Nutrition

Nutrition is an essential component for healthy growth and development. Human milk is the preferred form of nutrition for all infants. Breastfeeding provides the infant with micronutrients, immunologic properties, and several enzymes that enhance digestion and absorption of these nutrients. A recent resurgence in breastfeeding has occurred because of the education of mothers and fathers regarding its benefits and increased social support.

Children establish lifelong eating habits during the first 3 years of life, and the nurse is instrumental in educating parents about the process of feeding and the importance of nutrition. Most eating preferences and attitudes related to food are established by family influences and culture. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses like diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease.

Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake. The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems.

Dental Care

Dental caries is the single most common chronic disease of childhood (Cheng, Han, and Gansky, 2008; Heuer, 2007). Nearly one in five children between the ages of 2 and 4 years has visible cavities (Kagihara, Niederhauser, and Stark, 2009). The most common form of early dental disease is early childhood caries, which may begin before the first birthday and progress to pain and infection within the first 2 years of life (Kagihara, Niederhauser, and Stark, 2009). Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children. Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care.

Immunizations

The two public health interventions that have had the greatest impact on world health are clean drinking water and childhood vaccination programs. Immunization rates differ depending on children’s race and ethnicity, family income, the state in which they live, types of vaccinations, and their age (whether adolescent or younger children). The nurse should review individual immunization records at every clinic visit, avoid missing opportunities to vaccinate, and encourage parents to keep immunizations current. Nurses are responsible for keeping up with changes in immunization schedules, recommendations, and research related to childhood vaccines.

Obesity and Type 2 Diabetes

Childhood obesity is the most common nutritional problem among American children, is increasing in epidemic proportions, and is associated with type 2 diabetes (Cali and Caprio, 2008; de Onis, Blössner, and Borghi, 2010; Matyka, 2008; Raj and Kumar, 2010). Obesity in children and adolescents is defined as a body mass index (BMI) at or greater than the 95th percentile for youth of the same age and gender (Schwartz and Chadha, 2008). The National Health and Nutrition Examination Survey reported that the prevalence of overweight children doubled and the prevalence of overweight adolescents tripled between 1980 and 2000 (American Dietetic Association, 2008).

Advancements in entertainment and technology such as television, computers, and video games have contributed to the growing childhood obesity problem in the United States. In the National Longitudinal Study of Adolescent Health, screen time (TV, video, computer use) interacts with genetic factors to influence BMI changes (Graff, North, Monda, et al., 2011). Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low-income, minority children. Overweight youth have increased risk for developing hypercholesterolemia, insulin resistance, diabetes, hypertension, and heart disease (Matyka, 2008; Schwartz and Chadha, 2008) (Fig. 26-1). The U.S. Department of Health and Human Services suggests that nurses focus on prevention strategies to reduce the incidence of overweight children from the current 20% in all ethnic groups to less than 6%.

Childhood Injuries

Injuries are the most common cause of death and disability to children in the United States (Schnitzer, 2006) (Table 26-1). Motor vehicle accidents (MVAs) continue to be the most common cause of death in children older than 1 year. Other unintentional injuries (choking, drowning, fires, and firearm accidents) take the lives of children every day. Many childhood injuries and fatalities could be prevented by implementing programs of accident prevention and health promotion.

The type of injury and the circumstances surrounding it are closely related to normal growth and development (Box 26-2). As children develop, their innate curiosity compels them to investigate the environment and to mimic the behavior of others. This is essential to acquire competency as an adult but can also predispose children to numerous hazards.

The child’s developmental stage partially determines the types of injuries that are most likely to occur at a specific age and helps provide clues to preventive measures. For example, small infants are helpless in any environment. When they begin to roll over or propel themselves, they can fall from unprotected surfaces. The crawling infant, who has a natural tendency to place objects in the mouth, is at risk for aspiration or poisoning. The mobile toddler, with the instinct to explore and investigate and the ability to run and climb, may experience falls, burns, and collisions with objects. As children grow older, their absorption with play makes them oblivious to environmental hazards such as street traffic or water. The need to conform and gain acceptance compels older children and adolescents to accept challenges and dares. Although the rate of injuries is high in children younger than 9 years, most fatal injuries occur in later childhood and adolescence.

The pattern of deaths caused by unintentional injuries, especially from MVAs, drowning, and fires, is remarkably consistent in most Western societies. The leading causes of death from injuries for each age-group according to gender are presented in Table 26-1. The majority of deaths from injuries occur in boys. It is important to note that accidents continue to account for more than 3 times as many teen deaths as any other cause (Annie E. Casey Foundation, 2009). Fortunately, prevention strategies such as the use of car restraints, bicycle helmets, and smoke detectors have significantly decreased fatalities for children. Nevertheless, the overwhelming causes of death in children are MVAs, including occupant, pedestrian, bicycle, and motorcycle deaths; these account for more than half of all injury deaths (Centers for Disease Control and Prevention [CDC], 2006). Children older than 1 year of age have the highest rate of death from MVAs, primarily from a failure to properly use car restraints (Fig. 26-2).

Pedestrian accidents involving children account for significant numbers of motor vehicle–related deaths. Most of these accidents occur at midblock, at intersections, in driveways, and in parking lots. Driveway injuries typically involve small children and large vehicles backing up.

Bicycle-associated injuries also cause a number childhood deaths. Children ages 5 to 9 years are at greatest risk for bicycling fatalities. The majority of bicycling deaths are from head injuries. Helmets greatly reduce the risk for head injury, but few children wear helmets (Castle, Burke, Arbogast, et al., 2010). Community-wide bicycle helmet campaigns and mandatory-use laws have resulted in significant increases in helmet use. Still, issues such as stylishness, comfort, and social acceptability remain important factors in noncompliance. Nurses can educate children and families about pedestrian and bicycle safety. In particular, school nurses can promote helmet wearing and encourage peer leaders to act as role models.

Drowning and burns are among the top three leading causes of deaths for males and females throughout childhood (Fig. 26-3). In addition, improper use of firearms is a major cause of death among males (Fig. 26-4). During infancy, more boys die from aspiration or suffocation than do girls (Fig. 26-5). Approximately 70% of all unintentional poisonings are reported in children younger than 2 years (Bronstein, Spyker, Cantilena, et al., 2008; Franklin and Rodgers, 2008) (Fig. 26-6). By ages 4 to 5 years, unintentional poisonings are uncommon. Intentional poisoning, associated with drug and alcohol abuse and suicide attempt, is the second leading cause of death in adolescent females and third leading cause in adolescent males.

Violence

Youth violence is a high-visibility, high-priority concern in every sector of U.S. society. (U.S. Department of Health and Human Services, 2011). Strikingly higher homicide rates are found among minority populations, especially African-American children. The causes of violence against children and self-inflicted violence are not fully understood. Violence seems to permeate American households through television programs, commercials, video games, and movies, all of which tend to desensitize the child toward violence. Violence also permeates the schools with the availability of guns, illicit drugs, and gangs. The problem of child homicide is extremely complex and involves numerous social, economic, and other influences. Prevention lies in better understanding of the social and psychologic factors that lead to the high rates of homicide and suicide. Nurses need to be especially aware of young people who harm animals or start fires, are depressed, are repeatedly in trouble with the criminal justice system, or are associated with groups known to be violent. Prevention requires early identification and rapid therapeutic intervention by qualified professionals.

Pediatric nurses can assess children and adolescents for risk factors related to violence. Families who own firearms must be educated about their safe use and storage. The presence of a gun in a household increases the risk for suicide by about fivefold and the risk for homicide by about threefold. Technologic changes such as childproof safety devices and loading indicators could improve the safety of firearms (see Community Focus box).