Child Health Nursing B.Sc. N.

3rd year Q 1 Definition: Acute Rheumatic fever is an acute autoimmune collagen disease occurs as a hypersensitivity reaction to group.Abeta hemolytic streptococcal infection.It is characterized by inflammatory lesions of connective tissue and endothelial tissue. Pathophysiology of the disease: The exact etiopathogenesis of ARF is not well understood.Preceding streptococcal infection may not always clinically manifest. It is considered as a sort of clinically manifest.There is an antigen-antibody reaction usuall following streptococcal sore throat. Antibody titer elevated in majority of the patients,although the streptococci have never been isolated from rheumatic lesions in joints,heart or in the blood stream. The autoantibodies attack the myocardium,pericardium and cardiac valves. Aschoffs bodies develop on the valves dysfunction.Severe myocarditis may result dilation of the heart heart failure. The antibodies may react with striated muscle, vascular smooth muscle and nervous tissue resulting joint inflammation .involuntary movements as chorea and lesions in blood vessels and other connective tissues. CLINICAL MANIFESTATIONS: 1.Carditis: It is an early manifestationsof rheumatic fever as pancarditis i.e, parcarditis, myocarditis and endocarditis. 2.Polyarthritis:It is usuall fitting or migratory type of joint inflammation with pain .decrease active movements, warm, tenderness redness and swelling. 3.Chorea: It is purposeless involuntary ,rapid movements, usually associated with muscle weakness, incoordination, involuntary facial grimace, speech disturbance.

4.Subcuutaneous nodules:It is found as firm painless nodule over the extension surface of certain joint,occiput and vertebral column. 5.Fever:Increase the body temperature is common findings. 6.Arthralgia DOAGNOSTIC EVALUATION: 1.The presence of two major or one minor criteria plus evidence of a preceding streptococcal infection is essential for labeling a case as rheumatic fever. 2.Doppler echocardiography is considered as an important diagnostic approach. 3.Artificial subcutaneous nodule test. 4.Chest X-rays. 5.Eletrocardiography. MANAGEMENT 1.Bedrestis important in the management of children with rheumatic fever.It is needed for at least 6-8 weeks till the rheumatic activity is disaooeared. 2.Nutrition diet to be provided with sufficient amount of protein,vitamins,Salt restriction is not necessary unless CCF is present. 3.Antibiotic therapy.penicillin is administered after skin test to eradicate streptococcal infection. 4.Aspirin is administered as suppressive therapy to control pain and inflammation of joints. 5.Steroid therapy is given as suppressive therapy along with aspirin. 6.Management of chorea can be done with diazepam. NURSING MANAGEMENT: Nursing assessment is vital for the care of the child with rheumatic fever.It should include special attention to vital signs, cardiac monitoring ,pain assessment. Nursing Intervention 1. Improving cardiac output bya) Providing rest as long rheumatic activity and heart failure persist.

b) Organising nursing care with uninterrupted rest modifying activities. c) Maintaining normal body temperature by managing fever. d) Providing bland diet with adequate nutrition and fluid intake withsalt restriction in case of CCF. e) Administering medication as prescribed with necessary precautions. 2.Relieving pain bya) Administering anti-inflammatory analgesics as prescribed and assessing features asprin toxicity. b) Providing comfortable position and support to the inflamed joints. 3) Protecting the child from injury bya )Removing hard and sharp objects from the childs reach. b) Assisting the child in feeding ,ambulation and other fine motor activities and chanalization of the stress. c) Administration of drugs to control the chores. 4)Health teaching for maintenance of health and prevention of complications: a) Explaining the duration of treatment its importance and compliance ,activity restriction,follow-up. Question:5 Write explanatory notes on any FIVE of the following: a) Cleft lip and cleft palate Cleft lip (cheiloschisis) and cleft palate (palatoschisis) are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or openinga gap. It is the non-fusion of the body's natural structures that form before birth. Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide Etiology and Factors: Genetic Disorders: Chromosomal Aberrations Teratogenically Induced Disorders Drugs: Dilantin, thalidomide, aspirin (when used in excess), retinoid, etc. Excessive alcohol, nicotine, caffeine. X-rays, some viral infections, etc.

Mechanically Induced Abnormalities Amniotic rupture Twins Intra-uterine tumors Irregularly shaped uterus, etc.

Diagnosis: the diagnosis is made at the time of birth by physical examination. Recent advances in prenatal diagnosis have allowed obstetricians to diagnose facial clefts in utero. If baby has a cleft lip, it will usually be picked up at the routine ultrasound scan at 18-20 weeks of pregnancy. Cleft lip can be easily diagnosed by performing ultrasonography in the second trimester of pregnancy when the position of the fetal face is located correctly A cleft palate will usually only be noticed when your baby is born, as it does not show up on an ultrasound scan. Management Medical Therapy: Neonatal care Risk of aspiration because of communication between oral and nasal cavities Airway obstruction (in addition to sequelae of aspiration, especially in Robin sequence in which the cleft palate [CP] is combined with micrognathia and the tongue has a normal size) Difficulties with feeding of a child with a cleft and nasal regurgitation Cleft lip treatment Within the first 23 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, the often preferred age is at approximately 10 weeks of age. If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard.

Cleft palate treatment Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. Approximately 20-25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows

Nursing management 1. Assess for problems with feeding, breathing parental bonding, and speech. 2. Ensure adequate nutrition and prevent aspiration. a. Provide special nipples or feeding devices (eg, soft pliable bottle with soft nipple with enlarged opening) for a child unable to suck adequately on standard nipples. b. Hold the child in a semiupright position; direct the formula away from the cleft and toward the side and back of the mouth to prevent aspiration. c. Feed the infant slowly and burp frequently to prevent excessive swallowing of air and regurgitation. d. Stimulate sucking by gently rubbing the nipple against the lower lip. 3. Support the infants and parents emotional and social adjustment. a. Help facilitate the familys acceptance of the infant by encouraging the parents to express their feelings and concerns and by conveying an attitude of acceptance toward the infant. b. Emphasize the infants positive aspects and express optimism regarding surgical correction. 4. Provide preoperative care. a. Depending in the defect and the childs general condition, surgical correction of the cleft lip usually occurs at 1 to 3 months of age; repair of the cleft palate is usually performed between 6 and 18 months of age. Repair of the cleft palate may require several stages of surgery as the child grows. b. Early correction of cleft lip enables more normal sucking patterns and facilitates bonding. Early correction of cleft palate enables development of more normal speech patterns. c. Delayed closure or large defects may require the use of orthodontic appliances. d. The responsibilities of the nurse are to: 1. Reinforce the physicians explanation of surgical procedures. 2. Provide mouth care to prevent infection. 5. Provide postoperative care. a. Assess airway patency and vital signs; observe for edema and respiratory distress. b. Use a mist tent, if prescribed, to minimize edema, liquefy secretions, and minimize distress. c. Position the child with cleft lip on her back, in an infant seat, or propped on a side to avoid injury to the operative site; position the child with a cleft palate on the abdomen to facilities drainage.

d. Clean the suture line and apply an antibacterial ointment as prescribed to prevent infection and scarring. Monitor the site for signs of infection. e. Use elbow restraints to maintain suture line integrity. Remove them every 2 hours for skin care and range-of-motion exercises. f. Feed the infant with a rubber-tipped medicine dropper, bulb syringe, Breck feeder, or soft bottle-nipples, as prescribed, to help preserve suture integrity. For older children, diet progresses from clear fluids; they should not use straws or sharp objects. g. Attempt to keep the child from putting tongue up to palate sutures. h. Manage pain by administering analgesic as prescribed. 6. Provide child and family teaching. Demonstrate surgical wound care. Show proper feeding techniques and positions. Explain that temperature of feeding formulas should be monitored closely because new palate has no nerve endings; therefore; the child can suffer a burn to the palate easily and without knowing it. Explain handling of prosthesis if indicated. Stress the importance of long-term follow up, including speech therapy, and preventing or correcting dental abnormalities. Discuss the need for, at least, annual hearing evaluations because of the increased susceptibility to recurrent otitis. The child may require myringotomy and surgical placement of drainage tubes. Teach infection control measures

Speech and hearing treatments A tympanostomy tube is often inserted into the eardrum to aerate the middle ear. This is often beneficial for the hearing ability of the child. Speech problems are usually treated by a speech-language pathologist. In some cases pharyngeal flap surgery or augmentation pharyngoplasty is performed to reduce the escape of nasal airflow in speech sounds requiring oral air pressure, to improve the pronunciation of those sounds, and reduce nasality in those parts of speech that are not normally nasalized.

Short Notes

b) Gestational Assessment: To obtain a more accurate idea of the gestational age, the Ballard scoring method can be used. The accuracy of the method depends on the experience of the examiner. With practice and careful attention to detail, the infants correct gestational age can b e estimated with an accuracy of about 2 weeks. If the scored age is within 2 weeks of the gestational age suggested by the mothers dates, then accept her dates as correct. However, if the scored age is more than 2 weeks higher or lower than the mothers dates, then her dates are probably incorrect and the scored age should be used. The scored gestational age can also be used to decide whether the gestational age, determined by obstetric assessment, is correct or notthe arm around the neck. In more mature infants the arm cannot be easily pulled across the chest. Score 1 if the arm can be wrapped tightly around the neck (like a scarf). Score 0 if the elbow can only be pulled beyond the chest but not fully wrapped around the neck. Score 1 if the elbow reaches the other side of the chest but cannot be pulled beyond the chest. Score 2 if the elbow can reach the midline of the chest. Score 3 if the elbow cannot reach the midline of the chest. Score 4 if the elbow cannot be pulled as far as the side of the chest. Heel to ear: Hold the infants toes and gently pull the foot towards the ear. Allow the knee to slide down at the side of the abdomen. Unlike the illustration, the infants pelvis may be allowed to lift off the bed. Observe how close the heel can be pulled towards the ear. More mature infants have less flexion of the hips and, therefore, you cannot bring the heel towards the ear. Score 1 if the heel can easily be pulled to the ear. Score 0 1 if the heel can almost reach the ear. Score 1 if the heel gets close to the ear. Score 2 if the heel can be pulled just beyond halfway to the ear. Score 3 if the heel can be pulled halfway to the ear. Score 4 if the heel cannot not be pulled halfway to the ear. 2-e External features Six external features are examined. The infant has to be turned over to examine the amount of lanugo on the back. If the infant is too sick to be turned over, then the amount of lanugo is not scored. chest and abdomen, and also look at the limbs. More mature infants have thicker skins. Score 1 if the skin is sticky and transparent. Score 0 if the skin appears very thin, red and gelatinous (jelly-like). Score 1 if the skin is thin and smooth with many small blood vessels visible. Score 2 if the skin is thicker with only a few blood vessels seen. Fine peeling of the skin is often noticed, especially around the ankles. Score 3 if the skin is pale and slightly dry with only a few bigger blood vessels seen.

Score 4 if the skin is dry and cracked with no blood vessels visible. Score 5 if the skin is very thick and looks like leather. Lanugo: This is the fine, fluffy hair that is seen over the back of small infants. Except for very immature infants that have no lanugo, preterm infants have a lot of lanugo and this decreases with maturity. Score 1 if no lanugo is seen in a very small infant. Score 0 if there is only some lanugo in a very small infant. Score 1 if the lanugo is thick and present over most of the back. Score 2 if the lanugo is thinning, especially over the lower back. Score 3 if there are bald areas with no lanugo. Score 4 if very little lanugo is seen. These are always bigger infants. Plantar creases: Use your thumbs to stretch the skin on the bottom of the infants foot. Only note definite creases and not very fine wrinkles, that disappear when the skin is stretched. More mature infants have more creases. To measure the length of the foot in very small infants place a ruler on the sole and measure the distance in mm from the back of the heel to the tip of the big toe. Score 2 if there are no creases at all (there may be fine wrinkles) and the heel-toe distance is less than 40 mm. Score 1 if there are no creases at all and the heel-toe distance is 40 to 50 mm. Score 0 if shallow, red creases are present, especially over the anterior sole, and the heel to toe distance is more than 50 mm. Score 1 if shallow, red creases are present, especially over the anterior sole. Score 2 if deeper creases are present on the anterior third of the sole only. Score 3 if deep creases are present over two thirds of the sole. Score 4 if the whole sole is covered with deep creases. Breast: Both the appearance of the breast and the size of the breast bud are considered. Palpate for the breast bud by gently feeling under the nipple with your index finger and thumb. More mature infants have a bigger areola and breast bud. Score 1 if the areola (pink skin around the nipple) cannot be seen. Score 0 if the areola is very small but can be seen. Score 1 if the areola is small and flat, and no breast bud can be felt. Score 2 if the breast bud can just be felt and the areola is stippled (has fine bumps). Score 3 if the areola is raised above the surrounding skin and the breast bud is easily felt (34 mm). Score 4 if the areola appears distended and the breast bud is the size of a pea (510 mm). Ears and eyes: Both the shape and thickness of the external ear are considered. With increasing maturity the edge of the ear curls in. In addition, the cartilage in the ear thickens with maturity so that the ear springs back into the normal position after it is folded against the infants head. The eyelids separate with increasing maturity.

Score 2 if the eyelids are tightly fused (stuck together). Score 1 if the eyelids are still partly fused. Score 0 if the eyelids are open and the ear is soft and flat and stays folded. Score 1 if the ear slowly unfolds, and the upper margin of the ear (pinna) has started to curl in. Score 2 if the upper margin of the ear is well curled and the ear unfolds quickly. Areas of cartilage still feel soft, especially towards the edge of the ear. Score 3 if the cartilage feels firm throughout the ear, and the ear springs back rapidly if folded. Score 4 if the ear feels stiff and the whole ear margin is well curled in. Genitalia: Male and female genitalia are scored differently. With maturity the testes descend in the male and the scrotum becomes wrinkled. In females the labia majora increase in size with maturity. Note that a score of 1 is not given. Males: Score 1 if the scrotum is very small, flat and smooth with no testes palpable. Score 0 if the scrotum has faint wrinkles (rugae) with no testes palpable. Score 1 if there are a few wrinkles on the scrotum and the testes are felt high in the groin. Score 2 if there are a few wrinkles and the testes are felt high in the scrotum. Score 3 if the testes are in the scrotum and the skin of the scrotum has a lot of wrinkles. Score 4 if the scrotum hangs low with fully descended testes. Females: Score 1 if the clitoris is prominent and the labia flat. Score 0 if the clitoris is prominent and the labia minora (inner labia) still small. Score 1 if the clitoris is prominent and the labia minora are larger. Score 2 if the labia majora (outer labia) and labia minora are of equal size. Score 3 if the labia majora are bigger than the labia minora. Score 4 if the labia majora cover the clitoris and labia minora.

Short Notes c) Epispadias: congenital defect in which the urinary meatus is located on the upper side of the penile shaft; less common than hypospadias Clinical manifestations: Ventral or dorsal placement of the urethral opening Altered urinary stream Diagnostic evaluation Based on physical examination Therapeutic management is surgical intervention usually done in one stage Goal of surgery: To make urinary and sexual function as normal as possible and to improve the cosmetic appearance of the penis, Release of chordee and lengthening of the urethra o Repositioning of the meatus at the penile tip

o Reconstruction of the penis o Usually done between 6 and 12 months of age o No circumcision of infant with hypospadias o Urinary diversion is used after surgery to allow healing (stents or catheters) Epispadias repair Since the initial description by Jeffs of the staged reconstructive approach to exstrophy, the timing of the epispadias repair has changed. Originally, Jeffs advocated epispadias repair as the last stage of reconstruction. However, he later recognized that earlier epispadias repair increased the success of later continence procedures by stimulating bladder growth and increasing bladder capacity.141 In the MSRE, epispadias repair (stage 2) is now typically performed at 12 18 months of age via the modified CantwellRansley technique Epispadias repair can prove challenging. The goals of epispadias repair include a straight penis and urethra, easy urethral catheterization, normal erectile function, and a cosmetically satisfactory phallus. These goals allow the patient to stand while voiding and to have intromission during intercourse.

Short Notes d) PEDIATRIC HIV: Human immunodeficiency virus: It is the member of the Retroviridae family and belongs to the Lentivirus genus that infects mainly helper T lymphocytes (CD4 lymphocytes), monocytes and macrophages AIDS is the immunologic deficiency disorder which is caused by HIV which destroys the bodys ability to fight infection. OR It is the result of progression of HIV infection. EPIDEMIOLOGY: The World Health Organization (WHO) estimated that more than 38.6 million persons worldwide were living with HIV infection at the end of 2007; 2.3 million of these were children under 15 years of age. Approximately 90% of pediatric HIV infections are acquired from infected mother. Mother to child transmission may occur passively in uetro (30-35%) during delivery (60-65%) and also through breast feeding ( 10-15%). AIDS ranks among the top ten causes of the death in children aged 1-4 years.

ETIOLOGY: There are two types of transmission:

Horizontal Vertical Transmission Transmission HORIZONTAL TRANSMISSION Horizontal transmission of HIV occurs through intimate sexual contacts or parental exposures to blood or body fluids containing visible blood. Infection is transmitted to children through transmission of infected blood before mandatory screening of blood and blood products. Most of these children are infected during treatment f hemophilia. VERTICAL TRANSMISSION This is also called peri-natal transmission occurs when an HIV infected pregnant woman passes the infection to her infant. Transmission can occur during the birth from blood, amniotic fluid and exposure to genital tract secretions, and after birth through breast milk from HIV positive mother. PATHOPHYSIOLOGY: Any cause either vertical or horizontal

Human immunodeficiency virus enters the blood of infant or children

HIV destroys the helper T cells (target cells)

Virus sheds protein coat

Viral RNA is converted with reverse transcriptase into viral DNA

Viral DNA integrates with host cell DNA

Virus infects daughter cells and results in the lysis of the infected cell

The net result of an HIV infection is decreased cellular immunity CLINICAL MANIFESTION The neonate is asymptomatic at birth. The time period for development of opportunistic infection varies; however, the interval from HIV infection to the onset of overt AIDS is shorter in children than adults, and shorter in children infected perinatally than in those infected through transfusion. When infected, the child with HIV is classified as: 1. Category N: not symptomatic 2. Category A: mildly symptomatic with two or more of the following: Lymphadenopathy Hepatomegaly Splenomegaly Dermatitis Parotitis Recurrent or persistent upper respiratory infection 3. Category B: moderately symptomatic with additional previous symptoms: Anemia Cardiomyopathy Hepatitis Nephropathy Diarrhea Toxoplasmosis 4. Category C: severely symptomatic: Multiple, recurrent infection Encephalopathy Lymphoma Wasting syndrome

DIAGNOSTIC EVALUATION: Most children with AIDS are diagnosed early in life. 1. Serologic test for the detection of virus performed within 48 hours of birth, are monitored in infants born to HIV positive mothers.

2. Infants with initially negative test should be retested at 1-2 months. 3. Tests are again repeated at 3 and 6 months, and then again at 15 and 18 months. 4. The most preferable test is polymerase chain reaction (PCR) and other test include p24 antigen, or HIV culture (which is not universally available). 5. When the infant has had two negative tests, testing with enzyme-linked immunosorbent assay (ELISA; HIV antibody) should be done at 12, 15 and 18 months. 6. After two consecutive negative results with ELISA, the child is considered free of HIV. 7. In addition, complete blood count and CD41 T-cells subset is performed at 3-6 months. 8. The Centers for Disease Control and Prevention (CDC) considers childhood under 13 years of age to be infected if their symptoms meet the CDC criteria for AIDS. 9. Laboratory tests are used to determine the severity of disease which includes VIRAL LOADS.is the number of circulating HIV particles per millimeter. Viral loads of less than 10,000 are low risk. Viral loads of 10,000-100,000 are moderate risk. Viral loads greater than 100,000 are high risk. A T4 (CD4) count of >500 cells/mm3 for 6-12 years of age, 71000 cells/mm3 for 1-5 years of age, and 71,500 cells/mm3 for 12 months of age represents a component immune system. Management of infant and children with AIDS: It includes medical management and nursing management. Medical management: Medical management begins with prevention of the HIV from mothers to newborn. Due to the rapidity of the disease progression in perinatally transmitted HIV infection, early identification of infected infants is important to ensure the most effective treatment. Pregnant women with HIV infection who are treated with zidovudine (AZT) and deliver their babies by cesarean section reduce the chance of transmission to 1%. All infected mother should receive oral zidovudine (AZT) after the first trimester of pregnancy and intravenous AZT during labor and delivery; in addition, the newborn of an infected mother should receive 6 weeks of oral AZT after birth. All infants of infected mothers should start prophylaxis against PCP, a pneumocystis carinii pneumonia ( a commonly serious or fatal outcome in infants) by the age 4-6 weeks of age and continue to 12 months. Drugs used for PCP prophylaxis include Trimethoprim-sulfamethoxazole. Dapsone or aerosolized pentamidine.

A CBC with differential is performed at birth, 4-6 weeks, and 12 weeks to monitor for drug side effects

Nursing management: 1. ASSESSMENT: Physiologic assessment: Assessment centers on observation and evaluation of potential sites of infection. Assess the breath sounds, respiratory status, arterial blood gases, level of consciousness, and mental status. Any developmental delays in motor skills or intellectual functioning, which could results from encephalopathy and poor nutrition, and can signal an increasing severity in symptom level. Psychosocial assessment: Assess family support system and coping mechanisms. Assess the familys ability to care for the child. If the mother is infected, inquire about the extended familys ability to provide daily care as well as emotional support. 2. DIAGNOSIS AND INTERVENTIONS: The accompanying nursing care plan includes common nursing diagnosis that apply to child hospitalized with AIDS. Other nursing diagnosis may include the following: Diagnose 1) organisms. Interventions: a) b) c) d) e) Use hand-washing techniques to minimize exposures to infective organisms. Advice visitors to use good hand washing technique. Place child in room with non infectious children or in private room. Restrict contact with persons who have infection. Administer antibiotics as prescribed. Risk for infection related to impaired body defenses, presence of infective

Diagnose 2. Chronic pain related to disease process (i.e., encephalopathy, treatments) Interventions: a) b) c) d) Assess pain. Observe for sign of pain and discomfort. Medicate for pain as ordered, monitor and document result. Implement general comfort measuring e.g position or holding.

Diagnose 3: Altered nutrition: less than body requirements related to recurrent illness, diarrheal losses, loss of appetite. Interventions: a) Provide high-calorie, high-protein meals and snacks to meet body requirements for metabolisms and growth. b) Provide food child prefers to encourage eating. c) Fortify foods with nutritional supplements to maximize the quality of intake. d) Provide meals when child is most likely to eat well. Diagnose 4: Impaired social interaction related to physical limitations, hospitalizations, social stigma toward HIV infection. Interventions: a) Assist child in identifying personal strength to facilitate coping. b) Educate school personnel and classmates about HIV infection so that child is not unnecessarily isolated. c) Encourage child to participate in activities with other children and family.

Discharge planning: a) The diagnosis of AIDS is surrounded by strong emotions and fears. b) Be honest and direct. c) Explain that there is no evidence that casual contact among family members can spread the infection. d) Discuss the familys finances as well as health insurance coverage for the childs care. Assess the familys ability to provide nutritious food, required medications, and a supportive environment. National AIDS Control Organization Guidelines for HIV care and treatment in infants and children The National AIDS Control Organization would like to acknowledge the support provided by Indian Academy of Paediatrics, Clinton Foundation, UNICEF and the WHO Country Office (India) in the development of these guidelines. Care of exposed child immediately at birth Care of HIV-exposed infants should follow standard neonatal care according to safe motherhood guidelines including the following:

1. The babys mouth and nostrils should be wiped as soon as the head is delivered. 2. Infants should be handled with gloves until all blood and maternal secretions have been washed off (early baby bathing). 3. The cord should be clamped soon after birth. Diagnosis of HIV infection in children < 18 months For children < 18 months old, both breastfed and non-breastfed, born to a HIV positive mother the following testing strategy applies according to the NACO programme: 1. The first HIV DNA PCR shall be conducted at 6 weeks of age. If the PCR test is positive, the test is to be repeated immediately (or as early as possible) for confirmation. 2. If the first PCR is negative in a non-breastfed baby, confirm with a second PCR test at 6months. 3. If the child is breastfed and initial PCR test at 6 weeks is negative, PCR testing should be repeated at 68 weeks after cessation of breastfeeding to rule out HIV infection. 4. In case of mixed -feeding the same strategy to be applied as for a breast fed baby. 5. If symptoms develop at any time, the child should be tested appropriately (PCR orELISA/rapid) at that age. 6. A report of HIV Positive is given when 2 PCR tests are positive; and a r eport of HIV negative is given when 2 PCR tests are negative.

Nutrition in HIV infected infants and children I HIV-infected infants should follow the below protocol: 1. Be measured monthly, using the standardized growth curves. 2. Thereafter, children should be weighed at each review and full nutritional assessments should be made every three months unless the child in question requires particular attention because of growth problems or special nutritional requirements. Palliative care in childrend These guidelines describe that palliative care: 1. 2. 3. 4. 5. Provides relief from pain and other distressing symptoms Affirms life and regards dying as a normal process Intends neither to hasten nor postpone death Integrates the psychological and spiritual aspects of patient care Offers a support system to help the patient live as actively as possible until death

6. Offers a support system to help the family cope during the patients illness and in their own bereavement 7. Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated Will enhance the quality of life, and may also positively influence the course of illness.

Shor Notes: e) Classification of Protein energy malnutrition[PEM] It is syndrome of clinical & biochemical changes caused by varying degrees of protein caloric, vitamins & minerals deficiencies & affecting almost all body systems. Classification of Protein energy malnutrition[PEM] Indian Academic of Pediatrics (IAP) When the child is having weight >80% of expected weight for age, considered as normal. Grade I- Between 71-80 % Grade II- Between 61-70% Grade III- Between 51-60% Grade IV- 50%

Welcome classification Clinical classification Depend on wt for age (+/-) edema [ (Actual wt +stander wt)/2 *100%] - <60% -edema marasmus - < 60% +edema marasmic kwash - (60 80)% + edema kwashiorkor - (60 80)% - edema Under wt (not accurate if related to mortality & morbidity )

Gomes classification 90 -75% 1st degree mild malnutrition 74%-60% 2ed degree moderate malnutrition <60% 3ed degree sever malnutrition

Waterloo classification Wt/Ht >90% 90%-81% 80%-70 % < 70 % Wt/Ht & Ht for age Acute & chronic malnutrition Severity Normal mild Moderate Sever Ht for age >95% 95%-90% 89% 85% < 85%

WHO classification (Wt/Ht) Acute & chronic Z-scoring (Z normal 50 percentile) 1 Z 90% of median Wt/Ht 2 Z 80% of median Wt/Ht 3 Z 70% of median Wt/Ht 4 Z 60% of median Wt/Ht Sever malnutrition below 3Z MUAC (Midway b/w acromion& olecranon) For up to 5yrs only. Ht > 68 cm. 16 - 13 cm normal. 13,5-12;5 cm mild malnutrition. <12;5 cm sever malnutrition.

Good, rapid & reliable indicator

Short Notes Freuds Psychosexual Development Short Notes Short Notes g) NICU ORGANIZATION PHYSICAL FACILITES: SPACE: The size of the unit is related to the expected population intended to be served. In India, about 15 to 20 percent of newborn babies need special care. If the center is to serve as a referral unit for the infants born outside the hospital, allowance should be made for additional physical facilities and space. In a maternity unit having 2,000 deliveries per year, facilities for special care of 8 high- risk infants should be available. Each infant should be provided with a minimum area of 100 sq.ft. Or 10M2. There should be no compromise on space and its adequacy is crucial for reduction of nosocomial infection. Space should be allocated within the nursery complex for promotion of breast feeding, expression of breast milk and its storage. The entry of visitors to this area should be restricted and it should be kept adequately warm. Facilities for maintaining asepsis and weighing the babies should be available in the transitional care room (TCR). LOCATION: The neonatal unit should be located as close as possible to the labor room and obstetric operation theater, to facilitate prompt transfer of sick and high- risk infants. The presence of an elevator in close proximity is desirable for transport of out born infants. In tropical countries, the nursery should not be located on the top floor of the hospital but there should be feasibility for the sunlight to peep into the nursery to enhance brightness and provide ultraviolet rays to augment asepsis. FLOOR PLAN: The unit facility should preferably be in a square space so that abundant open unencumbered space is available. A split unit i.e. on either side of the hospital corridor should be avoided for ease of mobility and for prevention of infections. The walls should be made of washable glazed tiles and windows should have two layers of glass panes to ensure some

measure of heat and sound insulation. Adequate number of deep wash basins with elbow of foot operated taps, having constant round- the- clock water supply should be provided. Built- in wall wooden cabinets with foldable covers are useful for stacking purposes. The doors should be provided with automatic door closers. In addition to the special care area, minimal care and isolation rooms, x- ray room, laboratory and a procedure room. The growing nursery is used with advantage for education of mothers in child craft activities and promoting the practice of breast feeding. The cleaning area is used for sterilization of equipment and for fumigation of incubators in a specially designed vapor proof chamber. Isolation room is used to nurse potentially infected inborn or out born babies. The obviously infected inborn with open sepsis should be admitted in a septic nursery, which must be located away from the SCNU and manned by different nursing and resident staff. VENTILATION: Effective air ventilation of nursery is essential to reduce nosocomial infections. The most satisfactory ventilation is achieved with laminar air flow system which is rather expensive. When centralized air conditioning is used, minimum of 12 changes of room air per hour are recommended. The air conditioning ducts must be provided with Millipore filters (0.5 u) to restrict the passage of microbes. A simple method to achieve satisfactory ventilation consists of provision of exhaust fan in a reverse direction near the ceiling for input of fresh uncontaminated air and fixation of another exhaust fan in the conventional manner near the floor for air exit. A constant positive air pressure should be maintained in the nursery so that contaminated air form the corridors does not gain access into the nursery. The use of chemical air disinfection and ultraviolet lamps are no more recommended. LIGHTING: The nursery must be well illuminated and painted white or slightly off white to permit prompt and early detection of jaundice and cyanosis. It is best achieved by cool white fluorescent tubes to provide at least 100 foot candle, shadow- free illumination at the infants level. The number and exact location of fixtures can be worked out taking into account size of the nursery, height of the ceiling, and availability or otherwise of sunlight. Spot illumination for various procedures can be provided by a portable angle- poise lamp having two 15 watt fluorescent bulbs which when held at a distance of about one foot from the infant, produce about 100 foot candle intensity of light. In places where electrical failure is frequent and prolonged, the electrical failure is frequent and prolonged; the electrical system of the nursery complex must be

attached to a generator. Exposure of preterm babies to strong light has been incriminated as a risk factor for the development of retinopathy of prematurity. The nursery light should be dimmed at night to simulate day- night pattern to promote hormonal surge and growth of babies. ENVIRONMENTAL TEMPERATURE AND HUMIDITY: The temperature of the nursery complex must be maintained around 26 2C in order to minimize effects of thermal stress on the babies. This is best achieved by centralized air conditioning having temperature control knobs in the nursery. In places where air conditioning id not feasible, room temperature can be reasonably well maintained in winter by use of radiant heaters and hot air blowers. Portable radiant heater, infrared lamp or bakery bulb can be used to provide additional source of heat to an individual infant. ACOUSTIC CHARECTERISTECS: the ventilation system, incubators, air compressors, suction pumps and many other devices used in the nursery produce noise. Sound intensity in the nursery should not exceed 75 db to protect hearing of nursery personnel and infants. Excessive noise may lead to hearing loss, physiological and behavioral disturbances such as sleep disturbances, startles and crying episodes, hypoxia, tachycardia and increased intracranial pressure. The fabrication and redesigning of nursery equipment should take into account the desirability of minimizing noise by dampening the sound by acoustic or other means. It is desirable to have effective sound proofing of ceilings, walls, doors and floor when a new nursery is designed. Telephone rings and equipment alarms should be replaced by blinking light. Instead of air compressors, centralized sources of compressed air, oxygen and suction should be provided. Decibel meter should be installed to monitor sound effects of meaningful sounds such as gentle music or recording of parent voice should be harnessed to provide physiologic stability to the babies. HANDLING AND SOCIAL CONTACTS: Excessive and rough handling of delicate newborn babies is associated with several adverse physiological consequences such as excessive cryi9ng sleep disturbances, tachycardia or bradycardia, hypoxia and rise in blood pressure and intracranial pressure. Handling should be gentle and kept to the barest minimum without compromising care. Soothing words, gentle stroking and rocking should be practiced after a painful procedure. Gentle caressing, cuddling and touching by the mother are desirable to provide comfort and confidence to the baby and aid the process of healing. Infants should be

exposed to gentle and soothing tactile, kinesthetic, vestibular, motor, auditory and visual experiences to provide opportunities for early learning and improvement in behavior. Parents should be allowed unrestricted entry to the nursery to provide these useful sensorimotor stimuli. It enhances the process of bonding between the baby and the family. COMMUNICATION SYSTEM: The nursery complex should be provided with an intercom system so that additional person can be called for help in case of emergency without leaving the sick infant. A direct line external telephone is mandatory so that parents have an easy access to inquire about welfare of their infants and in turn they can be readily contacted whenever needed. Mobiles phones should not be used near the vicinity of the nursery because the electromagnetic waves are likely to interfere with the functioning of the electronic equipment. ELECTRICAL OUTLETS: There should be adequate number (8-12 electrical points at the height of 4-5 feets) of light and power electrical points attached to a common ground. Each infant must be provided with at least eight electrical outlets. The electrical equipment used in the nursery must be checked at least once a month for leakage of current and adequacy of grounding. The voltage supply to the nursery should be stabilized with the help of a voltage servo- stabilizer. There should be round- the- clock power back up including provision of UPS system for the sensitive equipments. CIRCULATION EQUIPMENT

Defibrillator (shock advisory module and or external pacing facility to be decided by local policy)

ECG electrodes Defibrillation gel pads or self-adhesive defibrillator pads (preferred) Selection of intravenous cannulae Selection of syringes and needles Cannula fixing dressings and tapes Seldinger central venous catheter kit Intravenous infusion sets 0.9% sodium chloride - 1000 mL x 2 Arterial blood gas syringes

Tourniquet

DRUGS a) Immediately available prefilled syringes

Adrenaline (epinephrine) 1 mg (1:10,000) x 4 Atropine 3 mg x 1 Amiodarone 300 mg x 1

b) Other readily available drugs Intravenous medications:

Adenosine 6 mg x 10 Adrenaline 1 mg (1:10,000) x 4 Adrenaline 1 mg (1:1,000) x 2 Amiodarone 300 mg x 1 Calcium Chloride 10 mL of 100mg per mL x 1 Chlorphenamine 10 mg x 2 Furosemide 50 mg x 2 Glucose 10% 500 mL x 1 Hydrocortisone 100 mg x 2 Lidocaine 100 mg x 1 Magnesium Sulphate 50% solution 2 g (4 mL) x 1 Midazolam 10 mg x 1 Naloxone 400 mcg x 5 Normal Saline 10 mL ampoules Potassium Chloride for injection (See NPSA Alert) Sodium Bicarbonate 8.4% - 50 mL x 1

Other medications / equipment:

Salbutamol (5 mg x 2) and Ipratropium Bromide (500 mcg x 2) nebules Nebuliser device and mask GTN spray

Aspirin 300 mg