The Infant (0–1 year)

Alterations in Health (Diagnosis)

• Covers expected growth, motor, cognitive, psychosocial, and social development from birth through 12 months, with the anticipatory guidance that goes with each. Full-term averages: head circumference 34.8 cm (13.7 in) male and 33.8 cm (13.3 in) female, 1-2 cm larger than chest; length 50 cm (19.7 in) male and 49 cm (19.3 in) female; weight 3600 g (7 lb 15 oz) male and 3200 g (7 lb) female. Up to 10% of birth weight is lost by day 3-4 from fluid shifts, meconium, and low intake, and regained within about 2 weeks.

Health Promotion & Disease Prevention

• Rear-facing federally approved car seat, semi-reclined, in the back seat to prevent slumping and airway obstruction
• Newborns discharged before 48 hr need provider exam within 48 hr of discharge
• Immunizations: Hep B at birth; DTaP, RV, IPV, Hib, PCV, and Hep B at 2 months; DTaP, RV, IPV, Hib, and PCV at 4 months; DTaP, PCV, RV, and Hib at 6 months, with IPV and Hep B any time from 6-18 months; influenza yearly from 6 months as the inactivated IM form
• Nutrition under 1 month is breast milk or iron-fortified formula only — fats supply 40-50% of energy; cow's milk is not appropriate
• CDC, WHO, and AAP recommend exclusive breast milk to 6 months with continued breastfeeding beyond
• Vitamin D supplement within the first days of life for exclusively breastfed infants; iron if prescribed

Assessment — Risk Factors

Assessment — Expected Findings

• Posterior fontanel closes 6-8 weeks; anterior fontanel closes 12-24 months
• Weight doubles by 4-6 months and triples by 12 months
• Length increases about 25 cm (10 in) in the first year, faster in the first 6 months
• Head circumference grows about 1 cm per month during year 1
• Teeth: first eruption 6-10 months (average 8 months); 6-8 teeth by 1 year; about 20 deciduous teeth by 3 years
• Teething may cause drooling, chewing, irritability, poor sleep, low-grade fever, ear rubbing, decreased appetite
• Piaget sensorimotor stage, birth to 24 months: reflexive to repetitive to imitative behavior; tasks are separation, object permanence (about 9-10 months), and mental representation
• Crying is the first verbal communication — 2-3 hr/day for the first 6 weeks, often clustered in afternoon and evening

Laboratory Tests

Diagnostic Procedures

Nursing Care

Medications

Therapeutic Procedures

Client Education

Interprofessional Care

Complications

Alterations in Health (Diagnosis)

• Vaccines stimulate antibody production against a specific disease using a killed or weakened form of the organism. The Advisory Committee on Immunization Practices sets the schedule. Preterm infants receive each vaccine at the same chronologic age as full-term infants. A catch-up schedule on the CDC website covers missed doses. Goals are to reduce or eliminate infectious diseases in the population and to prevent those diseases and their complications.

Health Promotion & Disease Prevention

• Hepatitis B: minimum age birth, 3 doses at birth, 1-2 months, and 6-18 months; at least 4 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3; final dose no earlier than 24 weeks of age and at least 16 weeks after the first; withhold for preterm infants under 2,000 g if the mother is hepatitis B negative
• Rotavirus: minimum age 6 weeks, 2 doses of Rotarix (2 and 4 months) or 3 doses of RotaTeq (2, 4, 6 months); do not start the series at 15 weeks 0 days or older and give the last dose by 8 months 0 days
• DTaP: minimum age 6 weeks, 5 doses at 2, 4, 6 months, 15-18 months, and 4-6 years; at least 6 months between doses 3 and 4; dose 4 may be given as early as 12 months; dose 5 is unnecessary if dose 4 was given at 4 years or older and at least 6 months after dose 3
• Tdap: minimum age 11 years, one dose at 11-12 years then Td booster every 10 years; one dose in each pregnancy between 27 and 36 weeks regardless of prior timing; for wounds, give Tdap or Td if a minor clean wound and over 10 years since the last dose, or over 5 years for all other wounds
• Hib: minimum age 6 weeks, 4 doses (ActHIB, Pentacel, Vaxelis) at 2, 4, 6 months and a 12-15 month booster, or 3 doses (PedvaxHIB); use a different Hib product for the booster; only 1 dose is needed for unimmunized children 15 months or older
• PCV13: minimum age 6 weeks, 4 doses at 2, 4, 6, and 12-15 months; follow current dual-series guidance with PPSV23 for high-risk conditions

Assessment — Risk Factors

Assessment — Expected Findings

Laboratory Tests

Diagnostic Procedures

Nursing Care

• Obtain guardian consent before administration
• Give the vaccine information statement and review it with guardians and older children, documenting each VIS publication date
• Reassure caregivers that MMR is not associated with autism
• IM route: vastus lateralis for infants and young children, deltoid for older children and adolescents
• Subcutaneous route: outer upper arm or anterolateral thigh
• Choose needle size by route, site, age, and volume — adequate length reduces injection site swelling and tenderness
• Use comfort strategies to minimize discomfort
• Effectiveness is shown by development of immunity and by local reactions resolving without pain, fever, or swelling
• Anaphylaxis to any vaccine contraindicates further doses of that vaccine or any vaccine containing that substance

Medications

Therapeutic Procedures

Client Education

Interprofessional Care

Complications

• DTaP mild: injection site redness, swelling, and tenderness, poor appetite, vomiting, low fever, drowsiness, irritability, anorexia
• DTaP moderate reactions: crying that cannot be consoled lasting 3 hr or longer, temperature reaching 40.6 C (105 F) or above, seizures with or without fever, and a shock-like state
• DTaP severe: acute encephalopathy, rare; encephalopathy within 7 days of a prior dose contraindicates further doses
• LAIV: allergic reaction, vomiting or diarrhea, nasal congestion and runny nose

Alterations in Health (Diagnosis)

• Covers newborn and infant complications: phenylketonuria, meningocele and myelomeningocele, necrotizing enterocolitis, respiratory distress syndrome, congenital hypothyroidism, substance-exposed infants, hyperbilirubinemia, chromosomal abnormalities, newborn sepsis, plagiocephaly, newborn seizures, and preterm complications. PKU is an inherited deficiency of phenylalanine hydroxylase, so phenylalanine cannot convert to tyrosine and accumulates. Meningocele and myelomeningocele are neural tube defects arising when the neural tube fails to close in the third to fourth week of embryonic development. Necrotizing enterocolitis is inflammation of GI mucosa from ischemia or hypoxia, killing mucosal cells and leaving necrotic patches that impair digestion. Hyperbilirubinemia is elevated blood bilirubin producing jaundice that begins in the head, especially sclera and mucous membranes, and progresses down the body. Physiologic jaundice is benign and reflects normal breakdown of fetal red cells plus liver immaturity, while pathologic jaundice (hemolytic disease of the newborn) appears before 24 hr of age; normal unconjugated bilirubin in a term newborn is 0.2-1.4 mg/dL. Newborn sepsis is organisms or their toxins in blood or tissue during the first month, with subtle findings that mimic other diseases.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• PKU is autosomal recessive; prevention depends on identifying affected people of reproductive age, who must follow strict dietary guidelines from 3 months before conception through pregnancy
• Neural tube defects: medications or illicit substances in pregnancy, malnutrition, insufficient folic acid, radiation or chemical exposure, prepregnancy obesity, diabetes, hyperthermia, low vitamin B12, prior child with a neural tube defect
• Necrotizing enterocolitis: prematurity, small for gestational age, respiratory distress syndrome, congenital heart defect, gestational diabetes, exchange transfusion, hypoxic events such as shock or asphyxia, and enteral or formula feeding
• Respiratory distress syndrome: preterm birth, cesarean birth, multifetal pregnancy, maternal diabetes, premature rupture of membranes, sepsis, cold stress, and perinatal asphyxia from meconium staining, cord prolapse, or a nuchal cord
• Congenital hypothyroidism: female sex, low birth weight, low maternal iodine during pregnancy
• Substance exposure: maternal substance use before knowing of the pregnancy, and maternal substance use disorder
• Pathologic hyperbilirubinemia: a bilirubin plotted in the high-risk zone of the hour-specific nomogram, Rh or ABO incompatibility with a positive direct Coombs, cephalohematoma or heavy bruising, and jaundice before 24 hr of age
• Pathologic hyperbilirubinemia: exclusive breastfeeding, gestational age 35-36 weeks, sibling with jaundice, hereditary hemolytic disease, East Asian or Asian American race

Assessment — Expected Findings

• PKU: delayed milestones, irritability, musty urine odor, heart defects, hypopigmentation
• Meningocele/myelomeningocele: sac-like cyst protruding midline from the spine, most often lumbar or lumbosacral, with sensory and neuromotor dysfunction whose type and severity depend on the level of the defect
• Neural tube defect assessment: observe lower extremity movement and response to stimuli, urinary incontinence, possible limb deformities
• Necrotizing enterocolitis: abdominal distention, decreased bowel sounds, bloody stools, new or worsening apnea, hypotension, lethargy, poor feeding, temperature instability
• Respiratory distress syndrome: respiratory rate above 60/min, grunting on expiration, nasal flaring, retractions, labored effort, fine crackles, and cyanosis; as it worsens the newborn becomes unresponsive and apneic with diminished breath sounds
• Congenital hypothyroidism is masked at birth by maternal hormone and emerges across about 6 weeks: sleepiness, poor suck, enlarged tongue, breathing difficulty, jaundice, cool dry skin over the extremities, temperature and pulse below normal, hypotonia with diminished deep tendon reflexes, constipation, and a distended abdomen
• Neonatal abstinence and opioid withdrawal, CNS: increased wakefulness, high-pitched shrill or incessant cry, irritability, tremors, hyperactivity with increased Moro and deep tendon reflexes, increased muscle tone, skin abrasions and excoriations
• Withdrawal, metabolic/vasomotor/respiratory: nasal congestion with flaring, frequent yawning, skin mottling, tachypnea over 60/min, sweating, temperature over 37.2 C (99 F)

Laboratory Tests

• Newborn metabolic screen by blood spot within 2 days of birth identifies PKU early; some states repeat it at 1-2 weeks, and a heel-prick test confirms a positive screen
• CBC with differential, comprehensive metabolic panel, and blood cultures
• Culture and sensitivity of blood, tracheal secretions, and cerebrospinal fluid for sepsis
• T3, T4, and TSH for congenital hypothyroidism
• Urine or meconium drug screen and hair analysis identify the substance used; blood tests distinguish withdrawal from other CNS irritability

Diagnostic Procedures

• Abdominal x-ray in necrotizing enterocolitis: intestinal dilation, marked distention, and free abdominal air if perforation occurred
• ABGs in respiratory distress syndrome show hypercapnia with respiratory or mixed acidosis; chest x-ray supports diagnosis
• X-rays to evaluate bone growth and thyroid ultrasound for congenital hypothyroidism
• Transcutaneous bilirubin is a noninvasive measurement
• Continuous video EEG is the gold standard for newborn seizures

Nursing Care

• PKU: start dietary restriction as soon as it is diagnosed, use a formula low in phenylalanine, and allow breastfeeding only in moderation since breast milk contains phenylalanine
• PKU: monitor for findings, consult a registered dietitian, provide parent education and support, and refer to support groups
• Neural tube defect preoperatively: protect the sac, place the infant unclothed in a radiant warmer, and apply a sterile moist nonadhering dressing of 0.9% sodium chloride, rewetting as needed to prevent drying
• Inspect the cyst for fluid leak, irritation, and infection, give prescribed antibiotics, avoid rectal temperatures, and prepare the family for surgery within 24-72 hr of birth
• Neural tube defect postoperatively: monitor vital signs and intake and output, assess the surgical site for redness, edema, and drainage, manage pain, assess for CSF leak, and keep the infant prone until other positions are prescribed
• Measure head circumference, assess fontanels for bulging, check skin integrity and bowel and bladder function, screen for latex allergy, and assess cognitive and motor development
• Necrotizing enterocolitis prevention: withhold feedings 24-48 hr after birth asphyxia and start with breast milk, which is protective
• Necrotizing enterocolitis treatment: stop all feedings at the first sign, give IV fluids or TPN to rest the gut, insert an NG tube for decompression, and measure abdominal girth just above the umbilicus every 8 hr
• Surfactant administration: assess ABGs, respiratory rhythm, rate, and color before and after, suction beforehand if needed, verify endotracheal tube placement, and avoid suctioning the tube for 1 hr after the dose

Medications

• Lung surfactants beractant, poractant alfa, and calfactant restore surfactant and improve compliance in preterm newborns with respiratory distress syndrome
• Phenobarbital, an anticonvulsant, reduces CNS irritability and controls seizures — assess the IV site frequently for phlebitis and check for incompatibilities
• Sapropterin lowers phenylalanine levels, given orally with frequent phenylalanine monitoring
• Indomethacin promotes closure of a patent ductus arteriosus

Therapeutic Procedures

• PKU dietary management: limit high-phenylalanine foods such as meat, eggs, and milk, and encourage low-phenylalanine foods such as potatoes, lettuce, peas, and bananas
• Meningocele or myelomeningocele sac closure as soon as possible to prevent injury and infection
• Temporary colostomy may be needed for necrotizing enterocolitis
• Exchange transfusion for severe hyperbilirubinemia

Client Education

• Teach parents postoperative home care
• Avoid latex exposure and know that disposable diapers, cleaning gloves, and water toys can contain it; watch for allergic reaction and learn proper epinephrine use
• Report signs of shunt malfunction or hydrocephalus: fussiness, lethargy, vomiting, bulging fontanels or prominent scalp veins, increasing head circumference
• Refer the mother to drug or alcohol treatment
• Stress sudden unexpected infant death prevention, since rates are higher in newborns of mothers who used methadone
• Teach parents to monitor skin integrity

Interprofessional Care

• Consults may include neurosurgery, urology, neurology, orthopedics, social services, and physical and occupational therapy

Complications

• Untreated PKU: cognitive impairment that can be severe, hyperactivity, erratic behavior with fright reactions, arm biting, and head banging, and seizures
• Skin pressure injury — monitor skin and under splints and braces and reposition off bony prominences
• Latex allergy risk — reduce exposure
• Increased intracranial pressure from shunt malfunction or hydrocephalus — prepare for shunt placement or revision and manage pain
• Anemia of prematurity — delay cord clamping when possible, minimize and document blood draws, and transfuse as prescribed
• Retinopathy of prematurity — immature retinal vessels constrict with high oxygen concentrations and the retina can detach causing blindness; PO2 above 95 mm Hg sharply raises risk, so monitor saturation continuously
• Acute bilirubin encephalopathy — newborn brain cells are vulnerable to high bilirubin; treat with phototherapy or exchange transfusion

Alterations in Health (Diagnosis)

• Emergencies requiring rapid assessment and intervention, and a chance to teach families and communities. In respiratory insufficiency the child works harder to breathe while gas exchange stays largely adequate, or becomes hypoxic and acidotic; in respiratory failure the blood can no longer be adequately oxygenated. Apnea means breathing stops longer than 20 seconds, central or obstructive in origin, sometimes with hypoxemia or bradycardia. Respiratory arrest is total cessation of breathing, and a foreign body can obstruct the airway. Sudden unexpected infant death is an infant death in the first year that is sudden and unexpected, whether or not a cause is later found.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Respiratory emergencies: infants and toddlers, obstructive lung disease from infection, anaphylaxis, bronchiectasis, or asthma, and restrictive disease from cystic fibrosis, pneumonia, or interstitial lung disease
• Drowning: ages 1-4 years, swimming pool access, inadequate supervision near water, no life jacket, no swimming lessons, absent protective barriers
• Brief resolved unexplained event: gastresophageal reflux, respiratory or other infection, seizure, feeding regimen, metabolic disorders, neurologic disorders, sleep position
• Sudden unexpected infant death: maternal smoking in pregnancy, secondhand smoke, co-sleeping, non-crib sleep surface, prone or side-lying sleep, low birth weight, prematurity, twin or multiple birth, limited prenatal care, respiratory illness, family history, poverty, and age 1-6 months
• Poisoning: age under 6 years and toddlers especially; medications, household chemicals, and hazardous substances stored improperly; cosmetics, plants, and heavy metals as toxic sources; lead from lead-based paint or contaminated soil

Assessment — Expected Findings

• Early respiratory distress: restlessness, tachycardia, tachypnea, nasal flaring, grunting, retractions, diaphoresis, dyspnea, and wheezing
• Advanced hypoxia: bradycardia, extreme restlessness, central or peripheral cyanosis, stupor, and coma
• Choking: universal choking sign of clutching the neck, inability to speak, weak ineffective cough, high-pitched sound or no sound, cyanosis
• Submersion: record where and when the child was submerged, whether CPR or rescue breathing was needed, respiratory status, core temperature for hypothermia, and any head or neck injury
• Brief resolved unexplained event: apnea during the event, color change to pallor or cyanosis, hypotonia, and being sleepier than usual
• Poisoning history: name and location of the agent, amount ingested, and time of ingestion
• Acetaminophen 0-24 hr: nausea, vomiting, sweating, pallor; 24-72 hr: apparent improvement with right upper quadrant pain; 72-96 hr hepatic stage: confusion, stupor, jaundice, coagulation disturbance with the greatest risk of death; then gradual recovery
• Aspirin acute toxicity: vomiting, nausea, tinnitus, disorientation, dizziness, tachypnea, abdominal pain, and seizures; chronic toxicity is subtler but adds tachycardia, bleeding tendencies, and more severe seizures

Laboratory Tests

• Directed by history and assessment: CBC with differential, ABGs, urinalysis, blood cultures, liver function tests, and blood levels of lead, iron, and acetaminophen

Diagnostic Procedures

• Chest x-ray, viral studies, lumbar puncture, and CT for altered mental status

Nursing Care

• Follow American Heart Association CPR guidelines for respiratory and cardiac arrest and facility protocol for activating the rapid response team
• Use current basic life support and pediatric advanced life support guidelines for neonates and children
• Position to maintain a patent airway, monitor respiratory status and vital signs, give oxygen, suction as needed, and prepare for intubation
• Give prescribed medications, IV fluids, and emergency drugs; update the family on the child's status; and keep a calm, comforting manner
• Choking: back blows combined with chest thrusts for infants, abdominal thrusts for children and adolescents
• Remove visible obstructions or large debris from the mouth but never perform a blind finger sweep
• Place a recovered child who resumes breathing in the recovery position — side-lying with knees bent for stability
• Submersion injury care depends on the degree of cerebral insult: give oxygen and possibly mechanical ventilation, monitor vital signs, manage shivering, and watch for cerebral edema and respiratory distress
• Brief resolved unexplained event: monitor for recurrent events and keep the family informed about testing

Medications

Therapeutic Procedures

Client Education

• Learn CPR and recognize the signs of choking
• Teach prevention strategies including recognizing choking hazards for toddlers
• Drowning can happen anywhere water is present — bathtub, toilet, bucket, pool, pond, or lake — and even a small amount of water is enough; submersion injury is more common than drowning and usually leads to hospitalization and sometimes rehabilitation
• Latch toilet seats closed, never leave a child alone in the bathtub, and never leave a child unattended in a pool even if they can swim
• Poison prevention: keep toxic agents out of reach, lock cabinets, use the dosing device supplied with liquid medicine, discard unused medications, never call medicine candy, use non-mercury thermometers, remove lead-based paint, wash hands before eating, and consider parental workplace lead exposure
• Teach safe sleep and the risks of co-sleeping
• Routine lead screening at 1, 2, and 3 years, with case management for elevated levels and referral to community nursing, teachers, and early intervention

Interprofessional Care

Complications

• Outcome varies with the degree of anoxic insult or the blood lead level; cognitive impairment can follow lead exposure