Health Problems of Newborns and Infants.
Routine Health Screenings.
Growth and Development of the Newborn
1. Identify the adaptive changes that occur during the transition to extrauterine life.
2. Describe the normal physiological development of the newborn.
3. Discuss the psychosexual, cognitive, and psychosocial development of the newborn.
4. Identify and explain aspects of health promotion and maintenance pertinent to the newborn.
5. Describe family educational needs regarding health promotion of the newborn.
6. Explain the etiology and treatment of the high-risk newborn.
7. Discuss the nurse's role in caring for healthy and high-risk newborns.
Growth and Development of the Infant
1. Discuss physiological growth and developmental milestones of infants.
2. Discuss the process of infant fine and gross motor development, including the principles associated with them.
3. Describe infant psychosexual, cognitive, and psychosocial development.
4. Describe health promotion and maintenance activities for infants.
5. Discuss caloric and fluid requirements for infants.
6. Describe play activities of infancy.
7. Discuss educational strategies for caregivers of infants as related to nutritional needs, growth and development patterns, stranger and separation anxiety, and safety.
GROWTH, MATURATION, AND DEVELOPMENT
Growth, maturation, and development are common terms used to describe human development. An explanation of these terms and of the age ranges associated with child development is needed before principles, issues, and theories can be understood. Growth refers to a physiologic increase in size through cell multiplication or differentiation. This is most obviously seen in weight and height changes occurring during the first year of life. Maturation refers to changes that are due to genetic inheritance rather than life experiences, illness, or injury.
These changes allow children to function at increasingly higher and more sophisticated levels as they get older. Development refers to the physiological, psychosocial, and cognitive changes occurring over one's life span due to growth, maturation, and learning, and assumes that orderly and specific situations lead to new activities and behavior patterns (Figure 1).
Figure 1 (A) Toddlers are developing their gross motor skills. (B) School-aged children often become involved in physical activities and team sports.
The five stages and age ranges of human development relating specifically to pediatric nursing are found in Table 1.
Table 1. Stages,
Related to Pediatric Nursing
Principles of Growth and Development
At least eight principles providing a framework for studying human development are embedded within the issues and theories discussed in the following pages. Although not all of these principles are proven by research, they are often observed in children and generally assumed to be true (Hetherington & Parke, 1993; Murray & Zentner, 2001).
1. Development is orderly and sequential. This principle suggests that maturation follows a predictable and universal timetable. For example, children learn to crawl before they learn to walk, and they learn to walk before they learn to run. These changes occur rapidly during the first year of life and slow during middle and late childhood. Even though the onset and length of each developmental change vary among children, the basic sequence is the same, allowing comparison to norms.
2. Development is directional. Skill development proceeds along two different pathways: cephalocaudal and proximodistal. Cephalocaudal development proceeds from the head downward. Therefore, areas closest to the brain or head develop first, followed by the trunk, then legs and feet. For example, head control is followed by sitting, then crawling, and then walking. Proximodistal development proceeds from the inside out. Controlled movements closest to the body's center (trunk, arms) develop before controlled movements distant to the body (fingers). For example, grasping changes from using the entire hand to just the fingers as infants get older.
3. Development is unique for each child. Ever)' child has a unique timetable for physiological, psychosocial, cognitive, and moral development. For example, some children can name four colors by the time the y are 3 years old, whereas others cannot name four colors until they are 4V2 years old. Some children walk well at 11 months; others do not walk well until they are 14 months old.
4. Development is interrelated. Physiological, psychosocial, cognitive, and moral aspects of development affect and are affected by one another. For example, central nervous system maturation is necessary for cognitive development. Children cannot be independent in toileting if they are not aware of the urge to void and cannot independently remove clothing.
5. Development becomes increasingly differentiated. This means responses become more specific and skillful as the child grows. Young infants respond to stimuli in a generalized way involving the entire body, whereas older children respond to specific stimuli in a more refined and specialized way. For example, infants will react with their entire body to pain by crying and withdrawing, whereas a child is able to localize the pain, can often identify its source, and may only withdraw the extremity experiencing the pain. An infant will use the entire hand to grab a toy before developing the fine motor ability necessary for the pincer grasp.
6. Development becomes increasingly integrated and complex. This means, as new skills are gained, more complex tasks are learned. For example, learning to drink from a cup initially requires eye-hand coordination, then grasping, and then hand-mouth coordination. Infants' cooing is followed by babbling, before these sounds are refined into the understandable speech of a child.
7. Children are competent. They possess qualities and abilities ensuring their survival and promoting their development. For example, newborns can cough, sneeze, suck, swallow, digest, breathe, and elicit caretaking responses from adults. Children make their needs known to caregivers in increasingly sophisticated ways so that others know if they are cold, hungry, or in pain.
8. New skills predominate. This occurs because of the strong drive to practice and perfect new abilities, especially early in life, when the child is not capable of coping well with several new skills simultaneously. For example, when children are learning to walk, talk, or feed themselves with utensils, their attention and effort is focused on developing that one skill; they do not usually learn to walk, talk, and feed themselves at the same time.
Issues of Human Development
Theories on growth and development are often considered from the perspective of seven issues. These issues help explain how development occurs and what humans are like and can be applied to theories of human development. These issues answer questions related to the importance of biology or the environment on development, whether children are inherently good, bad, or actively involved in their own development, if development occurs gradually or abruptly, if children are more similar than different from one another, or if one's personality or way of interacting with others remains stable throughout life. The issues discussed include nature versus nurture, continuity versus discontinuity, passivity versus activity, critical versus sensitive periods, universality versus context specificity, assumptions about human nature, and behavioral consistency.
Nature versus Nurture
One of the more important and oldest issues discussed in human development is the nature/nurture controversy. This debate concerns the influence that biology (nature) and the environment (nurture) have on an individual. Nature describes genetically inherited traits such as eye color or body type, or disease such as cystic fibrosis or hemophilia. This view sees development as predetermined by genetic factors and not altered by the environment. A person believing in the principle of nature would suggest that all normal children achieve identical developmental milestones at a similar time due to maturational forces. If children differed in achieving these milestones, it would be because of differences in their genetic makeup. Nurture refers to the influences that the environment has on development, and includes the influences that child-rearing methods, culture, learning experiences, and society have on development. A person believing in the principle of nurture would suggest that development can take different paths depending on the experiences that an individual has over a lifetime.
Today, most developmentalists believe that both nature and nurture are important, and that the relative contribution of each depends on the aspect of development studied. Developmentalists today are also more concerned about how biological and environmental factors interact to produce developmental differences and changes, rather than the importance of one over the other .
Continuity versus Discontinuity
This issue addresses the nature of change across development. Continuity suggests that change is orderly and built upon earlier experiences. Development is a gradual and smooth process without abrupt shifts; the course of development looks like a smooth growth curve. This issue also suggests early and late development are connected; aggressive toddlers become aggressive adults, curious infants become creative adolescents, and shy preschoolers become introverted adults. Finally, continuity proposes that changes occur quantitatively, or in degrees. For example, when children grow older, they become taller, run faster, and learn more about the world around them.
Discontinuity suggests development is a series of discrete steps or stages that elevate the child to a more advanced or higher level of functioning with increased age. The course of development looks like a flight of stairs. There is no connection between early and later development; behavior seen later in life has replaced behavior seen earlier in life. For example, infants once comfortable around strangers may come to fear them as they get older; a shy and introverted preschooler may become an outgoing, extroverted adolescent. Discontinuity would also argue that adult behavior cannot be predicted by knowing what the person was like as a child. Finally, discontinuity implies qualitative change, or changes that make the individual different as growth occurs, as when a nonverbal infant becomes a toddler using language, or when a prepubertal child becomes a mature adolescent.
Passivity versus Activity
This issue views the child as either a passive recipient shaped by external environmental forces, or as internally driven and actively participating in development. The passive view suggests that child-rearing beliefs, practices, and behaviors cause children to be either shy or assertive. Children become delinquent because of their association with an antisocial peer group. Talented and creative teachers deserve credit for a child's interest in mathematics or literature. Those disagreeing with this view believe children purposefully, creatively, and actively seek experiences to control, direct, and shape their development. Active children also modify caregiver, peer, and teacher behavior (Figure 2).
Figure 2 Active children are interested in learning about other children's projects and art work.
For example, an inquisitive, friendly child may encourage that same behavior in an otherwise indifferent or unfriendly peer or adult.
Critical versus Sensitive Period
This issue concerns the importance of different time periods in development, and asks if some phases are more important than others in developing particular abilities, knowledge, or skills. The critical period refers to a limited time span when a child is biologically prepared to acquire certain behaviors, but needs the support of a suitably stimulating environment. Indeed, there are some periods during development when children need to experience certain sensory and social input if their development is to proceed normally. The first 3 years of life are important for developing language, social, and emotional responsiveness. If there is little or no opportunity for these experiences during this time, children may have difficulty learning language, developing close friendships, or having an intimate emotional relationship later in life.
The sensitive period, on the other hand, is a time span that is optimal for certain capacities to emerge when the individual is especially receptive to environmental influences (Bornstein, 1989). Supporters of this view believe some behaviors can be modified during early development. For example, infants reared in an impoverished orphanage grew up without identifiable intellectual deficits if they were placed in a stimulating and nurturing adoptive home (Skeels, 1966). The fact that early experiences can be modified suggests humans are malleable and adaptable and, for some areas of development, there are sensitive rather than critical periods.
Universality versus Context Specificity
The importance of culture to development is embedded within this issue. Some theorists believe an individual's culture has a profound influence on development. Others suggest there are culture-free laws of development that apply to all children in all cultures. For example, universality would say humans follow similar developmental pathways regardless of their culture: language is acquired and used at 11-14 months of age, cognitive changes preparing children for school or higher learning occur during 5-7 years of age, and sexual maturity is reached during the preteen or teenage years. Context specificity on the other hand, would suggest there are differences in children related to cultural values, beliefs, and experiences. For example, some societies encourage early walking by providing opportunities to exercise and practice these new skills, whereas in other societies carrying or swaddling infants is the norm, thereby reducing the chance of walking until older.
Assumptions about Human Nature
The doctrine of original sin used by Thomas Hobbes (1588-1679) to describe a child's nature, suggests children are inherently evil and selfish egotists who must be controlled by society. The doctrine of innate purity, proposed by Jean Jaques Rousseau (1712-1778), suggests children are inherently good and born without an intuitive sense of what is right and wrong. The doctrine of tabula rasa, proposed by John Locke (1632-1704), suggests children are neither good nor evil, but rather enter the world as a blank slate without inborn tendencies, and are molded through life experiences. These assumptions are based on 17th and 18th century social philosophers and rarely addressed directly in theories of human development today. However, emphasis on positive or negative aspects of a child's character and a particular theorist's belief reflect an individual's orientation and assumptions about human nature. For example, if one believes children are inherently caring and helpful, or on the other hand, innately selfish, child-rearing practices would vary. Permissive parents may believe children should be allowed to develop without interference (innate purity), whereas authoritarian parents may take an approach that would combat and control their child's selfish and aggressive impulses so they would develop positive behaviors.
This issue addresses whether or not a child's basic behavioral traits change according to the setting (school, neighborhood, family). Some theorists suggest individual personality characteristics and predispositions cause children to behave similarly no matter the setting. Others suggest children's behavior changes from one setting to another. Those supporting the former view would say a particular child can always be described as honest, helpful, aggressive, or independent, no matter the situation. The latter view would argue children's behavior shifts according to the situation and who/what is present—friend in need, angry caregiver or teacher, competitive game, or a difficult test.
Skinner and Operant Conditioning
Operant conditioning, a term originated by B. F. Skinner (1904-1990), involves behavioral changes due to either negative (punishment) or positive (reinforcers) consequences rather than just the occurrence of a stimuli. If behavior is rewarded, the likelihood of it reoccurring increases; if behavior is punished, chances are it will not reoccur. Positive reinforcement includes friendly smiles, praise, or special treats/privileges; punishment includes criticism, a frown, or withdrawal of privileges. Skinner discovered behavioral change became more permanent when consequences were provided intermittently rather than continuously, and believed the essence of development involved constantly acquiring new behaviors or habits due to reinforcing or punishing stimuli. He emphasized why behaviors occur rather than simply describing the behavior seen (Skinner, 1953).
Bandura and Social Learning
A third kind of behaviorism is social learning, proposed by Albert Bandura (b. 1925). According to this view, children learn by imitating and observing others (a model), as well as by classical and operant conditioning. Social learning theorists also believe behavior is influenced by the environment and learned through various experiences. However, they do not believe behavioral change is a mindless response to stimuli. Rather, they suggest personality, past experiences, relationships with the model, the situation itself, and cognition also impact behavioral change (Bandura, 1977). Cognition plays a part because to successfully imitate behavior, a child must be capable of remembering, rehearsing, and organizing the behavior seen. Children often will think about connections between behavior and consequences and will likely be affected more by what they believe will be the consequences rather than what the consequences actually are. For example, learning to play a musical instrument is expensive for families, and demanding and time consuming for children. However, children and their parents continually tolerate the cost and inconvenience because they are anticipating rewards once the child learns to play the instrument.
Bandura also believes modeled behavior can be weakened or strengthened depending on whether it is punished or rewarded. Bandura suggests observational learning (learning that results from merely watching others), where children acquire a variety of new behaviors when "models" are merely pursuing their own interests and not attempting to teach, reward, or punish, is another important method of learning behaviors. For example, research has shown children who watch television violence frequently are more aggressive than those children who do not watch very much television violence (Murray & Zentner, 2001). Finally, Bandura found children tend to model behavior of children and adults of their same gender more often than not, and males model behavior of others more often than females do.
Although behaviorism has been criticized for denying the inherent capabilities of persons to willfully respond to environmental situations and its relative elementary nature, it is useful in health care. Positive behaviors can be reinforced by encouragement, praise, and other rewards, and behaviors needing to be altered or removed from a child's repertoire can be extinguished by either ignoring or punishing. Parents commonly use these concepts when toilet training or teaching their children cooperation, compromise, helpfulness, and empathy. Some academic and preschool programs and parents use behavior modification and time-out activities to modify and change undesirable behavior in children. Operant conditioning can also help plan new or extinguish undesirable behavior by providing specific guidelines, determining available reinforcers, identifying responses acceptable for reinforcement, and planning how reinforcers will be scheduled so behavior is repeated.
Social learning theory is also readily applicable to health care. Children often will cooperate with procedures (blood draws, X rays) if they see other children or adults they emulate cooperating for the same procedure. Nurses can help parents realize that their appearance and behavior is often imitated by their children, and determine who might be significant role models for their children to emulate. Finally, nurses need to demonstrate nurturing approaches or discipline methods so parents learn effective parenting practices.
GROWTH AND DEVELOPMENT OF THE NEWBORN
The neonatal or newborn period is defined as the first 28 days, or 4 weeks, of life. This chapter will present the normal changes that occur during the transition to extrauterine life and the normal physiological, psychosexual, cognitive, and psychosocial development that occurs during the newborn period as well as information related to the high-risk newborn. Nursing care of the normal and high-risk newborn will also be presented.
Fetal circulation is different from neonatal circulation due to structural differences that include the (1) placenta, (2) umbilical arteries and veins, (3) ductus venosus, (4) foramen ovale, and (5) ductus arteriosus. The placenta provides oxygen and nutrients for the fetus, and removes carbon dioxide and other waste products. The umbilical cord connects the fetus to the placenta, and contains two arteries and one vein. Blood from the placenta flows through the umbilical vein to the abdominal wall of the fetus. The umbilical vein then divides into two branches. A small portion of the blood flows through one branch and to the liver, sinusoids, and hepatic vein before entering the inferior vena cava. Sixty percent of the blood flows through the ductus venosus (a shunt in the fetus that carries oxygenated blood from the umbilical veins) and directly enters the inferior vena cava (Moller & Dwan, 1992a). The blood then enters the right atrium. Most blood will bypass the fetal lungs via the foramen ovale (an opening between the right and left atria) and enter the left atrium. From the left atrium, the blood enters the left ventricle and is pumped into the aorta to the hypogastric arteries. The small amount of blood that does pass from the right atrium to the right ventricle will pass into the pulmonary artery. From the pulmonary artery, a small amount will go to the nonfunctional lungs into the pulmonary vein, left atrium, left ventricle, and to the aorta. The remainder of the blood will pass through the ductus arteriosus (channel between the main pulmonary artery and the aorta) to the aorta. The hypogastric arteries lead to the iliac arteries, which give rise to the umbilical arteries, which then return the blood to the placenta. Figure 7-1 represents fetal blood flow.
The transition to extrauterine life begins with the loss of the umbilical cord and the initiation of respirations. With the initiation of respirations, the PaO2 levels are increased, and several changes occur. Decreased pulmonary vascular resistance results in increased pulmonary blood flow, causing an increase in the pressure of the left atrium, a decrease in pressure of the right atrium, and closure of the foramen ovale. The foramen ovale closes shortly after birth and then undergoes fusion of the tissue margins during early childhood. Increased PaC>2 levels also lead to an increase in systemic vascular resistance, a decrease in systemic venous return, cessation of umbilical venous return, and closure of the ductus venosus. The closure of the ductus venosus occurs gradually over a period of about 2 weeks. Since systemic resistance is greater than pulmonary resistance, a left-to-right shunt occurs within the heart, resulting in closure of the ductus arteriosus (usually within 24 hours of birth) and gradual obliteration over the next month (Moller & Dwan, 1992b). Figure 7-2 represents transition to extrauterine life.
The average period of transition is 6—12 hours, but may be shorter or longer depending on the neonate's ability to adjust to the stresses of labor, delivery, and a new environment (Kelly, 1994). Therefore, during this transition period, the neonate needs to be closely observed for any difficulties so that appropriate interventions can be offered.
Most people visualize a newborn as the baby seen in advertisements (Figure 7-3); however, the actual appearance may be a surprise to caregivers. The newborn's head, which is one-quarter of the total body size, may appear out of proportion to the body and be misshapen due to the labor and delivery process (molding; Figure 7-4). A caput succedaneum may be present as well, especially after a long labor. A caput is the swelling of the soft tissues of the scalp. The swelling may extend across the suture lines, is evident within 24 hours after birth, and usually resolves within a few days. The collection of blood between the skull bone and the periosteum as a result of the rupture of blood vessels secondary to head trauma from the birth process may result in a cephalhematoma. A cephalhematoma develops 24-48 hours after birth and does not cross the suture lines (Figure 7-5).
A cephalhematoma may take 2—3 weeks to resolve. Reassurance to the caregivers is needed that many of these characteristics will change over the future weeks and months and that the newborn will then begin to take on the appearance of a "normal" baby. Eyelids may be puffy and eye color indistinguishable. In addition, the newborn has a large, round abdomen with an umbilical area that may protrude for several weeks until the cord stump falls off. The caregiver should be instructed on appropriate umbilical cord care.
The extremities may appear short in comparison to the body, but hands should be able to touch the upper thighs when extended. The legs may appear to be bowed and the newborn typically remains in a position with the extremities flexed. The skin is delicate, often mottled, or acrocyanosis may be present. Acrocyanosis is the bluish discoloration of the hands and feet caused by the instability of the peripheral circulation system.
Many caregivers are afraid to touch the baby's head or "soft spot" due to the fear of causing damage. The soft spots, or fontanels, occur at junctions or suture lines of the skull bones, allowing for adaptation to the pelvis shape during delivery and growth of the brain over the coming year (Figure 7-6). The posterior fontanel typically closes by 3 months of age, while the anterior fontanel closes around 8-18 months of age. Caregivers need reassurance that many of these characteristics will change during these time periods and the newborn will then begin to take on the appearance of a "normal" baby.
Shape and Symmetry
With the child sitting upright either in the caregiver's arms or on the examination table, observe the symmetry of the frontal, parietal, and occipital prominences. Normally, the shape of a child's head is symmetrical without depressions or protrusions. The anterior fontanel may pulsate with every heart beat. The infant of Asian descent generally has a flattened occiput, more so than infants of other races. A flattened occipital bone with resultant hair loss over the same area is abnormal and is usually caused by the infant being in the supine position for prolonged periods of time.
Head control is assessed when the infant is in a sitting position. With the head unsupported, observe the infant's ability to hold the head erect. At 4 months of age, most infants are able to hold the head erect and in midline. To evaluate for head lag, pull the infant by the hands from a supine to a sitting position. Again by 4 months of age, the head should stay in line with the body when being pulled forward. Documented prematurity, hydrocephalus, and illnesses causing developmental delays are possible causes of head lag. Significant head lag after 6 months of age may indicate brain injury and should be further investigated.
Newborn head lag
Place the child in an upright position. Using the second or third finger pad, palpate the anterior fontanel at the junction of the sagittal, coronal, and frontal sutures. Palpate the posterior fontanel at the junction of the sagittal and lambdoidal sutures. Assess for bulging, pulsations, and size. Crying will produce a distorted, full, bulging appearance. The anterior fontanel is soft and flat. Size ranges from 4 to 6 centimeters at birth. The fontanel gradually closes between 9 and 19 months of age. The posterior fontanel is also soft and flat. The size ranges from 0.5 to 1.5 centimeters at birth. The posterior fontanel gradually closes between 1 and 3 months of age. It is normal to feel pulsations related to the peripheral pulse.
If palpation reveals a bulging, tense fontanel, this is abnormal and indicates increased intracranial pressure. A sunken, depressed fontanel occurs with dehydration, A wide anterior fontanel in a child older than 2V2 years is an abnormal finding. An anterior fontanel that remains open after 2V2 years of age may indicate disease such as rickets. In rickets, there is a low level of vitamin D relative to decreased phosphate level. A posterior fontanel greater than 1.5 cm in diameter is abnormal and occurs with congenital hypothyroidism.
With the finger pads, palpate the sagittal suture line, which runs from the anterior to the posterior portion of the skull in a midline position. Palpate the coronal suture line, which runs along both sides of the head, starting at the anterior fontanel. Palpate the lambdoidal suture. The lambdoidal suture runs along both sides of the head, starting at the posterior fontanel. Ascertain if these suture lines are open, united, or overlapping. Grooves or ridges between sections of the skull are normally palpated up to 6 months of age. Suture lines that overlap or override one another, giving the head an unusual shape, warrant further investigation. Craniosynostosis is premature ossification of suture lines, whereby there is early formation and fusion of skull bones. Craniosynostosis may be caused by metabolic disorders or may be a secondary consequence of microcephaly. Figure 14-8 illustrates a superior and lateral view of an infant head.
With the finger pads, palpate the skull in the same manner as the fontanels and suture lines. Note surface edema and contour of the cranium. Normally, the skin covering the cranium is flush against the skull and without edema. A softening of the outer layer of the cranial bones behind and above the ears combined with a ping-pong ball sensation as the area is pressed in gently with the fingers is indicative of craniotabes, an abnormal finding. Craniotabes is associated with rickets, syphilis, hydrocephaly or hypervitaminosis.
Infant Head Structures.
Another abnormal finding in a newborn is a cephalhematoma, or a localized, subcutaneous swelling over one of the cranial bones. Refer to Chapter 7 for additional information about a cephalhematoma.
Another variation in the newborn that causes the shape of the skull to look markedly asymmetric is known as caput succedaneum or swelling over the occipitoparietal region of the skull. A newborns head may also feel asymmetric due to molding of the cranial bones as a result of induced pressure during delivery.
From infancy through about 8—10 years, you should assess the eyes toward the end of the assessment, with the exception of testing vision, which should be done first. Remember that the child's attention span is short, and attentiveness decreases the longer you evaluate. Young children generally are not cooperative for eye, ear, and throat assessments. Place the young infant, preschooler, or school-aged or adolescent child on the examination table. The older infant or the toddler can be held by the caregiver.
Several screening tests are available to evaluate visual acuity in children including the adult Snellen, Snellen E, and Allen. The child's age and developmental level determine the measures used. The adult Snellen chart can be used on children as young as 6 years, provided they are able to read the alphabet. The Snellen E chart, which shows the letter "E" facing in different directions, is used for a child over 3 years of age or any child who cannot read the alphabet. Test eveiy 1-2 years through adolescence. If the child resists wearing a cover patch over the eye, make a game out of wearing the patch. For example, the young child could pretend to be a pirate exploring new territory. Use your imagination to think of a fantasy situation. The Allen test (a series of seven pictures on different cards) can be used with children as young as 3 years of age (American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Opthalmology, 1996).
Snellen E Chart
Ask the child to point an arm in the direction the E is pointing. Observe for squinting. Vision is 20/40 from 2 to approximately 6 years of age, when it approaches the normal 20/20 acuity. The test is abnormal if results are 20/40 or greater in a child 3 years of age or 20/30 or greater in a child 6 years or older, or if results are different in each eye.
Nearsightedness or myopia is the result of congenital cataracts, retinal trauma, or a tumor.
With the child's eyes both open, show each card to the child and elicit a name for each picture. Do not use any pictures with which the child is not familiar. Place the 2-3-year-old child 15 feet from where you will be standing. Place the 3-4-year-old child 20 feet from you. Ask the caregiver to help cover one of the child's eyes. Show the pictures one at a time, eliciting a response after each showing. Show the same pictures in different sequence for the other eye. To record findings, the denominator is always constant at 30, because a child with normal vision should see the picture on the card (target) at 30 feet. To document the numerator, determine the greatest distance at which three of the pictures are recognized by each eye, for example, right eye = 15/30, left eye = 20/30. The child should correctly identify three of the cards in three trials. Two- to three-year-old children should have 15/30 vision. Three- to four-year-old children should be able to achieve a score of 15/30 to 20/30. Each eye should have the same score. If the scores for the child's right and left eyes differ by 5 feet or more or either or both eyes score less than 15/30, refer the child to an ophthalmologist.
The Hirschberg test (corneal light reflex) and the cover-uncover test screen for strabismus. The latter is the more definitive test.
Hold a pen light by the side of your head with one hand so the light is facing straight ahead. The pen light should be approximately 12 inches from the child's head. Using your other hand turn the child's head so the light is in the midline position toward the child's eyes. Make a general observation of the light reflection relative to both cornea noting symmetry and central location. The reflected light should be seen symmetrically in the center of both corneas.
Esotropia, thought to be congenital, occurs when the light reflection is displaced to the outer margin of the cornea as the eye deviates inward. Some theories suggest that neurological factors contribute to its development. Exotropia occurs when the light reflection is displaced to the inner margin of the cornea as the eye deviates outward. This abnormality can result from eye muscle fatigue or can be congenital. More information on eye abnormalities can be found in Chapter 31.
This test is performed on infants greater than 6 months of age through school-age. Stand 2 feet in front of the child. Place the child in a seated position on the examining table or caregiver's lap. Ask the child to focus attention on the pen light by the side of your head. Place a cover card or your hand over one eye. Wait until the uncovered eye focuses then remove the occluder and evaluate the eye just uncovered for focusing movement.
The normal finding is neither eye moves when the occluder is being removed. Infants younger than 6 months of age display strabismus due to poor neuromuscular control of eye muscles. It is abnormal for one or both eyes to move to focus on the penlight during assessment. Assume strabismus is present. Strabismus after 6 months of age is abnormal and indicates eye muscle weakness.
Sit at the child's eye level. Observe for symmetrical palpebral fissures (opening between the margins of the upper and lower eyelids) and position of eyelids in relation to the iris. Normally, the palpebral fissures of both eyes are positioned symmetrically. The upper eyelid covers a small portion of the iris, and the lower lid meets the iris. Epicanthal folds are normally present in children of Asian descent. An epicanthal fold is an excess skinfold over the angle of the inner canthus of the eye. It is abnormal for a portion of the sclera to be seen above the iris as it is in children with hydro-cephalus. As the forehead becomes prominent, the eyebrows and eyelids are drawn up, creating a setting sun appearance of the child's eyes. Children with Down syndrome have a fold of skin covering the inner canthus and lacrimal caruncle. During embryonic development, the fold of skin slants in a downward direction toward the nose.
If lacrimal duct obstruction is suspected, use the index finger to lightly palpate the lacrimal sacarea while bracing the child's head with the other hand. Note drainage from the lacrimal duct orifice. The child's caregiver reports that the child is unable to produce tears, an abnormal finding. The lacrimal ducts should be open by 3 months of age. Dacryocystitis is an infection of the lacrimal sac caused by obstruction of the lacrimal duct. It is characterized by tearing and discharge from the eye.
Anterior Segment Structures
The sclera is observed mainly to determine its color. Normally, the newborn exhibits a bluish -tinged sclera related to thinness of the fibrous tissue. The sclera is white in light-skinned children and a slightly darker color in some dark-skinned children. A yellowish color to the sclera indicates jaundice, which is due to hemolysis of red blood cells, non-functioning liver cells, or obstruction of bile in the common or hepatic duct.
Using the light source on the opthalmoscope, observe the iris for lesions and color. Up to about 6 months of age, the color of the iris is blue or slate gray in light-skinned infants and brownish in dark-skinned infants. By 12 months of age, complete transition of iris color has occurred. Small white Hecks, called Brushfield's spots, noted around the perimeter of the iris are abnormal. Brushfields spots are found on the iris of the child with Down syndrome. The spots develop during embryonic maturation.
The pupils should be inspected for size, shape, equality, and response to light. Pupils should be equal in size; however, a small number of individuals (5%) normally have pupils of different sizes (Jarvis, 1996). To test for pupillary light reflex, dim the room lights. Position the child according to age. Move the lighted instrument in from the side and observe the change in the size of the pupils. The pupils should react equally and accommodate to light. An abnormality is suspected if one or both pupils are nonreactive. Any central nervous system insult (e.g., head injury, meningitis, seizures) may cause an abnormal response.
Turn the opthalmoscope to 0 diopters. Stand 10-12 inches from the client and observe the pupil through the opthalmo-scope's window. Note the color of the reflex within the eye. In children, the red reflex appears as a brilliant, uniform red glow. In newborns and infants, the red reflex will appear lighter. In many darker-skinned individuals, the reflex will appear darker. Black spots or opacities within the red reflex are abnormal and may indicate a cataract. Chromosomal disorders, intrauterine infections, and ocular trauma are possible causes of cataracts in newborns. A yellowish or white light reflex (cat's eye reflex) is also abnormal and may indicate retinoblastoma, a malignant glioma located in the posterior chamber of the eye.
Assess the retinal background for color. Divide the retina into four quadrants and follow the retinal arteries and veins from the disc to periphery. Note the size and distribution of retinal arteries and veins. The retinas background is generally pink but may be lighter in some Caucasians and darker in African American individuals. There is no difference in normal vasculature among children and adults. A red to dark-red color is abnormal. Some areas may be rounded or flame shaped. Hemorrhage is seen in trauma. Bleeding into the optic nerve sheath is found in children who have been physically shaken.
At a 15° lateral position to the eye, move in closer to the eye approximately 1 inch from the child. Move the diopter to -5 to 0. Locate a vessel and move medially (nasal side) to locate the disc. Observe the color of the disc along with margin definition. The disc is creamy yellow to salmon in color. The disc is lighter in an infant. It measures about 1.5 mm in diameter and is round in shape. The margins of the disc are regular and clearly defined. If abnormal, the margins are blurred. In papilledema, the optic disc margins are abnormal. The margins are poorly defined (blurred) related to increased intracranial pressure.
Perform auditory testing at about 3^ years of age or when the child can follow directions. Prior to 3 years of age, the following are a few parameters for evaluating hearing:
1. Does the child react to a loud noise?
2. Does the child react to the caregiver's voice by cooing,
smiling, or turning eyes and head toward the voice?
3. Does the child try to imitate sounds?
4. Can the child imitate words and sounds?
5. Can the child follow directions?
6. Does the child respond to sounds not directed at him
Inspection of Pinna Position
Position the child on the caregiver's lap or examining table. Draw an imaginary line from the outer canthus to the top of the ear. The top of the ear should be at or a little above the imaginary line. An abnormal finding occurs when the top of the ear is below the imaginary line drawn from the outer canthus to the top of the ear. Kidneys and ears are formed at the same time in embryonic development. If a child's ears are low set, renal anomalies must be ruled out. Low-set ears can also occur in Down syndrome.
Internal Ear Inspection
A cooperative child may be allowed to sit for the assessment. A young child may be held as shown in Figure 14-9A. Restrain the uncooperative young child by placing him or her supine on a firm surface. Instruct the caregiver or assistant to hold the child's arms up near the head, embracing the elbow joints on both sides of either arm. Restrain the infant by having the caregiver hold the infant's hands down.
With your thumb and forefinger grasping the otoscope, use the lateral side of the hand to prevent the head from jerking. Your other hand can also be used to stabilize the child's head. Pull the lower auricle down and out to straighten the canal. This technique is used in children up to about 3 years of age. Use the adult technique after age 3. Insert the speculum about V4 to Vg inch, depending on the child's age. Suspected otitis media must be evaluated with a pneumatic bulb attached to the side of the otoscope's light source. Select a larger speculum to make a tight seal and prevent air from escaping from the canal. If a light reflex is present, focus on the light reflection. Gently squeeze the bulb attachment to introduce air into the canal. Some nurses prefer to gently blow air through the tubing rather than squeezing air into the canal. Observe the tympanic membrane for movement.
The tympanic membrane is transparent and pearly gray to light pink in color. The membrane is smooth and continuous. Light from the otoscope is reflected off the membrane. The tympanic membrane moves when air is introduced into the canal.
Observe the size and shape of the external nose, which should be symmetric and positioned in the center of the face. A short and small, large, or flattened nose may indicate congenital anomalies. Observe the external nose for flaring, discharge, or odor. Nasal flaring indicates respiratory distress. Purulent yellow or green discharge accompanies an infection. Clear, watery secretions may indicate allergic rhinitis, the common cold, or a foreign body. A foul odor may indicate a foreign body lodged in the nasal cavity. In an infant and young child, the nasal cavity can be visualized by tilting the head back and pushing the tip of the nose upward. The nasal mucosa should be firm and pink.
Patency of the nares must be determined at birth because newborns are obligatory nose breathers. With the infant's mouth closed, block one nostril and then the other. Observe the respiratory pattern. If total obstruction exists, the infant will not be able to inspire or expire through the uncompressed nostril. If obstruction is suspected, an assessment for choanal atresia should be performed. Information about the assessment can be found in Chapter 7. In choanal atresia, there is a unilateral or bilateral bony or membranous septum between the nose and the pharynx.
Mouth and Throat Inspection
Observe if the lip edges meet, which is normal. Cleft lip is seen as a separated area of lip tissue. It involves the upper lip and sometimes extends into the nostril. A cleft lip is an obvious finding during a newborn assessment. It occurs mainly on the left side and is more frequently found in males. A cleft lip develops during the fifth to sixth week after fertilization. Genetics plays a small role in etiology. Refer to Chapter 23 for a full discussion of cleft lip.
If the child is unable to open the mouth on command, use the edge of a tongue blade to lift the upper lip and move the lower lip down. The buccal membranes are pink, moist, and smooth. Thrush, a thick, curdlike coating on the buccal mucosa or tongue, is abnormal. It can be acquired when a newborn passes through the vagina during delivery.
Count the number of teeth present on the gum line. Observe the condition of teeth surface for caries or chips. Infants cut their first tooth between 5 and 8 months. By one year of age there are normally eight teeth. Between 5 and 6 years of age, a child will shed the lower central incisors. About 1 year after deciduous shedding, the first permanent teeth erupt. A lack of visible teeth coupled with roentgeno-graphic findings revealing absence of tooth buds is abnormal. Absence of deciduous teeth beyond 16 months of age signifies an abnormality most commonly related to genetic causes. It is abnormal for the teeth to turn brownish black, possibly with indentations along the surfaces of the teeth. These brownish black spots may be caries (cavities), which can be caused when a child falls asleep with a bottle in the mouth (Jones, Berg, & Coody, 1994).
Observe the palate for continuity and shape. For infants, you will need to use a tongue depressor to push the tongue down. Infants usually cry in response to this action, which allows visualization of the palates. The roof of the mouth is continuous and has a slight arch. It is abnormal if the roof of the mouth is not continuous. This anomaly is called cleft palate. Cleft palates vary greatly in size and extent of malformation. The degree of malformation is classified into two groups. A midline malformation may involve the uvula or extend through the soft or hard palates or both. If associated with cleft lip, the malformation may extend through the palates and into the nasal cavity. Cleft palates form between the sixth and tenth week of embryonic development, during fusion of the maxillary and premaxillary processes. Genetics plays a small role in etiology.
Epstein's pearls in the newborn appear on the hard palate and gum margins and are abnormal. The pearls are small, white cysts that feel hard when palpated. These cysts result from fragments of epithelial tissue trapped during palate formation.
Observe the position and color of the uvula. Observe the color and size of tonsillar tissue in the oropharynx. The tonsils are part of the lymphatic system and normally are hypertrophied in early childhood. Beginning at age 10 years, they gradually shrink in size. Tonsillar size ranges from +1 to +4 (Figure 14-10). Up to the age of 10 years, a tonsil grade of 2+ is considered normal. Tonsils should not interfere with the act of breathing. Excessive salivation is an early sign of a tracheoe-sophageal fistula (TEF). Drooling is accompanied by choking and coughing during the child's feeding. The esophagus failed to develop as a continuous passage during embryonic formation. Refer to Chapter 23 for additional information on TEF.
Observe the neck in a midline position while the child is sitting upright. Note shortening or thickness of the neck on both right and left sides. Note any swelling. Normally, there is a reasonable amount of skin tissue on the sides of the neck and no swelling. Unilateral or bilateral swelling of the neck below the angle of the jaw is abnormal. Enlargement of the parotid gland occurs in parotitis or mumps, an inflammation of the parotid gland. There is pain and tenderness in the affected area.
Use the first two finger pads to palpate the thyroid gland and its lobes. Have the younger child who is unable to swallow on command take a drink from a bottle. Upon palpation, note any tenderness, enlargement, or masses. An enlarged thyroid gland can be indicative of hyperthyroidism.
1. Stanhope, M., & Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St. Louis: Mosby.
2. Stanhope, M., & Lancaster, J. (2006). Foundations of Nursing in the Community: Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier.
Recommended Optional Materials/References
3. Hitchcock, J.E., Schubert, P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action / Delmar.
4. American Psychological Association. (1994) Publication Manual of the American Psychological Association (4th ed.). Washington, DC: Author.
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