ESSENTIAL NEWBORN CARE

 in support of the millennium developmental goal #4 - to reduce childhood mortality

 sepsis neonatorum - high incidence in Philippines
 PRIORITIES (TIME BOUND)
o A - AIRWAY (time bound intervention - priority, cannot be postponed)
 prevent asphyxiation - accounts for 31% of newborn death; often times read or seen in death certificates
 WHAT CAUSES ASPHYXIATION? umbilical cord is clamped → no more oxygen from placenta →
hypoxia → hypercapnia (high CO2 in the body) → CO2 is converted into carbonic acid → acidosis →
CNS depression → bradypnea, bradycardia, decreased LOC
 acidosis is more fatal than alkalosis because our body is safer in an alkali environment; the buffer
systems prevent acidosis in our body
 neonate must breath after birth; if not, asphyxiation may result 
 neonates breathe after birth by crying so stimulate the newborn to cry effectively after birth to prevent
asphyxiation
o prevent aspiration
 suction with bulb syringe PRN if (with nasal obstruction / meconium stained amniotic
fluid [green amniotic fluid]) to prevent aspiration
 suctioning is no longer routine
 hyperventilate before suctioning and check the HR
 fluid in mouth that is clear - this is amniotic fluid and suctioning is not indicated
 meconium stained amniotic fluid (green amniotic fluid) NORMAL if the baby is in
breech presentation; however, if cephalic position, this indicates fetal distress and
SUCTION
 encourage to cry effectively to maximize lung expansion → there should be a color
change; if the baby continues to be cyanotic despite effective crying, this indicates
congenital heart disease (transposition of the great vessels - aorta is located in the right
side instead of left, pulmonary vein is located at the left side instead of right side)
 acrocyanosis is normal; central cyanosis is abnormal
 OXYGEN PRECAUTION - retrolental fibroplasia (if baby is term) / retinopathy of
prematurity (if baby is preterm)
 B - BODY TEMPERATURE (time bound intervention)
o newborns after birth will expect a physiologic heat loss after birth (37.2 C down to 35.5 C to
36.5 C)
o extreme hypothermia can cause COLD STRESS → ACIDOSIS
o newborns are prone to cold stress due to extreme hypothermia → non-shivering thermogenesis
→ increase O2 consumption → decreased O2 & increased CO2 → (respiratory) ACIDOSIS
o extreme hypothermia → burns brown fat for heat → ketones / fatty acids →
(metabolic) ACIDOSIS
o MANAGEMENT
 dry baby immediately after birth (evaporation)
 put on top of mother's body - SSC or skin to skin contact (conduction) - "Unang Yakap"
 put under the floor lamp, drop light or radiant warmer. avoid putting crib near the cold
wall (radiation)
 avoid cold draft: aircon, fan, open window or door (convection)
 postpone the bath until temperature is stable (for a minimum of 6 hrs); use warm water
during bathing
 C - CERTIFY THE BIRTH
o IDENTIFICATION
  plastic bracelet (ankle - so it doesn't slide off easily) and crib card; ideally, there should
be two plastic bracelets - both unreliable bc its detachable
 footprints - more reliable (no longer recommended bc it will not last and no longer
accurate and the stamp pad facilitates spread of infection)
 DNA - most ideal
o REGISTRATION
 local civil registrar then NSO for birth certificate 
 only a professional birth attendant can sign (doctor, midwife, nurse - birth attendants /
hilots are cosigned by the midwife)
 D - DETERMINE ADAPTATION TO EXTRAUTERINE LIFE - APGAR SCORE
o created by VIRGINIA APGAR

CRITERIA ASSESS 0 1 2
PULSE  cardiac rate (apical absent less than 100 higher than 100
pulse)
RESPIRATION cry (listen & observe) absent weak, slow irregular strong, regular
ACTIVITY muscle tone limp, floppy tone (frog some flexion, little movement well flexed, active
like)
GRIMACE reflex irritability no response grimace (facial expression cry, gag, cough, pulls
only) away
APPEARANCE color (circulatory pale / blue all over acrocyanosis (extremities are pink / red all over
system) blue)

o a crying baby is breathing baby

o to reverse the effect of narcotic given to the mother (which causes respiratory depression) -
NALOXONE (Narcan)
o SCORE INTERPRETATION
 0-3 - POOR CONDITION
 resuscitate needed / NICU
 4-6 - FAIR CONDITION BUT GUARDED (CLOSER MONITORING)
 baby goes to the NICU
 7-10 - GOOD CONDITION
 allowed to do Unang Yakap then Rooming In
 NON TIME BOUND INTERVENTIONS
o EYE CARE (CREDE'S PROPHYLAXIS)
 prevents opthalmia neonatorum (contracted from the mother who has either gonorrhea
or chlamydia) which can cause blindness
 done to ALL babies delivered either CS or NSVD after initial bonding / first complete
breastfeeding (time best done)
 tetracylin, erythromycin, betadine eyedrops on the lower conjunctival sac
 silver nitrate - only effective against gonorrhea, irritating to the eyes (can cause neonatal
conjunctivitis)
 if silver nitrate is used, rinse it off with NSS to prevent neonatal conjunctivitis
o CORD CARE
 clamp the cord when it is no longer pulsating, at 2 cm and 5 cm from the base
 DO NOT MILK THE CORD
 after cutting the cord, count the number of blood vessels (2 arteries & 1 vein - AVA); one
artery instead of two, notify the physician as there might be kidney agenesis (baby is born
with one kidney instead of two) or cardiac defects
 prevent infection of the cord of the neonate - clean with soap and water if soiled
 promote drying - expose to air
 do not use abdominal binders
  should fall off between 7-10 days
o VITAMIN K
 promotes the synthesis of prothrombin which helps to clot, prevent bleeding 
 neonates cannot synthesize Vit. K because of absent intestinal bacterial flora
 1 mg IM in the thigh muscle (vastus lateralis) - biggest muscle mass and most highly
developed
 avoid using the gluteal muscle (buttocks) because of the danger of sciatic nerve trauma
causing paralysis; gluteal muscles can be used when it's developed (child has been
walking for at least 1 year)
 offer oral Vit. K if parents refuses IM (however, absorption is not as efficient)
o INJECT HEPATITIS B & BCG
 BCG - at right deltoid for quick assessment
o INITIAL BATH
 done best when vital signs (esp. temp) is stable / 6 hours after birth
 DO NOT remove vernix caseosa (which has an antibody effect, prevents evaporation of
moisture of baby's skin)
o ROOMING IN (BONDING AND FEEDING)
 R.A. 7600 (Rooming In / Breastfeeding Act of 1992)
 E.O. 51 (Milk Code of the Philippines)
 breast feeding - the best feeding, must be done at least 8 times a day (on demand &
exclusive)
 antibody (IgA) - passive natural immunity
o IN BORN ERROR IN METABOLISM SCREEN (IENMS) / NEWBORN SCREENING
ACT OF 2004
 done to diagnose inborn errors in metabolism - congenital adrenal hyperplasia,
galactosemia, phenylketonuria, G6PD, cretinism that may cause death or mental
retardation, done by heel prick when the baby is at least 24 hours old / not more than
72 hours
 BEST TIME - 48 hours

RISK NEONATES

PREMATURE INFANTS

 most common risk mother is pre-eclamptic mothers

 born before 37 completed weeks of pregnancy
 RESPIRATORY DISTRESS
o over all the organs are not yet mature or ready to function
o immature alveoli with less amount of surfactant
o problems - atelectasis, prolong apnea (more than 20 seconds), cyanosis, asphyxia
o symptoms - nasal flaring, fast breathing (60 bpm or more), chest indrawing, grunting (regular)
o management
 monitor for respiratory distress syndrome (RDS)
 MD inserts an ET (endotracheal tube)
 artificial surfactant is given via the ET - Survanta (to prevent lungs from
collapsing)
 given O2 by CPAP (continuous positive airway pressure) via mech vent / ambubag
 risk for retinopathy of prematurity; monitor with O2 sat
 REGULATION OF BODY TEMPERATURE
 o due to immature hypothalamus, less amount of subcutaneous tissues
o put in an incubator for maintenance of neutral (stable) temperature settings
o kangaroo care
 NUTRITIONAL DIFFICULTIES
o prone to aspiration (w/ continuous vomiting → alkalosis) / gastric distention, hypoglycemia
o management
 gavage (oro gastric tube / OGT) feeding of breast milk which is pumped at home and
brought to the hospital (should be labeled with the date and time she pumped her breast)
 frozen breast milk is good for 1 year
 prep the frozen breast milk - never attempt to microwave the frozen breast milk as
it destroys the antibodies, use a warm water bath & immerse the breast milk into it
(keep changing the water until desired temperature is achieved)
 small, frequent feedings (SMF)
 HEMATOLOGIC DIFFICULTIES
o immature liver function 
o problem - hyperbilirubinemia prone to kernicterus (brain damage) -
o jaundice occurs because of increased indirect bilirubin which is fat soluble and therefore, non-
excretable; in order to excrete it, it must be converted into water soluble bilirubin (which is done
by the liver) and excreted through urine & feces.
o management - phototherapy (when the light strikes the baby's skin, the blood undergoes
conversion of the bilirubin)
 nursing responsibilities
 promote hydration to promote efficacy of the phototherapy (so the neonate pees &
excretes the bilirubin)
 cover the eyes and genitals to protect them from potential damage
 effective photo therapy - decreased jaundice, stool color becomes darker & urine
becomes more yellow
 LOW RESISTANCE TO INFECTION
o causes - immature immune system
o problem - sepsis neonatorum
o management - strict compliance with nursery aseptic protocol, antibiotic as ordered

POST MATURE INFANT

 born more than 42 weeks in gestation

 most preventable by knowing the EDC
 problem - placental degeneration causing decreased utero-placental perfusion
 appearance - long but thin, dry cracking skin, no vernix & lanugo, long hair & nails, alert look, possible
IUFD (intra uterine fetal death)
 associated problems
o hypoxia due to placental insufficiency
o hypoglycemia due to decreased glycogen
o fetal distress - earliest sign is an increased movement beyond normal / restlessness
o seizure disorders
o meconium aspiration - infection & respiratory distress

BABY OF DIABETIC MOTHER

 placenta produces HPL (human placental lactogen) which is an insulin antagonist so there's decreased
production of insulin
  effect on baby
o intrauterine hyperinsulinism → more glucose absorption macrosomia (large fetus) →
MACROSOMIA → PRETERM DELIVERY
o intrauterine hyperinsulinism → after birth hypoglycemia
 during pregnancy, mother takes insulin so that the glucose in her blood will be normal
 management
o monitor signs & symptoms of hypoglycemia - tremors, irritability, restlessness
o monitor blood glucose level (CBG) / hemoglucotest
 normal glucose level (adult) - 80-120 mg/dL
 normal glucose level (children) - 40-60 mg/dL
o if the glucose level is lower than normal - give glucose (D50W) as ordered IV
o monitor the condition as the children is growing up as diabetes is hereditary

NEWBORN WITH INBORN ERRORS IN METABOLISM

 R.A. 9288 - Newborn Screening Act of 2004

 CONGENITAL ADRENAL HYPERPLASIA (CAH)
o decreased cortisol, severe salt loss, dehydration
o if not treated, death in 9-13 days
o management - NaCl supplement
 GALACTOSEMIA
o inability to metabolize galactose in milk
o vomiting, diarrhea, liver damage, cataract, growth failure, brain damage
o management - no animal source milk / no breastfeeding, soy formula is given (Isomil, Nursoy,
Prosobee)
 PHENYLKETONURIA (PKU)
o inability to utilize an essential amino acid causing mental retardation
o phenylalanine is converted into melanin so neonates are typically albinos
o management - special formula (Lofenalac / Phenelac)
 G6PD (GLUCOSE 6 PHOSPHATE DEHYDROGENASE)
o breakdown of RBC causing anemia
o management - avoid triggers like beans, napthalene, sulfas, antimalarial drugs
 CONGENITAL HYPOTHYROIDISM (CRETINISM)
o deficiency in thyroid hormones causing physical, developmental, and mental delay
o management - thyroid supplement for life (Synthroid)

NORMAL GROWTH AND DEVELOPMENT

 growth - an increase in the number and size of cells, measured in terms of quantity
 development - capacity of functioning or skill, measured in terms of quality
 PRINCIPLES
o each child is unique or individualized
o continuous process
 begins at conception and ends at death
o play is essential in the life of a child
 GAMES CHILDREN PLAYS
 things to consider - SAFETY, DEVELOPMENTAL STAGE
  INFANTS
 plays alone - solitary games
 plays with their body and senses (first plays with mouth)
 toys - mobiles, rattles, teething rings, music boxes, squeeze toys
 TODDLERS
 possessive / don't like sharing - parallel play (loves to play beside another
child but must have each a toy parallel games)
 toys - promote skills of walking (push and pull toys), talking (toy
telephone), coordination (blocks)
 PRESCHOOL
 loves to share and imitate adults in their play
 role play - cooperative / associative games
 toys - role playing games (play school, play house, doctor-nurse kit, etc)
 SCHOOL AGE
 must have a winner at the end of the game / competitive games
 toys - card games, scrabble, hopscotch, skipping rope, etc
o rate of growth varies
 rapid stages (growth spurts) - infancy & adolescent
 slow periods (growth gaps) - toddler, preschooler, school age
o directional
 growth is horizontal and vertical 
 developmental is cephalo-caudal (gross motor) and proximo-distal (fine motor)
 assessment of growth
o physiologic loss of weight days after birth - 5-10% of birth weight
o most rapid during infancy & adolescent stages - birth weight doubles at 6 months, triples at 1
year
 assessment of development
o DDST - denver developmental screen test
o MMDST - metro manila developmental screen test
o areas assessed
 gross motor skills - skills done by the large muscles, develops cephalo-caudal
 0 months - no head control
 2 months - lifts head up till the chin
 4 months - lifts head and chest
 6 months - sits w/ support
 8 months - sits w/o support
 10 months - stands w/ support
 12 months - stands w/o support & walks w/ support
 14-15 months - walks w/o support
 fine motor skills - skills done by small muscles (hands), develops proximo-distal
 interpersonal - social
 language

INFANT (1 month to 12 months)

 ORAL STAGE / TRUST vs. MISTRUST / ID principle (pleasure) / sensorimotor

 infant receives stimulation and pleasure through his mouth, answering their cry (needs) helps develop
trust
 sucking pleasure
 oral frustration - the baby's cry was ignored; this lays down the foundation for mistrust
  oral fixations - residuals of the oral stage as a result of mistrust which include drug abuse, swearing,
overeating, smoking, alcoholism, nail biting, thumb sucking

TODDLER (1-3 years)

 ANAL STAGE / AUTONOMY vs. SHAME/DOUBT / EGO principle (reality/self)

 must made aware of the difference between the reality and pleasure (needs vs. wants)
 to the toddler, the feces is not a waste product - it's a gift as it comes from the anus (the most important
part of him)
o fecal smearing
 toddlers don't like to see their mothers/primary caregiver upset (bc he has learned to trust them)
 finds pleasure in controlling his elimination
 TOILET TRAINING begins
o recommended to be started at 18 months with bowel first (bc there is control of the sphincters as
the spinal cord has been fully myelinated)
o most important factor READINESS (physical and psychological - willing to postpone a pleasure
for a bigger pleasure)
o completed by 4 years old
o if toilet training is too strict/rigid, he develops the same idea in life (must be rigid, perfect) and so
therefore, they will be perfectionists (may be prone to suicide) → anal retentive
o if toilet training is too loose, child turns out to be someone who has no care in life (messy,
unorganized, etc) → anal explosive 
 feeling of independence
 BEHAVIORS
o negativism ("NO" stage which may be verbal or nonverbal) - set limits, offer acceptable choices
o temper tantrums - ignore the behavior, time-out (if the child is hurting himself / 1 minute per
each year of his life / only used in toddlers and preschoolers)

PRESCHOOL (3-7 years)

 PHALLIC STAGE / INITIATIVE vs. GUILT / SUPEREGO principle (balances between the id & the
ego)
 oedipal (boy to his mother - mama's boy) / electra phase (girl to her father - daddy's girl) - child turns
toward the parent of opposite sex
 initiative develops if the child is allowed the freedom to initiate small activities and is appreciated for it.
 stage of "KUSA" (initiative)
 BEHAVIORS
o very curious - "WHY" stage; asks many questions (300-400/day)
o awareness of gender differences (genitals most important part of their body)
o touches/explores their body
o masturbation (as he is curious about his body) - ignore the behavior as the stage will pass (if not
ignored, he will feel guilty)
 phallic fixations - exhibitionism, rape
o exhibits fear of bodily injury (fear of mutilation / castration complex)
 when you explain procedures to the preschooler, avoid words related to castration (e.g.
cut)
 when injecting a preschooler, cover the site you have injected with a band-aid
 cover wounds with band-aids, no matter how small
o very imaginative - engages in fantasy play
 at the age of 5, the superego has developed and so therefore, memory has developed
SCHOOL AGE (7-12 years)

 LATENCY STAGE / INDUSTRY vs. INFERIORITY

ADOLESCENTS

 GENITAL STAGE / IDENTITY vs. ROLE CONFUSION /

CONGENITAL HEART DISEASES

 left ventricle - heart's main pumping chamber, has the thickest muscle and therefore, the strongest pump
 AORTA IS LOCATED ON THE LEFT SIDE and so therefore,
o right to left shunt - cynanotic because the aorta gets unoxygenated blood
o left to right shunt - acyanotic because the aorta does not get unoxygenated blood 

ACYANOTIC

 left to right shunt

 no cyanosis bc aorta does not get unoxygenated blood
 leads to CONGESTIVE HEART FAILURE
 VENTRICULAR SEPTAL DEFECT (VSD)
o there's a hole between the ventricles; blood from left ventricle goes to the right ventricle
o right ventricle gets congested → hypertrophy → muscle overstretches → compensation →
CHF
 ATRIAL SEPTAL DEFECT (ASD)
o there's a hole in between the atrium; some of the blood from the left atrium goes to the right
atrium
o right atrium gets congested (full of more than the normal amount blood) so it enlarges
(hypertrophy)
o the myocardium (the muscle) overstretches so compensatory mechanisms kick in → it tries to
empty it out by pumping faster & eventually it gets exhausted over time (and the contraction
weakens) → cardiac output decreases → less blood to the organs (esp. the kidneys) →
CONGESTIVE HEART FAILURE
 PATENT DUCTUS ARTERIOSUS (PDA)
o there is a connection between the aorta (greater pressure) & pulmonary artery
o blood from the aorta goes down to the pulmonary artery and so, the right ventricle gets
congested because the blood returns to the ventricle instead of going to the lungs
 COARCTATION OF THE AORTA (COA)
o the aorta gets smaller → the left ventricle gets congested (blood can only go through the
ascending aorta so there's more blood to the arms than the lower extremities)
o higher BP in upper extremity than the lower extremities (as opposed to the normal with the lower
extremities having a higher BP)
 SUMMARY - acyanotic cardiac conditions → congestion of cardiac chamber → compensates by
INCREASING rate of CONTRACTION → CONGESTIVE HEART FAILURE
o left sided failure - pulmonary congestion systems (dyspnea, productive cough, rales/crackles), 
 inspiratory - stridor 
 expiratory - wheeze
 o right sided failure - systemic congestion symptoms (distended neck veins, pedal edema, ascites,
hepatomegaly)
 SYMPTOMS - early symptoms (pulmonary symptoms (dyspnea, fast breathing, moist cough,
rales/crackles)
 DIAGNOSTIC
o chest x-ray - pulmonary edema & cardiomegaly)
o echocardiography / MRI - type and size of defect
o cardiac catheterization - identifies pressure inside the heart (CHF), determines what type of
acyanotic disorder depending on the direction of the contrast dye
 MANAGEMENT
o CORRECTIVE SURGERY - indicated if in failure and defect is large (no possibility of
spontaneous closure)
 open heart - defect is inside the heart (ASD, VSD)
 close heart - defect is outside the heart (PDA, COA)
o PREVENT CHF
 improve cardiac output
 cardiac glycoside - digoxin (increases strength of contraction & decreases the rate
of contraction)
 prevent Na retention & promote elimination of excess fluids (which cause burden to his
heart)
 diuretics - furosemide (Lasix) [a loop diuretic that is fast acting]; look out for
hypokalemia (safest way to replace K loss - eat potassium rich foods)
 ACE inhibitors - captopril [promotes urination and prevents sodium & water
retention to lessen the edema]
 promote low sodium intake
 low sodium formula - Lonalac
 clarification on solids allowed
 NOT ONLY THE SALTY FOODS ARE RICH IN SODIUM (carbonated drinks,
tocino, pan de sal, etc)
o DECREASE OXYGEN DEMAND
 cluster nursing care (put interventions together so pt. has more time to rest)
 quiet play activity
 decrease stress and anxiety level
 small, frequent feedings
o PREVENT RESPIRATORY INFECTIONS
 vitamin C
 promote immunization

CYANOTIC (disorders start with T)

 right to left shunt

 cyanosis bc aorta gets unoxygenated blood
 leads to POLYCYTHEMIA
 TRANSPOSITION OF THE GREAT VESSELS (biggest and worst congenital anomaly)
o aorta is located on the right side; the pulmonary vein is located on the left side
o all of the blood returning to his body is coming from the right - it's all unoxygenated (pure
unoxygenated blood so baby is cyanotic from the beginning)
o symptoms
 persistent cyanosis in spite of vigorous crying
  less symptomatic if with a septal defect; if there is no septal defect, neonate will die
within hours
o management
 palliative - emergency balloon septostomy
 then followed with corrective open heart surgery (usually done before toddler stage)
 TETRALOGY OF THE FALLOT
o D - displaced aorta (overriding) - in the middle instead of slightly to the left
o R - right ventricular hypertrophy
o O - opening in the septum (VSD)
o P - pulmonary artery stenosis (narrowed)
o blood remains in the right ventricle (bc of the pulmonary artery stenosis) → blood that goes to
the lungs is less → less blood in the left atria → since there is a higher pressure in the right side,
blood from the right side (unoxygenated) goes to the left side → since the aorta is in the middle
of the septum, the unoxygenated goes to the aorta 
o symptoms
 usually seen when the child is more active because if increased oxygen demand
(bc mixed blood flow with oxygenated & unoxygenated blood)
 exertional dyspnea with central cyanosis
 activity induced "TET" spells relieved by squatting (decreased venous return from the
legs so the pressure in the right side of the heart decreases) & knee chest position 
 clubbing of fingers due to peripheral hypoxia; Schamroth's test (there should be a
diamond)
 normal nail beds - 160 degrees
 clubbed fingers - more than 180 degrees
 polycythemia due to chronic hypoxia 
 kidney produces erythropoetin which prompts the bone marrow to produce blood
 polycythemia → increased viscosity of the blood (thickened blood) → blood flow
slows down → clot formation → smallest blood vessels are affected first (vessels
to and from the brain) → cerebral thrombosis / STROKE
 stunted physical growth and delayed development
 MANAGEMENT
 SURGICAL - palliative close heart then corrective open heart
 DECREASE OXYGEN DEMAND (*see interventions for ACYANOTIC)
 MONITOR Hgb and Hct COUNT - detects early polycythemia
o Hgb (12-14) / Hct (35-45%)
 ASSIST IN PHLEBOTOMY AS NEEDED TO BE DONE 
o do not administer heparin/aspirin because of the future surgery
 INCREASE FLUIDS / MAINTAIN IVF LINE AS NECESSARY
o eatable drinks (slurpee, ice creams, sherbet, gelatin, juicy fruits)
o use play to encourage them to drink - simon says

ACQUIRED HEART DISEASES

RHEUMATIC HEART DISEASE

 complication of rheumatic fever (which is a complication of strepto infection)

RHEUMATIC FEVER
  JONES CRITERIA (major symptoms)
o J - joint pain (migratory polyarthritis)
o O - carditis (endocarditis - innermost layer of the heart)
o N - nodes (subcutaneous nodules)
o E -  erythema marginatum (rashes on the trunk)
o S - syndenham's chorea (st. vitus dance) - involuntary jerks
 DIAGNOSIS
o jones criteria + increased ASO titer = rheumatic fever
 normal ASO (anti-streptolysin O) titer = 0-200 IU
o echocardiography - if with valve damage (mitral valve stenosis/insufficiency) → RHEUMATIC
HEART DISEASE
 MANAGEMENT
o DECREASE DEMAND FROM WEAKENED HEART
 complete bed rest / modify lifestyle after discharge (child can still go to school but cannot
participate in physical activities)
 cluster care
o PREVENT FURTHER CARDIAC DAMAGE (RHEUMATIC HEART DISEASE)
 medications - penicillin IM once a month x 3-5 years (injected at the gluteal muscle) /
ASA / steroids
 SAFETY PRECAUTION FOR CHOREA

GIT PROBLEMS

CLEFT LIP

 unilateral or bilateral
 baby will find it difficult to create the suction needed to feed properly
 MANAGEMENT
o SURGICAL - cheiloplasty / Z-plasty
 never on prone - no head control
 prevent tension on the suture lines - anticipate needs to lessen crying & use of arm
restraints (best: an elbow restraint/device)
 clean suture lines after feeding 

CLEFT PALATE

 milk may go through the nose or to the middle ear (so they will have chronic otitis media)
 speech defects (nasal twang)
 MANAGEMENT
o SURGICAL - uranoplasty / palatoplasty (recommended to be done before the child begins to
talk / before the child goes to school)
 should be on prone position to promote natural drainage of secretions
 no covering on the operative area
 feeding device post-op → drink from CUPS, never use straw (avoid any feeding method
which requires sucking bc it builds up negative pressure and promotes pain and bleeding)

TREACHEOESOPHAGEAL FISTULA / ATRESIA OF THE ESOPHAGUS

  atresia - no connection between the food pipe and esophagus
 fistula - a connection between the trachea and esophagus
 problems - aspiration / nutrition
 congenital, the food goes to the lungs
 SIGNS and SYMPTOMS
o mom w/ polyhydramnios (bc babies do not swallow the amniotic fluid)
o baby is drooling / very mucousy (a lot of oral secretions)
o 3 Cs during feeding (suction right away)
 C - COUGHING
 C - CHOKING
 C - CYANOSIS
 DIAGNOSTIC EXAM - x-ray
 MANAGEMENT 
o SURGICAL (as soon as possible) 
 PREVENT ASPIRATION
 suction PRN, strict NPO
 PROMOTE NUTRITION
 gastrostomy feeding (PEG - percutaneous endoscopic gastrostomy) - give
breastmilk 
 TPN as ordered (check blood sugar)

PYLORIC STENOSIS

 muscles of the pyloric sphincter thicken so the exit becomes narrowed → severe distention of the
stomach after feeding → increased pressure in the stomach → PROJECTILE VOMITING
 SYMPTOMS
o abdominal distention after feeding, projectile vomiting, dehydration, hypokalemia (muscle
weakness), metabolic alkalosis, weight loss, palpable olive shaped mass in RUQ
 DIAGNOSTIC - x-ray w/ barium
 MANAGEMENT - SURGICAL - pyloromyotomy with pyloroplasty

INTUSSUSCEPTION

 small intestines telescopes into the lumen of another → distention → obstruction → bile stained
vomitus → blood vessels caught between layers → blood supply decreased → tissue necrosis →
bleeding → CURRANT-JELLY STOOL 
 vomitus - describe the color, odor, taste (ask the patient)
o stomach obstruction - sour, yellow, bits and pieces of things eaten
o small intestine obstruction - green (bile stained), bitter
o large intestine obstruction (hirschsprung / colorectal cancer) - fecaloid vomitus, brown
 SYMPTOMS
o sausage shaped mass, bile-stained vomitus, currant-jelly stool (blood with mucus in the stool),
spasmodic abdominal pain (bc of the bleeding necrotic area)
 DANGER - perforation causing peritonitis
 MANAGEMENT
o SURGICAL - immediate surgery to prevent perforation that can lead to peritonitis
(RESECTION & ANASTOMOSIS)

HIRSCHSPRUNG DISEASE
  congenital aganglionic megacolon
 absence of parasympathetic nerve supply (ganglion cells) on the large intestines
 rectus sigmoid - most common site affected → stool backs up in the colon bc of shruken rectus sigmoid
→ abdominal distention → reverse peristalsis (left to right instead of right to left) → fecaloid vomitus
 SYMPTOMS
o in the nursery - delayed meconium
o later symptom - conspitation (less than 3 times a week), ribbon like/pellet like stool, abdominal
distention with possible fecaloid vomitus, weight loss
 DIAGNOSTIC - rectal biopsy (barium enema to determine extent)
 MANAGEMENT
o SURGICAL - ERPT (endorectal pull through - removes the portion that has no nerve
supply)
 before surgery, promote elimination → regular colonic irrigation, palliative colostomy

IMPERFORATE ANUS

 SYMPTOMS
o absence of meconium
o unable to insert rectal thermometer
 MANAGEMENT

o palliative colostomy 
o anoplasty, pull through procedure
 before 1 year old (10 months old); scheduled before toilet training occurs
 however, they have no sphincters (so food must be controlled)

NEURAL TUBE DEFECTS

 caused by inadequate intake of folic acid during pregnancy

SPINA BIFIDA

 meningocele - consist of a sac filled with spinal fluid only (legs still move)
 meningomyelocele - sac containing meninges, spinal fluid & spinal cord with its nerves (legs are
completely paralyzed)
 MANAGEMENT
o surgical closure preferred within 24-48 hours after birth to prevent local infection and trauma to
the exposed tissues
o PROTECT SAC AGAINST PRESSURE, INJURY, AND INFECTION
 place on PRONE POSITION
 NO DIAPER (possibility of fecal contamination, clean immediately after defecation)

DELAYED SURGERY CAN LEAD TO

HYDROCEPHALUS

 water in the head → increased ICP, sunset eyes, bulging fontanels

 MANAGEMENT
o MEDICAL - mannitol, dexamethasone
 o SURGICAL - insertion of ventriculoperitoneal shunt to bypass the point of obstruction → CSF
from the head is reabsorb in the peritoneal cavity

KIDNEY PROBLEMS

NEPHRITIS (ACUTE GLOMERULONEPHRITIS) / NEPHROSIS (NEPHROTIC SYNDROME)

NEPHRITIS
etiology - GABHS → better prognosis
sx - hematuria, periorbital edema, hypertension
interventions - complete bed rest (in acute stage),
antibiotics, antihypertensive, diuretics, low sodium,
low protein if increased creatinine, skin care
NEPHROSIS
etiology - unknown (auto-immune)
sx - proteinuria (albuminuria), hypoproteinemia,
decreased plasma osmotic pressure → more edema
(ascites) & anasarca, hyperlipidemia 
interventions - ambulate as tolerated (to prevent bed
sores), diuretics, steroids (prednisone), low sodium,
high protein, low fat diet, IV albumin, skin care

RESPIRATORY CONDITIONS

PHARYNGITIS / TONSILLITIS

 PHARYNGITIS - throat
 TONSILLITIS - tonsils
 TONSILLOPHARYNGITIS - both
 caused by GABHS (Group A beta hemolytic streptococcal infection)
 removal of tonsils (criteria)
o so big that one cannot breathe anymore - kissing tonsils (tonsils meet each other)
o pus filled abscess (where the streptococcus lie)
o frequency of tonsillitis (three times a year or more)
 MANAGEMENT
o if (+) GABHS - antibiotic (pencillin / erythromycin if with allergy)
o antipyretic PRN (no aspirin bc of gastric upset, hyperacidity, tinnitus, bleeding)
o TONSILLECTOMY if recurrent, with peritonsillar abscess, with massive hypertrophy causing
dyspnea
 pre op - check dental status (any loose teeth) and bleeding status (bleeding disorder)
 post op
 position PRONE or LATERAL position - promotes natural drainage of secretion
(open postoperative wound)
 observe for bleeding - frequent swallowing and restlessness
 prevent bleeding - ice collar bc it causes vasoconstriction and numbs the part →
decreased pain, avoid suctioning throat clearing, avoid valsalva maneuver
 diet resumes once fully awake and can swallow - cold, clear, non-irritating fluids
(cool water, ice cold apple juice/buko juice/lychee juice, frozen gelatin / almond
gelatin, suck on frozen popsicle, sherbet; DO NOT GIVE A JUICE COLORED
RED)
 ice cream not advisable - if given, make sure child drinks lots of cold water after
 progression of diet - clear liquids → general cool liquids → soft diet → diet as
tolerated (or DFA - diet for age)
SPASMODIC CROUP / LTB (LARYNGOTRACHEOBRONCHITIS)

 caused by a virus 
 SYMPTOMS
o earliest manifestation - hoarseness (brassy spasmodic "seal-like" cough)
o inspiratory stridor, fever
o possible respiratory distress due to LARYNGOSPASM
 MANAGEMENT
o SUPPORTIVE CARE - prevent coughing causing laryngospasm & respiratory distress
o avoid respiratory irritants (pollutants, dust, baby powder) & sudden temperature changes
o feed & hydrate with aspiration precaution
o decrease oxygen demand (cluster care) 
o administer high humidity w/ mist therapy during attacks
 use a cool mist vaporizer in the hospital
 steamy bathroom at home
 "toub" / "soub" - do not put vicks on the water 
 croup tent, cool mist tent, cold oxygen tent
 change damp bedding and clothing

BRONCHIAL ASTHMA

 acute (and therefore, curable) asthma

 bring the child to an allergologist / in adult, not curable → pulmonologist
 EXTRINSIC ASTHMA - allergens induced (GIT/RT)
o dust, perfume, pollens, animal fur, egg whites, chicken, chocolate, etc
 INTRINSIC ASTHMA - idiopathic / inert on the patient (stress/anxiety)
 BOTH leads to the production of HISTAMINE → bronchospasm, inflammation & edema of the
airways, accumulation of tenacious secretions
 MANAGEMENT
o allergen control - skin testing followed by hyposensitization (for 3 years)
o DURING EXACERBATION
 administer bronchodilators / aerosol
 puffers (contain steroid) make sure to rinse the mouth off after to prevent oral
thrush
 IVF drugs (aminophylline, steroids)
 position - orthopneic 
 allay anxiety
 promote oral fluids with aspiration precaution
 limit milk (has the possibility to promote viscosity of the mucus, making
secretions thicker) / avoid vit. C (an allergen; can trigger asthma attacks)
 promote breathing exercise - "purse lip breathing" to promote release of CO2
 toys to promote breathing: whistle, flute, trumpet, harmonica, blow bubbles

HEMATOLOGIC PROBLEMS

IRON DEFICIENCY ANEMIA

  more common in children 6 months and older - iron from the mother has been used up & occurs due to
overfeeding of milk (poor in iron)
 MANAGEMENT
o introduction of supplmentary / complementary feedings at 6 months (one at a time only to rule
out allergies)
o iron rich foods - cereals, egg yolk, dark green leafy vegetables (malunggay, talbus ng kamote,
saluyot), dark meat (organ meat)
o supplemental iron preparation (FeSO4) with vit. C - clean the mouth after, dark tarry stool
(meaning that iron has been absorbed)

HEMOPHILIA

 deficiency in FACTOR VIII (antihemophilic factor)

 transmitted as x-linked from carrier mom to affected son (symptomatic)
 women are merely carriers; only males are affected
 daughter gets it as a trait from carrier mom (asymptomatic)
 SYMPTOMS
o easy bruising (hematomas)
o easy epistaxis & gum bleeding
o hemarthrosis (bleeding in between the ball joints; pain & swelling) - joints affected are weight
bearing joints like knees and hips, hinge and ball joints
 MANAGEMENT
o MEDICAL - transfusion of factor VIII, cryoprecipitate, platelet concentrate
o prevent bleeding (avoid trauma - e.g. contact sports) - swimming, badminton is appropriate
o PRICES technique
 P - protective devices
 R - rest (immobilize)
 I - ice (vasoconstriction)
 C - compress (apply pressure)
 E - elevate (above the heart)
 S - support (parents, MDs (including psychologist), nurses, dentist, physical therapist,
nutritionist [should be prevented from becoming obesity bc of hemoarthrosis], etc)
o tattoos are allowed so long it's not a needle tattoo (henna, etc); earrings should be magnet;
circumcision is allowed (doctor will check his factor level / laser circumcision)
o before any surgery, factor VIII must be administered

LEUKEMIA

 most common form of childhood cancer 

 cancer of the blood
 immature WBCs (lymphoblast) not capable of phagocytosis is formed
 FORMS
o lymphocytic leukemia (most common in children) - good prognosis
 lympathic system source (lymphoid stem cell)
 lymphoid stem cell matures into WBCs
o myelocytic leukemia (most common in adults) - poor prognosis
 bone marrow source (myeloid stem cell)
 myeloid stem cell matures into RBCs, platelets, WBCs → poor prognosis
 THREE MAIN CONSEQUENCES - infection, anemia, bleeding tendencies
 DIAGNOSTIC - bone marrow biopsy (early detection → early treatment → better prognosis)
 MANAGEMENT

o REMISSION INDUCTION - IV (systemic chemotherapy)

o CNS PROPHYLACTIC THERAPY - intrathecal chemotherapy (bc brain - main target for
metastasis of leukemia)
o INTENSIFICATION or CONSOLIDATION THERAPY - regular systemic and intrathecal
chemotherapy
o MAINTENANCE THERAPY
o MOST IDEAL intervention - bone marrow transplant