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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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