for children to compensate for feeling of smallness and helplessness. During the paly children experience control over the objects and the environment, while they 90have very little control over events in the reality. The play provides and opportunity for the acceptable outlet of their negative feelings.
• Social Development: Children develop the capacity to cooperate with their peers Group's plays provides opportunities to develop skills in social interactions and to realize the consequence of behaviors on others. Children increase the language ability and the rules of social living, through the play. Through different types of plays, children learn to control their impulses and learn the meaning of sharing experience.

• It is important to provide toys suitable for children's physical and psychosocial development. Toys may not be expensive but must be able to create interest in the children.
• The toys should be safe, durable, attractive, appealing and suitable to the needs, age, and experience of the children.
• The toys which can cause injuries or which are accident prone should be checked frequently to avoid accidents.
• Adult's guidance is required for assisting children in relating to each other and for providing safety, self-respect, and for the intellectual and emotional development.

• The play is a very import component of children's life. It has special importance in the hospital to help sick children to continue to grow and develop to preserves their sense of wholeness, to understand hospital procedures and to act out emotions for the hospitalized children, the hospital is a new environment with a new routine. Sick children suffering from pain and confusion may be under the stress.
• The nurse must remember the following factors while selecting play for the sick children.
  • The capacity of the children to play during their illness.
  • Limitations of play and toys for an immobilized child.
  • Sick children may prefer small simple toys
  • The interest of the children to enjoy play
  • The maintenance of the play materials
  • There should be a separate play room in the unit, if possible.

1. Define the following terms:
   1. Hypothermia
   2. Otitis media91
   3. Mental retardation
   4. Toddler
   5. Hydrocephalus

2. 1. Define growth and development.
   2. Write the factors affecting growth and development.

3. 1. What is nephrotic syndrome?
   2. Write down its sign and symptoms.
   3. Explain medical and nursing management of nephrotic syndrome?

4. Describe the nursing management of a child suffering from diarrhea.

5. Write the short notes on any five:
   1. Apgar score
   2. Breastfeeding
   3. National child labor policy
   4. Safety and prevention of accidents in toddlers
   5. Low birth weight
   6. Cleft lip and palat

 

1. Hypothermia
2. Otitis media
3. Mental retardation
4. Toddler
5. Hydrocephalus

2. 1. Define growth and development.
   2. Write the factors affecting growth and development?

Genetic Factor	Prenatal Factors	Postnatal Factors
1. Heredity	1. Maternal malnutrition	1. Growth potential
2. Sex	2. Maternal infections	2. Nutrition
3. Race and nationality	3. Maternal substance abuse	3. Childhood illness
4. Maternal illness	4. Physical environment	4. Physical environmental
		5. Psychological
		6. Cultural influences
		7. Socioeconomic status
		8. Climate and season
		9. Play and exercise
		10. Intelligency
		11. Hormonal influence

• Genetic factors: Heredity: Heredity decides size and shape of the body. Therefore, family members bear resemblance. The characteristics are transmitted through genes that are responsible for family illness, for example, diabetes.
• Sex: The sex of children influences their physical attributes and patterns of growth. Sex is determined at conception. A birth, male babies are heavier and longer than the female babies. Boys maintain this superiority until about 11 years of age. Girls mature earlier than boys and bone development is more advanced in girls. But mean height and weight are usually less in girls then boys at the time of fall maturity.
• Race and Nationality: Growth potential of different racial group is different in varying extent. Physical characteristics of different national groups also vary. Height and status of Americans and Indians are usually differ because of the differences in growth patterns.

• Intrauterine environment is an important predominant factors of growth and development. Various conditions influence the fatal growth in utero.93
• Maternal Malnutrition: Dietary insufficiency and anemia lead to intrauterine growth retardation. Low birth wt and preterm babies have poor growth potentials. In later life, those children are usually having disturbances of growth and development.
• Maternal Infections: Different intrauterine infections like HIV, HBV, STORCH, etc. May transmit to the fetus via placenta of affect the fetal growth. Various complications may occurs like congenital infections, etc. Which ultimately affect the growth and development in extrauterine life.
• Maternal Substance Abuse: Intake of teratogenic drugs by the pregnant women in the first trimester affects the organogenesis and lead to congenital malformations which hinder fetal growth. Presence of congenital anomalies in later life influence childhood growth and development. Maternal tobacco intake and alcohol abuse also produce fetal growth restriction.
• Maternal Illness: Pregnancy: Induced hypertension, anemia, heart disease, hypothyroidism, DM, chronic Renal failure, etc. have adverse effect on fetal growth. Iodine deficiency of the mother may lead to mental retardation of the baby in later life.

• Growth Potential: Growth potential is indicated by the child's size at birth. The smaller the child at birth, he smaller she/he is likely to be in subsequent years. The larger the child at birth, he larges she/he is likely to be in later years, how birth wt babies have various complication in later life which retard child's growth.
• Nutrition: Balanced amount of essential nutrients have great significant role in growth and development of children. Both quantitative and qualitative supply of nutrition, e.g. protein, fat, carbohydrates, vitamins and minerals in the daily diet are necessary for promotion of growth and development, Adequate food intake helps the child in body building, energy production/protection from infections. The nutritional requirements during growth period depend upon age sex, growth rate, level of activity and health status of the child.
• Childhood Illness: Chronic childhood diseases of heart, [congenital heart disease, rheumatic heart disease], chest [tuberculosis, asthma] kidney [nephrotic syndrome] liver [cirrhosis], malignancy, malabsorption syndrome, digestive disorders, endocrinal abnormalities, blood disorders, worm infestation, metabolic disorder, etc. generally lead to growth impairment.
• Acute illnesses like ARI, diarrhea, repeated attack of infections result in malnutrition and growth retardation.
• Congenital anomalies, accidental injury and prolong hospitalization usually have adverse effect on growth and development.
• Physical Environment: Housing, living conditions safety measures, environmental sanitation, sunshine, ventilation and fresh air, hygiene, safe water supply, etc. are having direct influence on child's growth and development.
• Psychological Environment: Healthy family good parent child relationship and healthy interaction with other family members, neighbors, friends, peers and teachers are important factors for promoting emotional, social and intellectual development, lack of love affection and security leads to emotional disturbances which hinders emotional maturity and personality development. Broken family, inappropriate school environment have poor effect on psychological development.
• Cultural Influences: Growth and development of an individual child are influenced by the culture in which he or she is growing up. The child rearing practices, food habit, traditional beliefs, social, etc. Influence the child's growth and development.
• Socioeconomic Status: Poor Socioeconomic groups may have less favorable environment for growth and development then the middle and upper groups. Parents of unfortunate financial conditions are less likely to understand and adopt modern scientific child care.
• Climate and Season: Climatic variation and seasonal changes influence the child health weight gains is greatest in late summer, rainy season and autumn. Maximum gains in height among children occur in the spring. These variations may be due to difference in activity level.94
• Play and Exercise: Play and exercise promote physiological activity stimulate muscular development. Physical, Physiological, social, moral, intellectual and emotional development area enhanced by play and exercise.
• Intelligency: Intelligence of the child influences mental and social development. A child with higher intelligence adjusts environment promptly and fulfil own needs and demands, whereas a child with low level of intelligence fail to dotted. Intelligence is correlated to some degree physical development.
• Hormonal and Influence: Hormones are the important as acts of infernal environment which have vital role in growth and development of the children. All hormonal in the body affect growth in some manner. The important three influencing hormones are sematotropic hormone, thyroid hormone and adrenocortiropic hormone, thyroid hormone and adrenocorticopopic hormone that stimulate to secrete gonadotropic hormones other hormones that less directly influence the process of growth and development include insulin, parathormone, cortisol and calcitonin.

3. 1. What is nephrotic syndrome?
   2. Write down its sign and symptoms.
   3. Explain medical and nursing management of nephrotic syndrome.

1. Pale, irritable and fatigued child
2. Child gain weight
3. Decreased urine output
4. Dark, frothy urine, hematuria may be present
5. Abdominal ascites
6. Waxy pallor of the skin
7. Hypertension
8. Anorexia
9. Anemia
10. Amenorrhea or abnormal menses.

• Defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema.
• The primary objective of therapeutic management is to reduce excretion of urinary protein and maintain protein free urine.

• Providing care during hospitalization.
• Administering medications.
• Maintaining proper fluid balance and assessing edema.95
• Providing a nutritious diet.
• Preventing infection.
• Preventing skin breakdown.
• Promoting optimal psychosocial growth.
• Providing emotional support and education for all family members.

• Sodium restriction is prescribed during period of massive edema
• Normal protein intake is usually prescribed.

• Steroid therapy with oral prednisolone is the most significant aspect of management of nephrotic syndrome. It is given 2mg/kg/day in 2 to 3 divided doses for at least 4 to 6 weeks and then gradually tapered off or abrupty stopped, after another 4 to 6 weeks, antacid is given along with prednisolone to prevent gastric complication.
• Antibiotic therapy: Is indicated in the presence of any infection. Prophylactic use of antibiotic is not recommended.
• Diuretics are prescribed in the presence of severe edema and massive ascites, fursemide 1-3mg/kg/day in 2 divided doses alone or with spironolactone 2-3mg/kg/day in 2 divided doses in given, rapid fluid loss should not be attempted in 8 to 12 hours. Potassium supplementation to be given along with diuretics.
• Immunosuppressive drugs: [Levamisole, methotrexate, cyclophosphamide, cyclosporine, chlorambucil] may be administered along with prednisolone in case of frequent [4 or more per year] relapses and in steroid dependent cases.

• Rehydration therapy: The management of diarrhea in a vast majority of children is best done with ORS [Oral rehydration salts] solution and continued feeding.
• Replacement of fluids by rehydration therapy is the principal measure.
• It can be provided by ORT [Oral rehydration therapy] or IV fluid therapy shows standard formulation of ORS as recommended by WHO and approved by Government of India.

Component	Content per Liter water
Sodium chloride	3.5 gm
Potassium chloride	1.5 gm
Sodium Citrate	2.9 gm
Glucose anhydrous	20.0 gm

• Mix entires content of the packed in one litter of water.
• ORS solution to be used within 24hrs of preparation.
• ORT means drinking of solution of clean water sugar and mineral sals to replace the water and salts lost from the body during diarrhea, especially when accompanied by vomiting, e.g. gastroenteritis, ORT is beneficial in three stages of diarrheal disease, e.g:
  1. Prevention of dehydration.
  2. Dehydration of the dehydration child and maintenance of dehydration after severely dehydration patient has been rehydrated with IV fluid therapy. OPT is provided with ORS solution home available fluid, e.g. fruit juice, tender coconut water, dal-soup, subject [with suger and salt of lemon] week tea, etc.97

• Moniter the character, amount and frequency of diarrhea and the presentations of diarrheal disease may vary with severity, specific cause and type of onset.
  Dehydration is tea important life threatening factors which is usually associate with diarrhea.
• Diarrhea stool are usually loose or watery in consistency. It may be greenish or yellowish green in color with offensive smell. It may contain mucus pus or blood and may expelled with force, preceded by abdominal pain, frequency of stool varies from 2 to 10 per day or more low grade fever.
• Thirst, anorexia with intermittent vomiting and abdominal distension.
• Behavioral change like irritability, restlessness, weekness, lethargy, sleepness, dilirium, stopor and flaccidily all usually present.
• Physical charges like loss of wt, poor skin torgor, dry mucous membranes dry lips, pullor, sunker, eyes, depressed fontanelles are also usually found.
• The vital signs all changed as low blood pressure techycardic, rapid respiration, cold limbs and collapse.
• There is decreased or absent sinaly output.
• Convulsions and loss of consciousness may also present in some children with diarrheal disease.

• Physical examination with through history of illness and assessment of degree of dehydration are important diagnostic criterias of prompt initiation of management.
• Stool examination can be done for routine and microscopic study and identification of causative organisms.
• Blood examination can be performed to detecd electrolyte imbalance, acid-base disturbances, hematocrit value, TC, DC, ESR, etc. The suspected associated cause should be ruled out for adequate management.

• Monitor electrolyte level
• For mild to moderate dehydration provide oral rehydration therapy avoid carbonated beverages those cointaining high amount of suger.
• For sever dehydration, maintain NPO status to place he bowel at rest and provide fluid and electrolyte replacement by IV as prescribed if potassium is prescribed by IV ensure the to child has voided prior to administering.
• Reintroduce a normal diet once rehydration is achieved.
• Provide enteric isolation as required.
• Instruct tea parents in good handwashly technique
• Provide proper rest to the children.
• Change diapers as soon as soiled, avoid use of plastic pants.
• Cleans buttocks with warm water after each stool apply protective ointment vaseline to provide skin barrier (remove before applying heet to area)
• Prevent spread of infection protect surrounding area from contamination by use of a pad in bed or an caregiver's lab or antimicrobial therapy may or may not affect the course of the diarrhea depending an the causative agent
• Entertoxigenic E.coli is treated with with neomycin enteroinvasic E.coli as well as shigella may respond to ampicillin when therapy is indicated.
• Antibiotics, especially ampicillin, amoxicillin, and chloramphenical may be given to young infants who have salmonella.

• The important preventive measure are improvement of food hygiene, personal hygiene and environmental hygiene.98
• These include safe water, adequate sewage disposal, handwashing practices, clean utensil, avoidance of exposers of food to dust of dirt, fly control.
• Washing of fruits of vegetable, etc.
• Avoidance of bottle feeding is most significant practice needed for prevention of diarrhea.
• Boiling or filtering to be practiced for safe drinking water.

1. Apgar score
2. Breastfeeding
3. National child labor policy
4. Safety and prevention of accidents in toddlers
5. Low birth weight
6. Cleft lip and palate

• ‘Apgar Scoring’ as described by Dr Virginia Apgar, Despite its limitations, it is an useful quantitative assessment of nernate's conditon at both, especially for the respiratory circulatory and neurological status, five objective criterics are evaluated at one minute and 5 minutes, after the neonates body is completely born. The criterias are, respiration, heart rate/minute, muscle tone, reflex irritability and skin color each of those criterics is an index of neonates depression or lack if it at birth and is given a score of 0, 1 or 2 the scores from each of the criteria are added to determine the total score. The neonate is in the best possible condition if the score is 10, score of 7 to 10 indicate or 10, score of 7 to 10 indicate no difficulty in adjustment in extrauterine life, score of 4 to 6 signify moderate difficulty if the score is 3 or below the neonate is in severe distress which must be treated immediately usually neonates have lower score at one minute, then the score at 5 minute due to the presence of depression immediate after birth. The 5 minute score has greater predictive value, since it correlates with neonatal morbidity, and morality. It also correlated more closely with the infants neurologic status at one year of age.

Criteria	0	1	2
Respiration	Absent	Slow, irregular	Good crying
Heart rate	Absent	Slow [Below 100]	More than 100
Muscle tone	Flaccid	Some flexion of extremities	Active body movement
Reflex response	No response	Grimace	Cry
Skin color	Blue pule	Body pink	completely
		extremities blue	pink.

• The breastfeeding provides close physical contact b/w the neonate and the mother which provides satisfaction. It provides an opportunity for infant mother attachment.99
• Human milk is available at the required temperature in required strength and is fresh and free from contamination as it directly comes in the baby's mouth.
• Human milk contains more lactalbumin, a more complete protein than casein because of its high percentage of amino acids. It is more eassly digested because of soft curds. Therefore, stomach emptying is rapid and thus requires frequent feeding.
• Extra lactose helps in synthesis of certain vitamins. It also contains a high amount of cystine, an aminoacid that may be essential during the neonatal period.
• Human milk contains high amount of lactose, a disaccharide, that is converted into monosaccharide glucose and galactose. Galactose is essential for the growth of the central nervous system unsaturated fatty acids in the human milk help absorption fat and calcium in the neonate. Iron in human milk is absorbed better in the neonate.
• The human milk contains increased amount of antibodies immunoglobulin A [IgA], which gives immunity to the neonate against certain disease. These antibodies are present in a high amount in the colostrum then in nature milk, In the intestines, it acts against bacteria and viruses lactogerin also inhibits the growth of bacteria
  • It contains lactalbumin bifidus which help in suppressing and E. coli lactabumin bifidus help to produce lactic acid, to pervert bacterial growth and make the stools acids.
  • Breast breastfeeding helps the mother in rapid involution of the uterus and lesser chance of breast cancer.

• The mother's disease to feed is the first requirement for successful lactation. She should be psychologically prepared to feed she should drink milk, juice or water before feeding.
• She must wash her hands before feeding.
• She should be physically and emotionally relaxed and comfortable.
• She can sit comfortably with a support at the back. It is advisable to hold the baby in her lap.
• If she is unable to sit, she may feed by lying an her side with a billow under the sloulder.
• She must check whether the baby has soiled the linen. If required the baby should be cleaned and dried to make the baby comfortable, before feeding.
• The baby's head should be supported and slightly raised. The baby may be hold in a semi sitting position with his/her head close to the breast and supported with one arm.
• The cheek of the baby should touch the nipple so that by rooting reflex the baby can get to the nipple and let down reflex is encouraged.
• If the breast is firm and full, it should be pressed with the first finger to prevent pressing of the baby's nose. Both breast should be feed at each time, alternately, using each breast first if possible one breast (which is given first) should be completely emptied at the alternate.
• During the first few days most of the babies fall asleep after feeding taking a few sucks. They should be aroused by gently tickle behind the ear or on the sale of the foot.
• Before removal of the baby from the breast, it is necessary to break sucking by putting a little finger into the corner of the baby's mouth.
• Every baby swallows some air during the feeding and should be held upright and patted on the back until the air is belched. If too much air is swallowed and not removed the baby may have vomiting, colic, or fretfulness. After feeding if required the diaper should be changed.
• After feeding, the body must be positioned on rigt side or on the abdomen.

• Psychological Factor: A shock strong pain, anger, anxiety or worry can affect the “Let-down” reflex. The mother should be encouraged and given support by a calm of positive attitude to develop a confidence that any difficulties may be overcome. She should be explained the proper technique of relaxation and feeding. She should make sure that the neonate is sucking and should be encouraged to feed more often to increase sucking stimuli. In a case of severe anxiety, sedative may be ordered by the doctor for a short time.100
• Early breast engorgement: During the early period after delivery, breast may be felt full and uncomfortable. Some mothers get hard engorged breasts. With the pain. This problem can be solved by application of warm compresses to the breast and then expressing the excess milk, later, the milk production gets adjusted according to demand of the baby.
• Flat and inverted nipple: If nipples are flat and it is difficult for the baby to get hold of the nipple and pull it into the mouth stimulation of the sucking reflex may be interrupted. A flat or inverted nipple may be pulled outward with the fingers to stimulat erection. After making the nipple erect, the baby can be gently put to the breast. If it is not successful, the nipple-shield may be used some babies who get accustomed to the nipple shield may be reluctant to return to the mother's nipple. Therefore wearing a specially prepared plastic cup b/w the feeding may be helpful.
• Sore nipple: Nipples may be sore because of faulty sucking technique, such as the baby takes an insufficient amount of areola surrounding the nipple into the mouth, while nursing. Also it may be sore due to the long period of vigorous sucking, sucking in a bed position, engorged breast, fissures, and oral thrush of the baby, sore nipples are very painful.
• Sore nipples can be prevented by proper antenatal care decreasing the length of the feeding time and increasing the frequency of feeding may also help. The use of soap on the breast should be avoided as it causes drying. The cream may be used be the doctor's advice or any edible oil can be applied on the nipple b/w feed.

• The government of India adopted a National Policy for children in August 1974, Keeping in view the united National Declaration of the Rights of the child and the constitutional provisions.
• The policy declares “It shall be the policy of the state to provide adequate services to children, both before and after birth and though the period of growth to ensure their full physical, mental and social development. The state shall progressively increase the scope of such services so that, within a reasonable time, all children in the country enjoy optimum conditions for their balanced growth.
• According to the declaration the development of children has been considered as integral part of national development. The policy recognizes children as the “nations’ and supremely important asset’ and declares that the nation is responsible for their “nurture and solicitude.”
• A number of programs were introduced by the Govt of India, after the declaration of nation policy for children. The important programs are ICDS scheme, programs of supplementary feeding, nutrition education, production of nutritious food, welfare of handicapped children national children's fund, CSSM programs, etc.

• A Comprehensive health program for all children and provision of nutrition services for children.
• Provision of health care, nutrition and nutrition education for expectant and nursing mothers.
• Free and compulsory education up to the age of 14 years, informal education for preschoolers and efforts to reduce wastage and stagnation in schools.
• Out of school education for those not having access to formal education
• Promotion of games, recreation and extracurricular activities in schools and community centers.
• Special programs for children from weaker sections.
• Facilities for education, training and rehabilitation for children in distress.
• Protection against neglect, cruelty and exploitation.
• Banning of employment in hazardous occupations and in heavy work for children.
• Special treatment education, rehabilitation and care of physically handicapped, emotionally disturbed or mentally retarded children.
• Priority for the protection and relief of children in times of national distress and calamity.
• Special programs to encourage talented and gifted children, particularly from the weaker sections.
• The paramount consideration in all relevant lows in the “interests of children”.101
• Strengthening family ties to enable children to grow within the family, neighborhood and community environment.

• Provide safe playmaterials and toys.
• Floor should not be slippery.
• Furniture should be placed firmly to prevent full and the child should not be allowed to climb over it.
• The child must not be allowed to wear inflammable synthetic materials which may catch fire easily.
• Mother should not hold the baby in lap when drinking tea or coffee or during cooking.
• Child must not be allowed to stand in a car when in motion.
• Electric switch should be out of child's reach.

• Health education is considered as vaccination for prevention of accidents. The significant role of nursing personal is to improve the level of knowledge and awareness about the safety precautions. Parents should be taught to anticipate the risk, to maintain discipline and to provide time to supervise children. Anticipatory guidance should be provided to the parents family members, school teacher, grown up children and general public about prevention of accidents.
• Provision of safe environment to eliminate or reduce the hazardous conditions for the children. It should be arranged at home, school, community and hospitals.
• Safe child care should be organized and provided to prevent accidental hazards. Assessment of child's characteristics for accidental liability is important parents should be involved in safety program of child care. Elimination of causative fectors need to be emphasized through health education.
• Assisting in medical care to prevent disabilities and handicapped condition is an important responsibility of the nurse.
• Emergency care at comprehensive trauma care unit improves the survival rate. Rehabilitation facilities should be organized with necessary referral.
• Public health measures regarding prevention of accidents should be implemented. Traffic rules restriction of speed, use of helmets, avoidance of alcohol while driving, regular checking of vehicles, etc. must be strictly enforced. Nurse should make the people aware to about the strict implementation of rules.
• Participate in policy making of research activities related to accidents prevention of changing of behavior for controlling accidents.

• Low birth wt baby is small in size with relatively large head.
• General activity of the baby is poor with sloggist or incomplete neonatal reflexes such as more, sucking and swallowing reflex.
• Skin in shiny, thin, delicate and pink with little vernix caseouse and plenty langugo hair. There is loss subcutaneous fat.
• Wt 2,500 grams or less
• Length 44 cm or less.
• Head is larger than body, skill banes are soft, sutures are widey separated and fontanelles are large.
• Eyes remain closed and protuding to shallow orbits ears are soft, flat and cartilage is not fully developed.102
• Genitalia: In male baby, testes are undescended and in femal baby, laibia minors is exposed due to poorly developed. And widely separated labia majorg clitoris is hypertropied and prominent.
• Poor muscle tone.

• Care of LBW babies of birth: Efficient resuscitation of prevention of hypothermia are important aspect of care at birth. Delayed cord clamping may improve the iron stores and reduce the incidence of hyaline membrane disease. It should be done according to baby's condition. Continuous breathing support may be necessary warmth should be maintained by heat source, vitamin ‘K’ 0.5 ng should be administered intramuscularly Then after stabilization of condition the baby should be transfered to neonatal intensive care unit for special care with all precautions.
• Care at neonatal intensive care unit: National intensive care unit should provide as like as intrauterine environment for the LBW neonates. The NICU should be warm, free from excessive sound and love smoothing light, protection from infections should be ensued by aseptic measures and effective handwashing rough handling and painful procedures should be avoided. Baby should be placed on a soft-comfortable, ‘nestled’ and cushioned bed continuous monitoring of the baby's clinical states are vital aspect of management which depends open the wt of the baby.
• Maintenance of breathing: Respiratory distress is the commonest problem in LBW baby. Baby should be. positioned with neck slightly extended and air passage to be cleared by gently suctioning to remove the secretion if needed. Oxygen thereby should be administered only when indicated. Head box to be used for oxygen healthy baby's respiration rate, rhythm, signs of distress, chest retraction nasal flaring apnea, cyanosis, oxygen saturation, etc. to be monitored at frequently interval.
• Maintaince of stable body temperature: Environmental temperature should be maintained accordingly to baby's weight of age. Baby's skin temperature should be maintained 36.5 to 37.5°c. Baby with birth weight of less than 1200 gm should be cared in the intensive care incubator with 60 to 65 percent humidity, oxygen if needed and thesmoneutral environment for better thermal central and prevent heat loss. Kangaroo mother care can be provided when the baby's condition stabilizes Baby should be clothed with frock, cap, socks, of mittens, constant monitoring of temperature is essential with low reading thermometer. Bathing should be delayed. All measures to be taken to prevent heat loss external heat sources to be used for thermal protection of these neonates, whe never needed.
• Maintenance of nutrition of hydration: Caloric needs of nongrowing LBW babies during first week of life are 60 Kcal/kg/day fluid requirements of LBW babies are given in following:

  Day	<1000 gm	1000-1500 gm	>1500 gm
  1st and Bid	100-120	80-100	60-80
  3rd and 4th	130-140	110-120	90-100
  5th and 6th	150-160	130-140	110-120
  7th and 8th	170-180	150-160	130-140
  9th onwards	190-200	170-180	150-160

  Requirement of all nutrient should be maintained with adequate feeding should be initiated early. Those babies who have good suckiy and swallowing reflexes should start breastfeeding as well as possible.
• Prevention of infections: LBW Babies are prone to infections due to poor immunity measures to be teaken to present nosocomial infections through handwashing, separate baby care articles, restriction of visitor. Strict of aseptic technique to be followed of all invasive procedure.

• Cleft lips: Incomplete fusion of maxillary and premaxillary processes. Fusion should be completed between 5 to 8 weeks of fetal life.103
• Cleft palate: Incomplete fusion of palatal structure may involve soft or hard palate and may extend into nose, forming an oronasal passageways fusion should be completed b/w 9 to 12 weeks of fetal life.

• Genetic
• Hereditary
• Environmental factor, exposure to radiation or rubella virus, chromosome abnormalities and teratogenic factors.

• Cleft lip: Difficulty feeding—Infant cannot from vacuum with mouth to suck, may be able to breatfeed [breast may fill cleft, making sucking easies]
• Mouth breathing dries mucors membranes, bredisposing infant to infection.

• Cleft lip can range from a slight notch to a complete separation from the floor of the nose.
• Cleft palate can include nosal distortion, midline or bilateral cleft, and variable extension from the uvula of soft and hard palate.

• Assess the ability to suck, swallow, handle normal secretions and breathe without distress.
• Assess fluid and calories intake daily and moniter weight.
• Modify feeding techniques, plan to use specialized feeding techniques, obturators, and special nipples and feeders.
• Hold to child in on upright position and direct the formula to the side and back of the mouth to prevent aspiration, feed small amounts gradually and burp frequently
• Position on side after feeding.
• Keep suction equipment and bulb syringe at bedside.
• Encourage breastfeeding if appropriate.
• Teach the parents special feeding or suctioning techniques.
• Teach the parents the ESSR [enlarge, stimulate sucking, swallow Rest/method of feeding and method of feeding, e.g. enlarge the nipple, stimulate the such reflex, swallow, rest to allow the child to finish swallowing what has been placed in the mouth.
• Encourage the parts to describe their feedings related to the deformity.

• Cleft lip: Repaired in first few week after birth further modification may be necessary, aids infant's ability to suck, helps parents with visible aspects of the defects.
• Cleft palate: Surgical intervention and repair may occur as early as the neonatal period but not later than b/w 12 to 18 months done before speech is fully developed.104

• The mother should be explained about the proper breastfeeding and the bottle feeding to help the infant gain weight.
• The infants should be encouraged to lie on its back to practice for postoperative essential positioning especially with the aim restraints.
• Prevent infection from irritation of the lip.
• Parents should be motivated to provide love and affection to develop an attachment.
• Feed slowly burp frequently bec of swallowed air.
• Instructions should be give to last feed six hours before the surgery.
• Prevent infection from irritation of the lip.

• Maintain patient airway because of edeme and infent's habit of mouth breathing, keep lallygoscope, endotracheal tube of suction equipment nearby.
• Cleanse suture line to prevent crust formation and eventual sculling.
• Minimize crying because of pressure on suture line, encourage a parent to stay with child.
• Place infant in supine position with arm or elbow restraints, change position to side or sitting up to prevent hypostatic pneumonia remove restraints only what infant is suberized.
• Support parents design heeley process.

• Child is allowed to lie on the abdomen.
• Feedings are resumed by bottle, breast of cup.
• Oral packing may be secured to the palate (removed in 2 to 3 days).
• Do not allow the child to brush his or her teeth.
• Instruct the parents to avoid offering hard food items to the child such as toast or cookies.
• Avoid contact with sharp object near the surgical site.
• Avoid the use of oral suction or placing objects in the mouth such as tongue depresser.
• Thermometer, straws, spoons, forks or pacifiers.
• Provide analgesics for pain.
• Instruct the parents in feeding teachings of in the care of the surgical site.
• Instruct the parents to monitor for signs of infection at the surgical site, such as redness, swelling, or drainage.
• Encourage the parents to hold the child.
• Initiate appropriate referrals for speech impairment or language-based learning difficulties.
• Soft elbow or Jacket restraints maybe used (check agency policies and procedures) procedures to keep the child from touching the repair site, remove restraints at least every 2 hours to assess skin integrity of allow for exercising the arms.