Pediatric Primary Care

HEALTH MAINTENANCE

Pediatric primary care includes health promotion and disease prevention interventions that will positively affect the well-being of children and their families. The goal of pediatric primary care is to achieve physical, emotional, and developmental health for all children. Primary prevention—through immunizations, proper nutrition, and safety counseling—are essential components of pediatric health care.

Immunizations

Disease prevention through immunizations has significantly reduced childhood morbidity and mortality from infectious diseases. However, despite effective immunization availability, vaccine-preventable diseases are still present in the United States and continue to pose significant public health problems. The rate of immunization in the United States exceeds 90% for children ages 19 to 35 months for poliovirus vaccine; measles, mumps, rubella; Hepatitis B, and varicella vaccine. However, rates vary by state and decrease after this age. Rate of immunization for routine vaccines for adolescents ages 13 to 17 range from 26.7% (human papillomavirus vaccine) to 55.6% (Tdap vaccine).

Nurses are in a vital position to promote child health by assessing, recommending, and administering immunizations. Also, nurses are frequently asked to provide documentation (to parents or caregivers) of the immunizations that have been administered in order to facilitate children’s enrollment in day care, school programs, and summer camp participation. A review of immunizations and administration of needed vaccines should be done at every health care visit.

Barriers to Vaccination

There are many reasons that parents or caregivers may give to refuse vaccination for their children.

Safety concerns, such as concerns that the child may develop learning disabilities. Information about vaccine safety can be obtained from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/vaccinesafety/Concerns/Index.html.
Concern for the pain inflicted on the child.
Because the vaccine programs have been successful for many years, many parents have no memory or knowledge of the serious vaccine-preventable illnesses that have been near eradicated.
Unfortunately many parents may be influenced by high-impact negative media information regarding vaccinations despite the fact that most is not supported by evidence.

General Considerations

Requirements of National Childhood Vaccine Injury Act (Effective 1988)

This act mandated providers to notify all patients and parents about the risks and benefits associated with vaccines.
The patient, parent, or legal guardian should be informed about the benefits and risks of immunizations. They must be provided with the current Vaccine Information Statement (VIS), developed by the CDC, before the administration of the vaccine. Health care providers must record the name of the VIS publication (eg, polio), date of VIS publication, and the date the VIS was given to the patient or his or her family on the child’s medical record.
Federal law mandates that all health care providers must record the following information in the patient’s permanent medical record: month, day, and year of administration; vaccine or other biologic administered; manufacturer, lot number, and expiration date; and name, address, and title of the health care provider administering the vaccine.
In addition, the site and route of administration should be documented in the patient’s record.
Health care providers are required to report selected events occurring after vaccination to the Vaccine Adverse Events Reporting System, part of the CDC Immunization Safety Office, which monitors and investigates possible vaccine adverse effects.

Routine Vaccinations for Children in the United States

The Advisory Committee on Immunization Practices (ACIP) annually develops written recommendations for the CDC regarding the routine administration of vaccines, along with schedules detailing the appropriate timing, dosage, and contraindications for children and adults in the civilian population in the United States. The most recent recommendations are reviewed below, but complete immunization schedules can be found at www.cdc.gov/vaccines.

Childhood-recommended vaccines (ages 0 to 6 years) include diphtheria, tetanus toxoid, acellular pertussis (DTaP); inactivated poliovirus vaccine (IPV); measles, mumps, rubella (MMR); Haemophilus influenzae type b (Hib) vaccine; hepatitis B vaccine (HBV); Varicella; pneumococcal conjugate vaccine (PCV7 and PCV13); rotavirus (Rota); hepatitis A (HepA); and meningococcal vaccine (MCV4). An influenza vaccine is recommended to be given annually for healthy children ages 6 months to 19 years old.

The recommended immunization schedule for persons ages 7 to 18 years includes tetanus toxoid, diphtheria, and acellular pertussis (Tdap); human papillomavirus vaccine (HPV); MCV4; pneumococcal polysaccharide vaccine (PPV)—to certain groups at high risk; annual influenza vaccine (live attenuated influenza vaccine [LAIV] or trivalent inactivated influenza vaccine [TIV]); HepA—for certain groups of children; HBV; MMR; Varicella; and IPV, if necessary, to equal a total of four doses.

Immunization Schedules

Routine immunizations are started in infancy. However, if a child is not immunized in infancy, immunizations may be started at any age and a slightly different schedule may be followed, depending on the child’s age and the prevalence of specific diseases at that time.
An interrupted primary series of immunizations does not need to be restarted; rather, the original series should be resumed regardless of the length of time that has elapsed.
The immunoresponse is limited in a significant proportion of infants and the recommended booster doses are designed to ensure and maintain immunity.
Current recommended immunization schedules can be found at www.cdc.gov/vaccines/.
When using a combination vaccine, if there is a contraindication to any of the components, do not vaccinate.

Contraindications and Precautions

It is important to read the manufacturer’s insert for each vaccine before administration.

Contraindications to all vaccines:
- Anaphylactic reaction to a vaccine or a vaccine constituent.
- Moderate or severe illnesses with or without a fever. Children with moderate or severe illnesses, with or without fever, can be vaccinated as soon as they are recovering and no longer acutely ill.
All live virus vaccines (live oral poliovirus vaccine [OPV], MMR, Varicella) are contraindicated in pregnancy, immunosuppression or immunodeficiency, and household or close contact with those who are immunosuppressed or immunodeficient.
- MMR vaccine should be considered for all symptomatic human immunodeficiency virus (HIV)-infected persons who do not have evidence of severe immunosuppression or evidence of measles immunity.
- Varicella vaccine should be considered for asymptomatic or mildly symptomatic HIV-infected children.
Diphtheria, tetanus, and pertussis (DTP)/DTaP—encephalopathy within 7 days of administration of previous dose of DTP/DTaP.
- Infants and children with stable neurologic conditions, including well-controlled seizures, may be vaccinated; however, such vaccination should be decided on an individual basis.
IPV—anaphylactic reaction to neomycin, streptomycin, or polymyxin B.
MMR and Varicella—anaphylactic reactions to neomycin or gelatin.
Influenza—anaphylactic reaction to eggs or egg protein. Persons with asthma, reactive airway disease, or other chronic pulmonary or cardiovascular disorders should not receive LAIV.
HBV—anaphylactic reaction to baker’s yeast.
Meningococcal vaccines—can be given to pregnant women; should not be administered with other vaccines for children with sickle cell disease or those without a functioning spleen.

Misconceptions Concerning Vaccine Contraindications

Some health care providers and parents inappropriately consider certain conditions or circumstances to be contraindications to vaccination. Conditions most commonly regarded as such include:
- Mild acute illness with low-grade fever or mild diarrheal illness in an otherwise well child.
- Current antimicrobial therapy or the convalescent phase of illness.
- Reaction to a previous DTaP dose that involved only soreness, redness, swelling in the immediate vicinity of the vaccination site, or temperature of less than 105° F (40.5° C).
- Prematurity.
- Person using aerosolized steroids, short course of oral steroids (less than 14 days), or topical steroids.
- Pregnancy of mother or other household contact.
- Recent exposure to an infectious disease.
- Breastfeeding.
- History of nonspecific allergies or relatives with allergies.
- Allergies to penicillin or other antibiotic, except anaphylactic reactions to neomycin or streptomycin.
- Allergies to duck meat or duck feathers.
- Family history of seizures in people considered for pertussis or measles vaccination.
- Family history of sudden infant death syndrome in children considered for DTaP vaccination.
- Family history of an adverse event, unrelated to immunosuppression, after vaccination.
- Malnutrition.
In most cases, children with the above conditions can still be immunized.

Vaccine Administration Considerations

Strict adherence to the manufacturer’s storage and handling recommendation is vital. Failure to observe these precautions and recommendations may reduce the potency and effectiveness of vaccines.
Health care personnel administering vaccines should be immunized against measles, mumps, rubella, hepatitis B, influenza, tetanus, pertussis, and diphtheria. Varicella vaccine is recommended for health care providers with no serologic proof of immunity, prior vaccination, or previous disease. Gloves should be worn when administering vaccines. Good handwashing technique is mandatory before and after vaccine administration.
Sterile, disposable needles and syringes should be discarded promptly in appropriate biohazard containers. Do not recap needles.
Parenteral vaccines should be administered in the anterolateral aspect of the upper thigh in infants and in the deltoid area of the upper arm in older children and adolescents. Recommended routes of administration are included in the package inserts of vaccines.
Before administering a subsequent dose of any vaccine, question patients and parents about adverse effects and possible reactions from previous doses.
Routine vaccines can be safely and effectively administered simultaneously in most healthy children.

Specific Immunizations

DTaP

Administered I.M.
A time lapse of 8 weeks is recommended between the first three DTaP injections for desirable maximum effects.
Administration of acetaminophen at the time of immunization and at 4 and 8 hours after immunization decreases the incidence of febrile and local reactions.
Tdap is recommended for children over age 7 years. In 2006, vaccination guidelines for pertussis included recommendations that Tdap be routinely used in adolescents 11 to 18 years of age and single doses for adults 19 to 64 years of age in attempts to control recent pertussis outbreaks.
For contaminated wounds, a booster dose of tetanus should be given if more than 5 years have elapsed since the last dose.
For infant pertussis protection, ACIP has recommended that Tdap be given during each pregnancy between 27 and 36 weeks gestation to maximize the maternal antibody response and passive antibody transfer to the infant.

Tuberculin Skin Test

It is recommended that, if indicated, the tuberculin test be given before or at the time of the MMR vaccine. The measles vaccine may temporarily suppress tuberculin reactivity for 4 to 6 weeks, so result many not be accurate during that time frame.
The frequency of repeated tuberculin testing depends on the following:
- Risk of tuberculosis exposure to the child.
- Prevalence of tuberculosis in the population group.
- Presence of underlying host factors in the child (immunosuppressive conditions or HIV infection).
Children who have immigrated or been adopted from another country may have received an immunization for tuberculosis (BCG vaccine). It is not recommended in the United States due to low effectiveness.
- BCG may cause a false-positive tuberculosis (TB) skin test; however, screening for tuberculosis should still occur.
- Interferon-gamma release assays (IGRAs) are the preferred method of testing for tuberculosis in those immunized with BCG. An IGRA measures how strong a person’s immune system reacts to TB bacteria by testing the person’s blood in a laboratory.
- Chest x-ray confirms pulmonary disease.

Measles Vaccine

Usually given between ages 12 and 15 months, but should be given at 12 months in high-risk areas. Second dose is recommended between ages 4 and 6 years.
Administered subcutaneously.
During an outbreak, infants as young as age 6 months can be immunized. A second dose should be given between ages 12 and 15 months and again at school entry.
Mild postimmunization symptoms include transient skin rashes and fever up to 2 weeks after vaccination.
Immunoglobulin preparations will interfere with the serologic response to measles vaccine; therefore, wait the specified time after administration for vaccination.

Meningococcal Vaccine

Usually given between the ages of 11 and 12 years, with a booster dose at age 16 years for healthy children. Is administered earlier (minimum age of 9 months) for some children with underlying conditions or children who are resident or travel to countries with epidemic disease.
Administer the MPSV4 vaccine subcutaneously into the fat of the arm. The MCV4 vaccines are given I.M.
Mild postimmunization symptoms such as local discomfort may occur. A small percentage of those who receive the vaccine may develop a fever. Severe reactions (such as an allergic reaction) are very rare.

Mumps Vaccine

Usually administered in combination with measles and rubella vaccine between ages 12 and 15 months.
Second dose administered as MMR is important because a substantial number of cases have occurred in people with previous immunizations.
Important to immunize susceptible children approaching puberty, adolescents, and adults.

Rubella Vaccine

Two doses of rubella vaccine are recommended to avoid consequences such as congenital rubella syndrome; usually administered in combination with mumps and measles.
Important to immunize postpubertal individuals, especially college students and military recruits.
Women should avoid pregnancy within 3 months of vaccine due to the theoretical risk to the fetus.

Polio Vaccine

Two types of trivalent vaccine have been developed—OPV and IPV (given I.M. or subcutaneously). Both are effective in preventing poliomyelitis; however, as of 2000, both the ACIP and CDC recommend exclusive use of IPV for infants and children in the United States, in order to reduce the risk of vaccine-induced polio from OPV.
Since live OPV is excreted in the stool for up to 1 month after vaccination, vaccine-induced polio is a risk to both the nonimmune child and any immunosuppressed contact.

Haemophilus Influenzae Type B Vaccine

Incidence of invasive disease caused by Hib has declined dramatically since the introduction of the conjugate vaccine.
Several different types of Hib vaccines are available. Different vaccines have different schedules.
Minimal adverse reactions (pain, redness, or swelling at immunization site for less than 24 hours).

Hepatitis B Vaccine

There are two schedules for this vaccine. Infants born to hepatitis B surface antigen (HBsAg)-negative mothers should receive the routine schedule. Infants born to HBsAg-positive mothers should be on an accelerated vaccination schedule
Recommended for all infants born to HBsAg-negative mothers. Three-dose schedule is initiated in neonatal period or by age 2 months; the second dose is given 1 to 2 months later; the third dose, 6 to 18 months later.
All infants born to HBsAg-positive mothers, including premature neonates, should receive hepatitis B immunoglobulin and HBV within 12 hours after birth. The second dose is given between ages 1 and 2 months; the third dose at age 6 months.
Preterm neonates weighing less than 2,000 g may have lower seroconversion rates. Initiation of HBV should be delayed until just before hospital discharge if the infant weighs 2,000 g or more or until about age 2 months when other routine immunizations are given.
All children and adolescents who have not had HBV should be immunized.
Administered I.M.

Pneumococcal Vaccines

There are two types of pneumococcal vaccines:
- PCV7/Prevnar (must be administered I.M.).
- 23-valent PPV/Pneumovax (may be given I.M. or subcutaneously).
Since 2000, the pneumococcal has been included in the recommended childhood vaccines for all children ages 2 to 23 months and for certain children ages 2 to 5 years.
Efficacy for the vaccine is 97% and the adverse effects are mild (fever and localized tenderness and redness at the injection site).
PPV is recommended for children ages 2 to 5 years in certain high-risk groups (sickle cell disease, functional or anatomic asplenia, nephrotic syndrome, chronic renal failure, immunosuppressive disorders, HIV infection, and cerebrospinal fluid leak).

Influenza Vaccine

The influenza vaccine known as TIV or LAIV contains three virus strains and is changed yearly, based on predictions of predominate strains expected to circulate in the upcoming influenza season. LAIV was approved for use in those ages 2 through 49 years in the United States in 2003 and is administered intranasally. TIV is available in both pediatric and adult formulations and is administered I.M.
The influenza vaccine should be given annually to children ages 6 months through 18 years. The “Recommended Immunization Schedule” provides more specifics.
This vaccine is given annually, before flu season, usually in October, November, or December.
In children ages 8 years and younger, the first time influenza vaccine is administered, two doses should be given 1 month apart. In subsequent years, only one dose is needed.
TIV should be used for children with asthma, children 2 to 4 years who had wheezing in the past 12 months, or children who have any other underlying medical contraindications to the LAIV.

Rotavirus Vaccine

In 2006, a live, oral vaccine—Rotateq—was licensed. In the United States, routine vaccination of infants—with three doses of rotavirus vaccine administered at 2, 4, and 6 months—is recommended.

Varicella Virus Vaccine

Varicella virus vaccine contains live, attenuated virus; approved for children 12 months and older and for adults.
Administered subcutaneously at 12 to 15 months; second dose at 4 to 6 years (or at least 3 months after first dose).
May be given to older children and adults who do not have immunity. In those older than age 13, the second dose may be delayed only 4 weeks following first dose.

Nutrition in Children

The nutritional status of the child is an important aspect of health maintenance. A balanced diet influences child growth and psychosocial development. Feeding provides emotional and psychological benefits in addition to nutritional needs. In the United States, obesity in childhood has become a major problem and in developing countries, undernutrition—due to scarcity of nutrient-rich foods—leads to malnutrition and illness. In addition, anorexia, bulimia, and other dietary restrictions may place children and adolescents at risk for serious health consequences. Good eating habits, nutrient-rich foods, and physical activity introduced early in life can help foster good nutrition practices into adulthood. Nurses can be instrumental in providing factual information to both parents and children on typical nutritional needs and those required for specific sport participation. Table 42-1 presents nutritional guidelines based on age and developmental maturation.

Breastfeeding

Breastfeeding is the natural and ideal nourishment that will supply an infant with adequate nutrition as well as immunologic and anti-infection properties. With breast milk being at the proper temperature, it may prevent other GI disturbances as well. The development of allergies is reduced in breastfed babies.
Breastfeeding is recommended solely for infants to 6 months of age. As the infant grows and develops, the breast milk properties change in respect to amounts of fat, carbohydrates, and protein as well as physical properties such as pH needed for the respective age of the infant.
Breastfeeding provides psychological and emotional satisfaction for the infant and mother and can promote bonding. The physical closeness may also provide comfort after a frightening or painful procedure.
Breastfeeding can be continued through most illnesses and hospitalizations of the infant. In times of stress, the infant may cope with breastfeeding better than bottle-feeding. Because breast milk is more easily and quickly digested, shorter periods without food preoperatively and postoperatively may be necessary. Attempts should be made to maintain the breastfeeding bond and routines of the child and mother.
- Supplemental artificial formula can be given to the infant if the mother is not available.
- The mother can pump her breasts so that milk can be given to the infant by way of bottle when she is not available.
- Breast milk can be frozen for up to 6 months (check the facility’s specific policy).
- Thaw frozen breast milk for use in tepid water. Do not use a microwave, which may destroy vitamins and nutritional properties as well as result in extreme overheating of portions of the breast milk.
Stress of new motherhood or illness in the infant or mother may decrease the mother’s milk supply and inhibit her “letdown” reflex, as well as increase or decrease the infant’s desire to suckle. Pumping may be initiated to help stimulate the mother’s milk supply. An electronic pump may be necessary if prolonged pumping is expected or if manual pumping is not successful.
Education and encouragement should be offered to all new mothers and those having difficulty or concerns about breastfeeding (see Patient Education Guidelines 42-1, page 1420).

Bottle-Feeding

Bottle-feeding is a method of supplying nutrition to the infant by oral feedings, using a bottle and nipple setup.
Bottle-feeding can supplement breastfeeding with formula or water, or can be the sole means of nutritional intake for the infant.
Bottle-feeding can also provide intermittent feedings of expressed breast milk when the mother cannot be present at the time of the feeding.
Bottle-feeding can be a time of bonding between the mother and infant. The father or other capable members of the family should be taught bottle-feeding technique as well (see Procedure Guidelines 42-1, pages 1421 and 1422).
Some mothers may have chosen bottle-feeding for a variety of reasons, ranging from poor milk production, discomfort (psychological or physical) with breastfeeding, or drug treatment not compatible with breastfeeding. It is important that health care providers offer mothers information on all methods but not be judgmental when the mother choses one method over another.

Safety

Safety is an important aspect of child health and well-being. Injuries are the leading cause of death for children in the United States. Additionally, injury is a significant cause of childhood morbidity. Although childhood deaths from other causes have decreased, deaths from injuries remain constant.

Table 42-1 Nutrition in Children

AGE AND DEVELOPMENTAL INFLUENCE ON NUTRITIONAL REQUIREMENTS AND FEEDING PATTERNS	FEEDING PATTERN AND DIET	NURSING CONSIDERATIONS AND PARENTAL GUIDANCE
Neonate
*Birth-4 weeks* Neonate’s rapid growth makes infant especially vulnerable to dietary inadequacies, dehydration, and iron-deficiency anemia. Feeding process is basis for infant’s first human relationship, formation of trust. Feeding reinforces mother’s sense of “motherliness.” Neonates require more fluid relative to their size than adults. Sucking ability is influenced by individual neuromuscular maturity. Infant *1-3 months* Infants consume more formula or breast milk with each feeding and sleep for longer periods. Infants have increased interaction during feeding due to cooing and development of a social milestone. Bowel movements become less frequent. Breast-fed infants may not have a bowel movement after each feeding.	Breast milk or formula is generally given in 6-8 feedings per day, spaced 2-4 hours apart. Feeding schedules should be individualized according to infant’s needs. Breast-fed infant up to 6 months will not need supplemental vitamins or minerals. Bottle-fed infant may benefit from supplements.	Provide information to help parents make decision concerning breast- or bottle-feeding. Support parents in their decision. *Breast-fed infant:* Help mother assume comfortable and satisfying position for self and baby. Help mother to determine schedule, timing, and when infant is satisfied. Provide specific information about: Feeding technique: position, “bubbling.” Care of breasts. Manual expression of milk from breast. Maternal diet. *Bottle-fed infant:* Provide specific information about: Type of formula. Preparation of formula: measuring and sterilization. Equipment—types of bottles and nipples. Sterilization of equipment. Technique of feeding: position, “bubbling.” Help mother to determine when infant is satisfied; develop schedule for feeding. Provide information about normal characteristics of stools, signs of dehydration, constipation, colic, milk allergy. Discuss need for prescribed supplements and how to administer (by dropper). Discuss need for additional fluids during periods of hot weather and with fever, diarrhea, and vomiting. Observe for evidence of common problems and intervene accordingly: Overfeeding. Underfeeding. Difficulty digesting formula because of its composition. Improper feeding technique; holes in nipples too large or too small; formula too hot or too cold; uncomfortable feeding position; failure to “bubble”; improper sterilization; bottle propping. Bottles should never be given to infants to take to bed.
Infant
*3 months-1 year overview* Increased neuromuscular development allows infant to make transition from a totally liquid diet to a diet of milk and solid foods as well as to more active participation in the feeding process. *3-6 months* Sucking reflex becomes voluntary and chewing action begins; infant can approximate lips to rim and cup and may begin drinking from cup at 6 months. *6-12 months* Loses maternal iron stores at 6 months; first tooth erupts between ages 6 and 9 months; eyes and hands can work together; infant can sit without support and has developed grasp; can feed self a biscuit; bangs objects on table; able to hold own bottle between ages 9 and 12 months; can “pincer” grasp food; able to be weaned from bottle as child becomes developmentally able to take sufficient fluids from the cup. Food provides the infant with a variety of learning experiences; motor control and coordination in self-feeding; recognition of shape, texture, color; stimulation of speech movement through use of mouth muscles. Mealtime allows the infant to continue development of trust in a consistent, loving atmosphere. The infant is forming lifetime eating habits; it is therefore important to make mealtime a positive experience.	Number of feedings per day decreases through the first year. By ages 4-6 months, generally ready to begin strained foods. The usual sequence of foods is cereal followed by fruits and vegetables. Meats may be started between 8 and 9 months. Sequence may vary according to preferences of the family and health care provider. Mashed table foods or junior foods are generally started between ages 6 and 8 months, when infant begins chewing action. Infant begins to enjoy finger foods between ages 10 and 12 months. The transition from iron-fortified formula or breast milk to cow’s milk is usually advised at about age 12 months. By age 1 year, most infants are satisfied with three meals and additional fluids throughout the day.	The person feeding should be calm, gentle, relaxed, and patient in approach. When first offered puréed foods with a spoon, the child expects and wants to suck. The protrusion of the tongue, which is needed in sucking, makes it appear as if the child is pushing the food out of the mouth. This response should not be interpreted as dislike for the food; it is a result of immature muscle coordination and surprise at the taste and feel of the new food. The baby foods selected should be high in nutrients without providing excessive calories. Personal and cultural preferences should be considered. Iron-fortified formulas and cereals are needed to prevent physiologic anemia. New foods should be offered one at a time and early in the feeding while the infant is still hungry. Allow 3-5 days between new foods. Infants should be observed for allergic reactions when new foods are added. Common allergies are to citrus juices, egg whites, cow’s milk, and peanut butter. These foods should be avoided until age 12 months. Also avoid honey until age 12 months due to the risk of infantile botulism. Finger foods should be selected for their nutritional value. Good choices include teething biscuits, cooked vegetables, bananas, cheese sticks, and enriched cereals. Avoid nuts, raisins, and raw vegetables, which can cause choking. Parents can be taught to prepare their own strained or junior foods using a commercial baby food grinder or blender. Weaning is a gradual process. Assist parents to recognize indications of readiness. Do not expect the infant to completely drop old pattern of behavior while learning a new one; allow overlap of old and new techniques. Evening feedings are usually the most difficult to eliminate because the infant is tired and in need of sucking comfort. During illness or household disorganization, the infant may regress and return to sucking to relieve his or her discomfort and frustration. NURSING ALERT Obtain a thorough nursing history for the hospitalized infant that includes feeding pattern and schedule; types of foods that have been introduced; likes and dislikes; breast- or bottle-fed, type of bottle; temperature at which infant prefers foods and fluids.
Toddler *1-3 years* Growth slows at the end of the first year. The slower growth rate is reflected in a decreased appetite. The toddler has a total of 14-16 teeth, making him or her more able to chew foods. Increased self-awareness causes the toddler to want to do more for self. Refusal of food or of assistance in feedings are common ways in which the toddler asserts him- or herself. Because body tissues, especially muscles, continue to grow quite rapidly, protein needs are high.	Transition from a bottle to a cup at age 1 is recommended to prevent tooth decay. Appetite is sporadic; specific foods may be favored exclusively or refused from time to time. Child may be ritualistic concerning food preferences, schedule, and manner of eating. Diet should include a full range of foods: milk, meat, fruits, vegetables, breads, and cereals. Iron-fortified dry cereals (rice, barley) are an excellent source of iron during the second year of life. Older toddler can be expected to consume about one half the amount of food than an adult consumes. Whole milk is recommended up to age 2 years.	Provide foods with a variety of colors, textures, and flavors. Toddlers need to experience the feel of foods. Offer small portions. It is fun for the child to ask for more. It is more effective to give small helpings than to insist that he or she eat a specific amount. Maintain a regular mealtime schedule. Provide appropriate mealtime equipment: Silverware scaled to size. Dishes—colorful, unbreakable; shallow, round bowls are preferable to flat plates. Plastic bibs, placemats, and floor coverings permit a relaxed attitude toward child’s self-feeding attempts. Comfortable seating at good height and distance from table. Adults who help toddlers at mealtime should be calm and relaxed. Avoid bribes or force-feeding because this reinforces negative behavior and may lead to a dislike for mealtime. Encourage independence, but provide assistance when necessary. Do not be concerned about table manners. Avoid the use of soda or “sweets” as rewards or between-meal snacks. Instead, substitute fruit, juice, or cereal. Toddlers who show little interest in eggs, meat, or vegetables should not be permitted to appease their appetite with carbohydrates or milk because this may lead to iron-deficiency anemia. Milk should be limited to approximately 16 ounces/day. NURSING ALERT Nursing history for the hospitalized toddler should include feeding pattern and schedule; food likes and dislikes; food allergies; special eating equipment and utensils; whether child is weaned; what child is fed when ill.
Preschooler *3-5 years* Increased manual dexterity enables child to have complete independence at mealtime. Psychosocially, this is a period of increased imitation and sex identification. The preschooler identifies with parents at the table and will enjoy what parents enjoy. Additional nutritional habits are developed that become part of the child’s lifetime practices. Slower growth rate and increased interest in exploring his or her environment may decrease the preschooler’s interest in eating. Eating assumes increasing social significance. Mealtime promotes socialization and provides the preschooler with opportunities to learn appropriate mealtime behavior, language skills, and understanding of family rituals. NURSING ALERT Consider cultural differences. Allow parents to bring in favorite foods or eating utensils from home for the hospitalized preschooler. Encourage family members to be present at mealtime.	Appetite tends to be sporadic. Child requires the same basic four food groups as the adult, but in smaller quantities. Generally likes to eat one food from plate at a time. Likes vegetables that are crisp, raw, and cut into finger-sized pieces. Often dislikes strongtasting foods.	Emphasis should be placed on the quality rather than the amount of food ingested. Foods should be attractively served, mildly flavored, plain, as well as being separated and distinctly identifiable in flavor and appearance. Nutritional foods (eg, crackers and cheese, yogurt, fruit) should be offered as snacks. Desserts should be nutritious and a natural part of the meal, not used as a reward for finishing the meal or omitted as punishment. Unless they persist, periods of overeating or not wanting to eat certain foods should not cause concern. The overall eating pattern from month to month is more pertinent to assess. Frequent causes of insufficient eating: Unhappy atmosphere at mealtime. Overeating between meals. Parental example. Attention-seeking. Excessive parental expectations. Inadequate variety or quantity of foods. Tooth decay. Physical illness. Fatigue. Emotional disturbance. Measures to increase food intake: Allow child to help with preparations, planning menu, setting table, and other simple chores. Maintain calm environment with no distractions. Avoid between-meal snacks. Provide rest period before meal. Avoid coaxing, bribing, threatening. Place children in small groups, preferably at tables during mealtime. Use nursing history to determine likes and provide simple foods in small portions. Peanut butter and jelly sandwiches are often favorites. Allow and encourage children to feed themselves. Do not punish children who refuse to eat. Offer alternative foods.
School-age Child Slowed growth rate during middle childhood results in gradual decline in food requirements per unit of body weight. The preadolescent growth spurt occurs about age 10 in girls and about age 12 in boys. At this time, energy needs increase and approach those of the adult. Intake is particularly important because reserves are laid down for the demands of adolescence. The child becomes dependent on peers for approval and makes food choices accordingly. The child experiences increased socialization and independence through opportunities to eat away from home (eg, at school and homes of peers).	By this time, food practices are generally well established, a product of the eating experiences of the toddler and preschool period. Many children are too busy with other affairs to take time out to eat. Play readily takes priority unless a firm understanding is reached and mealtime is relaxed and enjoyable.	Nutrition education should help the child to select foods wisely and to begin to plan and prepare meals. Parental attitudes continue to be important as the child copies parental behavior (eg, skipping breakfast, not eating certain foods, consuming fast foods frequently). Most children require a nutritious breakfast to avoid lassitude in late morning. Mealtime should continue to be relaxed and enjoyable. Diversions, such as television, should be avoided. Calcium and vitamin D intake warrant special consideration. They must be adequate to support the rapid enlargement of bones. Parents and health care professionals should be alert to signs of developing obesity. Intake should be altered accordingly. Table manners should not be overemphasized. The young child typically stuffs mouth, spills food, and chatters incessantly while eating. Time and experience will improve habits. Provide some companionship and conversation at the child’s level during meals. Peers should be invited occasionally for meals. NURSING ALERT Nursing history of the hospitalized child should include food preferences; mealtime patterns and snacks; food allergies; food preferences when ill. Provide opportunities for children to eat in small groups at tables. Consider cultural differences. Allow parents to bring in favorite foods from home. Allow child to order his or her own meal.
Adolescent *11-17 years* Dietary requirements vary according to stage of sexual maturation, rate of physical growth, and extent of athletic and social activity. When rapid growth of puberty appears, there is a corresponding increase in energy requirements and appetite. Menstruating teen is particularly susceptible to iron-deficiency anemia.	Previously learned dietary patterns are difficult to change. Food choices and eating habits may be quite unusual and are related to the adolescent’s psychological and social milieu. Generally, a significant percentage of the daily caloric intake of the adolescent comes from snacking.	Continue nutrition education, with emphasis on: Selecting nutritious foods high in iron. Nutritional needs related to growth. Preparing favorite “adolescent foods.” Foods and physical fitness. Informal sessions are generally more effective than lectures on nutrition. Special problems requiring intervention: Obesity. Excessive dieting. Extreme fads—eccentric and grossly restricted diets. Anorexia nervosa and bulimia. Adolescent pregnancy. Iron-deficiency anemia. Provide nutritious foods relevant to the adolescent’s lifestyle. Discourage cigarette smoking, which may contribute to poor nutritional status by decreasing appetite and increasing the body’s metabolic rate. NURSING ALERT Allow hospitalized adolescent to choose own foods, especially if on a special diet. Provide a refrigerator in the recreation room for snacks or utilize a snack cart. Serve foods that appeal to adolescents. Use a nursing history similar to that for the school-age child.

PATIENT EDUCATION GUIDELINES 42-1

Breastfeeding

Breastfeeding is the best possible source of nutrition for your infant. It provides an immunologic boost for the infant, protects against breast cancer, hastens postpartum healing, and serves as a wonderful bond between the infant and mother.

You should begin breastfeeding in a quiet, comfortable place that is free from interruption. You may need a pillow to help support the infant and a footstool to use to elevate your leg.
Make sure the infant is awake and dry before the feeding is started. If awake and comfortable, the infant will settle down and feed better. The infant should also be hungry.
Dress the infant appropriately so that the infant is not too warm or too cool during the feeding. If too warm, the infant may fall asleep after the first few sucks of milk. A sleepy infant will not nurse well. If too cool, the infant may be fussy and restless.
Position infant at the breast by placing the infant in a semi-sitting position with face close to the breast and supported by one of your arms and hand. A pillow may be used under the infant for support. You may need to support your breast with your other hand. Proper positioning will provide the infant with comfort and security and make it easier for the infant to suck and swallow. This makes the nipple more easily accessible to the infant’s mouth and prevents obstruction of nasal breathing.
When the feeding is to start, let the breast touch the

infant’s cheek. Do not hold the cheek, but try to help the infant find the nipple. The rooting reflex will take over and the infant will turn head toward breast with mouth open. If you touch the cheek, the infant will become confused, perhaps turning toward your hand.
The infant’s lips should be out over the areola and not just around the nipple before beginning to suck. Because the nipple is so small, suction cannot be achieved merely by grasping it. The areola must be in the infant’s mouth to establish suction and make the suck effective.
You may notice the “let-down” reflex during the nursing period. Milk flowing from the other breast during nursing is quite normal.
The length of feeding time may vary from 5 to 30 minutes. Let the infant nurse until satisfied. When the infant is satisfied and has nursed well, the infant is relaxed and usually falls asleep. The infant will stop sucking.
Burp the infant during and at the end of the feeding to prevent abdominal distention or regurgitation from air swallowed during the feeding.
One or both breasts may be used at each feeding. It makes no difference as long as the infant is satisfied at the end of the feeding and one breast is completely emptied at the feeding. If both breasts were used, the second breast is not usually emptied and should be used first at the next feeding. Regular and complete emptying of the breast is the only stimulation for the production of milk.
When the infant has stopped sucking, the infant typically likes to cling to the breast. To break this suction, insert a finger to the corner of the infant’s mouth and gently pull.
When the infant has finished feeding, change the diaper if it is wet or soiled. Position the infant on the right side in bed. Note whether the infant appears satisfied or still seems to be hungry.
To continue successful breastfeeding, get adequate rest and nutrition.
For information and support, contact La Leche League International, 957 N. Plum Grove Rd., Schaumburg, IL 60173, (800) 525-3243, www:illi.org; or read their publication The Womanly Art of Breast-feeding (8th ed.).

Role of the Nurse

Identify environmental hazards and act to reduce or eliminate them.
Identify behavioral characteristics of individual children that may be related to accidental liability and caution parents accordingly. Pay particular attention to children who show the following:
- Characteristics that increase exposure to hazards, such as excessive curiosity, inability to delay gratification, hyperactivity, and daringness.
- Characteristics that reduce the child’s ability to cope with hazards, such as aggressiveness, stubbornness, poor concentration, low frustration threshold, and lack of self-control.
Provide anticipatory guidance about child development as it relates to accidents. Direct preventive teaching toward the intended audience, be it individuals or groups, children or adults.
Participate in policy-setting for accident prevention with great emphasis on effective public health measures.

Principles of Safety

The type of accident likely to occur is influenced by the child’s age and developmental level. Parents who have knowledge of their own child’s typical behavior patterns may foresee potential accident situations.
Children are naturally curious, impulsive, and impatient. The young child needs to touch, feel, and investigate. Consistent adult supervision will enable children to learn in a safe environment.
Children copy the behavior of their parents and absorb parental attitudes. Parents and other adults should be a role model for using proper and safe methods.
Children become less careful and less willing to listen to warnings and to observe routine safety precautions when they are tired or hungry.
An estimated 90% of all accidents are preventable.

PROCEDURE GUIDELINES 42-1

Bottle Feeding

EQUIPMENT

Sterile nipple and bottle (can be washed in dishwasher or in hot soapy water and rinsed well)
Formula or breast milk (prepared according to manufacturer’s directions)

PROCEDURE
Nursing Action			Rationale
Preparatory phase
1.	Infant should be awake and hungry. Change wet or soiled diaper.		1.	A sleepy infant will not feed well. A dry diaper will provide comfort so that the infant will settle down and feed more easily.
2.	If using new bottle and nipple, boil for 5 minutes immersed in a covered pan. Remove bottle and nipple and place upside down on a clean towel to cool and dry. Commercial sterilizers may also be used.		2.	Prevent possible contamination by bacteria or other particles.
3.	Check formula for proper type and amount. Prepare according to manufacturer instructions.		3.
	a.	For babies up to 6 months, mix concentrated or powdered formula with water that has been boiled (unless commercially prepared water is marked as sterile).		a.	Boiling water kills bacteria in the event of contaminated water supply.
	b.	If using tap water, run the faucet for 2 minutes to flush out any lead or other impurities before boiling.		b.	Running the tap removes impurities that standing water may pick up from the plumbing.
	c.	Boil water vigorously for 1-2 minutes, let cool, and add to formula.
4.	Use cold formula, if tolerated, but some infants prefer warmed formula.		4.	Infants may prefer cold formula if started on it from the beginning.
	a.	Warm bottle by holding it under very warm running water for a few minutes or putting the bottle in a pan of warm water (away from the heat source). Commercial bottle warmers may be used. Shake bottle vigorously after warming.		a.	Overheating must be avoided to prevent burns to the infant’s sensitive mouth. Shaking will distribute fluid temperature evenly.
	b.	Test formula temperature by squirting some on your inner wrist before feeding.		b.	The inside of the wrist is more sensitive to test temperature than other areas of the skin.
5.	Sit in a comfortable chair. Cradle the infant with one hand and arm, while supporting the infant against your body or lap.		5.	Proper position will provide the infant with comfort and security and will make it easier to suck and swallow. Holding the infant will enhance bonding and provide sensory stimulation.
Performance phase
1.	Let the infant root for the nipple by touching the corner of the infant’s mouth with the nipple.		1.
	a.	When the infant’s mouth opens, insert the nipple.		a.	Rooting is a natural reflex.
	b.	Position the nipple on top of the tongue and far enough into the mouth so suction can be created.		b.	Suction will be created when the infant sucks if the nipple is positioned properly in the mouth.
2.	Hold the bottle at an angle to completely fill the nipple with fluid.		2.	Prevents the infant from sucking and swallowing excessive air.
3.	Never prop the bottle or leave the infant unattended during feeding.		3.	This is unsafe. Should vomiting occur, aspiration is more likely.
4.	Handle the bottle carefully so as not to contaminate the nipple or fluid.		4.	Contamination will increase the risk of GI disturbances.
5.	Feed until the infant stops sucking; varies from 10 to 25 minutes.		5.	Feeding time is individual, based on age, size, how vigorously the infant sucks.
6.	Burp the infant after every 2-3 ounces during the feeding and at the end of the feeding.		6.	Most infants swallow some air with feeding. These positions aid in expelling air and thus prevent abdominal distention, discomfort, and regurgitation. Vigorous handling or patting may result in the infant spitting up or regurgitating fluid.
	a.	Place the infant in a sitting position in your lap, tilt slightly forward, and gently rub or pat the back.
	b.	Place the infant in a prone position on your shoulder or in your lap and gently pat or rub the back.
Follow-up phase
1.	After final burping, keep the infant in an upright position for 10-15 minutes (longer if the infant has reflux). If restless, burp the infant. Note if any spitting up occurs.		1.	Prevents regurgitation, but it is not abnormal to bring up small amounts of formula.
2.	Throw away any leftover formula in the bottle after the feeding.		2.	Avoids bacterial contamination.
	a.	Discard any formula that has been left out unrefrigerated for 2 hours.
	b.	Refrigerate extra bottles after mixing formula; discard if not used in 24 hours.
	c.	Do not reuse the bottle for a subsequent feeding (refill and reuse) without properly cleaning.

General Areas of Adult Responsibility for Child Safety

Motor Vehicle

Automobiles should be in good mechanical condition.
Use properly fitted and installed car seats and seat belts. Be aware of the guidelines for restraints based on the child’s age, weight, and height.
- Rear-facing car seat until age 2, or if child has outgrown the manufacturer’s recommendation for maximum height and weight.
- Front-facing car seat from age 2 until the child has outgrown the manufacturer’s recommendation for maximum height and weight.
- Belt-positioning booster seat until the vehicle seat belt fits properly, typically when the child has reached 4 feet, 9 inches in height, between 8 and 12 years of age.
All children younger than 13 years should be restrained in the rear seats of vehicles (when the vehicle has a rear seat with lap
and shoulder belts) for optimal protection. The center rear seat is the safest seat for a child.
The driver should look carefully in front and back of the car before getting into the car.
Lock all car doors.
Never leave young children in a car alone.
Do not place heavy or sharp objects on the same seat with a child.