LESSON № 1 (Practical class –

LESSON № 1 (Practical class – 6 hours)

 

Topics:

Physical and psychomotor development of children.

A newborn baby.

Methods of clinical examination of children.

Feeding and nutrition healthy children.

 

Physical development is the process that starts in human infancy and continues into late adolescent concentrating on gross and fine motor skills as well as puberty. Physical development involves developing control over the body, particularly muscles and physical coordination. The peak of physical development happens in childhood and is therefore a crucial time for neurological brain development and body coordination to encourage specific activities such as grasping, writing, crawling, and walking. As a child learns what their bodies can do, they gain self confidence, promoting social and emotional development. Physical activities geared toward aiding in physical development contribute significantly to a person’s health and well-being.

 

CRITERIA FOR THE EVALUATION OF PHYSICAL DEVELOPMENT

 

The basic criteria for the evaluation of physical development of the child are:

 

• Body weight

• Body length

• Head circumference

• Chest circumference

• Proportionality of these parameters

 

Child development stage describes theoretical milestones of child development. Many stage models of development have been proposed, used as working concepts.

 

This material puts forward a general model based on the most widely accepted developmental stages. However, it is important to understand that there is wide variation in terms of what is considered “normal,” driven by a wide variety of genetic, cognitive, physical, family, cultural, nutritional, educational, and environmental factors. Many children will reach some or most of these milestones at different times from the norm.

 

The term childhood is non-specific and can imply a varying range of years in human development. Developmentally, it refers to the period between infancy and adulthood. In common terms, childhood is considered to start from birth. Some consider that childhood, as a concept of play and innocence, ends at adolescence. In many countries, there is an age of majority when childhood officially ends and a person legally becomes an adult.

 

 

   

   

        

          

 

 

Neonatology is a part of pediatrics which studies newborn infant, its physiology, and pathology; treatment, and prevention of its diseases, and disorders; peculiarities of nursing, and feeding.

 

Neonatological terms

 

Gestational age (or more correctly the menstrual age) is measured from the first day of the mother’s last normal menstrual period. The average gestational age is 40 weeks (280 days). The majority of infants are born between 37 weeks (259 days) and 42 weeks (294 days) and are referred to as term infants.  Preterm infants are those born before 37 weeks while post-term infants are born on or after 42 weeks.  Infants are no longer described as premature or post-mature.

 

Intrauterine periods of development:

 

1.                 Embrional development begins from the zygote formation, lasts till 8 weeks of gestation. In this period different organs and systems are formatted. Risk factors: genetical, physical, chemical, alimentary, toxicosis, mother’s diseases.

 

 

2.                 Placental development begins in the 8 weeks of gestations. Continue till the end of pregnancy. Is characterized by differentiations of fetal tissues and organs, enlargement of the fetus weight and length.

 

 

Risk factors: external influence, mother’s diseases, toxemia, immune incompatibility between mother and fetus, placental disorders, placental placement and development abnormalities, umbilical cord and fetal membranes abnormalities.

 

Intranatal, neonatal and perinatal periods:

 

Intranatal period begins from the first signs of the delivery, extends until the birth of the baby. Risk factors: delivery abnormalities, intra birth infection of the newborn.

 

Neonatal period begins from the birth of the baby, extends until 28 days after birth. Neonatal period divides on:

 

1.                 Early neonatal period – from the birth until 7 days after birth.

 

2.                 Late neonatal period – from 7 days until 28 days after birth.

Perinatal period begins from 28 weeks of gestation, extends until the 7 days after delivery, and includes:

 

a) late antenatal period (from 28 weeks of gestation to 40 weeks of gestation);

 

b) intranatal period (from the first signs of the delivery until the baby is born);

 

c) early neonatal period (from the birth of the baby until 7 days after birth)

 

Live birth – the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life such as heartbeat, umbilical cord pulsation, or definite movement of voluntary muscles, whether the umbilical cord has been cut or the placenta is attached. A live birth is not necessarily a viable birth. See early neonatal death.

 

THE INFANT AT BIRTH

 

Apgar score: The normal neonate should breathe and cry within 30 seconds.  The following procedure is followed immediately after the baby is born. This should be done at one minute and usually is repeated at five minutes. Scoring system designed by Virginia Apgar ca. 1953 for heart rate, respiratory effort, tone, reactivity, color. By convention, scores are assigned at 1 and 5 minutes, with additional scores given at 5-minute intervals if the most recent score is less than 7. The 1 minute score indicates the need for resuscitation, while the 5 minute score gives an indication of the success of the resuscitation attempts. 

 

 

 

SCORE	0	1	2
SIGN
Heart rate	Absent	<100 beats/min	>100 beats/min
Respiratory effort	Absent	Weak, irregular	Strong cry
Muscle tone	Flaccid	Some flexion	Well
Reflex irritability (response to catheter in nostril)	No	Grimace	Cough or sneeze
Skin colour	Blue, pale	extremities blue	pink

        

        

SCORE

7 – 10                                                        No or mild depression

4 – 6                                                          Moderate depression

0 – 3                                                          Severe birth asphyxia

 

          

Diagnostic criteria moderate – 4-6 balls on the 1st minute with the improvement on the 5th minute; severe – 0-3 balls on the 1stminute, with the improvement on the 5th minute; 5-6 balls on the 1st and 5th minute without improvement                                                              

 

 However, if the one-minute score is normal the assessment at five minutes is ofteot required.

 

Clearing the airway Suctioning the mouth and pharynx is usually unnecessary if the infant cries well at birth and the one minute Apgar score is normal.  Suctioning with a soft catheter and low negative pressure not exceeding -10 cm H20 may be required to clear blood or excessive mucus in selected cases (e.g. after Caesarian section).  Suctioning should be gentle and as brief as possible to avoid reflex apnea, bradycardia or damage to the mucous membranes.

 

Heat conservation Measures should be taken to prevent excessive cooling of the infant e.g. early drying, warm towel, warm delivery room, prevention of unnecessary exposure, etc.  Too often the baby is left exposed in a cold draughty labor ward and forgotten, while the attendant concentrates on the mother.

 

Umbilical cord   In the normal infant the umbilical arteries go into spasm at delivery.  It is advisable to delay clamping the cord until the baby has taken a few breaths so as to encourage transfusion of blood via the umbilical vein into the infant’s circulation from the placenta.  There is, however, no difference in the hemoglobin concentration at three months between babies with early or late clamping of the umbilical cord.

Immediate clamping of the cord is indicated in asphyxiated babies (who need resuscitation) or in cases where Rhesus incompatibility is expected.

 

A sterile plastic umbilical clamp or tie is applied around the cord 2 cm from the skin and the cord above this is cut off.  Subsequent care entails application of 90% alcohol (surgical spirits) to the stump twice a day.  The stump will usually come away between 7-10 days after birth.

 

Eyes  Routine prophylaxis against Gonococcal ophthalmia neonatorum is recommended.  Chloromycetin eye ointment is usually used or 20 % natrii sulfacyl.  Erythromycin or tetracycline has the added advantage of activity against Chlamydia infection.

 

Vitamin K1 Each newborn should receive an intramuscular injection (into the anterolateral thigh) of 1 mg vitamin K1 to prevent hemorrhagic disease of the newborn.

 

Position of the baby after birth Although it is often suggested that the baby be laid in a 10o head down position, there is no evidence that this has any benefit over being placed flat on his/her side.

 

The initial assessment of the newborn Immediately after birth the baby is briefly examined to exclude:

 

·                   birth trauma e.g. facial palsy, fractures

 

·                   congenital deformities e.g. meningomyelocoele, club foot, exomphalos, anal atresia, genital anomalies, etc.

 

·                   respiratory distress

 

·                   severe anaemia

 

Maternal Handling If circumstances permit, the mother should be encouraged not only to hold but also to suckle her baby immediately after delivery.  This is not only of psychological benefit but also stimulates uterine contractions which fascilitate delivery of the placenta.  The sucking reflex is at its height after birth.

 

Further care of the baby The baby should be weighed and the head circumference measured.  Length usually is not recorded as it is difficult to measure accurately.  If there is any doubt about the well-being of the baby, observe the newborn infant for a few hours in a nursery before he/she goes to the mother (the healthy infant delivered by Caesarian section is usually observed for a few hours only).  This period provides an ideal opportunity to look out for hypothermia, respiratory distress, abnormal neurological features such as jitteriness, convulsions, excessive lethargy, etc.  Normal term infants delivered vaginally should remain with their mothers.

 

The first bath A normal baby may be bathed on the first day provided his temperature is within the normal range (i.e. approximately 36oC).  Early bathing is of no physiological advantage to the baby and should certainly be delayed in ill infants.  Infants born to HIV positive women are often bathed after delivery to remove contaminated blood and secretions.

The first feed

The normal infant should be put to the breast immediately after birth.  This prevents hypoglycemia, allows assessment of sucking ability and provides antibodies in the colostrum.  If not put to the breast at birth, let the infant suckle as soon as possible.

 

Later feeding of the newborn is 7 times a day every 3 hours with a night 6-hour break. Milk volume could be found by formula: 2% body weight * N (number of days of life). This is all day volume. If drinking is need it is calculated as 5ml * body weight * day of life per day. 5% glucose or boiled water could be given.

Delivery Room Examination The purpose of the delivery room history and examination is to identify major congenital malformations or other risk factors that would mandate transfer to the Neonatal Intensive Care Unit rather than the Newborn Nursery.

 

History: Inquire about high risk factors which may be assoclated with respiratory depression, such as: antepartum fetal bradycardia or tachycardia, meconium-stained amniotic fluid, maternal fever, placental abnormalities, premature or prolonged rupture of membranes (PROM), administration of narcotics, preeclampsia or eclampsia, diabetes, multiparity, use of recreational drugs, abnormal presentation of the fetus.

 

Detailed Newborn Examination

General Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth.

Skin Color

 

·                   Pallor – associated with low hemoglobin

 

·                   Cyanosis – associated with hypoxemia

 

·                   Plethora – associated with polycythemia

 

·                   Jaundice – Elevated bilirubin

 

·                   Slate grey colour – associated with methemoglobinemia

Skin Lesions Milia, miliaria; erythema toxicum; cafe au lait spots – suspect neurofibromatosis if there are many large spots. Junctional nevi – if large numbers, suspect tuberous sclerosis, xeroderma pigmentosus, generalized neurofibromatosis.

Neurological Exam

State of alertness Check for persistent lethargy or irritability.

Posture In term infant, normal position is one with hips abducted and partially flexed and with knees flexed. Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers covering the thumb.

Tone Support the infant with one hand under his chest. The neck extensors should be able to hold the head in line for 3 seconds. Should not have more than 10% head lag when moving from supine to sitting position.

Reflexes must be symmetrical. Biceps jerk test C5 and C6, Knee jerk tests L2-L4, Ankle jerk tests S1, S2. Truncal incurvation reflex tests T2 through S1. Anal wink test S4, S5. Other primitive reflexes include the Moro, palmer and planter grasps, sucking and rooting reflexes, and the asymmetric tonic neck reflex (ATNR). Asymmetric tonic neck reflex (seen in ventral suspension with arms rigidly extended and fists clenched) is abnormal.

 

When reflexes appear and disappear:

 

Reflex	Stimulation	Response	Duration
Babinski	Sole of foot stroked	Fans out toes and twists foot in	Disappears at nine months to a year
Blinking	Flash of light or puff of air	Closes eyes	Permanent
Grasping	Palms touched	Grasps tightly	Weakens at three months; disappears at a year
Moro	Sudden move; loud noise	Startles; throws out arms and legs and then pulls them toward body	Disappears at three to four months
Rooting	Cheek stroked or side of mouth touched	Turns toward source, opens mouth and sucks	Disappears at three to four months
Stepping	Infant held upright with feet touching ground	Moves feet as if to walk	Disappears at three to four months
Sucking	Mouth touched by object	Sucks on object	Disappears at three to four months
Swimming	Placed face down in water	Makes coordinated swimming movements	Disappears at six to seven months
Tonic neck	Placed on back	Makes fists and turns head to the right	Disappears at two months

 

 

 

THE HEALTHY NEONATE AND MINOR DISORDERS

 

Weight

 A weight loss of up to 10% of birth weight may occur during the first 3 to 5 days of life. Birth weight is usually regained by the seventh day. Subsequent weight gain is usually about 200g a week (25-30 g/day) for the first three months.

 

Head and neck

 

·                      Head circumference – 33 to 37 cm (average 35 cm)

 

o          Average increase approximately 7.5 mm/week (1 mm a day)

 

·                     Shape

 

o         caput succedaneum: oedematous thickening of the scalp in the presenting area.  It disappears within a day or two

o         anterior fontanelle: diamond-shaped and variable size, normally slightly concave and may be seen to pulsate

o         moulding: altered head shape in response to pressure, sometimes with overriding cranial bones

o         plagiocephaly:  “parallelogram skull”, with flattening of one side of the occiput and the opposite frontal region and face.  Distinguish from unilateral craniosynostosis due to premature fusion of one coronal suture with lack of growth on that side (early surgical correctioecessary)

o          craniotabes (softening of skull bones) is a normal finding in most newborns and many infants up to 3 months.

 

·                     Neck

 

o          the newborn baby generally appears to have a short neck.  Midline swellings such as dermoid and thyroglossal cysts are uncommon

 

o         sternomastoid “tumour” – a hard lump in the body of the sternomastoid muscle appearing some days after birth.  Caused by trauma or avascular necrosis.  It may cause torticollis which usually improves with physiotherapy.  Uncommon.

 

·                     Eyes

 

o         examination difficult at first because of strong reflex closure.  Baby often opens eyes if held erect.

o         pupil should appear black and not grey.

o          “red reflex” should be present.

o          colour of iris indefinite and not predictable.

o          sclerae often have a blue tinge.

o          tears rare in first few weeks.

o         infants are able to see from birth and should follow a red or bright moving object.

o         subconjunctival haemorrhage:  a bright red patch, often adjacent to the cornea has no serious significance and disappears within a few weeks.

o         abnormally large eye/s may indicate congenital glaucoma (early treatment very important).

 

·                     Nose and mouth

 

o         the newborn infant is an obligatory nose breather.  Nasal obstruction, congenital (choanal atresia) or acquired (e.g. nasal secretions), may cause feeding problems or respiratory distress.

o         sucking blisters: thickened areas on the upper lip, usually in the midline.

o         epithelial pearls are small whitish areas a few mm across, usually visible in the midline on the hard palate.  They are of no significance.

o         tongue-tie when the frenulum linguae is inserted into or near the tip of the tongue, rarely interferes with sucking or future speech and is usually best left well alone.

 

·                     Teeth

 

o         adventitious teeth may occasionally be present at birth.  They are usually loose, do not interfere with sucking, and fall out spontaneously.  Rarely, primary teeth may also be present at birth.

 

Skin

Vernix caseosa	Protective greasy white substance secreted by fetal sebaceous glands.  Not present in preterm infants, and decreases in quantity after term.
Traumatic cyanosis of the face	Due to many small petechial haemorrhages in the skin after congestion of the head with the cord around the neck
Superficial skin peeling	Common during the first week.  It is especially marked in post-term or wasted babies.
Hair	Colour at birth is poor guide to future shade.
Lanugo	is fine facial and body hair which is a feature of preterm babies.
Milia	White pin-head size spots on the forehead, nose, upper lip, and cheeks.  These are tiny sebaceous retention cysts. Approximately 40% of newborn infants develop milia. Typically, the rash appears after 4-5 days in full-term newborns. Infants born prematurely are less commonly affected. The milia lesions range from 1-2 mm in size and are papular. These lesions are called Epstein pearls when present on the soft or hard palate. Prognosis is excellent because milia is a benign self-limiting rash. Milial lesions disappear in a few days without leaving any scars.
Miliaria	obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week.
“Mucus burns”	Red scald-like lesions around the mouth and cheeks due to regurgitated gastric juice (high hydrochloric acid content).
“Mongolian spot”	Flat blue-black areas over sacrum or buttocks, and occasionally on back, shoulders, hands and feet.  Disappear by 4 years.
Erythema toxicum neonatorum	Very common.  Red blotchy rash, associated with central pin-head papules (which may look like pustules but contain eosinophils) on the trunk, extremities, and the face. It occurrs between the second and eighth days.  Seldom seen in preterm infants. Individual lesions are transitory, often disappearing within hours and then appearing elsewhere on the body. They then tend to spread centripetally.
Breasts	Breast enlargement is common in both male and female babies, usually lasting a week or two (but may persist for months).  It is due to the effect of oestrogen and progesterone.  No treatment is necessary.  Handling must be avoided as this may cause true mastitis.

 

 

Gastrointestinal tract

 

·                     Vomiting Babies normally swallow a variable quantity of air when feeding and commonly bring up a small amount of milk when winded.  Occasional large vomits without cause may occur.  Persistent vomiting however, should be assessed carefully and investigated especially if bile is present.

 

Serious causes

 

o         alimentary tract obstruction due to atresia, meconium ileus, volvulus, strangulated hernia, inspissated milk, Hirschsprung’s disease and necrotising enterocolitis

 

o         marked gastro-oesophageal reflux

o         infection (including urinary tract)

o         cerebral pathology (including intracranial bleed or meningitis)

o         metabolic disorders

                  

Faeces

 

o         Meconium is passed within 48 hours of birth in the majority of babies.  (When passed in utero it usually indicates fetal distress).  Obstruction may rarely be caused by a firm meconium plug, and may be relieved by gently inserting a small glycerine suppository into the anus.

 

o         Stools replace meconium on day 3 or 4.

 

o         Breast milk stools are usually bright yellow (vary from orange to green), may vary from watery to pasty, and may contain mucus or milk curds.  Two to five stools are usually passed each day, but the variation ranges from one stool a week to 12 a day.

 

o         Cow’s milk (formula) stools are pale yellow, firmer and less frequent (up to 5 a day)

 

o         “Starvation stools” which occur in under-fed infants are characteristically small and dark green

 

o         Blood in stools is commonly due to swallowed maternal blood (distinguished from fetal blood by Apt test)

 

Renal function

 

·                     newborn infants should pass urine within the first 24 hours

·                     boys should pass urine with a good stream (dribbling suggests posterior urethral valves)

·                     in the first few weeks the infant empties his bladder up to 20 times a day

·                     urates may colour the urine heavily leaving a brick-red stain on the nappy (sometimes mistaken for blood)

·                     the newborn kidney is less able to excrete a solute load and has a reduced concentrating capacity in comparison with the older child

·                     Urine collection:  most easily done using a collecting bag, but contamination is a risk.  Uncontaminated urine may be obtained by suprapubic bladder puncture.

 

Genitalia

 

·                     term male infants usually have testes in the scrotum at birth.  The majority of incompletely descended testes come down within the first month

 

·                     preterm babies tend to have incompletely descended testes and a less well-developed scrotum

 

·                     fluid hernia (soft swelling of scrotum which transilluminates easily) is common.  Most disappear spontaneously within the first year

 

·                     foreskin is normally adherent to the glans penis and cannot be pulled back without trauma:  90% become fully retractable by the age of 3 years.  Pulling back the foreskin in infancy is therefore not advisable and routine circumcision is medically unnecessary

 

·                     a mucoid vaginal discharge is present iearly all mature female infants at birth

 

·                     vaginal bleeding occasionally occurs at the end of the first week (a hormone withdrawal effect of no pathological significance) CONCEPT ABOUT

 

Caring for baby

 

Care of the Eyes

 

 

 

It is part of the routine care of the newborn to give prophylactic eye treatment against gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery. This practice was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose.

 

 

 

Erythromycin or tetracycline Opthalmic Ointment:

 

These ointments are the ones commonly used now a days for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.

 

Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes.

 

 

 

Vitamin K or Aquamephyton

 

 

 

The newborn has a sterile intestine at birth, hence, the newborn does not possess the intestinal bacteria that manufactures vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5 (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborn’s vastus lateralis (lateral anterior thigh) muscle.

 

 Care of the cord

 

 

 

The cord is clamped and cut approximately within 30 seconds after birth. In the delivery room, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the newborn is brought to the nursery, another clamp is applied ½ to 1 inch from the abdomen and the cord is cut at second time. The cord and the area around it are cleansed with antiseptic solution. The manner of cord care depends on hospital protocol. What is important is that the principles are followed. Cord clamp maybe removed after 48 hours when the cord has dried. The cord stump usually dries and fall within 7 to 10 days leaving a granulating area that heals on the next 7 to 10 days.

 

 

Instruction on cord care:

 

No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that cord does not get wet by water or urine.

 

Do not apply anything on the cord such as baby powder or antibiotic, except the prescribed antiseptic solution which is 70% alcohol.

 

Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine.

 

Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air.

 

If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten.

 

Report any unusual signs and symptoms which indicates infection.

 

Foul odor in the cord

 

Presence of discharge

 

Redness around the cord

 

The cord remains wet and does not fall off within 7 to 10 days

 

Newborn fever

 

A premature baby, or preemie, is born before the 37th week of pregnancy. Premature birth occurs in between 8 percent to 10 percent of all pregnancies in the United States. Because they are born too early, preemies weigh much less than full-term babies. They may have health problems because their organs did not have enough time to develop. Preemies need special medical care in a neonatal intensive care unit, or NICU. They stay there until their organ systems can work on their own.

 

 

 

Perinatal asphyxia

 

Perinatal asphyxia, or birth asphyxia, results from an inadequate intake of oxygen by the baby during the birth process – before, during, or just after birth. Decreased oxygen intake can result in chemical changes in the baby’s body that include hypoxemia, or low levels of oxygen in the blood, and acidosis, in which too much acid builds up in the blood.

 

Symptoms

Symptoms of birth asphyxia may not be obvious, but the most common symptoms include:

Before birth, abnormal fetal heart rate and low pH levels, indicating too much acid

At birth, poor skin color, low heart rate, weak muscle tone, gasping or weak breathing, and meconium stained amniotic fluid

 

 

Diagnosis

Severe acid levels

Apgar score of 0 to 3 for longer than 5 minutes

Evidence of neurologic problems, including coma and seizure

Problems with one or more organ systems, including circulatory, digestive and respiratory

 

 

Treatment

Treatment may include:

giving the mother extra amounts of oxygen before delivery

emergency delivery or cesarean section

mechanical breathing machine

medication

 

Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures.2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.

 

Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:

 

 

Term gestation?

 

 

Crying or breathing?

 

 

Good muscle tone?

 

If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.

 

If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:

 

 

Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)

 

 

Ventilation

 

 

Chest compressions

 

 

Administration of epinephrine and/or volume expansion

 

Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required (see Figure). The decision to progress beyond the initial steps is determined by simultaneous assessment of 2 vital characteristics: respirations (apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or less than 100 beats per minute). Assessment of heart rate should be done by intermittently auscultating the precordial pulse. When a pulse is detectable, palpation of the umbilical pulse can also provide a rapid estimate of the pulse and is more accurate than palpation at other sites.

 

 

 

 

 

A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures, but the device takes 1 to 2 minutes to apply, and it may not function during states of very poor cardiac output or perfusion. Once positive pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 vital characteristics: heart rate, respirations, and the state of oxygenation, the latter optimally determined by a pulse oximeter as discussed under “Assessment of Oxygen Need and Administration of Oxygen” below. The most sensitive indicator of a successful response to each step is an increase in heart rate.

 

 

HEALTH OF CHILDREN

For estimation of the child’s health, 4 criteria are established:

(a) A functional condition of the basic systems (respiratory, cardiovascular, etc.).

(b) The degree of resistibility and reactance of an organism – i.e. how the child endures possible viral and bacterial diseases (influenza, bronchitis).

(c) The condition of physical and neuro-psichological development.

(d) Presence or absence of a chronic pathology.

 

 

In our country there are some types of treatment and prophylactic institutions for children:

 

1. Pediatric department at a maternity hospital.

2. Pediatric polyclinic is an institution for treatment and prophylaxis whose personnel serves children before they turn 18 years old outside the hospital (at home). Due work of all medical personnel the following basic functions of polyclinic performed (medical work, prophylactic work, anti-epidermical work).

3. Children’s hospitals for children till 15-years of age.

4. Dispensary is an institution for treatment and prophylaxis where children with certain group of diseases (for example, antituberculous, endocrinopathic) examined, constantly observed and treated if necessary.

5. Children’s health centre is an institution for treatment and prophylaxis that located in appropriate resort zones (in Ukraine it is Crimea, Carpathian Mountains, etc.). Sick children are sent there for the period of 1-3 months or longer if necessary. The children are cured there by specific methods. For example: climate therapy, thalassotherapy, mud cure, estuary cure, sand baths, balneotherapy.

 

THE METHODS OF CLINICAL EXAMINATION OF CHILDREN.

 

1. Clinical methods: history taking, general examination.

2. Laboratory methods.

3. Additional methods (ECG, X-rey, ect).

4. Consultation with experts.

 

Inspection

 

The method of observation is used during physical examinations. Inspection, or “looking at the patient,” is the first step in examining a patient or a body part.

 

Palpation

The method of “feeling” with the hands is used during physical examinations. The examiner touches and feels the patient’s body part with his hands to examine the size, consistency, texture, location, and tenderness of an organ or body part.

 

Auscultation

 

This method used to “listen” to the sounds of the body during a physical examination can be performed by listening with the ear but is usually done by listening through a stethoscope. Health care providers routinely auscultate a patient’s lungs, heart, and intestines to evaluate the frequency, intensity, duration, number, and quality of sounds. Health care providers also use auscultation to listen to the heart sounds of unborn infants.

 

Percussion

A method of “tapping” of the body parts during  physical examination with fingers, hands, or small instruments to evaluate the size, consistency, borders and presence or absence of fluid in body organs. Percussion of a body part produces a sound (like playing a drum) that indicates the type of tissue within the organ. Lungs “sound” hollow on percussion because they are filled with air. Bones and joints “sound” solid. The abdomen “sounds” like a hollow organ filled with air, fluid, or solids.

 

 GENERAL EXAMINATION OF THE CHILD

 

The investigation of the patient begins with the general physical examination. Thus, during the initial interview with the mother and child the doctor automatically begins this. The necessary conditions and rules of general physical examination:

 

·        The examination room should be warm enough.

 

• By day, the position the child is facing a window and in the evening or at night there should be sufficient electric illumination. Only under these conditions, it is possible to observe even minor colour changes in the skin, sclera, mucous membranes and rashes, pigmentations on the body surface, etc.

 

• Thus it is necessary to judge the general behaviour of the child and his/ her reaction to the environment.

 

• The position of the patient is very important for diagnosis.

 

• Simultaneously, it is possible to obtain the data concerning speech of the child.

 

• It is essential to pay attention to the voice of the patient, especially early age children.

 

• A quiet condition of the child is preferred. It is not necessary to awake the sleeping child suddenly. Please keep in mind: while sleeping, the parameters of some systems are optimal.

 

• Only in few cases, the physical examination is carried out forcedly. • The child should be undressed gradually, to carry out the full body examination (to access the condition).

 

• Sometimes, when the child is in puberty age, the doctor examines the child without the presence of his or her parents. If there is any necessity to examine the reproductive organs it is highly appropriate to invite a similar-sex doctor for that.

 

• Please bear in mind: during the whole period of your general examination, it is important to maintain the contact with the child.

 

• Sometimes, during the general examination, an attentive the doctor is lucky and makes the correct diagnosis at once.

 

 

 

History taking

 

 

 

Communication skills

 

 1. Communication with the patient and/or family:

·        Establish rapport with the patient and family.

·        Identify the primary concerns of the patient and/or family.

·        Recognize the triangular relationship between the physician, patient and parent and be able to communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan and have the opportunity to ask questions; be aware that the relationship changes with increasing age of the child.

 

·        Provide anticipatory guidance during health maintenance visits, including the newborursery visit.

 

·        Recognize the important role of the patient’s education in management of acute and chronic illnesses.

 

2. Written communication skills:

·        Write a complete summary of the history and physical examination in a timely manner which is suitable to place in the patient’s chart.

·        Outline the different formats for documenting the history and physical examination which may be used in different clinical settings.

·        Write admission orders for a hospitalized patient.

·        Write a prescription.

 

 

3. Oral communication skills:

·        Present a complete, well organized summary of the findings of the patient’s history and physical examination, modifying the presentation to fit the situation.

·        Communicate effectively with other health care workers, including consultants, nurses and social workers.

·        Explain the thought process that led to the diagnostic and therapeutic plan.

 

·        Use precise descriptions of physical findings and avoid vague terms and jargon, such as “clear” and “ARD”.

Interviewing

 

1. Patient interviews occur in a variety of clinical settings, including initial history for a hospital admission or first ambulatory visit, health maintenance visit, acute care visit, interim visit for a child with an acute or chronic health condition. The doctor should develop an awareness that in conducting a medical interview in a variety of settings, it is sometimes appropriate to obtain a complete medical history, while at other times a more limited, focused or interval history is appropriate. Initially, the emphasis should be on obtaining complete medical histories. Opportunities to do more focused work-ups should be available as the doctor builds competence.

 

2. Obtain a medical history from thesecond party (usually the parent), as well as from the patient, noting the increased reliability of obtaining information directly from the patient as the patient matures. The doctor must be aware of issues of appropriate privacy at all ages and confidentiality in older children and adolescents.

 

3. Obtain a relevant history that is unique to paediatrics in addition to the standard medical history.

 

 The passport data

 

1.     The passport

 

Ø     Name.

Ø     Surname of child.

Ø     Date of birth.

Ø     Age.

Ø     The address (residence).

Ø     Date hospitalization.

Ø     Discharging date (Do not mention if the patient is still in hospital

Ø     date of history taking).

Ø     Treatment period (Do not mention if the patient is still till last date of history taking).

2. Complaints.

3. Anamnesis of disease.

 

Attention!!! At the end after collecting the concerned complaints and anamnesis

come to know about the affected systems and organs. Sometimes it also helps

relative diagnosis of the suspected disease.

4. The anamnesis of life.

(a) Obstetric anamnesis (children till 3 years):

• From which pregnancy and birth.

• Duration of previous pregnancy and birth (if any).

• Toxemia during I and II period of present pregnancy (nausea, vomiting,

hypertension, nephropathy, eclampsia).

 

• Diseases during the present pregnancy, and the treatment.

• Mothers nutrition.

• Professional hazards.

• Possibility of abortion and prophylaxis.

• Other features of current pregnancy.

• Birth: period, preterm or post-term birth.

 

Neonatal period:

 

•  Weight, length of body circumference of head and thorax.

•  Cry after birth, resuscitation, degree of asphyxation.

•  Jaundice (parameters of bilirubin, medical assistance, etc.).

•  Possible gynecological trauma.

•  Discharge date from maternity centre with child’s weight.

•  Day of detachment of umbilical cord and healing of umbilical wound.

•  Time of placement of infant to mother’s breast.

• Possible diseases during this period.

 

(b) Physical and neuro-psychological development of the child:

• According dynamics of weight and length as per months.

• Developmental criteria of NPD.

• At what age the child began his/her schooling.

• Progress at school.

 

The conclusion about physical and NPD.

 

Information regarding 1 st year of life is collected for age group up to 3 years.

 

(c) Breast-feeding (for children till 1 year):

• Natural, artificial, mixed, reasons for the previous one’s.

• Discontinuation of breast-feeding and reason.

• Initiation of weaning and when.

• Feeding schedule, volume, contents and in take of juices.

• In patient’s history, it is recommendable to prescribe nutritional list with essential calculations and final rational corrections of nutritional contents.

 

 

 

Dear students! At first you might get an idea of uncompleted diet (volume of accepted food, mode of feeding, etc.) instently you will find the violation. In that case you must suggest the lackings of the concerned diet with your recommended list with calculations.

 

 

 

(d) Vaccination (when and which, post vaccination period).

(e) Diseases till date:

• When and which, duration and complications.

• Related treatment.

 

 Attention! At the description of this part, we take account of severity, duration of the previous diseases and at what age they were. Depending on this, some diseases are described in detail, about others it is possible not to mention.

 

For example:

 

1. If the child at 1 year, got infected 3 rd time (pneumonia) then in such situation it is necessary to describe about all the previous infections the child has had: and also the full details about the kind of disease, the treatment, course of treatment, duration of disease, copy of X-ray to be attached (if present).

 

2. If the patient is diagnosed with Gastritis at the age of 14 and at the age of 1 year was having pneumonia then in his case history it is not necessary to mention about the disease from which he/she suffered in his/her childhood.

 

(f) Allergic anamnesis.

(g) Hereditary and family anamnesis.

(h) Social-economic conditions (may be: satisfactory or unsatisfactory).

 

 

 

3. The epidemioloaical anamnesis (with conclusion).

 

 

 

CONCLUSION is described according to the ANAMNESIS of LIFE and EP1DEMIOLOGICAL ANAMNESIS (this section is filled only by the student in the case history).

 

4. Status praesens objectivus (the data of objective signs).

 

The general condition of the child (satisfactory, moderate, severe, very severe) – the specified section of the case history always begins with these words. After this the following critereas are mentioned:

 

– How patient feels, reaction to others.

– Position on the bed (active, passive, compelled).

– Consciousness (clear, sopor, absent).

– Mood (quiet, deppressed, excited).

– Sleep.

 

In newborn focus is given at the basic parameters, which reflects the functioning of the central nervous system this includes:

 

• Active movement.

• Congenital unconditioned reflexes

• Muscles tone (depending on the different possitions of child).

• Intensity of sucking.

• Cry.

• Degree of thermoregulation.

 

Anthropometrical parameters: weight and length of the body, circumference of head and chest, index of Chulitskaya (till 8 years) and Arisman (for all age groups), characteristics according to percentile tables with the conclusion.

 

 

 

 Attention! All the forthcoming systems are written according to the following four attributes and only in such sequence:

 

• Inspection

• Palpation.

• Percussion.

• Auscultation.

 

 

 

Skin: color and its disorders (pallor, icterus, hyperemia, cyanosis), elasticity, humidity (humid, dry), rash, hemorrhages, scars, hair, nails, peeling, sometimes thickness.

 

Mucous membranes: color, hemorrhages, etc.

 

Subcutaneous layer: uniformity of distribution, thickness, condensation, edema (their localization and distribution), tissue turgor.

 

Muscular system: underdeveloped muscles, satisfactory (according to age), developmental anomalies of muscles (atrophy, hypertrophy, hypotonic, hypertension, paralyses and paresis).

 

Bone system:

 

• The size and form of head, their deformalities (frontal, occipital, parietal tubercle, craniotabes etc.), the sizes of frontal fontanel, the bones density.

• The form of thorax, rachitic ‘rosary’, Harrison fissure, ‘rickety thickening of wrists and ankles’, ‘the strings-of-pearls’, curvatures of backbone and extremities, platypodia.

• The form, size, quantity, consistancy, mobility, paining, edema and hyperemia of joints.

 

Attention! During the mentioning of this particular section of the case history it is necessary to mention the specific symptoms according to the age of the child.

 

 

 

For example: such symptoms of rickets as rachitic ‘rosary’, ‘strings-of-pearls’ and other are seen only in 1-2 years of life as the rickets is diagnosed only at this age. Such symptoms are not to be specified in grown up individuals.

 

Lymphatic system (if lymph nodes are palpated, then it is necessary to specify the place of their localization with estimation of criteria).

 

Respiratory system:

 

• Frequency of respiration per minute (normal, bradypnea, tachypnea ).

• Rhythm (rhythmical, arrhythmic, apnea).

• Pathological respiration (chaotic, Biot’s, Kussmaul’s, Cheyne-Stokes and Grocco– Frougoni).

• Breathings types (thoracic.abdominal and mixed).

• Nasal breathing (free, difficult, is absent).

• Voice (aphonia, wheeze, etc.).

• Cough during examination, presence of sputum.

• Dyspnea (inspiratory, expiratory or mixed).

• Thorax (form, arrangement of ribs, symmetricity and participation in breathing).

 

Palpation (resistency, paining, thickness of skin folds from both sides at level of scapula).

• Voice tremor.

• Topographical percussion: upper border of the lungs from anterior side and posterior side, width of Kronig’s area, from inferior border of lungs along line medioclavicular dextra, medioaxillaris, scapular lines from both sidesand excursion of lungs (as per age groups).

• Comparative percussion (vesicular resonance, decrease in resonance, dull sound, tympanic – respective of location).

• Corani’s, Arkavin’s, Maslov’s, Filosofov’s bowl symptoms.

Auscultation (breath puerile, vesicular, bronchial, exagerrated, weakened vesicular, amphoric, cogwheel; dry sonorous and whistling rales, moist rales (small, medium and large bubbling), crepitation, noise of pleural rub (as per location, quantity).

• Bronchophony.

 

Circulatory system:

 

 

• External examination and palpation (pulsation of carotid artery, swelling and pulsation of cervical veins, venous complex, cardiac thrust and cardiac hump, epigastrcal pulsation, apical thrust and its location, force, extension, ‘purr of cat’; radial artery pulse, and its characteristic – frequency in minute, synchronism, filling, tension and rhythm).

• Percussion (comparitive and absolute dullness of heart).

• Auscultation (heart sounds, their clearness, clearity, presence of loudness, splitting of sounds, rhythm; systolic and diastolic characteristics of murmuring -timbre, intensity, place of clear auscultation, irradiation, continuity, conductivity, dependence on positional changes and work; pericardial friction rub).

• Blood pressure.

 

• Functional cardiac test (Stange’s, Gench’s and Shalkov’s tests, orthostatic test of Martinet) for children over 5 years.

 

Digestive system:

 

 

• Inspection of mouth – mucous membrane (humid, dry, clear, color); fauces (color, posterior pharingal wall, tonsils); tongue (clear, humid, color, follicles, cracks, papillary condition); teeth (milk, permanent, dental formula ).

• Inspection of stomach – form and size of abdomen, expansion of frontal veins of belly, visible peristaltic, divergence of recto-abdominal muscle, umbilical condition and participation belly in breathing.

• Percussion of abdomen (ascites, method of fluctuation, hepatical sizes as per Kurlov’s method, spleen, Mendel’s symptom).

• Superficial palpation of abdomen (tension, painess, hyperesthesia, its presence and localization).

• Deep methodical palpation as per Obraztsov-Strazhesko: palpation sigmoid, caecum, ascending, tranverse – and descending guts, palpation of liver (the bottom edge: sharp, rounded, soft, dense, painfull, painless, smooth surface, prominence), Kehr’s, Lepine’s, Ortner’s, Murphy’s, Mussy, Boas’s symptoms, palpation of stomach (painess, ‘splashing sound’), spleen, mesenterical lymph nodes, pancreas (Grott’s method, Desjardin’s and Mayo-Robson’s points), Shchotkin-Blumberg and Rovsing symptoms, etc.

• Auscultation (stomach size by auscultational friction method, peristaltical appearance).

• Anal condition (crack, open, prolapse of anus).

• Excretes (color, smell, consistancy and pathological impurity).

 

 

 

The system of kidneys and urinary paths:

 

• Examination: appearance of paleness, ‘renal edema’, examination of lumbar region.

• Palpation of kidneys and along ureter.

• Percussion of upper boundary of urinary bladder.

• Pasternatskiy’s symptom.

• Frequency and characteristic of urination (painfull, enuresis, etc.).

• Urine (external appearance – color, transparency, mucus, sediment and pus).

 

Nervous system: criterias of NPD and their corresponding development are described for children up to 3 years. During presence of following pathological deviations (rigidity of occipital muscles, stretch of frontal fontanel, Kernig’s, Brudzinski’s and other symptoms, etc.) the data is attributed to all age groups.

 Endocrine system: disorders of growth (gigantism, nanism, hypostature) and weight of body (hypotrophy, exhaustion, paratrophy and adiposity), condition of thyroid gland (size), sexual development (development of secondary sexual characters, corresponding to age, menstrual cycle).

 

 

NORMATIVE PARAMETERS OF DIFFERENT KINDS

 

INSPECTIONS OF CHILDREN HEMATOLOGY

 

·        The general analysis of blood

 

METABOLISM

 

The normative data of blood serum

 

 

 

 

NEFROLOGY

 

The general urinalysis

 

 

 

DEFINITION OF QUANTITY OF BLOOD CELLS IN URINE

Functional renal tests

 

Urea – 3.33-8.33 mmol/L

 

Creatinine – 0.04-0.1 mmol/L

 

Rest nitrogen – 14.3-28.6 mmol/L (20-40 mg%)

 

For newborn – till 50-70 mmol/L (1-2 weeks)

 

Filtration clearance based on endogenic creatinine – 80-120 mL/min

 

The blood analysis on liver function

 

Total bilirubin – 8.5-20.5 mmol/L

 

Conjugated (=direct reacting) bilirubin – 2.05-5.1 mmol /L

 

Unconjugated (indirect reacting) bilirubin – 6.5-15.4 mmol /L

 

Grinstedt reaction – (1.6)1.8-2.2 ml

 

Thymol (=turbidity ) test – 1-6.5 units (from a 2 nd year of life)

 

ALT=SGPT – 0.1-0.75 mmol/h/L (=0-30 units; SGPT – 17-350 nmol.secVL)

 

AST=SGOT -0.1-0.45 mmol /h/L (=0-40 units: SGOT- 117-450 nmol .secVL)

 

 

Normally the breathing rate per minute dependence on the age and is equal to:

Newborn                                                   40-60

Till 1 year of age                                       30-35

5 years old                                                25

10 years old                                              20

More than 12 years old                             20-16

 

Normally Pulse rate per minute:

Newborn babies                                        120-140 (up to 160)

Breast-feeding age                                     120

5 year                                                        100

10 year                                                      85

12 year                                                      80

15 year                                                      70-75

 

Normal values of blood pressure:

At birth                                                     85/50 mmHg

6 months                                                   90/60 mmHg

6 years                                                      100/60 mmHg

10 years                                                    110/60 mmHg

12 years                                                    115/60 mmHg

16 years                                                    120/65 mmHg

 

As a rough guide, blood pressure iormal children :

 

Mean diastolic = 55 + age in years

 

Mean systolic = 90 + age in years

 

 Borders of relative heart dullness and transversal heart distance.

Normally the liver sizes:

I – 9-11 cm

II – 7-9 cm

III – 6-8 cm

 

 Physical development is a dynamic process of growth and biological maturation of the child in any given period of childhood.

 

Rules of measurement of body weight are: It is necessary to check the equal horizontal position of the balance and if necessary to adjust it before each weighing of the child. Children up to 6 months of age are placed supine on a special children’s balance. Children more than six months old may be placed on the same balance in a sitting position. If it is not contraindicated according to health conditions, the child should be nude and dressed with a preliminary weighed napkin.

 

 

 

 

In the first days after the birth the child’s weight decreases a little. This is called physiological loss of body weight. A reduction of weight up to 6-8% from weight of the body at birth is considered as a maximum limit. This process continues for up to the third day of life and by the 7 th -8 th day the weight of the newborn is restored – such ideal type of changes are noticed in 1/5 of all newborns. In the rest cases the necessary increase in body weight till the initial value is delayed till the second week of a life – the ‘slow’ type. In rare cases the restoration of body weight occurs in the third week of the life of the child. Physiological loss of weight of a body is due to the following factors. In the first day of life, the child receives a small amount of mother’s milk at the loss of a great amount of energy because right after the birth all organs and organ systems of the newborn starts functioning. Three quarters of the lost body weight are due to the ‘perspiratio insensibilis‘. that is due to excretion of liquids without the sensation of this process through skin. The liquid is lost through the functional respiratory system after birth also.

 

Excretion of urine, meconium, falling off of the umbilical stump and drying of umbilical wound are the other reasons of reduction of body weight of a newborn.

 

The following parameters are applied for calculating the ideal body weight (IBW) of the child in the first year of life: Every month during the first half-year of life the weight increases by 800 g and during the second half-year – by 400 g.

 

Example: Body weight of a child at birth is 3500 g; right now he is 9 months old, at this age the actual weight of his body is equal 3500 + 800×6 + 400×3 = 9500 g.

 

In the practical work of a pediatrician for getting a more exact parameter of weight, the data of monthly increase in body weight of a child (see Table 1) in the first year of life are used.

 

Laws of increase of body weight and lengths for the first year of life.

 

 

After the breast feeding period up till 10 years of age the parameter of actual body weight is calculated with by the formula

 

The considered methods of definition of weight of a body are tentative, as the weight of the child is a highly variable parameter. It quickly reacts to various external and internal factors, depends on a heredity and race.

 

 

                                                                 

Empirical formulas:                2 – 10 years: W=10+2n;

10-16 years:        W=30+4(n-10),

or

W=2n+8 (kg),

where- age of child in years

 

 

         Attention!!! Not years after the first year of a life are meant but actual age of the child, i.e. the total age in years.

 

Body length:

 

Rules for the measurement of body length are the following

 

The length of the body of a newborn is of special importance as a parameter of maturity of the organism. Normally it is equal to 50 cm (50.7 cm and 50.2 cm for boys and girls respectively). Permissible fluctuations are 46-56 cm.

 

The child younger than 1 year is placed supine on a horizontal rigid measuring table or infant meter covered with napkin

 

The head of the child is held near the immovable wall of the measuring table so that the top edge of the external acoustic meatus and the edge of the lower eyelid of the child make one vertical line.

 

The legs in unbent position should be pressed on the wooden surface.

 

The mobile plank of the measuring table is applied to the soles of the feet.

 

The body length of the child is equal to distance between the immovable wall and the movable plank.

 

The numbers are printed along the edge of the measuring table.

 

The length (height) of older children  is measured in standing position on a standard wooden height measuring rod or stadiometer.

 

The child presses against the vertical rod his occiput, part of his backbone between the scapulas, his sacrum and heels.

 

The head is held in such a position that the lower eyelid and the top edge of external acoustic meatus make a horizontal line.

 

Hands are placed along the trunk, fingers are straight at the joints, palms are held against the thighs. In this position the moveable plate of the measuring rod is placed on the head and the place where it stops specifies the body height of the child.

 

The height of seriously ill patients of older age is measured individually in the supine position.

 

For calculation of parameters of ideal growth of children during the first year of life, following monthly changes of body length are used:

 

The first quarter (quarter is 3 months)      –        by 3 cm

The second quarter                                   by 2.5 cm

The third quarter                                       by 2 cm

The fourth quarter                                    by 1-1.5 cm

                                                                 

 

 

Empirical formula to calculate body height

         1-4 years: H=100-8(4-n);

5-15 years: H= 100+6(n-4),

or

6n+80 (cm), where- age of child in years

 

Faster increase in body length, so-called the first growth spurt (elongation), is observed in 4-5.5 years in boys and in 6-7 years in girls. Further the growth rate is slowed down. In 11-14 years for girls and 12-17 years for boys a second growth spurt is marked and after that – considerable slowdown.

 

The body length reaches its maximum in 18-20 years.

 

The head circumference of the child at birth is 34-36 cm (agreeable size – 32-38 cm) and the chest circumference is 32-34 cm. Methods for finding and calculating the parameters of physical development of the healthy child

 

The head circumference is measured by a tape-measure. It is put behind on a place of maximal protrusion of occipital tuberance and in front – on superciliary arches.

 

 

 

 

·        Age parameters of increase in head circumference are the following:

 

 

from birth till 6 months HC=43-1.5x(6-n),- age of child in months

from 6 till 12 months    HC=43+0.5x(n-6),- age of child in months

from 1 till 5 years         HC=50-lx(5-n),- age of child in years.

 

from 5 till 15 years:      HC = 50+0.6x(n-5),

n – age of child in years.

 

The chest circumference at the age of breast-feeding is measured in supine position, from the second year of life – in standing position. The tape-measure is put on the back below the angles scapulae, in the front – above the nipples and pulled approximately by 1 cm.

 

 

 

With girls in the puberty period the tape in the front is put above the mammary glands at a level of the fourth rib.

 

Age parameters of increase in chest circumference are the following:

 

First 6 months – by 2 cm monthly

Second half-year – by 0.5 cm monthly

10 years – by 1.5 cm annually

15 years – by 3 cm annually

 

Empirical formulas to calculate chest circumference

from birth till 6 months          ChC=45-2x(6-n),- age of child in months

 

 

from 6 till 12 months             ChC=45+0,5x(n-6),

n – age of child in months

 

from 1 till 10 years       ChC=63-l .5x(10-n),

n – age of child in years.

 

from 10 till 15 years     ChC=63+3x(n-10),

n – age of child in years

 

Assessment of physical development of the child

 

 

 

To value the proportionality and harmony of physical development of a child anthropometrics indexes are used.

 

1.     The index of fatness by Chulitska can be calculated for children of first 8 years of life.

 

I=3´shoulder circumference+thigh circumference+shin circumference-height (stature) (cm)

 

 Normal data according to age:

 

Infants        20-25 cm

 

Toddlers     20 cm

 

Preschoolers        10-15 cm

 

8 year child

         Decreases to 6 cm

 

 

         Decrease of this index shows on hypothrophia, exhaustion or great height. Its increase shows on paratrophy (obesity) or considerable delay of growth.

 

2.     The index by Erismann can be calculated for children by 15 years.

 

IE=chest circumference-½ height (cm)

 

 Normal data according to age:

 

Infants                                                       13,5 – 10 cm

Toddlers                                                    9 –6 cm

Preschoolers                                              4 – 2 cm

School-age children                                            0 cm

Teenagers                                                  1 – 3 cm

        

 

Decrease of this index, especially its negative meanings is the sign of dysproportionality of physical growth (excessive linear growth). Considerable increase of this index shows on dwarfism or small stature.

 

 For evaluating of physical development percentile tables are used.

 

Ø     Measurements of length, weight and HC between the 25th and 75th percentiles are likely to represent normal growth.

Ø     Measurements between the 10th and 25th percentiles represent less than average data and between the 75th and 90th – bigger than average data. These measurements may or may not be normal, depending on previous and subsequent measurements and on genetic and environmental factors.

Ø     Measurements between the 10th and 3d, and the 90th and 97th percentiles belong to low and high data, which require further examination.

Ø     Measurements below the 3rd and above the 97th percentiles are extremely low and extremely high and reflect pathological deviations of physical development.

6 columns (corridors) of the percentile tables specify size of parameters of physical development in a certain percent of children from the total number, which at each age = 100%.

 

All children are divided into 6 groups that correspond to each of the 6 columns:

 

1. First column – 3% (Attention! Percentile is such a value of the studied parameter, less of which can be found in a similar percent of children). I.e. in 3% of the total children in each age there are such parameters of physical development, which are specified in the first column of the table or even less than these parameters.

 

2. Second column – 10%, i.e. parameters of physical development, which do not exceed the figures specified in the column, are observed in everybody of the 10% of all children, including 3% from the first column. But actually exact parameters of physical development between I and II columns are present in 7 % of children (10%-3%).

 

3. Third column – 25% exact parameters between the second and third columns are found in 15% children (25% of III corridor- 10% of II corridor).

 

4. Fourth column – 75%; parameters from the third to fourth column are in 50% children (75%-25%).

 

5. Fifth column – 90% parameters of physical development from the fourth to fifth columns are present in 15% children (90%-75%).

 

6. Sixth column – 97% parameter of this corridor (from the fifth up to sixth column) are noted in 7% children (97%-90%). 3% of children have parameters of physical development above parameters of the sixth corridor (from a total sum of 100%- 97%).

 

 Together: 3% + 7% + 15% + 50% + 15% + 7% + 3% = 100%.

 

 

 

For example: All boys at the age of 6 months are 100 %. Among them 3% children (column I) have body length under 63 cm. The body length of 63-64 cm is noted in 7% boys (corridor II). 15% children (column III) have body length of 64-65.6 cm. Body length of 65.6-69.9 cm is an attribute of physical development of 50% boys (corridor IV). 69.9-71.3 cm – Body length of 15% children (corridor V). The values of 7% children (corridor VI) are even higher than the previous -71.3-72.5 cm. 3% of children have the highest (more than 72.5 cm) values among boys aged 6 months (from a total sum of 100% – 97% = 3%).

 

Hence, for finding-out the condition of physical development of a child and degree of its deviation both towards decrease and increase and also the proportionality of parameters it is necessary to establish the gender and age of the child and to place the anthropometrical data received after his measurement in the corresponding corridors of percentile tables. Values are considered as average or conditionally normative if they are characteristic for half of the healthy children of corresponding gender and age. I.e., if parameters of physical development of a child were found within the limits of 3 to 4 corridors of percentile tables, then they specify the average physical development of the inspected child and can be found in 50% (75%-25% = 50%) children. The final consideration of physical development of a child is given in Table 3 depending on the position of the anthropometrical data in other columns of percentile tables. The basis of initial decision in the medical conclusion concerning the condition of physical development of a child (average, high sizes, etc.) is the parameter – of body length. I.e. according to the column of the table, which contains this parameter.

 

 

 

Estimation of a condition of physical development of the child by percentile tables.

 

 

BIOLOGICAL ACCELERATION

 

From measurements and observations recorded over than past century, especially its second half, there appears to be a significant worldwide trend in the rate and age of maturation. Children from widely different populations are maturing earlier and becoming larger at each age.

 

Look through some examples:

 

·       25 to 30 years ago students used to learn such quarterly body length gain in infants: 3 cm, 2.5 cm, 1.5 cm and 1 cm per month. Nowadays data are 3 cm, 2.5 cm, 2 cm, and 1.5 cm per month.

 

·       At present the birth weight doubles at age 4 to 4½ months and triples by 10 to 11 months, while in the past it used to happen by the end of 6 months and at 12 months accordingly.

 

·       In 1960s the body length of 100 cm was showed in average by a 5 years old children and its yearly gain reached 5 cm till 9 years. At present time average 4 years child is 100 cm tall, and then he grows on 6 cm annually.

 

·       The average size increase since 1900 is near 1 cm per decade in height and 1 kg in weight in preschool children and 2.5 cm and 2.5 kg per decade during puberty.

 

·       At the beginning of last century chest circumference equals head circumference by 9 to 10 months, and nowadays by the end of 4 months.

 

·       In girls the age of menarche has advanced progressively.

 

There also appears to be a slight but not so marked increase in average adult height, since although children are growing faster they also stop growing sooner. The average young man reaches his full height at approximately age 20, whereas in 1900 he did not reach his final height until about 25 years. The trend appears to reach a plateau in populations with optimum environments, which suggested that there is a maximum end point.

 

Principal causes, actions of which are often combined, in the opinion of different scientists are the following:

 

(a) Considerable migration (territorial movement) of the population of the planet and marriage of persons of different races.

 

(b) More rational nutrition.

 

(c) Frequent overfeeding of the child, especially with proteins and fats, increasing growth through the endocrine system.

 

(d) Ecological factors:

 

• The influence of space radiation.

 

• The action of magnetic field.

 

• The raised radiation level.

 

• Modern chemical substances (therapeutic drugs, preservatives, pesticides, carbon dioxide gas, etc.).

 

 

Teething:

 Teething is the normal developmental process of primary tooth eruption, often characterized by parental reports of fever, fussiness, increased drooling, increased finger sucking, alterations in bowel pattern, and/or decreased appetite.

 

Retardation in dental development may indicate retardation of osseous maturation.

 

Studying teething is useless in assessing growth due to different dales and variability in eruption

 

 

 

 

 

Eruption of Milk Teeth (20 teeth) :

Lower central incisors                               7-8 months

Upper central incisors                               8-9 months

Upper lateral incisors                               10-11 months

Lower lateral incisors                                11-12 months

First molars                                              13-14 months

Canines                                                     17-19 months

Second molars                                          19-25 months

 

 

Eruption of the Permanent Teeth (32 teeth):

First molar                                                6-7 year

Central incisors                                         6-8 years

Lateral incisors                                         7-9 years

Canines                                                     9-11 years

First premolar                                           10-12 years

Second premolar                                       11-13 years

Second molar                                            12-13 years

Third molar                                               17-22 years

 

BREASTFEEDING

 

 Breastfeeding is one of the most effective ways to ensure child health and survival. Optimal breastfeeding together with complementary feeding help prevent malnutrition and can save about a million child lives. Globally less than 40% of infants under six months of age are exclusively breastfed. Adequate breastfeeding support for mothers and families could save many young lives. Human breast milk is the healthiest form of milk for babies.

 

Before the 20th century, breastfeeding was the main way of feeding babies. If for any reason the natural mother was unable to breastfeed, a wet nurse was used. Attempts were made in 15th century Europe to use cow or goat milk, but these attempts were not successful. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this did not have a favorable outcome either. True commercial infant formulas appeared on the market in the mid 19th century but their use did not become widespread until after World War II.

International Breastfeeding Symbol

 

WHO actively promotes breastfeeding as the best source of nourishment for infants and young children. Infants should be exclusively breastfed – i.e. receive only breast milk – for the first six months of life to achieve optimal growth, development and health. “Exclusive breastfeeding” is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers.

 

WHO strongly recommends

 

–         exclusive breastfeeding for the first six months of life;

–         breastfeeding should begin within an hour of birth;

–         breastfeeding should be “on demand”, as often as the child wants day and night;

–         bottles or pacifiers should be avoided.

–                     at six months, other foods should complement breastfeeding for up to two years or more.

 

Breastfeeding provides benefits for the infant.

 

1.           Early breast milk is liquid gold – known as liquid gold, colostrum is the thick yellow first breast milk that is made during pregnancy and just after birth. This milk is very rich iutrients and antibodies to protect baby. Although baby only gets a small amount of colostrum at each feeding, it matches the amount his or her tiny stomach can hold.

 

2.           Breast milk changes as baby grows – colostrum changes into what is called mature milk. By the third to fifth day after birth, this mature breast milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It is a thinner type of milk than colostrum, but it provides all of the nutrients and antibodies baby needs.

 

3.           Breast milk is easier to digest – for most babies, especially premature babies, breast milk is easier to digest than formula. The proteins in formula are made from cow’s milk and it takes time for babies’ stomachs to adjust to digesting them.

 

4.           Physical contact is important to newborns. It can help them feel more secure, warm, and comforted.

 

5.           Breast milk fights disease – the cells, hormones, and antibodies in breast milk protect babies from illness. This protection is unique. Breast milk:

 

– greater immune health – during breastfeeding, approximately 0.25-0.5 grams per day of secretory IgA antibodies pass to the baby via the milk. The main target for these antibodies are probably microorganisms in the baby’s intestine. There is some uptake of IgA to the rest of the body, but this amount is relatively small.Also, breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria).

 

– reduces sudden infant death syndrome;

 

– decreases risk of fewer infections (diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection);

 

– prevents diabetes – infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than babies with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its effects on the child’s weight.

 

– prevents childhood obesity – breastfeeding reduces the risk of extreme obesity in children. The protective effect of breastfeeding against obesity increases with the duration of breastfeeding. Infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late infancy than those who are breastfed. “Bottle-feeding, regardless of the type of milk, is distinct from feeding at the breast in its effect on infants’ self-regulation of milk intake.” This may be due to factor, that when bottle feeding, parents may encourage an infant to finish the contents of the bottle whereas when breastfeeding, an infant naturally develops self-regulation of milk intake;

 

– prevents necrotizing enterocolitis (NEC) – necrotizing enterocolitis is an acute inflammatory disease in the intestines of infants. It is mainly found in premature births/ NEC was found to be six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks, NEC was twenty times more common in infants fed exclusively on formula.

 

– prevents Crohn’s disease, ulcerative colitis, lymphoma, allergic diseases and other chronic diseases;

 

–                      enhancement of cognitive development – there is evidence that people who were breastfed perform better in intelligence tests.

 

Breastfeeding provides benefits for mother.

1.                                  Bonding.

 

Hormones released during breastfeeding help to strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates. Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.

 

The skin-to-skin contact between mother and baby can calm the mother and child.

 

2.                                  Hormone release.

 

Breastfeeding contact releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.Breastfeeding soon after giving birth increases the mother’s oxytocin levels, making her uterus contract more quickly and reducing bleeding.

 

3.                                  Weight loss.

 

As the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight. It has been observed that prolonged exclusivity of breastfeeding is associated with increased weight loss when controlling for gestational weight gain and postpartum caloric intake

 

4.                                  Long-term health effects

 

–         less risk of breast cancer, ovarian cancer, and endometrial cancer;

 

–         less risk of coronary heart disease, rheumatoid arthritis;

 

–         mothers who breastfeed longer than eight months benefit from bone re-mineralisation;

 

–         breastfeeding diabetic mothers require less insulin;

 

–         reduced risk of metabolic syndrome;

 

–         reduced risk of post-partum bleeding.Prevent postpartum depression.

 

5.                 Life can be easier for mother, who breastfeed –there are no bottles and nipples to sterilize. Mother does not have to buy, measure, and mix formula. And there are no bottles to warm in the middle of the night! Woman can satisfy baby’s hunger right away when breastfeeding.

 

6.      Breastfeeding can save money – formula and feeding supplies can cost well over $1,500 each year, depending on how much your baby eats. Breastfed babies are also sick less often, which can lower health care costs.

 

7.     Mothers miss less work – Breastfeeding mothers miss fewer days from work because their infants are sick less often.

 

Breastfeeding provides benefits for society.

 

 

1.     The nation benefits overall when mothers breastfeed. Recent research shows that if 90 percent of families breastfed exclusively for 6 months, nearly 1,000 deaths among infants could be prevented. The United States would also save $13 billion per year — medical care costs are lower for fully breastfed infants thaever-breastfed infants. Breastfed infants typically need fewer sick care visits, prescriptions, and hospitalizations.

 

2.     Breastfeeding also contributes to a more productive workforce since mothers miss less work to care for sick infants. Employer medical costs are also lower.

 

3.     Breastfeeding is also better for the environment. There is less trash and plastic waste compared to that produced by formula cans and bottle supplies.

 

 

 

To meet the growing needs of babies at six months of age, complementary foods should be introduced as they continue to breastfeed. Foods for the baby can be specially prepared or modified from family meals. WHO notes that:

 

·        breastfeeding should not be decreased when starting complementary feeding (weaning) complementary foods should be given with a spoon or cup, not in a bottle;

 

·        foods should be clean, safe and locally available; and

 

·        ample time is needed for young children to learn to eat solid foods.

 

 

 

In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants.

 

Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia).

 

Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).

 

 

WHO recommended plan of weaning in breast feeding

 

Food stuffs	Time of giving	Age (in months) depending volume of food
		6	7	8	9	10
Juice (fruit, vegetable), ml	6	30-50	50-70	50-70	80	100
Fruit puree, ml	6	40-50	50-70	50-70	80	90-100
Vegetable puree, g	6	50-150	150	170	180	200
Groats (porridge, rice, buckwheat), g	6-7	5-50	50-100	150	180	200
Cereals (barley, semolina, corn), g	7-8	5-50	50-100	150	180	200
Yoghurt, kefir, ml	8-9	–	–	10-50	50-150	150-200
Soft cheese, g	6,5-7,5	5-25	10-30	30	30	50
Yolk	7,0-7,5	–	1/8-1/4	¼-½	¼-½	½-3/4
Meat puree, g	6,5-7,0	5-30	30	50	50	50-60
Fish puree, g	9-10	–	–	10-20	30-50	50-60
Vegetable oil	6	½ tsp	½ tsp.	1 tsp	1 tsp	1 tsp
Butter	6-7	½ tsp	½ tsp	1 tsp	1 tsp	1 tsp
Bread, g	8-9	–	–	5	5	10

 

         FEEDING CHILDREN: 1 TO 3 YEARS

 

At the age of one year the child should have been introduced to a variety of (healthy) foods.  The child caow start receiving meals suitable for adults, with only slight adaptations.  It is therefore no longer necessary to prepare separate meals for  the toddler.  Care should, however, be takeot to prepare heavily spiced or fried foods.  

 

The child’s diet should contain a suitable balance of nutritious foods, including fruit, vegetables, whole and enriched grains and cereals, milk and other dairy products, meat, fish, poultry and other protein sources.

The amount of food the child requires depends on a variety of factors including gender, size and activity. 

The rate of growth at this age is slower than in the first year of life and this is associated with a decrease in appetite, which may further fluctuate on a daily basis. 

The change in the rate of growth is best illustrated by the birth weight which trebles in the first year of life and thereafter it takes another year before it is quadrupled.  There is generally a greater rate of increase in height than weight, transforming the chubby toddler into a leaner child.   It should be kept in mind that young children can only manage a small amount of food at a time.  It is recommended for the child to receive 5 to 6 smaller meals daily. 

These include mid-morning, mid-afternoon and bedtime snacks.  A general rule that can be followed is to offer a minimum of one tablespoon of each food for every year of age and thereafter to offer more food according to appetite. Snacks should be planned so that the child does not continuously snack. They should therefore be spaced to ensure that the child is hungry at meals and the interval between meals and snacks should be tailored to meet the child’s hunger and satiety cues.

 

 

 

 Childreeed to eat a good variety of foods, which will supply around 1300kcal and at least 16g protein per day. 

In this age group, with their  relatively high-energy requirements, it is not necessary to restrict fat and cholesterol, although grilled and baked foods always remain preferable to fried and fatty foods.

If the child is eating large amounts of fast food or junk food, it is likely that the dietary fat intake is too high. Conversely, care should be taken in order to ensure that parents who are aware of the association between diet the development of degenerative disease later in life, do not apply their adult dietary recommendations to this age group.  There are documented cases where toddlers showed poor weight gain and loose stools due to a diet low in fat and high in fibre.

Restriction of fat is not recommended before the age of 2 years due to this age group’s high energy needs and essential fatty acid requirements and the importance of fat on central nervous system development.

The suggested distribution of energy is: 50 – 60% carbohydrates, 30 – 35% fat and 10 – 15% protein.

Micronutrient Supplementation

Micronutrient supplementation in children, as with adults, is a hotly debated subject.  A micronutrient supplement is generally not required provided the child eats well and the diet is adequate in energy and protein.  Should a supplement be given, the choice should be for a complete supplement, since some supplements consumed often do not provide certain micronutrients that the child is at risk of having an inadequate intake e.g. iron and calcium.  The children who particularly may benefit from micronutrient supplementation are those: a) from deprived families, b) with poor eating habits and poor appetites, c) chronic diseases e.g. cystic fibrosis, d) on strict vegetarian diets, e) obese children on weight management programs.

 

Hints for Healthy Eating:

·        Children learn by example.  Set a good example by eating the same healthy dishes and also sharing mealtimes.

·        Discourage snacking on foods with poor nutrient density e.g. crisps, chocolates, sweets etc.  Keep a good supply of healthy foods e.g. fruit, yoghurt, which can be eaten between meals.

·        Minimise temptation by avoiding keeping foods with poor nutrient density e.g. chips, biscuits etc in the house.

·        Aim at 5 portions fruit and vegetables per day.  Give a variety of fruit and vegetables from an early age.

·        Try to avoid adding unnecessary sugar to drinks and foods.

·        Avoid sprinkling extra salt over food to avoid conditioning children to salty foods.

Milk intake

·        If the child is still being breast-fed at this age, maintenance of breast-feeding should be encouraged for as long as possible, preferably up to the age of two years. 

·        In most cases however, at the age of one year full cream cow’s milk may be introduced. 

·        Low fat cow’s milk should only be introduced at the age of two years in overweight children and at the age of five years iormal children. 

·        Milk remains an important source of energy and essential fatty acids high biological value  proteins and calcium. 

·        The intake of milk should, however, be limited to approximately 600ml per day.  Excessive amounts of milk could lead to poor intake of solid food. 

·        Cow’s milk is a poor source of certain minerals such as iron. 

·        An excessive intake of cow’s milk together with a poor intake of solids could lead to iron deficiency anaemia. 

Bibliography

а) Basic

1.                 Maureen R. Nelson. Pediatrics / Maureen R. Nelson. – NY: Demos Medical Publishing, 2010. – 259 p.

2.                 Vicky R. Bowden. Pediatric Nursing Procedures / Vicky R. Bowden, Cindy Smith Greenberg. – Philadelphia: Lippincott Williams & Wilkins, 2011. – 822 p.

3.                 Ruth McGillis Bindler. Clinical skills manual for pediatric nursing: caring for children / Ruth McGillis Bindler, Ruth C. McGillis Bindler, Jane Ball. – Pearson/Prentice Hall, 2008. -181 p.

4.                 John P. Cloherty, Manual of Neonatal Care, 6e / Eric C. Eichenwald, Ann R Stark. – Lippincott Williams & Wilkins, 2008 – 762 p.

5.                 Penny Tassoni. NVQ Level 3 Children’s Care, Learning and Development / Penny Tassoni,  Kath Bulman. – Heinemann, 2005 – 384 p.

b) Additional

1.                 Children develop skills

2.                 Neonatal resuscitation

 

 

Prepared by ass.prof. Luchyshyn N.Yu., MD, PhD