Infants grow very quickly in the first year of life, adding 20–30 cm to their height and doubling their birth rate by the age of 5 months (Table 2.2A). There is a rapid increase in size by the age of 2 years. From 2 onwards the child usually gains about 5–7.5 cm in height each year and approximately 3 kg in weight per year. Weight has a similar growth curve to height (Table 2.2B). When the child reaches adolescence, usually from 10 years onwards, there is a rapid growth in height, called a ‘growth spurt’. The hands and feet grow to full adult size earliest, followed by the arms and legs, and the trunk. Children will grow at different rates depending on genetics, nutrition, environment and illness conditions. So these are broad parameters which are a guide to assessment of growth and development.

Table 2.2 Height and weight gain by age

A Height gain by age
Age	Height
Birth–6 months	2.5 cm per month
6–12 months	1–5 cm per month
12 months–4.5 years	7.5 cm per year

B Weight gain by age
Age	Weight
Birth–6 months	140–200 g per week (doubles by end of 5 months)
6–12 months	85–140 g per week (triples by end of 1 year)
12–4.5 years	2–3 kg per year (quadruples by end of 2.5 years)

Measuring growth

To measure an infant’s length, the infant is placed supine on a measuring board with the head firmly at the top of the board and heels at the foot of the board.

To measure a child who can stand, use a wall-mounted stadiometer. Remove footwear and ask child to stand tall, with head in the mid-line and child looking straight ahead (parallel to the floor).

To weigh an infant, undress the infant, ensure the room is warm, and the weighing machine is calibrated and then record the weight.

To weigh a child, remove only shoes and stand child on weighing machine.

Language development (ability to speak and use words)

Infant – cooing, babbling, laughing, gurgling

1 year – can say few words, imitates sounds, recognizes some words

2 years – can use 2–3 words in phrases and knows about 200–300 short words, e.g. ‘want my teddy’

3 years – can use 4–5 words in sentences and has a vocabulary of 800–900 words

4–5 years – can use complete sentences clearly and has a vocabulary of 1500–2500 words

5–6 years – has a vocabulary of about 3000 plus words.

Deviations from normal

Pre-schoolers (< 5 years)

Communication delay or disorders may be present with preschoolers who:

Have atypical comprehension of commands or requests

May have few words or exhibit unintelligible speech

May omit many speech sounds or produce unusual combinations of speech sounds

Have limited vocabulary

May grunt or point to items rather than attempt to produce words

May show disinterest in toys or games suitable for their age group

May be withdrawn or prefer to play alone if speech disordered

May display aggression (e.g. tantrums, biting, kicking) because of frustration with communicating needs

Children who display these behaviours need appropriate referrals (e.g. speech and language therapist for necessary investigations, therapy, early intervention programme, early childhood education programme).

Language delay may be due to undiagnosed hearing loss or an infection such as otitis media (infection of middle ear) with effusion.

Language delay may be due to adverse social circumstances (e.g. neglect, parental depression or substance abuse) rather than a cognitive disorder.

Late talkers

Late talkers may display similar behaviour outlined above but the distinction is they generally:

Have better comprehension of spoken language and tend to understand age-appropriate commands

Develop normal language skills during early school years

Have normal hearing

Have age-appropriate non-verbal problem-solving skills e.g. can assemble age-appropriate puzzles and games.

Cognitive development (the ability to reason, think, perceptions, attention, memory)

Children who have cognitive delays or disorders usually display delays in problem-solving skills, memory skills, and general learning skills:

Problem-solving may be seen in delayed development of basic concepts such as object permanence

Memory can be demonstrated by inability to remember an event or words that were previously known

General learning skills can be seen in reduced ability to acquire new skills, learn simple tasks or to apply skills to new events

May play and interact with younger children

May have poor social skills and poor ability to assess social situations (e.g. autism)

May have age-appropriate language skills but display cognitive deficits (e.g. high functioning autism)

May display impulsivity, hyperactivity, and inattention (e.g. attention deficit hyperactivity disorder, ADHD).

Nutritional assessment

Nutrition relates to the physical and mental development of a child, their health and individual well-being. The energy supply of the body is obtained from nutrients to carry out vital functions to sustain life, to form new body components for growth and repair and to assist in the functioning of various body process, such as breathing and physical activity. The energy supply must be constantly replenished.

It is important to ensure that children have food while in hospital, whether it be solid oral food, enteral or parental feeding. Food contains nutrients digested by enzymes, which are regulated and controlled by hormones. There are six principal classes of nutrients:

It is important to remember that nutrients are often separated for study purposes, but are always interacting as a dynamic whole to produce and maintain the human body, providing energy, building and rebuilding tissue, and regulating metabolic processes. The essential function of minerals and vitamins is their regulation of physiological processes. The energy-yielding nutrients are carbohydrates, fats and proteins, which provide primary and alternative sources of energy. Water is the overall vital nutrient sustaining all life processes.

Guidance on the adequacy of nutrition is required and standards have been devised against which measured intakes can be compared. These standards are known as Recommended Daily Amounts (RDA).

The assessment of a child’s nutritional state is given high priority and most children’s nurses will already be familiar with the use of assessment tools and protocols in their daily management of a child.

Nutritional assessment in a children’s ward may vary from basic to complex nutritional requirements. Information collated to assist with the overall nutritional assessment should include:

child’s history

psychological and social status

physical examination

diet history

current dietary intake

anthropometric measurements

biochemical and laboratory data.

The above factors will all play an important role in assessing a child’s level of nutrition and hydration.

History, psychological and social status

A concise history provides the first clues about existing or potential undernutrition. Ascertain if the child has:

Been ill at home or on the ward for a long period of time prior to admission to hospital

Has recently suffered a bad experience (death of close family member, friend)

Is the family on income support, one parent family

The type of accommodation the child lives in

Observe the child:

Do they look thin or pale

The appearance of their skin in terms of colour and condition

Check nails: are they brittle

Look in the mouth: are the gums swollen, teeth discoloured

Are their clothes loose

Are their eyes sunken

Check their tongue for hydration, colour and condition.

These will all send warning signals to the trained eye that a problem with nutrition may exist, and may also give information about any recent loss of weight.

Physical examination

A physical examination involves observing the child’s general appearance and should include the following assessment:

Check the oral cavity – is there a sore mouth or lips?

Check for the presence of difficulty in chewing and swallowing or any physical difficulties with feeding.

Is there any nausea, vomiting, diarrhoea; this results in reduced absorption and appetite.

Any constipation will affect nutritional intake and can lead to a feeling of fullness, discomfort, depression and confusion, thereby reducing food intake.

Simple respiratory function tests can be recorded, such as vital capacity, maximum inspiration and maximum expiration, to determine respiratory muscle strength.

Diet history

A diet history should be obtained by asking the child and his/her parent or carer about their eating habits and consists of questions about:

Likes and dislikes, e.g. fruit and vegetables, meat

Religion – are there any long periods of fasting in the family – are they vegetarian?

Changes in weight; loss of subcutaneous fat, apathy or lack of energy

Type, quantity and texture of food eaten since the onset of illness, as disease often alters appetite

Have there been any changes in taste and the ability to obtain food?

Ask to recall food intake over the previous few days

If an infant consider if:

– they were breast or formula fed

– they are being weaned, e.g. solids, types, variety, feeding him/herself

– the milk the child is drinking now, e.g. semiskimmed (not recommended) or whole milk

– they have any allergies

– the infant’s bowel patterns, frequency and consistency

– are they in childcare during the day.

If an older child consider:

– if they eat breakfast, lunch and dinner

– their favourite foods, drinks, snacks, school lunch

– where they eat their meals, e.g. in front of the television

– if they clean their teeth after meals

– if they take any exercise.

Consider issues related to the parents/carers:

– Does the family eat meals together at the table?

– Preparation of food, eating in restaurants/takeaways.

– Is the child a fussy eater – loss or gain of weight recently?

All these factors should be noted and recorded in the child’s assessment and care plan. A food diary may be necessary to record total intake over a number of days / weeks.

Anthropometric measurements

One of the most important anthropometric measurements in determining nutritional status is weight, and changes in body weight do give an indication of the severity of malnutrition. All children that have been admitted to hospital or attended a healthcare clinic should have their weight measured and plotted on an appropriate centile chart. Accurate measurement of babies’, infants’, and children’s weight is vital for calculations of medications and fluids. Different skills are required for weighing a baby and an older child:

A baby or infant should be weighed naked (any additions e.g. splint/medical equipment should be noted in the notes)

Do not leave a baby/infant unattended in the scales

Always record exact weight, do not round the figures up or down.

Dress the baby/infant quickly

Height can also be used to determine if a child is growing at an optimal rate. Any reduction in growth rate may indicate a pathological disorder requiring possible diagnosis and intervention. The differences between measuring a baby’s/infant’s length and a child height is detailed in Table 2.3.

Table 2.3 Measuring a baby’s/infant’s length and a child’s height

Baby’s / infant’s length	Child’s height
The baby/infant should be lying down perfectly flat on a solid even surface	A child may require some input from a play specialist or nurse prior to the procedure
With assistance of another nurse/parent/carer position the baby on the measuring mat	Remove shoes and in some instances socks as well, hair clips
Baby/infant’s head should be touching the top of the mat	Position the child with their feet together, flat on the floor, legs straight, back against the wall, arms by their side, their head should be facing forward
The body should be in alignment	Put pressure on the child’s mastoids and take the reading of the height after full expiration
Record the baby/infant’s length	Record the reading viewed at eye level

Head circumference is used to monitor the growth of a child, especially those under 2 years, but continues to be useful after this age as it may detect abnormalities such as hydrocephalus, craniosynostosis or microcephaly. Any baby, infant or child with suspected neurological or craniofacial abnormality will need their head circumference measured more frequently, as this may indicate a raised intracranial pressure.

Biochemical measurements

Biochemical measurements can also be used, the most common in use are:

Serum albumin: with a level of less than 35 g/l being indicative of protein-energy malnutrition, it can be inaccurate as conditions such as stress, nephrosis and burns also exhibit hypoalbuminia. This makes the measurement often misleading and not altogether reflective of nutritional deficiency in the short term. In the chronic situation, serum albumin remains a simple and reliable indicator of malnutrition.

Serum transferrin: levels could be considered a better marker of acute nutritional depletion. Interpretation of serum levels is complicated by factors such as iron deficiency, which directly affects transferrin production and so may not be wholly appropriate as a predictor of malnutrition.

Serum haemoglobin: measurements will highlight the presence of anaemia, which has been correlated with pressure sore development. Anaemia can occur for a variety of reasons, but may be directly related to dietary inadequacy and questioning of dietary intake should always follow this up.

Promising results have been demonstrated when nutritional assessment has resulted in initiation of pre-operative feeding regimes. This method of identifying the high-risk patients results in an optimization of their nutritional status and may help to ensure an uneventful recovery. The patient in critical care not only has an increased demand for energy, but also, due to periods of reduction or cessation of nutritional intake, has a reduced supply of energy-containing nutrients. As a result, under-nutrition, or in severe cases, malnutrition may occur.

Malnutrition

The maintenance of health depends upon the consumption and absorption of appropriate amounts of energy and all the necessary nutrients. A shortfall of one or other over a period of days or weeks may lead to malnutrition.

Malnutrition itself is defined as a state that occurs when there is an imbalance between nutritional intake and nutritional requirement. When nutrition ceases during periods of fasting, there is a resulting loss of energy stores and malnutrition occurs.

Physiological effects of malnutrition

Carbohydrates are the first source of energy utilized by the body and are needed to maintain a normal blood glucose level. During starvation, carbohydrates are not available directly from the gut but the body uses carbohydrates stored as glycogen in the liver and skeletal muscles as a source of energy.

During the first day of fasting, low glucose levels stimulate glucagon secretion by the pancreas. As a result, glycogen is converted to glucose and released from the liver. This restores blood glucose levels to normal. Glycogen can be lost without any physiological consequences.

These mechanisms supply blood glucose but cannot sustain blood glucose for a long period of time.

Fat stores may be used for energy. This method requires a major body adjustment, as all other body tissues must reduce their oxidation of glucose and switch over to fat as their energy source.

As the liver metabolizes fat, ketone bodies are produced in large quantities. These are oxidized by the body into carbon dioxide, water and adenosine triphosphate (ATP).

If fasting continues, the brain has to gradually adapt to the use of ketone bodies as its major source of energy. When this occurs, depression of the central nervous system may ensue, leading to coma.

Since other body cells are also limited in the amount of ketone bodies they can metabolize, excess ketone bodies appear in the blood resulting in ketosis, which if not reversed by taking food can lead to a metabolic acidosis.

When fat reserves are completely depleted, the body will break down large quantities of muscle protein as a source of energy, to maintain cellular function. Large amounts of amino acids can be released and converted to glucose in the liver by gluconeogenesis or the amino acids may be oxidized directly. It is estimated that once protein stores are depleted to about one half of their normal level, death occurs. During fasting, amino acids contribute to blood glucose only after liver glycogen and fat stores are depleted.

Within the dietetic arena, promising results have been shown when a detailed nutritional assessment has taken place to ensure early feeding regimes. This method of early assessment results in an optimization of child’s nutritional status and can be seen as promoting a speedy and uneventful recovery. It is important to note that malnutrition reduces the body’s ability to:

Heal wounds, which increases risk of pressure sore development

Manufacture haemoglobin, which reduces the oxygen carrying capacity of the blood

Produce white blood cells, causing suppression of the immune response and reducing child’s defence mechanisms

Maintain adequate respiratory drive due to the reduction in pulmonary diaphragmatic muscle mass and strength, predisposing patient to respiratory failure.

Consequences of malnutrition in children

Higher incidence of pneumonia due to impairment in respiratory function.

Catabolism and weight loss are accelerated

There is impaired gut integrity.

Delayed wound healing; this can lead to reduced healing of surgical sites.

Have an increased susceptibility to wound or systemic infections.

There are decreased visceral proteins.

May reduce the metabolism of drugs.

Information should be based on nurses’ observations of the child

Pressure area risk assessment

Pressure ulcers are potentially an avoidable complication of bed rest and decreased mobility. Children who are at more risk of developing of pressure ulcers include:

those who are in a poor state of health and have numerous medical, surgical problems

the malnourished

babies, infants, children who have some degree of immobility, e.g. those nursed in intensive care, neonates, those undergoing prolonged surgery, spinal injury.

A baby is more likely to develop a pressure ulcer on the head or ear; children are at risk on the sacrum, heels, and elbows.

The pathogenesis of pressure ulcers is complex, since it is affected by so many predisposing factors. However, there are three major factors identified as significant:

1. Pressure greater than 25 mmHg will occlude capillaries. The tissues are thus deprived of blood, and if the pressure is maintained for a sufficient length of time, the tissues die.

2. Friction is a combination of pressure and friction caused by dragging children up the bed, which seriously damages the micro-circulation.

3. Pressure and strain to structures so great that they tear the muscle and skin fibres from their bony attachments cause shearing forces.

A child suffering from a combination of predisposing factors is more susceptible to developing pressure ulcers. Predisposing factors can be subdivided into two main groups:

1. Intrinsic factors – aspects of the patients’ condition, mental, physical, and medical states, e.g. malnutrition, age, altered consciousness, immobility.

2. Extrinsic factors – external effects of drugs, treatment regimes, manual handling techniques, personal hygiene, and weight distribution.

Those children at greatest risk from developing pressure sores may be identified using a pressure risk assessment. There are two examples of paediatric tools:

1. The Braden Q tool – used for children between the ages of 21 days to 8 years, contains the same six criteria for use with adults, which have been modified to make them developmentally appropriate for children. There is the addition of tissue oxygenation and perfusion:

– Intensity and duration of pressure

• mobility

• activity

• sensory.

– Tolerance of the skin and supporting structures

• moisture

• friction and shear

• nutrition

• tissue perfusion and oxygenation.

2. The Glamorgan Scale – developed especially for children and takes into consideration:

– Mobility

• cannot move without difficulty

• unable to change position without assistance / cannot control body movement

• some mobility, reduced for age

• normal mobility.

– Equipment/objects/head pressing or rubbing

– Significant anaemia

– Persistent pyrexia

– Poor peripheral perfusion

– Inadequate nutrition

– Low serum albumin

– Weight less than 10th centile

• 20 + very high risk.

It is important to note that both scales are over-cautious and potentially over-predict pressure sore risk, a criticism made of many risk assessment scores. Yet, it is better to over-predict than under-predict risk, as the cost of treating pressure sores is high, while the cost of preventing them is considerably less.

It is important to realize that a risk assessment score is not a definitive answer to the question of whether an individual will develop a pressure sore. The calculator is an aid to professional and clinical judgement in determining what resources are needed.

If used effectively, these tools can be used to justify a request for resources, such as specialized beds and/or efficient moving and handling equipment. Specialized kinetic beds can be used to facilitate in the turning process, relieve pressure and prevent pressure sore formation. These beds are very expensive and are not used routinely or to replace quality nursing care.

Wound assessment

Wound assessment is a complex task that requires concise information before deciding on a strategy for treatment. Using a measurement tool to assess wounds encourages consistent intervention irrespective of who assesses the wound at any time. A good wound assessment should include:

1. A body diagram to record the child’s wound sites and in the case of multiple wounds these should be numbered individually.

2. A separate assessment sheet should determine the site of each wound and/or the number identified from the initial body diagram.

3. Consider the major areas in relation to the condition of any wound (Table 2.4).

4. The maximum dimensions should be traced and recorded, giving the length, width and depth of the wound in centimetres, in order to have a standard method of measurement.

5. Consider the child’s age and weight and take into account current diagnosis and any medications.

Table 2.4 Major areas that should be included in a wound assessment

Record of wound site	Body diagram from different angles: Back Front Legs Front Back Medial Lateral
Condition of wound	Wound dimensions Nature of wound bed Exudate Odour Pain (site, frequency, severity) Wound margin Erythema of surrounding skin Condition of surrounding skin infection
Dimensions/drawing	Length Width Depth Outside tracking Health granulating tissue Sloughy areas
Documentation	All these points need to be taken into consideration when documenting nursing observations and wound treatments in relation to wound care