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Unit II:
The Infant and Congenital Malformations
Dehydration
Higher risk for dehydration than adults
• Babies have 5x greater surface area than adults
• Longer GI tract
• Metabolic needs are faster
- need for water
- excretion in GI tract
- heat production
• Immature kidneys
- babies cannot dilute or concentrate urine
• Evaluating Extent of Dehydration
• Interventions for Dehydration
• Hydrate
• Strict I&O; daily weight
• Pulse oximeter
• Check capillary refill
• Measure and weigh diapers
• Counting stools or weighing if liquid
• Check tongue for fissures
• Daily Maintenance Fluid Requirements
• Daily Fluid Calculation – Example #1
Child weighs 32 kg
• 100 x 10 for first 10 kg of body weight = 1000 mL
• 50 x 10 for second 10 kg of body weight = 500 mL
• 20 x 12 for remaining body weight = 240 mL
• 1000 + 500 + 240 = 1740 mL/24 hr
Daily Fluid Calculation – Example #2
Child weighs 8.5 kg
• 100 x 8.5 for first 10 kg of body weight = 850mL
• No further calculations
• 850 mL/24 hr
Daily Fluid Calculation – Example #3
Child weighs 14 kg
• 100 x 10 for first 10 kg of body weight = 1000 mL
• 50 x 4 for second 10 kg of body weight = 200 mL
No further calculations
• 1000 + 200 = 1200 mL/24 hr
STAGES OF THE THERAPEUTIC PLAN
1. Emergency Phase for severe dehydration
• Restore circulation rapidly (except in hypertonic)
• D51/4NS
• Checking for behaviors indicating hydration status
• Urine Specific Gravity - WNL1.010 to 1.015; Severely dehydrated 1.025
2. Repletion Phase
• Restore body fluids to volume that will permit adequate circulation and good renal
function
• IV solution given slower than in #1
• K+ is added to IV when renal function is
established. May add Na Bicarb if acidosis
MODEL FOR REHYDRATION
• Rehydration solution should consist of 75-90 meq of Na per liter
Give 40 to 50 mL/kg of rehydration solution over 4 hours
May need maintenance therapy (not to exceed 150 mL/kg/day of ORS
Late Recovery Phase
• Concerned with realimentation
• NO BRAT diet - Begin normal diet
Diarrhea
88-90% of all diarrhea is caused by rotavirus
Increase in November to May
Temporary lactose intolerance- don’t give milk
Acidosis
• Loss of bicarbonate – metabolic acidosis
• Impaired renal function
• Accumulation of lactic acid
• Ketosis
• Diarrhea – Nursing Interventions
Put in isolation (until stool cultures back)
I & O
Daily weights
Stool Cultures
Been out of the country? History
Cardiac
• Pediatric Indicators of Cardiac Dysfunction
• CHD
• Incidence: 5-8 per 1000 live births
– About 2-3 of these are symptomatic in first year of life
– Major cause of death in first year of life (after prematurity)
– Most common anomaly is ventricular septal defect
– 28% of kids with CHD have another recognized anomaly
Cardiac catheterization is a medical procedure used to diagnose and treat certain heart
conditions
• O2 saturation of blood in chambers and great vessels
• Pressure changes
• Changes in CO or stroke volume
• Detect anatomic abnormalities
Nursing Care
Prepare child and parent
Explain according to developmental level
- what they see, hear, and feel
- don’t say inject “dye” into arm
• NPO 4-6 hr (with babies 4 hr)
• Assess vital signs q15min x 4; then q1hr
• Check pulse distal to the site
• Take apical pulse for 1 minute
- dysrhythmias common
Nursing Care (cont)
• Check site for bleeding & phlebitis
• Assess for reaction to contrast media
• Check pulses for symmetry and equality
• Check legs for color, warmth, blanching, coolness, capillary refill
• Keep in bed for 24 hrs
• Keep extremities straight - 6-8 for arterial, 4-6 for venous
• Babies are at risk for hypoglycemia; start feeding right away
Fetal Circulation
• Changes in Fetal Circulation after Birth
1. Pulmonary Vascular Resistance
• Increases pulmonary blood flow to lungs; pulmonary artery pressure decreases
2. Foramen Ovale
• Functionally closes as a result of pressure changes in the right and left atrium
3. Ductus Arteriosus
• Closes as a result of increased O2 tension in arterial blood (10-15hrs after birth)
4. Ductus Venosus
• Closes as a result of the loss of blood flow from the placenta
5. Systemic Vascular Resistance
• Increases as a result of above
• Fetal Circulation
• Older Classifications of CHD
– Acyanotic:(left to right shunting)
• May become cyanotic
– Cyanotic: (right to left shunting
• May be pink
• May develop congestive heart failure (CHF)
• Newer Classification of CHD based on hemodynamic characteristics:
– Increased pulmonary blood flow
– Decreased pulmonary blood flow
– Obstruction of blood flow out of the heart
– Mixed blood flow
• Increased Pulmonary Blood Flow Defects
– Abnormal connection between two sides of heart
• Either the septum or the great vessels
– Increased blood volume on right side of heart
– Increased pulmonary blood flow
– Decreased systemic blood flow
Patent Ductus Arteriosus
Failure of Ductus Arterious to close after birth. Left to right shunt - Increased pulmonary blood flow
Acyanotic
Clinical Manifestations
• Machine type murmur
• Widened pulse pressure
• Cardiomegaly
• Bounding pulse
• Tachycardia
Ventricular Septal Defect
Clinical Manifestations
• Range in size from pinhead to no septum
• Increased pulmonary vascular resistance
• Large harsh murmur on left sternal border
• Easily fatigued
Complication
• CHF
Treatment
• Banding
• Large defects – Dacron patch
• Cardiopulmonary bypass
Pulmonic Stenosis
Clinical Manifestations
• Right ventricular hypertrophy - cardiomegaly
• decreased pulmonary blood flow
• Dyspnea and fatigue
• Cyanosis
Complication
• CHF
Treatment
• Infants – transventricular valvotomy (Brock procedure)
• Children – pulmonary valvotomy with cardiopulmonary bypass
• Balloon angioplasty
Coarctation of Aorta
Localized narrowing of aorta, near the insertion of the ductus arteriosus
Left to right shunt – Obstruction to blood flow from ventricles
Acyanotic
Clinical Manifestations
• High blood pressure and bounding pulses in the arms, weak or absent femoral pulses
• Cool lower extremities with lower blood pressure
• Dizziness, headaches, fainting, and epistaxis resulting from hypertension (older children)
Complication
• CHF – infants
• Cardiomegaly
• Hypertension, ruptured aorta, aortic aneurysm, and stroke
Treatment
• End-to-end anastomosis of the aorta
• Enlargement of the constricted section using a graph of prosthetic material or a portion
of the left subclavian artery
Post operative hypertension is treated with diuretic and ACE inhibitors or beta blockers
• Balloon angioplasty
Tetralogy of Fallot
Clinical Manifestations
• Infants are very cyanotic
• Poor feeding
• Babies have tet spells
• Children have increased hypoxia that cause clubbing, squatting, and poor growth
• Tachypnea & dyspnea
Complications
• Polycythemia
• Cerebral vascular disease
• Clubbing
Initial Treatment
• Put in knee-chest position
• 100% O2 by mask
• Morphine
Surgical Treatment
• Palliative shunt (temporary)
- May result in pulmonary artery distortion
• Complete repair – closure of the VSD and resection of the infundibular stenosis, with
placement of a pericardial patch to enlarge the right ventricular outflow tract
- Performed in the 1st year of life
Clinical Manifestations
• CHF
Therapeutic Management
• Digoxin
- increases force of contraction and decreased heart rate
- slows conduction through AV node, enhances diuresis
• Ace Inhibitors
- block conversion of angiotensin I into angiotensin II
- capoten, vasotec
- always check bp
• Diuretics
- Check potassium labs as K levels affect Digoxin absorption
Digoxin
Check pulse – babies < 100 bpm don’t give
Give at regular intervals
Give slowly, directing to the side of the mouth
Do not mix with foods or other fluids
Toxicity : vomiting and bradycardia
Elixir 50 mcg/mL; never give more than 1 mL
CHF
• CHF – Nursing Interventions
Neutral thermal environment
Treat infections
HOB up – reduce breathing efforts
decrease environmental stimuli to provide rest
Feed q 3hrs; give ½ hr to eat
Diuretics – strict I &O and daily weight
Kawasaki Disease (KD; Mucocutaneous Lymph Node Syndrome)
• An acute systemic vasculitis of unknown cause
• 75% of cases in children <5 yrs
• Three phases:
– Acute: sudden high fever, unresponsive to antipyretics and antibiotics
– Subacute: end of fever through end of all KD clinical signs
– Convalescent: clinical signs resolved, but laboratory values not returned to normal;
completed with normal values (6-8 weeks)
Risk for myocardial infarction
• Symptoms of MI in children
Abdominal pain
Vomiting
Restlessness
Inconsolable
Crying
Pallor to shock
Theraputic Management
• High doses of gammaglobulin or high doses of aspirin
- 1st 10 days of illness; single large transfusion over 10-12 hrs
- Aspirin 100mg/kg/q6hr; after fever 3-5mg/kg/day antiplatelet
Nursing Interventions
• Monitor cardiac status
• I & O
• Daily weights
• Mouth care
• Clear liquids, soft diet
• Promote rest
• Loose clothing
• Warm tub (arthritis)
• Teach parents to defer immunizations for 11 months
SIDS
http://www.youtube.com/watch?v=9Iu88-DaH0k&feature=related
• SIDS - Epidemiology
Higher percentage of males
Increased incidence in the winter
Greater incidence in African-Americans, Native Americans, and Hispanics
Lower socio-economic class
Pre-term infants
Low Apgar score
Birth order- highest in first borns
Lower incidence in breast-feed infants
Mother – young age, cigarette smoking, poor prenatal care, substance abuse
• SIDS – Nursing Implications
Teach parents
• Do not use soft bedding or fluffy pillows
• Do not sleep with infant
• Put babies on their backs
Death of a child
• Allow the parents to spend unlimited time with their baby
• Follow up
• Referrals – SIDS associations
Common grief response
• Denial
• Anger
• Hysteria
• Withdrawal
• Intense guilt
• No visible response
• Mourning period may take 1 year or more
RSV (respiratory synctial virus)
Between ages 2-12 months; rare after 2 years
Clinical Manifestation
• Bronchioles become inflamed & swollen; lumina filled with exudates
• Prolonged expiratory phase
• Obstruction in small air passages; patchy areas of atelectasis
• Dyspnea, irritability, tachypnea, nasal flaring, substernal intercostal retraction
• Fine rales and crackles
• Wheezing
• Emphysema with barrel chest
Diagnosis
• Nasal secretions
• ELISA
Treatment
• Rest
• O2 therapy
• Fluids (npo if tachypnea)
• Pulse ox
• Respiratory therapy – albuterol
• Corticosteriods (controversial)
• Suction
• Ribavirin (very controversial)
- 18-20hr/day for 7 days
- in isolation under hood
- teratogenetic drug
• Synergist (palivizumab)
- preemie with chronic lung disease
- $1400/shot once a month
• RSV immune globulin- neutralizes antibodies against RSV
Hydrocephalous
Non Communicating/Obstructive
• Obstruction to the flow of CSF through the ventricular system
Communicating/ Non Obstructive
• Impaired absorption of CSF within the subarachnoid space
• Malfunction of the arachnoid villi
Clinical Manifestations
• Infancy (early)
- Abnormally rapid head growth
- Bulging fontanels (especially anterior)
- Dilated scalp veins
- Separated sutures
- Cracked-pot sound
- Thinning of skull bones
• Infancy (later)
- Frontal enlargement, or bossing
- Depressed eyes
- Sun setting eyes
- Pupils sluggish, unequal response to light
Infancy (general)
- Irritability
- Lethargy
- Cries when picked up
- Early infantile reflex acts may persist
- Normally expected responses fail to appear
May display:
- Changes in LOC
- Opisthotonos (often extreme)
- Lower extremity spasticity
- Vomiting
Advanced cases:
- Difficulty in sucking and feeding
- Shrill, brief, high-pitched cry
- Hydrocephalus
• Childhood
- Headache on awakening; improvement following emesis or upright posture
- Papilledema
- Strabismus;diplopia
- Ataxia- Unsteady gait
- Irritability
- Lethargy
- Apathy
- Confusion
- Incoherence
- Vomiting
- Hydrocephalus
Treatment
• Ventriculoperitoneal (VP) shunt
- Spinal fluid drained into peritoneal cavity
- Need shunt revisions throughout their life
Complications
• Infection or malfunction
- 1-2 months after placement highest risk for infection
- Mechanical difficulties; kinking, plugging, or separation or migration of the
tubing
- Mechanical obstruction; tissue or exudate
Pre-op
• Head circumference
• Assess change in LOC
Post-op
• Position on unoperative side
• Keep flat (after 1st shunt)
• Check any drainage for glucose
• No sedation
• Shunt revision – HOB up
• Observe for ICP and infection
• NPO for 24-48 hr
• Teach parents signs of ICP
Spina Bifida
Clinical Manifestations
Spina bifida occulta
• Frequently no observable manifestations
• May be associated with one or more cutaneous manifestations:
- Skin depression or dimple
- Port-wine nevi, angiomas
- Dark tufts of hair
- Soft, subcutaneous lipomas
• May have neuromuscular disturbances:
- Progressive disturbances of gait with foot weakness
- Bowel and bladder sphincter disturbances
Spina bifida cystica
Sensory disturbances usually parallel to motor dysfunction
• Below second lumbar vertebra:
• Flaccid, partial paralysis of lower extremities
• Varying degrees of sensory deficit
• Overflow incontinence with constant dribbling of urine
• Lack of bowel control
• Rectal prolapse
• Below third sacral vertebra:
• No motor impairment
• Bladder and anal sphincter paralysis
• Spina Bifida – Nursing Implications
Position on their abdomen; frog-legs with hips abducted
Low trendelenburg (unless hydrocephalus)
Assess for hydrocephalus
Monitor sac
No diapers
No covers
Moist NS dressing over sac; change q2hr
Feeding – place in prone and nipple while head is turn to the side
• Latex Allergy
• Identified as serious health hazard when a child with spina bifida experienced
anaphylaxis due to latex allergy
• Spina bifida patients at high risk for latex allergy due to repeated exposure to latex
products from multiple surgeries and repeated urinary catheterizations
• Allergic Reactions to Latex
• Range from urticaria, wheezing, rash, to anaphylaxis
• Reactions tend to increase in severity when latex comes in contact with mucous
membranes, wet skin, bloodstream, or airway
• Cross-reactions with foods: banana, avocado, kiwi, chestnuts
Developmental Dysplasia of the Hip
Preluxation – (Acetabular Dysplasia)
• Shallow acetabulum
• Delay in acetabular development
• No dislocation of subluxation
Subluxation
• Incomplete dislocation; a dislocatable hip
• Femur in contact with acetabulum
– not displaced due to a stretch ligamentum teres and capsule
Dislocation
• Femoral head loses contact with acetabulum and is displaced posteriorly and superiorly
Galeazzi sign
• Asymmetry of gluteal and thigh folds with shortening of the thigh
Ortolani test
• Limited hip abduction, as seen in flexion
Allis sign
• Apparent shortening of the femur, as indicated by the level of the knees in flexion
Trendelenburg sign
• Pelvis tilts downward instead of upwards when weight is beared on affected hip
• Developmental Dysplasia of the Hip
Clinical Manifestations
Infant
• Shortening of limb on affected side
• Restricted abduction of hip on affected side
• Unequal gluteal folds (infant prone)
• Positive Ortolani test
• Positive Barlow test
• Developmental Dysplasia of the Hip
Older Infant and Child
• Affected leg shorter than the other
• Telescoping or piston mobility of the joint
• Trendelenburg sign
• Greater trochanter prominent and appearing above a line from anterosuperior iliac
spine to tuberosity of ischium
• Marked lordosis (bilateral dislocations)
• Waddling gait (bilateral dislocations)
• Developmental Dysplasia of the Hip
Treatment
• Bryant’s traction
- Loosens ligaments and muscles, easier to treat dislocation
Spica cast
Dennis Brown cast
Hypertrophic Pyloric Stenosis
Constriction of pyloric sphincter with obstruction of gastric outlet
Signs and Symptoms
Projectile vomiting; non bilious
Baby is always hungry
Signs of dehydration – Acid-base imbalance
Ph increases
Creatinine and BUN increase
Stools decrease
Visible peristaltic waves – see going left to right
Palpable – feels like an olive
Diagnosis – Upper GI or Ultrasound
Treatment - Fredet-Ramstedt procedure
• Minor procedure
• Post op vomiting common – keep IV
• Begin feedings 4-6 hr; 24 hrs give formula
• HOB in high fowlers
• Burp frequently
TEF
Clinical Manifestations
• Excessive salivation and drooling
• Three C’s of tracheoesophageal fistula
- Coughing
- Choking
- Cyanosis
• Apnea
• Increased respiratory distress after feeding
• Abdominal distention
Nursing Implications
• Immediately NPO
• HOB up to prevent reflux
• Suction frequently
• Begin antibiotics immediately
• Keep g-tube unclamped
Post-op
• Respiratory conditions
• G-tube feedings
• Tracheomalasia
Hirshprung’s
Pathophysiology
• Absence of autonomic parasympathetic ganglion cells in one section of the colon
• Problem in embryonic development
• Results in lack of propulsive movements (peristalsis)
• Accumulation of int. contents and distention of the bowel proximal to the defect causes
a large or megacolon
• Also internal rectal sphincter not relaxed prevent evacuation of solids, liquids, gas
• Most common site is rectosigmoid colon
• Intestinal distention and ischemia from distention of bowel wall cause enterocolitis—
leading cause of death
Clinical Manifestations
Vary according to age
Newborn
• Not pass meconium within24-48 hours
• Reluctance to drink
• Bile stained vomitus
• Abdominal distention if not treated- resp distress and shock
Infancy
• FTT
• Constipation
• Diarrhea and vomiting (explosive, watery diarrhea and fever signify enterocolitis)
Can have without diarrhea, but still have fever
Childhood
• Chronic symptoms of constipation - pass ribbon-like, foul smelling stools
• Abdominal distention; fecal mass palpable
• Visible peristalsis
Diagnostic Evaluation
• Newborn- fails to pass meconium
• Later childhood and infancy – history, rectum free of feces, sphincter tight, leakage of
liquids, gas and foul pale stool, chronic constipation, poor feeding poor weight gain
• Sometimes megacolon won’t develop until 3-4 weeks or months after birth
• *Need rectal biopsy
• *Anorectal mamometry- done NB and preemie. Insert cylinder with 3 balloons - test
reflex response of sphincters; internal sphincters don't relax
• Poorly nourished and anemic
Therapeutic Management
• Most children are treated surgically. 2 stage repair- Remove aganglionic section of
colon and do colostomy. At approx . 20 lbs (in 2 mo to 1 year) will do sphincterotomy
and pull-down of functional bowel and close colostomy
• Lately, if diagnosed in neonatal period, will do a 1 stage repair. Resect aganglionic
section and pull down colon and anastomose to rectum
Also, laparoscopic-assisted pull thru(-thru anus- pull affected area of bowel out)
• Good results; no major abdominal surgery; less hospital stay; no colostomy care;
completion of treatment at earlier age
Nursing Considerations
Preoperative
• Depends on condition of child and age. If malnourished- will need high cal; high protein;
low fiber diet and isotonic enemas, until condition improves and can withstand surgery
• Preop will have NG GoLytely, antibiotics and rectal irrigations. Daily abdominal
circumference
• Psychological preparation for colostomy
Post-op
• NPO ; IV; abdominal dressings; perianal dsgs; may have NG tube; ostomy care
Intussusception
Most frequent cause of intestinal obstruction during infancy
50% occurs less than 1 year (most 3 mo to 12 mo)
Most others occur before 2nd year (Some books say 3 yrs)
3 X more in males
Pathophysiology
Telescoping of one portion of intestine into another; most common site is ileocecal
valve
This causes obstruction to passage of GI contents
2 walls of intestine press against each other edema, inflammation decreased
blood flow
Decreased blood flownecrosisresults in hemorrhage, perforation, peritonitis
Cause unknown. May have a viral origin. More in cystic fibrosis and Celiac’s Disease
Clinical Manifestations
Sudden acute pain with intervals where child is normal
Vomiting; may pass 1 normal stool
Stools become red-currant jelly (blood, mucous, and stool)
Abdomen tender and distended
Sausage shaped mass in rt upper quadrant
Dance’s sign- lower rt quadrant feels empty- bowel distal to obstruction less involved;
free of contents
Chronic picture may appear as diarrhea, vomiting, constipation and periodic colic
Diagnostic evaluation
• Rectal exam
Therapeutic management
• Nonsurgical hydrostatic reduction. Successful 75% of time. If not; manual reduction
and resection any non-viable intestine
• Barium enema- barium becoming less used Use water soluble contrast or saline under
ultrasound or pneumonic insufflation with air or O2.
Nursing Care
• Prepare parents- teach using glove with water
• Pre-op- watch for passage of normal stool. Report immediately- could mean
intussusception resolved
• After hydrostatic reduction- chance of recurrence within 36 hour.
• Observe stool patterns
• Child kept in hospital ???? Observe 12-24 hours at least
GERD
GE reflux is the passive transfer of gastric contents into esophagus
Affects 1 in 300 to 1000 children
Caused by inappropriate relaxation of lower esophageal sphincter
GE reflux is the passive transfer of gastric contents into esophagus
Affects 1 in 300 to 1000 children
Caused by inappropriate relaxation of lower esophageal sphincter
Could be problem with CNS or developmentally exaggerated enteric reflex
High risk- children with TEF or other esophageal repair, neurological disorders, scoliosis,
asthma, CF
Could be problem with CNS or developmentally exaggerated enteric reflex
Clinical Manifestations
• Most common is passive regurgitation or emesis
• Poor weight gain, anemia, irritability, gagging and choking, apnea, recurrent
pneumonias, heme-positive emesis or stools
• Esophagitis from acidic gastric contents- anemia, discomfort, poor weight gain
Diagnostic Evaluation
• Need a history of feeding habits
• Stool guaic; growth assessment; UGI
• Esophageal PH monitoring
• Endoscopy to assess for esophagitis
• Sometimes Scintigraphy – a radionuclide added to formula; gamma counter detects
presence of formula in lungs or esophagus
• Multiple respiratory abnormalities
Therapeutic Management
• Controversy over thickened formula
• Better to combine with prone position, é 30°
• Position – prone with HOB elevated or flat
• Pharmacological treatment
• Antacids or H2 blockers – Tagament, Zantac, Pepsid (reduce acid in gastric contents)
• Prokinetic meds – Reglan, Urecholine; may decrease reflux
Nursing Interventions
• To keep elevated may need harness, wedge, elevated mattress
• Thicken feeding – 1 tsp to 1 tbsp of rice cereal per oz of formula. Enlarge nipple hole.
May need gavage feedings.
• Give pacifier – Increase sucking helps clear food from esophagus; keep quiet after
feeding
• If severe complications (ALTE’s; apnea) will do Nissen fundiplication. Also pyloroplasty;
g-tube
• Prognosis good for most. Most cured by 18 mo
• In severe cases- esophagitis; esophageal strictures; recurrent respiratory distress;
aspiration pneumonia
Cleft Lip and Palate
Diagnosis
• Obvious at birth
• Unilateral or bilateral
• Assessing a cleft palate
- Need thorough assessment of the mouth
- Put glove on and palpate for a cleft
- Suspect if infant is having trouble sucking
Treatment
• Repair lip first, then palate
• Z-shaped suture line
- protected by logan bow or butterfly suture
- don’t put them on their stomachs
- restrain arms and elbows
• Perform before faulty speech; before teeth
Long-term problems
• Speech impairment
• Otitis Media
Nursing Implications
• Feeding
- keep head upright
- watch when they eat
- large soft nipples
- encourage sucking
- frequent burping
- can breastfeed
Post-op Care after palate repair
• No tongue blades
• No straws
• No oral temperatures
• No forks; wide bowl spoon
• Discharge on soft diet
• Rinse mouth after feeding
• May have problems breathing
Classification of Anemias
• Etiology and physiology:
– RBC and/or Hgb depletion
• Morphology:
– Characteristic changes in RBC size, shape, and/or color
• Effects of Anemia on Circulatory System
• Hemodilution
• Decreased peripheral resistance
• Increased cardiac circulation and turbulence:
– May have murmur
– May lead to cardiac failure
• Cyanosis
• Growth retardation
• Iron Deficiency Anemia
• Failure To Thrive
Refers to a state of inadequate growth from inability to obtain and/or use calories required for
growth
It is a symptom, not a disease
No universal definition
Weight and sometimes height that fall below the 5th percentile for the child’s age
Must take into account cultural differences in build; plot on HT/WT chart
Failure To Thrive
Organic FTT (OFTT)
• Result of a physical cause (CHD,neuro prob, chronic UTI)
• Accounts for less than half of all FTTs
• Must be ruled out by physical assessment
Non-Organic FTT (NFTT)
• Definable cause that is unrelated to disease
• Psycho social factors
• Poor parenting skills/lack of knowledge
• Poverty, health beliefs, inadequate nutritional knowledge, family stress, feeding
resistance, insufficient breast milk
• Disturbance in mother/child attachment
Idiopathic or Mixed FTT
Diagnosis
• Plot on curve
• Dietary history
• Physical Examination
Characteristics of FTT Child
• Avoids eye contact (shows lack of bonding)
• Intense watchfulness
• Avoidance of contact – stiff or floppy
• Repetitive self-stimulating behaviors (rocking, head banging)
• Disturbed affect (irritability, apathy or extreme compliance)
• Sleep disturbances
• Lack of age-appropriate stranger anxiety
• Lack of appropriate preferences for parents
• Slow in social behavior – smiling
• Dietary “quirks” – turn away from food, regurgitation, etc.
• Failure To Thrive
Characteristic Behavior of Caregiver
• Substance abusers
• Inadequate support systems
• Poor parenting practices – lack of commitment to parenting
• No bonding due to lack of contact
• Making negative comments
• No name given to baby
Therapeutic Management
• Goal is reversing the malnutrition – may need hospitalization or close home health
monitoring
• Structuring the environment for positive psychosocial interactions
• Multidisciplinary team to work with family
Prognosis – Uncertain, related to cause & controlling factors
ASSESSMENT, TEACHING, ROLE MODEL