Infant and toddler growth and development
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Infant and Toddler Growth and Development. Elisa A. Mancuso RNC, MS, FNS Professor of Nursing. Growth of Infant. Cephalocaudal (head → toe) Proximodistal (trunk → periphery) General → Specific (Large → fine muscles) 1” a month during 1 st 6 months Average Ht 6 months 25 ½ inches

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Infant and toddler growth and development

Infant and Toddler Growth and Development

Elisa A. Mancuso RNC, MS, FNS

Professor of Nursing


Growth of infant

Growth of Infant

  • Cephalocaudal (head → toe)

  • Proximodistal (trunk → periphery)

  • General → Specific (Large → fine muscles)

  • 1” a month during 1st 6 months

  • Average Ht

    6 months 25 ½ inches

    12 months 29 inches

    • Use recumbent length until 3 years

    • than standing (vertical height)


Weight

Weight

  • 5-7oz/wk until 5-6 months

  • Birth weight doubles at 6 month

  • Birth weight triples at one year

  • Always refer to kilograms

    2.2 lbs = 1 kg

  • All medications based on weight in kg!


Head circumference hc

Head Circumference = HC

Reflects brain growth

  • Posterior fontanele closes @ 2 mos.

  • Anterior fontanel closes @12-18 mos.

  • Measure (Forehead → Occiput)

    • For 1st3 years


Chest cc and abdomen

Chest (CC) and Abdomen

Chest = Head circumference @ 1 year

  • Measure @ nipple line.

  • Barrel chested as infant

  • Chest > Head after 3 years

  • After 1 year of age,

    • A/P transverse diameter = 1:2

      Abdominal Girth

  • Measure above umbilicus

  • √ Abdominal distention

  • R/O liver or intestinal diseases


Growth charts

Growth Charts

  • Serial exams to assess growth progress

  • Plotted as percentiles:

    • 25th %, 50th %, 75th %, 95th %.

    • @ 95th % = Pt > 95% of kids.

  • Used to notice any ↓ or ↑in weight, height, or HC.

  • Specific charts for premature infants


Denver developmental screening test ddst denver ii

Denver Developmental Screening Test (DDST) Denver II

  • Assesses from birth → 6 years

  • Age divided monthly → 24 months,

    • then q 3 mos. → 6 years

  • Not an intelligence test

    Four categories

    • Personal/Social

    • Fine motor/Adaptive

    • Language

    • Gross motor


Infant reflexes

Infant Reflexes

  • Moro - Startle

    • Loud sound = extension & abduction of extremities

  • Tonic neck – Fencing

    • Turn head to one side ®

    • arm & leg extend on ® side

  • Babinski

    • Dorsiflexion of big toe and toes fan out

  • All of above disappear in about 3-4 months


Developmental skills

Developmental Skills

Trust vs Mistrust (Birth to one year)

  • Social responsiveness to others

  • Trust develops with regular consistent, loving care

  • Self reliance and develops confidence

    Early infancy 0 - 3 months

    Smiles at significant other

    Holds head & chest up when prone

    Reaches for objects-grasp

    Laughs


Developmental skills1

Developmental Skills

Early Infancy 4-6 months

  • Pulls self to sitting position

  • Sits with support

  • Rolls over = “Safety issue”

    • Tummy → back first at 2-3 months

    • Back → tummy by 6 months

      • stronger head and arm control

  • Transfers objects from hand to hand

  • Makes vowel sounds oh-oh


Developmental skills2

Developmental Skills

Late Infancy 6-9 months

  • Hold own bottle

  • Develops preference for dominant hand

  • Probes with index finger

  • Feeds self finger foods

  • Pincer grasp @ 9 months

    • thumb and index finger used

  • Sits erect-unsupported

  • Crawls

  • Separation Anxiety ↑cries with strangers

    Object Permanance

    Searches for items outsidefield of vision


Developmental skills3

Developmental Skills

9-12 months

  • Triple birth weight and ↑ height by 50%

  • Releases objects

  • Pulls self to feet

  • Sits from standing position

  • Walks with help

    • independent walking can be as late as 18 months!

  • Responds to name

  • Recognizes no

  • Says 4 -5 words: mama, dada, no, bye

  • Teething (age – 6 = # of teeth)

    12 mos – 6 = 6 teeth

    Cool cold items to chew on

    Tylenol 10-15 mg/kg q 4-6 hours


Developmental tasks

Developmental Tasks

  • Achieve physiological equilibrium

    • Rest, eat, play patterns

  • Develop basic social interaction

    • Desire for affection

  • Manage a changing body

    • ↑motor skills & eye-hand coordination

  • Learn to understand and control world

  • Develop a beginning symbol system

    • Communication


Immunizations

Immunizations

  • Regulated by CDC and American Academy of Pediatrics (AAP)

    www.cdc.gov/nip/vacsafe

    www.immunize.org

  • ↓ Infectious diseases = ↓morbidity & mortality

  • ↑ incidence of recent outbreaks:

    • immigration from poorly compliant countries

    • religious beliefs or cultural influences

    • ↓ trust of medical care or poor education

  • 2003 Nigeria stopped IPV

    • Rumors that IPV could transmit AIDS

      2006 20% of kids<5 no IPV and ↑ polio outbreak

  • 2005 Amish Polio outbreak


2009 immunizations

2009 Immunizations

Hep B Hepatitis B Vaccine (IM)

  • Birth, one month and six months

  • Mom (+) HBsAg

    • give baby HBIG (0.5mL) & Hep B within 12H

    • @ 2 separate sites

    • 90% infected infants → chronic Hep B carriers

  • 25%-50% infected before age 5 RT HBV Carriers

  • ↑ Transmission risk in adolescents

    • All kids entering 7th grade must have Hep B

      3 dose series


Immunizations1

Immunizations

IPV - Inactivated Polio Vaccine (SC)

  • 2, 4, (6-18) months and (4-6) years

  • Formerly used OPV –Virus shed

  • Contraindication; Allergy to neomycin

    HIB - Hemophilus Influenza Type B (IM)

  • 2, 4, 6 and (12-15) months

  • Not associated with Flu

  • Protects against many serious infections:

    • Epiglottitis and Bacterial Meningitis


Immunizations2

Immunizations

PCV7 - Polysaccaride Conjugate Vaccine-

(Prevnar) (IM)

  • 2,4,6 and (12-15) months

    PPV – Pneumococcal Polysaccharide (IM)

  • One dose > 2 years

    Protects against Strep pneumonia

  • 6-12 months of age at high risk for S. pneumoniae

    ↑ Risk patients

    • Sickle cell disease, HIV/immune deficiency

    • chronic cardiac or pulmonary etc

    • Must receive PPV vaccine in addition to PCV


Immunizations3

Immunizations

DTaP - Diptheria, Tetanus and acellular Pertussis (IM)

Diptheria

  • Rare throat infection

    • Gray/yellow film

      • difficult to remove

    • Air flow obstruction

    • Sepsis

      Tetanus

  • Clostridium produced in infected wounds

    • Severe muscle extension


Immunizations4

Immunizations

Pertussis

  • Gram negative bordetella pertussis

  • “whooping cough”

    • Post-tussive vomiting

    • Cyanosis

    • Subconjuctival hemorrhage

      Three stages:

  • catarrhal, paroxysmal (2 weeks) and decline

  • ↑ outbreaks in Adolescents and Adults

    RT ↓ titers

    www.pertussis.com


Immunizations5

Immunizations

DTaP Schedule

  • 2,4,6,15 months and 4-6 years for DTaP

  • √ Side Effect: Redness & swelling @ site

  • New booster recommendations 2005:

    • “Tdap” Adacel: one dose 11- 64 years or

    • Boostrix: single dose 10 -18 years of age

    • Adolescents 11-12 years of age should receive single dose of Tdap instead of Td

      (if up to date and have not yet received Td booster)

  • Need 5 year interval from Td to Tdap to ↓SE

    Contraindication:

    • Encephalopathy in 7 days of DTaP


Immunizations6

Immunizations

MMR - Measles, Mumps and Rubella (IM)

Measles

  • Viral illness - macular/papular rash

  • Kopliks spots oral mucosa

  • Encephalitis/pneumonia

    Mumps

  • Inflammation salivary glands/parotid

  • Boys develop orichitis/sterility

    Rubella

  • Viral illness- rash (face → body → extremities)

    Pregnancy exposure:

    • Fetal deafness, cataracts, cardiac defects, encephalitis


Immunizations7

Immunizations

  • MMR is live attenuated (weakened) vaccine

  • 12-15 months and 4 - 6years

  • Contraindication:

    Pregnancy

    Immunocompromised

    Allergy to neomycin


Immunizations8

Immunizations

Varicella (SC)

  • Varicella “chickenpox”

  • Live attenuated virus healthy children only

  • 12-18 months

  • 2nd dose @ 4-6 years

  • 2005 - All kids entering 6th grade

    • ↑Risk > 13 years

  • Give with MMR

    • MMRV new vaccine

      Contraindication

    • Pregnancy

    • Immunocompromised or

    • Allergy to neomycin


Immunizations9

Immunizations

MCV4 - Meningococcal Conjugate Vaccine 4 (IM)

MPSV4 - Meningococcal Polysacharide (SC)

  • Protects against N.meningitids (not all strains!)

  • MCV4/ Menactra:

    • One dose 11-12 years or @ high school entry or college freshman in dormitories

    • (↑risk smoking and crowds)

  • MPSV4/Menomune:

    Children> 2- 10 years ↑risk factors

    Sickle cell disease.


Immunizations10

Immunizations

TIV -Trivalent Inactivated Vaccine – Influenza (IM)

  • Influenza virus → pneumonia and death

    • 2004 -152 pediatric deaths

    • ↑↑ # of cases in February

  • 6 mos - 5 years of age annually

  • > 5 years only high risk population.

  • 0.25ml<3 years or 0.5ml>3 years

  • Contraindication – Egg Allergy

    • √ Eat baked goods can have vaccine

      LAIV - Live Attentuated Influenza Vaccine

      > 5 years (2 doses 1st time)


New vaccines added

New Vaccines Added

Rotavirus vaccine Rototeq

  • Rotavirus is primary cause of acutegastroenteritis in US

    • Three oral doses given at 2, 4 and 6 months

    • Dosing must be complete by 8 months of age

    • No catch-up for older infants

    • Do not re-administer if infant spits up


New vaccines added1

New Vaccines Added

Human Papillomavirus (HPV)

  • Non-enveloped dbl stranded DNA virus

  • >100 types with 15-20 oncogenic types

  • 75% of sexually experienced men and women age 15-49 years have had some type of HPV

    Quadrivalent HPV vaccine (Gardasil)

  • Protects against HPV 6,11, 16 & 18

  • Type 16 and 18 account for approx 70% of cervical cancers

  • ACIP recommended 6/29/06

  • Routine vaccination of girls 11-12 years but may begin @ 9

  • Catch-up vaccination for adolescents and young women who have not been previously vaccinated

  • Not indicated in pregnancy or hypersensitivity to substances


New vaccines added2

New Vaccines Added

HPV administration (3 separate doses 0.5ml IM )

  • 1st dose on elective date

  • 2nd 2 months from first

  • 3rd 6 months after first dose

    SE:

    Very painful

    Syncope & tonic –clonic movements

    √ Pt remains seated or lies down x 15 minutes

    Compliancy Issues:

    • Moral issues can intervene

    • Study with boys shows = a good immune response

    • ↑ Vaccinate girls RT ↑↑ risk of Cervical CA


Only true contraindications to vaccine administration

Only true contraindications to vaccine administration

  • Fever >102

  • Immunocompromised: (No MMR & Varicella)

    • HIV, Leukemia, Lymphoma

    • Alkylating agents or Antimetabolites

    • Daily Corticosteroids Dose:

      > 2 mg/kg or 20 mg/day

  • Allergy to vaccine component

  • Vaccine Adverse Event Reporting System

  • (VAERS)


Congenital defects

Congenital defects

Cleft palate

  • 1/750 births cleft lip

  • 1/2500 births cleft palate

  • Incomplete closure of the roof of the mouth

    • 6th -10th week of gestation

  • Opening from uvula→ soft palate → hard palate → lip

  • Cleft palate 1st sign

    • Formula coming out of nose

  • Gloved finger to assess soft and hard palate in

  • newborn


Etiology

Etiology

Multifactorial

  • Genetic-familial tendency

    • ↑ in Asians and lowest in African Americans

  • ↑ Caffeine

  • ↑ ETOH

  • Dilantin or Valium

  • ↓Folic Acid ↓ Vit A

    Sequella

    • Feeding difficulties

    • Speech difficulties

    • High risk for Otitis Media

      Serous and Bacterial


Interventions

Interventions

  • Review defect

    • Impact on infant

    • Before and after photos

    • Support Groups

  • 3P Feeding technique

    • Position - upright

    • Pore - soft, premie nipples

      • enlarged opening

    • Patience - burp frequently


Surgery

Surgery

  • Lip repair usually 1-3 months

    • Protect incision line after operation

  • Palate repair @ 18 months

  • Supine with ↑ HOB

  • Elbow restraints

  • √ I & O


Tracheoesophageal tef fistula

Tracheoesophageal (TEF) Fistula

  • Fistula

    • Opening between trachea and esophagus

    • Fluids enter lungs

    • ↑ Aspiration PN

    • Large amounts of air into stomach

      Esophageal Atresia EA

  • Esophagus ends in a blind pouch

    ↑ in Pre-term and/or Polyhydramnois

  • 30-50% multiple anomalies


Tef ea clinical signs

TEF/ EA Clinical Signs

  • Increased salivation

  • Drooling

  • “3 C’s”

    • Choking

    • Coughing

    • Cyanotic episodes

  • Laryngospasms

  • Abdominal distension

  • Unable to pass NGT with atresia


Interventions1

Interventions

  • NPO

  • ↑ HOB>30º

  • Maintain patent airway

  • NGT to low intermittent suction

  • Prophylactic antibiotics

    • Aspiration PN

  • Surgery correction of fistula

  • ASAP


Safety in infants

Safety in Infants

Accidents leading cause of death btwn 6-12 mos

Suffocation/Aspiration

  • # 1 cause of fatal injuries <1 year

  • √ toys, mobiles

  • No H2O mattress or pillows

    Falls

  • Walkers 45%

    Burns

  • H2O temp @ 160 scalds skin in 10 seconds

  • ↓ Temp to 120

    Poisonings

  • Plants, Cleaners, Grandma’s purse √ meds

    Cars

  • Car seat < 1 year back seat, facing rear


Nutrition

Nutrition

Vitamins for Infants

  • Fluoride

    • 0.25mg/day > 6 months - 3 years

    • Poly-vi-flor 1cc QD

    • >3 years ↑ 0.50mg/day

  • FeSO4

    • 0.5mg/kg/day > 6 months

    • if BF mother not taking supplements

    • after 6 months fetal stores are depleted)

      Vit D

      400 IU/day

      if BF mother not taking supplements


Breast milk

Breast Milk

  • Contains all nutrients and

    • A,B, E

    • Immunoglobulin IgA, T and B cells

  • Lacks Vit C, D and Fe

  • Twice sugar (lactose)= laxative effect

    • ↑ # of stools

  • ↑↑ lactalbumun more complete protein

  • ↓↓ caesin easier to digest


Formula

Formula

  • No more than 32 oz/day

  • No whole milk in infants!

    • No iron in milk

    • Infants unable to properly digest

    • ↑ ↑ irritation of intestinal mucosa, bleeding and anemia


Solids

Solids

  • Begin at 4-6 months

  • Too early introduction of solids

    • ↑ incidence of allergies and celiac disease.

    • No cereal in formula bottle!

  • Assess physiological readiness

    • ↓ Tongue extrusion reflex

    • ↑ Coordinated suck & swallow

    • Tooth eruption – ↑ biting & chewing

    • ↑ Pancreatic enzymes for complex nutrients

  • Introduce foods one at time

    • New food after 3 days:

    • Cereal → vegetables → fruits →meats → egg yolks

      Noegg whites <1 year

      No honey/corn syrup <2 years

      ↑ Risk of botulism

      No Nuts, Seeds or Popcorn


Kwashikor

Kwashikor

  • Severe protein deficiency

  • Adequate caloric intake and ↑ ↑ carb diet

  • Mycotoxin mold found in intestines

    Signs and Symptoms

  • Scaly, dry skin and ↓ pigmentation

  • Hair thin/dry and coarse

  • Ascites

    • Edema RT ↓ protein

  • Muscle atrophy

  • Irritable, lethargic, withdrawn

  • Permanent Blindness

    Diarrhea→Infection →Death


Nursing interventions

Nursing Interventions

  • Assess degree of malnutrition

  • Neurological/muscular impairments

    • √ Developmental milestones

  • Hyperalimentation

  • ↑ Protein diet

  • Antibiotics

  • Skin Care

  • Collaborate with OT and PT


Skin disorders

Skin Disorders

Eczema (5-7% Infants)

  • RT allergies (egg, soy and cow’s milk)

    • ↑ Ig E levels RT ↑ Histamine, Prostaglandins, Cytokines

  • ↑ with stress

  • 90% develop asthma

    Signs and Symptoms

  • ↑ in winter

  • Skin Rash

    • Erythematous, edematous,

    • Pruritic, dry and cracked

    • ↑ Lesions in skin creases,

      Cheeks, forehead & scalp

  • ↑ Risk of secondary infections


Treatment

Treatment

  • Hydrate

    • Brief bath with Dove soap

    • Lubricants –Eucerin cream

  • Topical steroids

  • Antibiotics if secondary infections

  • Elidel and Protopic 0.03% non-steroidal

  • Pimercrolimus and Tacrolimus

    • Only for children > 2 years

    • Black box warning

    • ?↑ risk of cancer


Impetigo

Impetigo

  • Toddlers and Preschoolers

  • ↑ incidence in Summer (hot/humid)

  • 1st Skin is broken via bug bite

    • infected - staph A or B strep

  • Very contagious

  • 1st Macular & Pruritic

  • 2nd Honey crusted, thick & bleed

  • Therapy

    • Wash lesion c warm soapy H2O

    • Soak and remove crusts

    • Bactraban BID 7 days

      PO Antibiotics

      PCN, EES, Lorabid, Zithromax


Sebborrheic dermatitis

Sebborrheic Dermatitis

Cradle Cap

  • Chronic inflammatory

    condition

  • Dysfunction of

    sebaceous glands

  • Infants produce a lot of sebum

  • Yellow scales from eyelids → Scalp

  • Therapy

    • Apply lotion, massage scalp

      Fine comb remove scales


Toddler 12 36 months

Toddler 12-36 months

  • Growth slows – Physiological anorexia

  • Average weight gain 4-6 lbs/year

  • BW quadrupled by 2 ½ years

  • Height 3 inches/year

  • HC growth slows

  • A/P diameter 1:2

  • Visual acuity 20/40

    • Eyes can accommodate objects @ distance

      ↑ Neuromuscular control

      Manipulates objects & people


Psychosocial development

Psychosocial Development

Autonomy vs. Shame and Doubt

  • “Me do” stage

  • Intense exploration of environment

  • Fighting for autonomy

  • Negativism “No”

  • Ritualistic behavior to control their environment

  • Body Image develops


Psychosocial

Psychosocial

  • 2nd Separation Anxiety

    • Cling and cry when left by parent

    • Be honest regarding separation do not disappear!!

  • Body image develops

    • knows certain body parts: eye, “pee pee”

  • Begins to acquire socially accepted behaviors


Toilet training

Toilet training

  • Holding on and letting go is very important!

  • Need to recognize the urge to “let go”

    1st Bowel control after 18 months

    2nd Bladder control @ 2½ - 3½ years

  • Daytime bladder control before nighttime

  • Regular BM and patterns or child will alert you

  • Needs ↑ awareness and self discipline

  • Harder to train children with history of

  • constipation


Temper tantrums

Temper tantrums

  • Common response to helplessness or frustration

  • Inadequate verbal skills

    • Can’t communicate needs!

    • Strike out physically

      Monitor for speech delay children!


Interventions2

Interventions

  • Set appropriate, clear and consistent limits

  • Safely isolate and ignore behavior

    • Remove from situation

  • Redirect or introduce another activity to restore self-esteem

  • Time out = minute per age

  • Do not let toddler get too tired, hungry or stimulated

  • After tantrum subsides provide love and

    attention


Developmental skills4

Developmental skills

  • 300 words by 2 years.

    • Understand more than they say

    • 2 yr old 65% of speech should be comprehendible

  • Knows first and last name

  • Dressing - takes off own clothes

  • Walk, run, and jump with both feet

  • Ride tricycle, build tower of blocks

  • Parallel play

    • Possession = ownership

  • Ritualism

    Comforting & ↓ Anxiety


Intellectual development

Intellectual development

5th Stage of Sensorimotor @12-18 months

  • Object permanence

    • Exists when not visible “Where’d it go?”

    • “Peek a Boo”

  • Active experimentation

  • Time perception

    • Holidays, morning, noon, night

    • 1 minute = 1 hour

  • Space perception

    • Nesting

    • Stands on stool to get object

      Magical thinking


Pre operational stage

Pre-operational Stage

Transitional Stage 18 - 24 mos

  • ↓ Trial and error

    • Memory and imitates actions.

    • sweeping floor with broom is mom cleaning

  • ↑ Problem solving

  • Egocentric- “I” “me” “mine”

  • Concrete thinking

    • Literal translation

    • “A little stick” for IV = tree branch

  • Sense of Time

    • Orientation RT activities

    • Mom will be back after nap instead of at 2 o’clock.


Toddler developmental tasks

Toddler Developmental Tasks

  • Differentiate self from others

  • Toleration of separation of parents

  • Slight delayed gratification

  • Basic toilet training

  • Socially acceptable behavior

    • Biting and spitting bad!

  • Communicates effectively

    Transitional objects

    Favorite toy, blanket

    ↓ stress


Nutrition1

Nutrition

  • ↓ Growth period = ↓ protein and fluids

  • Physiological Anorexia @ 18 mos

    • ↓ nutritional need = ↓ ↓appetite

  • Daily diet

    • Milk 2-3 cups/day

    • ↑ FE, CA, PO4

  • Very fussy and food jags (1-2 items only!)

    • Only peanut butter and bananas!

  • Want to feed themselves = MESSY!

  • May eat a lot one day

  • and not much following day


Nutrition2

Nutrition

  • Offer small, frequent nutritious snacks

    • Toddlers love to graze

  • Not too much milk or juice (↑ sugar)

    • Fills them up = won’t eat

  • Do not force child to eat.

    • Will eat when hungry.

    • If child is not losing weight it is ok.


Dentition

Dentition

  • Twenty primary teeth by 30 months

  • Brush teeth 2 x/day!

  • No bottles of juice or milk at bedtime.

  • Dental carries can occur.


Safety

Safety

  • Toddlers have no sense of danger

  • ↑↑ Locomotion = DANGER!!

  • Injuries cause > death in ages 1-4

    Motor Vehicle Crash (MVC) = #1!

  • ↑ Caused by lack or improper restraint

  • SUV

    • toddlers wander behind truck and get hit.

  • DWI

    • 2500 kids/year

    • 7/10 in car with impaired parent


Car seat safety rules

Car Seat Safety Rules

  • Universal Child Safety System (UCSS)

    • 2 point attachment with tether system

    • by 2002 all new cars must have entire UCSS

  • <12 years of age = sit in back of car

  • Infant = rear facing (1 yr and 20 lbs)

  • Forward facing convertible seat till 40 lbs

  • >40 lbs belt positioning booster seat

    New York State Seatbelt Laws

  • March 2005 any child <7 years of age

    • appropriate restraint system or booster seat

      80 lbs or 4 ft 9 inches may use seatbelt

      Seat belt must fit properly:

      on hips not stomach

      on shoulder not neck


Drowning

Drowning

  • # 2 cause of death for toddlers

    • Totally Preventable!

  • Only need 1” of H2O to drown

    • Bucket to clean car

    • Ponds

    • Pools

    • Beach

  • Always supervise near water!


Burns

Burns

  • 3rd cause of death (boys)

    • 2nd among girls

  • 20,000 injuries/year and 1,000 deaths

    • 16% RT child abuse

      Types

  • Thermal- flames, scalds (85%),hot objects

  • Electrical- socket, chewing wires

  • Chemical- Ingesting cleaning products

  • Radiation- sunburn


First degree superficial epidermis

First Degree/Superficial (epidermis)

  • Minor sunburn

  • Red, dry and painful

  • Heals spontaneously

    • 3-7 days

  • No therapy needed


Second degree partial thickness

Second Degree Partial Thickness

  • Involves epidermis and upper layer of dermis

  • Moist, bulla

  • Skin bright red

  • Painful

    Heals in 14 - 21 days with scarring


Third degree full thickness

Third Degree/ Full Thickness

  • Includes subcutaneous tissue

  • Dry, pale or brown/black

  • PAINLESS

  • Eschar-

    • thick leather like

    • dead skin

      Healing requires skin grafting

      • ↑ painful


Fourth degree full thickness

Fourth Degree/ Full thickness

  • Extends all the way to bone

  • Dry, whitish leathery appearance

  • ↓Sensation to pain

  • Scarring and contractures


Total body surface area tbsa

Total Body Surface Area (TBSA)

  • Varies with age

    • ↓ age = ↑ TBSA

    • ↑ surface area = ↑ Injury

      “Rule of Nines”

    • Determines % of burns

    • Transfer to burn unit BSA>10%

      Open palm of hand = 1 % of BSA

      Thorax 18% Head 19%

      Arm 8% Leg 13%


Management

Management

Respiratory

  • Maintain patent airway

  • R/O Inhalation injury

    • Smoke, steam, toxic fumes

    • Charred lips, singed nasal hairs,

    • soot covered nares

  • Humidified 100% O2

  • Assess for:

    • Respiratory Acidosis:

      • ↑ RR, retractions, nasal flaring, ↑↑effort, ↓O2

        Moist Breath sounds = Pulmonary edema

        √ Carboxyhemoglobin (CoHb) levels

        > 10% need hyperbaric chamber


Fluid resuscitation

Fluid Resuscitation

Hypovolemic “Burn” Shock

  • ↑↑ capillary permeability

  • Leakage of intravascular fluids

  • ↓↓ Perfusion, ↓↓ BP, ↑↑ HR, ↓ Output

  • Parkland Formula = 4mL LR x kg x %TBSA

    1st 24 - 48 hours until capillary integrity is restored

  • IV Maintenace Fluids: 4:2:1 Rule

    4mL/kg for 1st 10 kg 45 kg child: 4 x 10 = 40 mL

    2mL/kg for 10-20 kg 2 x 10 = 20 mL

    1mL/kg >20 kg 1 x 25 = 25 mL

    85 mL/H

    Maintain urine output 1-2ml/kg/hour-(foley)

    Strict I & O!

    √ SG √ Wt.

  • √ VS and LOC


  • Monitor lab values

    Monitor Lab values

    Hyperglycemia

    • ↑ NE/E, ↑stress, insulin resistance, glycogen released

      Hyponatremia

  • 3rd spacing 1st 24 hours = ↑NA excretion

    Hyperkalemia

    • 1st 24 hours = ↑ cell release of K+

      Hypokalemia

    • 2nd 24 -48 fluid shifts back to cell ↓ K+

      Hypoalbuminia (<2)

    • ↓ serum proteins 3rd spacing

    • Albumin 1 gm/kg/day

      Metabolic acidosis

    • Renal failure, tissue damage RT sepsis

      ↑BUN ↑Creatine = ↑ SG

    • Dehydration & renal failure


  • Pain management

    Pain Management

    • Acute

      • Burned skin and exposed nerves

      • Moaning, grimacing, restlessness, guarding, dilated pupils, clenched fists,↓↓ movement

    • Procedures: PAIN

      • Dressing changes ↑↑ anxiety & ↑↑ fear

    • Medicate prior to all procedures.

      • MSO4, Propofol, Fentanyl, Hydromorphone

    • Imagery, relaxation, distraction

      Therapeutic Touch


    Wound care

    Wound Care

    • Aseptic/sterile technique

      • ↓↓risk of infection

      • Invasive lines, compromised immune

    • Protective Isolation

    • Debridement

      • Remove dead tissue

    • Hydrotherapy

      • Soaking wounds - remove old dsg

      • 10 mins to prevent electrolyte and fluid loss

      • Washing area

        • Clean area & assess wound

        • √ color, drainage, odor, sloughing, granulation tissue


    Antimicrobial creams

    Antimicrobial creams

    Mafenide Acetate (Sulfamylon cream)

    • Painful but penetrates eschar

    • Gram (+)/(-) coverage

    • Apply & leave OTA or light dsg

    • √ Sulfa allergies

      • Hypersensitivity reaction

    • SE: Metabolic acidosis


    Antimicrobial creams1

    Antimicrobial creams

    Silver Sufadiazine (Silvadene)

    • Painless

    • Gram (-)/(+) coverage

    • Not to use on face or electrical burns

    • 1st Clean wound

    • Apply & leave OTA or light dsg

    • √ Sulfa allergy

    • SE: Transient leukopenia


    Antimicrobial creams2

    Antimicrobial creams

    Silver nitrate 0.5%

    • Most gram (+) & some gram (-)

    • Painless soak

      • Dampen dsg q 2H or TID

      • Need large bulky dsgs

    • Stains clothing and linens -black

    • SE: ↓ K+ ↓ Na+ ↓Cl+

      • √ lytes


    Skin grafts

    Skin Grafts

    • Autograft

      • Patient’s own skin

      • ↓ risk for Host Versus Graft (HVG) response

    • Transcyte

      • Newborn foreskin

      • Bioactive skin substitute

      • ↑ Re-epithelialization

        • ↓ dsg changes ↓ hospitalization

        • ↓scarring


    Nutritional support

    Nutritional Support

    • NPO x 24 hours

      • √ Bowel sounds √ Abd girth √ N & V

    • Curling’s Ulcer

      • ↓ GI perfusion ↑ occult blood via NGT & stool

    • 2-3 times daily calories for wound healing

      • ↑ BMR RT ↓ Protein & N loss

    • Protein 25% of calories-

      • eggs, peanut butter and milk

        ↑↑ Vit A and C important for skin

        oranges, grapefruit

        strawberries, broccoli


    Psychological needs

    Psychological Needs

    • ↑ Contractures & ↓ROM RT scars

    • Pressure Ace wrap cover to ↓↓ scars

    • Increase involvement in care

    • Play therapy & counseling

      • Ease transition → community

    • Prepare friends and school

      • Wounds/scarring & emotional needs

    • Support groups


    Poisoning

    Poisoning

    • 150,000 kids < 5 years old = 120 deaths/year

    • ↑ risk @ 2 years (improper storage)

    • Poison Control # = 1-800-222-1212

      www.lirpdic.org

      Aspirin Intoxication-

    • # 1 most ingested drug

    • ASA acetylsalicylic Acid

    • ↑ Availability in home

      • Combination OTC meds:

      • Peptol bismal, cough and cold, wart preparations

        Therapeutic Dose 40 -100 mg/kg

        Toxic dose 200mg/kg

        Severe toxicity 300 - 500mg/kg


    Signs and symptoms

    Signs and symptoms

    6 H delay before toxicity signs noted

    • Hyperventilation

      • ↑↑ RR ↓↓CO2

    • ↑ Metabolism

      • ↑↑BMR ↑↑ O2 use ↓↓ Glucose

    • Metabolic acidosis

      • ↑ ketones and organic acids

    • Bleeding

      • ↓↓ platelets


    Interventions3

    Interventions

    • √ Serum salicylate levels

      • Therapeutic 5-20mg/dl

      • Toxic >25mg/dl

    • Gastric lavageup to 4 hours post ingestion

    • Activated Charcoal (1g/kg)

      • ↓ absorption & ↑ elimination via GI tract

    • Vit K for bleeding

    • Correct lyte imbalances-

      • ↑↑ Ca+ ↑↑ K+

    • ↑↑ Hydration

      • Flush kidneys

    • ↑↑Calories

    • May need hemodialysis


    Acetaminophen overdose

    Acetaminophen Overdose

    • Most common acute drug poisoning

      • ↑↑ Risk c combination drugs

    • ↑↑ Risk for liver damage

      • RT metabolites binding to hepatocytes

    • ½ life = 3 hours

    • Liver necrosis within 2-5 days if not treated

    • Therapeutic dose = 90 mg/kg

    • Toxic dose = 150mg/kg


    Clinical signs

    Clinical signs

    • Phase one (1st 24 hours)

      • N/V, anorexia and malaise

    • Phase two (24-36 hours)

      • Hepatomegaly, RUQ pain, ↑↑LFT’s

      • ↑INR, PT, hyperbillirubin and oliguria

    • Phase three (2-5 days)

      • Encephalopathy, cardiomyopathy, anorexia, emesis, liver failure, hypoglycemia, coagulopathy, renal failure and death

        Phase four (7-8 days)

        Recovery or fatal hepatic failure


    Interventions4

    Interventions

    √Serum acetaminophen levels

    • ↑ validity 4 hours post ingestion.

    • Therapeutic level = 2 -20 mg

    • Toxic level > 50 mg

    • If extended release √ level 8 hours after ingestion.

    • Must know actual ingestion time.

      √ INR (1.0 WNL)

    • Earliest and most sensitive for hepatotoxicity

      √ LFTs (AST Aspartate Transaminase)

    • Bilirubin, PT

    • Released with hepatic injury

      √ BMP/ Panel 7

      √ Renal- BUN


    Interventions cont

    Interventions cont

    • Gastric lavage most effective with extended release

    • Activated charcoal most effective 1-2 hours after injestion.

    • N-acetylcystein-”Mucomyst”- PO

      • Loading dose = 140 mg/kg x 1 PO

      • then 70 mg/kg x 17 doses PO q 4H.

      • Most effective with-in 8 hours of ingestion

      • Must be initiated with-in 16 hours.

      • Mix with coke smells like rotten eggs

      • Charcoal may bind with mucomyst give 1 hour apart

    • May use IV mucomyst if pt not tolerating PO


    Lead poisoning plumbism

    Lead poisoning Plumbism

    • Home built before 1960’s

      • ↑ Risk for lead based paint (banned in 1978)

      • Recent ongoing renovations

    • Nearby industry

      • Battery plants, gas stations

      • Leaded gasoline in soil children place hands in mouth

    • Old furniture, ceramic pottery and lead toys

    • Folk Remedies

      • Azarcon, Greta, Ligra & Surma (200x Pb!)

    • ↑Risk

      < 6 years

      Urban areas

      Medicaid recipients 3 x’s lead levels

      Lead Screening

      Screen at 9 months to 1 year and then 2 years

      Earlier/ASAP with risk factors


    Clinical signs1

    Clinical signs

    • Most kids are asymptomatic! √ Level

      • Pb serum level > 10 is toxic

      • Pb > 45 = RX

      • Pb > 70 = Medical Emergency (RX & ICU)

        90% Pb attaches to RBC

      • Interferes binding of iron to heme molecules

      • √ H and H , Fe

      • ↓ HgB = Anemia

    • Absorption of Pb > Excretion

    • 24 H Urine (lead) >3 mg

      • Damages cells of proximal tubules

    • Lead deposits in tissues, bones, gums and abdomen

      Lead lines (bones, nails)

      X-rays; Femur and Tib/Fib for deposits

      Abdominal pain (paint chips on X-Ray)

      Vomiting & Constipation


    Cns symptoms

    CNS Symptoms

    • Hyperactivity

    • Aggression-irritability

    • Impulsiveness

    • Learning disabilities

    • Developmental delays

    • Lead Encephalopathy = Irreversible!

      • ↑ ICP

      • Seizures

      • Cortical atrophy-

        • Permanent brain damage→ Mental retardation

      • Coma and death


    Treatment1

    Treatment

    Chelation Therapy for level >45mg/dl

    Binds Pb to H20 water soluble form → excretion via urine

    • Must use two meds if levels >70mg/dl

      1. CaNa EDTA (calcium disodium edetate) IM/IV(20 doses)

    • √ adequate kidney function

    • Painful injections

      • Apply EMLA 2 H before and inject with procaine.

        2. BAL (dimercaprol) IM(24 doses)

    • √ renal function

    • Contraindicated with peanut allergy or G6PD

    • Usually not single therapy use in conjunction with EDTA

      3.Succimer (Chemet or DMSA) PO(43 doses)

    • Alternate treatment for EDTA

    • 19 day therapy


    Hydrocarbons

    Hydrocarbons

    • Gasoline and kerosene

      • ↑Risk for aspiration/pulmonary toxicity

    • Turpentine = systemic toxicity

    • Antifreeze

    • Carbon Tetrachloride

    • Baby Oil

    • Camphor (Moth Balls)

    • Inhaled or ingested


    Signs and symptoms1

    Signs and symptoms

    • Gagging, Choking, Cyanosis

    • N & V

    • ↑↑ RR Retractions Dyspnea Grunting

    • Aspiration PN in RUL

    • Seizures

    • Renal failure

    • Coma


    Therapy

    Therapy

    • No emesis RT ↑Risk of aspiration

    • Gastric lavage

    • Humidified ↑ O2 + PEEP

    • Hydration

    • Antibiotics

      • Prophylactic for PN


    Lye corrosives

    Lye, Corrosives

    • Strong alkali with ↑↑ PH

      • Dishwasher detergent (Electrosol tablets)

      • Batteries

      • Denture cleaners

      • Oven/ Drain cleaners

    • Erodes esophagus can cause perforation


    Signs and symptoms2

    Signs and symptoms

    • Severe Burning Pain

      • Mouth, throat and stomach

    • White swollen mucous membranes:

      • lips, tongue, pharynx

    • Inspiratory stridor & Dyspnea RT

      • Esophageal and tracheal edema

    • Drooling

    • Violent vomiting - blood & tissue

      ↑↑ Anxiety


    Treatment2

    Treatment

    • Don’t induce Vomiting!

    • Maintain patent airway

    • Administer analgesics

    • NPO or Dilute corrosive with 120 ml H2O only!

    • Steroids Methylprednisolone 2mg/kg/day

    • Humidified O2

    • Surgery

      • Batteries can cause esophageal and gastric burns

      • Esophageal strictures


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