NSC 312 NSS 323 MATERNAL AND CHILD HEALTH

COURSE GUIDE11

NATIONAL OPEN UNIVERSITY OF NIGERIA

COURSE CODE: NSC 312

COURSE TITLE: MATERNAL AND CHILD HEALTH

NURSING II
NSC 312 MATERNAL AND CHILD HEALTH 11

NATIONAL OPEN UNIVERSITY OF NIGERIA

COURSE GUIDE
NSC 312: MATERNAL AND CHILD HEALTH NURSING II

Source: www.livescience.com

INSTRUCTORS AND THEIR CONTACT INFORMATION:

COURSE TEAM

1. Mrs. Hanson V.F ( Team leader)

Tel: (234) 08130949720
Email: [email protected]
2. Mrs. Ibitoye O.F
NSC 312 MATERNAL AND CHILD HEALTH 11

Tel: (234) 07061683769

Email: [email protected]

COURSE COORDINATOR: Mrs. Hanson V.F

COURSE UNITS: 6 units (30 hours of Class Sessions and 135 hours of clinical practice)
 PRE-REQUISITE COURSES: NSC 315 course.

CON-CURRENT COURSES: All courses at the 300 level of the BNSc degree programme
SESSION: 2014/2015
COURSE OVERVIEW AND DESCRIPTION

Children deserve the best possible care, and this cannot be provided unless there is an
understanding of the context of children’s lives, both in the community at large and within
healthcare settings. The concept of partnership in child health and care focuses upon the need
to deliver paediatric care in collaboration with the child and the family. This course
encourages the prepares the learner to apply this approach to the delivery of child care in any
situation in which he or she works.

The terms and the philosophies applied to in this course can be adapted to suit a number of
healthcare workers at various levels and in a range of settings in order to develop caring
skills.

NSS 312, Maternal and Child Health Nursing II is a six (6) unit-course for the students in the
Bachelor of Nursing Science programme. The course is broken into 3 modules with 9 study
units. It is the second part of the course Maternal and Child Health Nursing I. The contents
cover growth and development of the neonate/infant, infant feeding methods and practices,
common childhood infections and management of a child from birth to adolescent.

The course presents up-to-date information that the nurse/nurse midwife requires in order to
provide safe and quality care to children within family context, in institutional care ( (for
example the hospital) and the community (in the school or the child’s own home).

COURSE AIM

The overarching aims are to help the learner build on the understanding of the fundamental
aspects of child care in order to facilitate safe and quality care; to drive effective practice; to
stimulate critical thinking and to generate discussions. This will encourage the development
of paediatric caring skills based on sound knowledge. The course will equip the learners with
the knowledge, skills and desirable competency in drug administration in midwifery, care
and management of a child from birth to adolescence.

COURSE OBJECTIVES
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At the completion of this course, the learners should be able to:

1. Discuss the concept of child care and cultural ideas affecting the care of the newborn.

2. Discuss prenatal development and factors that influence development.

3. Explain physiological and physical adaptation of the newborn at birth.

4. Apply the understanding of the physiology of lactation in education and capacity

building of mothers for effective breast feeding

5. Explain the principles of exclusive breast feeding and use the knowledge in promoting
EBF among mothers.

6. Apply the the principles and theories of child development in planning care for
children of different ages.

7. Utilize the approved guidelines in integrated management of childhood illnesses.

8. Apply the knowledge and skills acquired in conducting physical health assessment,
planning and implementing jointly planned care of children With families and other
health care providers.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Module contents :
Module 1 : Concepts and development of Child health Care

Module 2 The Newborn

Module 3 Culture and newborn infant care

Module 4: Nutritional needs of the newborn

Module 5: Growth and Development

Module 6: Common Childhood Diseases

Module 1: Concept and trends of child health Care

INTRODUCTION
In this module you will learn as a nurse preparing to care for today’s and tomorrow’s children
and child-rearing families faces vastly different responsibilities and challenges than did the
pediatric nurse of even a decade ago. Nurses and other health professionals are becoming
increasingly concerned with much more than the care of normal children and also the at-risk and
sick children. You will learn about prenatal development of the fetus , the critical periods of
development and the factors that affect prenatal development.as well as health teaching;
preventing illness; and promoting optimal (most desirable or satisfactory) physical,
developmental, and emotional health which have become a significant part of contemporary
nursing. Scientific and technological advances have reduced the incidence of communicable
disease and helped to control metabolic disorders. Patients now receive health care in the home,
at schools and clinics, and from their primary care provider.

MODULE OBJECTIVES
At the end of this module you will be able to:
i. Discuss the changing concepts in child health care
ii. Pre natal development
Module Content
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Unit 1: Changing concepts in child health care

Unit 2: Pre natal development

Unit 1: Changing concepts in child health care

1.1.0 Unit objectives
At the end of this unit you will be able to
a. Describe the different critical concepts of child health care
1.1.1 Introduction
Child health care has evolved from a sideline of internal medicine to a specialty that focuses on
the child and the child’s family in health and illness through all phases of development.
Technological advances account for many changes in the last 50 years, but sociologic changes,
particularly society’s view of the child and the child’s needs, have been just as important.
Pediatrics is a relatively new medical specialty, developing only in the mid-1800s. In colonial
times, epidemics were common, and many children died in infancy or childhood. In some cases,
disease wiped out entire families. In this unit, your knowledge of 6 critical concepts in child
health care will be expanded.

Content
1.1.2 Concepts of newborn care
1.1.2.1 Critical Concept
1.1.2.2 Critical Concept 2
1. 1.2.3 Critical Concept 3
1.1.2.4 Critical Concept 4
1.1.2.5 Critical Concept 5
1.1.2.6 Critical Concept 6
1.1.3 Activity
1.1.4 Self-Assessment Questions (SAQs) for Unit 1
1.1.4.1 What does concept 5 of the newborn care address?

1.1.2 Concepts of newborn care

1.1.2.1 Critical Concept 1
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Newborns have a unique appearance, with tiny features, disproportionately large heads, and a
look of vulnerability. Right after birth, they may have puffy features and misshaped heads.
Expecting parents can prepare themselves for the distinct even startling appearance of their
newborns by reading, viewing videotapes, or participating in childbirth classes. They should give
in to desires to nurture and protect their newborn. These are natural responses due, in part, to
their child's look of helplessness and vulnerability.
1.1.2.2 Critical Concept 2
Newborns spend their time in a narrow range of psychological states. They sleep for many hours.
When awake, they cry and eat. Two particularly important states are the alert and waking
periods, during which newborns visually explore the world and the people in it.
Infant caregivers and parents should be able to identify and understand the importance of each
newborn psychological state. Babies should be afforded opportunities to spend meaningful time
in each state; for example, a soothing, quiet space for uninterrupted sleep and a visually
stimulating environment for alert looking should be provided. Caregivers should respond
appropriately to infants' cries for food and nurturance.
Parents should learn to read newborn states and adjust interactions accordingly. Babies learn
most during the active and waking states; these are important times for moderate stimulation.
The drowsy state, in contrast, is a time when babies should not be disturbed.
1.1.2.3 Critical Concept 3
Breastfeeding is found to have significant developmental and health benefits for both infants and
their mothers. Children who are breastfed have a lower incidence of serious illness, tooth decay,
and childhood obesity. Mothers who breastfeed their baby show a higher-quality relationship
with their infants and are less likely to be afflicted with breast cancer.
Mothers should try to breastfeed their infants, even if only for a few months following birth. A
longer duration of breastfeeding will lead to even more positive outcomes for children.
Professionals can encourage new mothers to breastfeed by providing reading materials and
Website addresses describing the many health benefits and by introducing them to support
organizations, such as the La Leche League (http://www.lalecheleague.org).
1.1.2.4 Critical Concept 4
During waking states, newborns habituate to familiar sights and sounds; that is, once they come
to know something, they grow disinterested in it. They become excited when new objects appear
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

and new events occur. Parents can observe habituation processes in newborns as a way of
assessing perceptual and intellectual development. For example, when a baby studies a new
mobile and then shows disinterest in it over time, it can be concluded that the child has perceived
and learned about the mobile and is now ready for new stimulation. Parents should provide a
moderate amount of stimulation for newborns. If the environment does not include interesting
events or objects, babies will have nothing to study and habituate to. If too much stimulation is
provided, babies may not be able to study and become familiar with any one object or person.
They may become overwhelmed by the bombardment of perceptual stimuli.
1.1.2.5. Critical Concept 5
The time newborns spend in various states and how quickly they habituate to new stimuli vary
from one ethnic group to another. This may be due partly to genetics. However, parents of
diverse backgrounds respond in unique ways to newborn states. For example, some parents
respond quickly with warmth and feeding when babies cry; others are slower to respond or use
distracting techniques. These differences in interactions may explain some of the diversity in
infant states and behavior.
Parents should understand and be sensitive to cultural differences in newborn states and
habituation. Care should be taken not to misconstrue neonatal differences as deficits.
Parents should adjust their interactions to the unique state patterns of individual babies. Babies
who are easily upset and cry more often should be soothed and nurtured more. Those who are
often awake and active should receive more social stimulation. Babies who habituate more
slowly should not be overwhelmed with too many novel objects or people. Slow-habituating
babies may warm up slowly to new people, new room arrangements, and new experiences.
1.1.2.6 Critical Concept 6
Some newborns may be at risk of poor development. Low-birth-weight infants can suffer poor
developmental outcomes, particularly within families living in poverty. Genetic disorders and
illness may also threaten healthy development in the earliest days of life. Some problems stem
from barriers to health care for families of historically underrepresented groups.
Parents should provide special support for babies in high-risk categories and their families. Low-
birth-weight infants, for example, would benefit from greater social and intellectual stimulation
in child care. Parent education programs can be provided to help families of high-risk babies
provide positive interaction in the home. Parents should serve as advocates for families of
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

children in high-risk categories. Helping parents gain access to nutritional and health care
services is an important role of the infant care provider in modern life. Actually accompanying
family members to a clinic or a public assistance office may be necessary to overcome cultural
and linguistic barriers to family services.
Parents should take steps to reduce the risk of sudden infant death syndrome; caregivers and
medical professionals should educate them in how to do so. Among the recommendations:
Babies should always be put to sleep on their backs or sides—never on their stomachs. Adults
should never smoke around newborns.
Now that you have completed this study session, you can assess how well you have achieved its
Learning Outcomes by answering these questions. You can check your answers with the Notes
on the Self-Assessment Questions at the end of this Unit.

1.1.3 Activity
Visit the Infant welfare clinic, choose 2 newborn and discuss with their parents on
their feelings about their birth and babies. Submit your report to your preceptors.
1.1.4 Self-Assessment Questions (SAQs) for Unit 1
1.1.4.1 What does concept 5 of the newborn care address?
The time newborns spend in various states and how quickly they habituate to new stimuli vary
from one ethnic group to another. This may be due partly to genetics. However, parents of
diverse backgrounds respond in unique ways to newborn states. For example, some parents
respond quickly with warmth and feeding when babies cry; others are slower to respond or use
distracting techniques. These differences in interactions may explain some of the diversity in
infant states and behavior.
Parents should understand and be sensitive to cultural differences in newborn states and
habituation. Care should be taken not to misconstrue neonatal differences as deficits.
Parents should adjust their interactions to the unique state patterns of individual babies. Babies
who are easily upset and cry more often should be soothed and nurtured more. Those who are
often awake and active should receive more social stimulation. Babies who habituate more
slowly should not be overwhelmed with too many novel objects or people. Slow-habituating
babies may warm up slowly to new people, new room arrangements, and new experiences.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Unit 2: Pre natal development

1.2.0 Unit Objectives

At the end of this unit you will be able to:
i. Outline the three major stages in pre-natal development
ii. Describe the critical periods in pre-natal development
iii. List factors that influence pre-natal development

1.2.1 Introduction
The first 3 weeks of life is crucial to survival of a baby. The neonatal period is from birth to 28
days. The neonate after birth has to make physiological adjustment to extra uterine environment.
Health status of newborn depends on pre-natal development. In this unit, you will be exposed to
the pre-natal development, physiological status, assessment and common problems of neonate.

1.2.2 PRE-NATAL DEVELOPMENT

The word pre-natal means the period of development before birth. Conception takes place when
a male sperm cell unites with or fertilizes the female egg cell. Conception marks the beginning of
the pre-natal period of development. The pre-natal period of development spans approximately
nine calendar months or 265 days (plus or minus 14 days) of rapid growth and development.
Individual differences may, however, occur in the length of the pre-natal period. The shortest
time for the fetus to be born alive is 180 days. The longest time, regarded as the legal limit of
post-maturity, is 334 days.
1.2.2.1 Stages in Pre-natal Development
The pre-natal period consists of three distinct stages, namely: the germinal, the embryonic and
the fetal stages.
1. The Germinal Stage (Fertilization to 2 weeks)
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The germinal stage starts when the male sperm cell fertilizes the female egg cell. It is the shortest
stage of the pre-natal period of development. It lasts for about two weeks following conception.
During this stage, the new organism, now called the zygote travels towards the uterus. On
reaching the uterus, the zygote becomes implanted in the wall of the uterus. The wall of the
uterus is very rich in nutrients which nourish the zygote.
During the germinal stage, significant changes occur in the internal structure of the zygote. The
stage is characterized by rapid cell division.
In addition to increasing number, the cells of the zygote become increasingly specialized. The
mass of cells separate into the outer and inner parts. Some of the cells form a protective layer
around the mass of cells. Others begin to establish the rudiments of a placenta and the umbilical
cord. When fully developed, the placenta serves as a conduit between the mother and the
developing organism. The placenta provides nourishment and oxygen via the umbilical cord.
Also, waste materials from the developing child are removed through the umbilical cord.
2. The Embryonic Stage (2 weeks to 8 weeks)
The stage of the embryo starts from the end of two weeks after conception and extends to the end
of the second month. By the second week the organism had become firmly secured to the wall of
the mother’s uterus. At this point, the child is called an embryo.
The major highlight of this stage is the differentiation and development of the major organs and
the body systems. The embryonic disc first differentiates into three layers: the ectoderm, the
mesoderm and the endoderm. Each of these forms a different set of structures as development
unfolds.
• The Ectoderm. The outer layer is the ectoderm. The ectoderm forms the epidermis of the skin,
hair, nails, teeth, sense organs, the brain and the spinal cord.
• The Mesoderm. The middle layer is the mesoderm. The mesoderm produces the dermis or the
inner layer of the skin, the muscle, bones, blood, the circulatory system and the reproductive
system.
• The Endoderm. The inner-most layer is the endoderm. The endoderm produces the digestive
system, the pancreas and the thymus.
Every part of the human body is formed from the three layers of the embryo mentioned above.
The stage of the embryo is characterized by very rapid and orderly changes.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

By the end of the embryonic stage the organism resembles a miniature human being. All the
basic organs and features of the human being have been formed. However, the sex of the baby
cannot be known at this point. Beyond this stage, no other changes in the features take place.
The only further changes are in the relative size of the different parts of the body.
3. The fetal Stage (8 weeks to birth)
The fetal stage is the longest stage in the pre-natal period of development. During this stage, the
child is instantly recognizable. The stage starts at about 8 weeks after conception and continues
until birth.
The organism, now called the fetus, undergoes outstandingly rapid changes. It increases in length
about 20 times. Its proportions also change dramatically. At about the beginning of the fetal
stage, the head is about one-half of the fetal size. At the time of birth, the fetal head is only about
one quarter of the total size of the fetus.
The fetal stage witnesses increased complexity of the organs and systems. The organs and
systems become more differentiated and operational. For example, at 3 months, the fetus
swallows and urinates.
Arms develop hands. Hands develop fingers. Fingers develop nails.
At this period, the fetus makes itself known to the outside world. It becomes increasingly active.
By 4 months, the mother can feel the movement of the fetus. A wide range of fetal activities
become noticeable.
The fetus can now turn, do somersaults, cry, hiccup, clench its fist, open and close its eyes and
suck its thumb. The fetus responds to a variety of sensory stimulation such as: taste, smell, sight,
touch and sound. Indeed, it has been reported that the fetus heard and responded to sounds it had
heard repeatedly.
During the third trimester, the brain grows rapidly, expanding its abilities. The heart and lungs
strengthen, making it possible for the fetus to survive on its own if birth comes. The fetus stops
growing about 5 to 7 days before birth. It drops into position for delivery. A good number of
normal, full-term fetuses end in birth 259 to 273 days after fertilization. We note that good
nutrition on the mother’s part increases the chances of normal delivery, and a healthy baby.

1.2.2.2 Critical Periods in Pre-natal Development

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Critical periods in pre-natal development refer to periods when delicate and important organs
and systems of the body are being formed. These periods are considered critical because if the
uterine environment is not conducive major structural abnormalities or pre-natal death occur.
Such abnormalities may include central nervous system deformities, organ or system deformities
involving the heart, arms, legs, eyes, teeth, palate, external genitalia, or the ear. The effect of
adverse uterine environment is most potent at the critical periods of pre-natal development.
The critical periods are: the first trimester or the first three months after conception, the seventh
month, and the ninth month. We will look into more details of each of these critical periods.
 The First Trimester
As has already been noted, the first three months of pregnancy includes the germinal and
embryonic stages of pre-natal development. During this period, delicate organs and systems of
the body form and differentiate. Structural abnormalities and physiological defects of the heart,
the central nervous system, the spinal column, the eyes, the ears, the arms and the limbs are most
likely to occur during the first trimester.
 The Seventh Month
By the seventh month of pregnancy, the fetus would have attained sufficient development to be
viable. The fetus has a chance of survival outside the uterus if delivered pre-term. For a pre-term
baby to survive, the central nervous system and the brain must have developed sufficiently to
support partial regulation of breathing, swallowing and body temperature. If for whatever reason,
the brain and the nervous system failed to complete their development, a pre-term baby will be
negatively affected.
 The Ninth Month
By the end of nine calendar months or approximately 280 days of pregnancy, a child should be
delivered without much problem.
However, environmental conditions could introduce complications and make the birth process
problematic.
Conditions such as a weak womb, a narrow pelvis, improper position of the fetus, maternal
illness or malnutrition could result to prolonged labour. A convergence of several health factors,
namely: poverty, poor antenatal care, low levels of immunization and unsanitary delivery
conditions make the ninth month and the birth process a very critical period in developing
countries and especially in Nigeria
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

1.2.2.3 Factors influencing Pre-natal Development

Fetal environment exert significant influence on fetal development. The degree of influence
depends on the nature of the factor, the intensity and the time of exposure to factors. Among the
factors are the following: mother’s diet, mother’s age, mother’s illness and mother’s drug use.
1. Mother’s Diet
A mother’s diet plays an important role in sustaining the rapid development of the fetus during
the pre-natal development. Studies indicate that a mother who takes diet high in nutrients has
fewer complications during pregnancy. Labour is also easier, and the baby generally healthier
than a baby whose mother had a diet poor in nutrients. It has been reported that protein and
vitamin deficiencies in the mother’s diet can result to eye and internal organs defect, and an
increase in a number of malformation of the baby
2. Mother’s Age
The age of the mother at conception is an important factor that influences pre-natal development.
Babies born to teenage mothers are exposed to greater risks than babies born to mothers in their
twenties.
The mortality rate of infants and premature deliveries are higher in babies born to adolescent
mothers than in babies born to mothers in their twenties. Furthermore, the risks involved in
pregnancy are greater, not only for teenage mothers, but also for unusually old mothers. Older
mothers are more likely to give birth prematurely, and their children are more likely to have low
birth-weights. The incidence of children with Down Syndrome, a form of mental retardation, is
more among mothers who are more than 40 years at the time of conception.
3. Mother’s Illness
Infectious diseases abound in the African environment. This is more so in the slum areas of the
cities. These diseases include: rubella virus, genital herpes, human immuno deficiency virus
(HIV), some sexually transmitted diseases such as: syphilis and gonorrhea; chicken pox,
measles, tuberculosis, polio, cholera, leprosy and others.
When a pregnant woman contracts any of these diseases, it may not only affect her health, but it
may also be transmitted to the unborn baby.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Depending on when it strikes, an illness in a pregnant woman can have very serious
consequences for the unborn baby. The onset of rubella in the mother prior to the 11th week of
pregnancy is likely to cause in the baby blindness, deafness, heart defects, or brain damage.
Chicken pox may produce birth defects. Infants born to mothers with
HIV/AIDS (Acquired Immune Deficiency Syndrome) may have birth abnormalities, including
small, misshapen faces, protruding lips, and brain deterioration.
4. Mother’s Drug Use
Mother’s use of drugs poses risks to the unborn child. Even drugs prescribed by medical
professionals have sometimes posed serious consequences. In the 1950’s, many women who
were told to take thalidomide for morning sickness during their pregnancies gave birth to
children with stumps instead of arms and legs
The physicians who prescribed the drugs did not know that the thalidomide inhibited the growth
and development of limbs that normally would have occurred during the first three months of
pregnancy.
Pregnant mothers who used illicit drugs such as marijuana and cocaine gave birth to infants who
are irritable, nervous, and easily disturbed. In particular, cocaine use was found to produce
intense restriction of the arteries leading to the fetus, causing a significant reduction in the flow
of blood and oxygen. This process increased the risk of fetal death.
Also, mother’s use of alcohol and tobacco can have profound consequences for the unborn child.
Studies have found that children whose mothers consumed substantial quantities of alcohol
during pregnancy had below average intelligence and had problems in behavior and other
psychological functioning. It is because of the risks associated with alcohol and tobacco smoking
that physicians today counsel pregnant women to avoid any alcoholic beverages and tobacco
smoking.
1.2.3 Activity
Visit the ante natal clinic and discuss with 4 pregnant women on how they are coping with
pregnancy. Share your report on the discussion forum
1.2.4 Self -Assessment Questions (SAQ) for Unit 2
1.2.4.1 Describe the critical periods of pre natal development
1.2.4.2 Critical Periods in Pre-natal Development
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Critical periods in pre-natal development refer to periods when delicate and important organs
and systems of the body are being formed. These periods are considered critical because if the
uterine environment is not conducive major structural abnormalities or pre-natal death occur.
Such abnormalities may include central nervous system deformities, organ or system deformities
involving the heart, arms, legs, eyes, teeth, palate, external genitalia, or the ear. The effect of
adverse uterine environment is most potent at the critical periods of pre-natal development.
The critical periods are: the first trimester or the first three months after conception, the seventh
month, and the ninth month. We will look into more details of each of these critical periods.
 The First Trimester
As has already been noted, the first three months of pregnancy includes the germinal and
embryonic stages of pre-natal development. During this period, delicate organs and systems of
the body form and differentiate. Structural abnormalities and physiological defects of the heart,
the central nervous system, the spinal column, the eyes, the ears, the arms and the limbs are most
likely to occur during the first trimester.
 The Seventh Month
By the seventh month of pregnancy, the fetus would have attained sufficient development to be
viable. The fetus has a chance of survival outside the uterus if delivered pre-term. For a pre-term
baby to survive, the central nervous system and the brain must have developed sufficiently to
support partial regulation of breathing, swallowing and body temperature. If for whatever reason,
the brain and the nervous system failed to complete their development, a pre-term baby will be
negatively affected.
 The Ninth Month
By the end of nine calendar months or approximately 280 days of pregnancy, a child should be
delivered without much problem.
However, environmental conditions could introduce complications and make the birth process
problematic.
Conditions such as a weak womb, a narrow pelvis, improper position of the fetus, maternal
illness or malnutrition could result to prolonged labour. A convergence of several health factors,
namely: poverty, poor antenatal care, low levels of immunization and unsanitary delivery
conditions make the ninth month and the birth process a very critical period in developing
countries and especially in Nigeria
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Module 2: The Newborn

INTRODUCTION

Every newborn requires a brief physical examination within the first few minutes after birth and

then a full and detailed assessment within the next 48 hours and prior to discharge from hospital.

A follow up assessment should be performed later in the first week (by a midwife or General

Practitioner (GP) outside the hospital setting) and then at 6-8 weeks after birth. The physical

examination component of the newborn assessment is the most important screen for major occult

congenital anomalies.

In this module you will learn various activities around the assessment and care of a newborn

which will prepare you to render a professional care to the newborn.

MODULE OBJECTIVES

At the end of this module you will be able to:

i. Describe the physical and neurological assessment of the neonate

ii. Describe the care of the newborn

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

iii. Discuss the immunization schedule of the newborn baby from birth
Module Content
Unit 1 Features of the new born

Unit 2 Physiological, chemical and structural changes in the newborn

Unit 3 Care of the newborn

Unit 4 Immunization schedule

Unit 1. Features of the newborn

2.1.0 Unit objectives

2.1.1 Introduction

2.1.2 Features of the new born

2.1.2.1 Gastrointestinal System

2. 1.2.2 Circulatory System

2.1.2.3 Endocrine System

2.1.2.4 Neuromuscular System

2.1.2 3 Newborn Measurements

2.1.3 Activity

2.1.4 Self-Assessment Questions (SAQs) for unit 1

2.1.0 Unit objectives

At the end of this unit, you should be able to:
a. Describe the physical and physiological features of the new born
b. Assess and record the vital statistics of the newborn
c. Discuss the neurological features of the newborn

2.1.1 Introduction
The newborn is a unique individual different from the fetus, older infant, child, and adult. The
newborn’s anatomy and physiology change immediately after birth and continue to change as he
or she grows. It is essential for the nurse/midwife to be aware of adjustments the newborn must
make as he or she goes through transitions to life outside the womb. It also is important for the
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

nurse to know the characteristics of a normal newborn in order to make accurate assessments. In
addition, this knowledge will enable the nurse to appropriately answer parents’ questions and
concerns about their newborn. This unit explores the immediate and ongoing adaptation of the
normal newborn to life outside the womb and describes initial nursing assessments. A termed
newborn is born between 38th – 40 weeks. The baby usually cries and establishes rhythmic
respiration independently. Normal birth weight is between 2.5- 3.5kg.

Newborn baby

Source: newborns.standford.edu

2.1.2 Features of the new born

HEAD: - The newborn infant's head represents one-fourth of his total body length. Its
circumference is equal to that of his abdomen or chest. The average size is 33-35 cm.

a. Moulding. During delivery, for the large head to pass through the small birth canal, the skull
bones may actually overlap in a process referred to as molding. Such molding reduces the
diameter of the skull temporarily. This elongated look usually disappears a few hours after birth
as the bones assume their normal relationships.

b. Fontanels. The infant's skull is separated into six bones one from another along the suture
lines. Where more than two bones come together, the space is called a fontanel. This is the
unossified space or soft spot between the cranial bones of the skull in an infant. The infant's
pulse is sometimes visible there. The anterior fontanel is located at the intersection of the sutures
of the two parietal bones and the frontal bones. It is diamond-shaped and strongly pulsatile. It
normally closes at 9 to 18 months of age. The posterior fontanel is located at the junction of the
sutures of the 2 parietal bones and 1 occipital bone. It is small, triangular shaped, and less
pulsatile. It normally closes within 6 -12weeks.

c. Cephalohematoma. This is a collection of blood between a cranial bone and its overlying
periosteum. Bleeding is limited to the surface of the particular bone. It is caused by pressure of
the fetal head against the maternal pelvis during a prolonged or difficult labor. This pressure
loosens the periosteum from the underlying bone, therefore rupturing capillaries and causing
bleeding. It may be apparent at birth but sometimes are not seen until 24 to 48 hours of life
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

because subperiosteal bleeding is slow. It varies in size, rather firm to the touch and tends to
increase in size from 1 to 3 days and then become softer and more fluctuant. Most
cephalhematomas are absorbed within several weeks. No treatment is required in the absence of
unexplained neurologic abnormalities.

d. Caput Succedaneum. This is an abnormal collection of fluid under the scalp on top of the
skull that may or may not cross the suture lines, depending on the size. Pressure on the
presenting part of the fetal head against the cervix during labor may cause edema of the scalp.
This diffuse swelling is temporary and will be absorbed within 2 or 3 days.

Eyes: The infant's eyes may be folded and creased and may seem out of shape because they
contain little hardened cartilage. The infant's eyes may not track properly and may cross
(strabismus) or twitch (nystagmus). This will cause concern if it extends beyond six months.

(1) Color. At birth, the iris colour is usually blue in light-skinned baby and brown colour in dark-
skinned baby. A gradual deposition of pigment produces the final eye color of the baby at the age
of three to six months and sometimes it may take a year.

(2) Pupils. The pupils do react to light and the infant can focus on objects about eight inches
away. The infant's blinking is a natural protection reflex.

(3) Lacrimal apparatus. The lacrimal apparatus is small and nonfunctioning at birth and tears are
not usually produced with crying until one to three months of age.

Neck: - The infant neck is short, straight and may be creased anterior .Clavicles should be intact.
Head held in midline with free range of motion.
Chest: - The chest is circular and barrel shape with symmetric respiratory movement and Clear,
bilateral breath sounds. The breast is well-formed with symmetric nipples
Umbilicus: - There should be two arteries and one vein visible at birth. No intestinal structures
visible inside cord. The cord should be dry without bleeding, and odor
Skin: - The infant has delicate skin at birth that appears dark red because it is thin and layers of
subcutaneous fat have not yet covered the capillary beds. This redness can be seen through
heavily pigmented skin and becomes even more flushed when the baby cries.

a. Vernix Caseosa. This is a soft, white, cheesy, yellowish cream on the infant's skin at birth . It
is caused by the secretions of the sebaceous glands of the skin. It offers protection from the
watery environment of the uterus, is absorbed in the skin after birth, and serves as a natural
moisturizer.

b. Lanugo. This is a long, soft growth of fine hair on the infant's shoulders, back, and forehead.
It disappears early in postnatal life.

c. Mongolian Spots. These are blue-black colorations on the infant's lower back, buttocks, and
anterior trunk. They disappear in early childhood.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

d. Jaundice. This is a yellow discoloration that may be seen in the infant's skin or in the sclera of
the eye. Jaundice is caused by excessive amounts of free bilirubin in the blood and tissue.

e. Petechiae. These are small, blue-red dots on the infant's body caused by breakage of tiny
capillaries. They may be seen on the face as a result of pressure exerted on the head during birth.
True petechia does not blanch on pressure.

f. Milia. These are tiny sebaceous retention cysts. They appear as small white or yellow dots and
are common on the nose, forehead, and cheeks of the infant. They are of pin head size and
opalescent. Milia is due to blocked sweat and oil glands that have not begun to function properly.
They disappear spontaneously within a few weeks.

g. Birthmarks.

(1) These are small, reddened areas sometimes present on the infant's eyelids, mid-forehead, and
nape of the neck. They may be the result of local dilatation of skin capillaries and abnormal
thinness of the skin. They are sometimes called stork bites or telangiectasia. These marks usually
fade and disappear altogether. They may be noticeable when the infant blushes, is extremely
warm, or becomes excited.

(2) A Hemangioma or strawberry mark is a type of birthmark that is characterized by a dark or

bright red raised, rough surface. They do not develop for several days. They may regress
spontaneously or may even increase in size.

2.1.2.1 Gastrointestinal System

a. Mouth. The infant's lips should be pink and the tongue smooth and symmetrical. The tongue
should not extend or protrude between the lips. The connective tissue attached to the underside
of the tongue should not restrict the mobility of the tip of the tongue. The gums may have tooth
ridges along them, and rarely a tooth or two may have erupted before birth. The roof of the
mouth should be closed, and the uvula should be present. Sometimes there are glistening spots
(firm white or grayish-white nodules, usually multiple) on the palate that are referred to as
Epstein's pearls. A common site for them is at the junction of the hard and soft palates.

b. Stomach. The capacity of the infant's stomach is about 30 to 60 ml at birth, but increases
rapidly. Milk passes through the infant's stomach almost immediately. The infant is capable of
digesting simple carbohydrates and proteins, but has a limited ability to digests fats.

c. Intestines. Irregularity in peristaltic motility slows stomach emptying. Peristaltic increases in

the lower ileum, which results in one to six stools a day. The first stools after birth and for three
to four days afterwards are called meconium. Meconium is stringy, tenacious, and black and has
a tarry texture. With the ingestion of colostrums or formula, a gradual transition occurs. There
may be few greenish stools and the stools will gradually become more yellow. Formula stools
are lemon yellow and curdy. Breast milk stools are yellow-orange, soft, and more frequent.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Extremities: - Term baby assumes in utero flexed positioning at birth. The hand and legs should
be equal and should be able to perform symmetric full range of motion but extension may be
limited. Muscle tone congruent with gestational age. Ten fingers, ten toes appropriately spaced
with fingernails and toenails should be present with the fists clenched

2.1.2.2 Circulatory System

a. Blood Flow. When the umbilical blood stops flowing at birth, sudden pressure differences
occur within the circulatory system. These differences cause the blood flowing to the lungs and
liver to increase and the blood flowing through the bypass channels to decrease. Peripheral
circulation refers to residual cyanosis in hands and feet. This may be apparent for one to two
hours after birth and is due to sluggish circulation. Blood is shunted to vital organs immediately
after birth.

b. Blood Coagulation. During the first few days of life, the prothrombin level decreases and
clotting time in all infants is prolonged. This process is most acute between the second and fifth
postnatal days. It can be prevented to a large extent by giving vitamin K to the infant after birth.
With the ingestion of food, establishment of digestion, and maturation of the liver, vitamin K is
manufactured by the baby and clotting time stabilizes within a week to ten days.

2.1.2.3 Endocrine System

The endocrine glands are considered better organized than other systems. Disturbances are most
often related to maternally provided hormones (estrogen, luteal, and prolactin) that may cause
the following conditions:

a. Vaginal discharge and/or bleeding may occur in female infants. This discharge is white
mucoid in color. Bleeding may occur as a result of withdrawal from maternal hormones at the
time of birth. There are usually only a few blood spots seen on the diapers. The entire process
terminates in one to two days.

b. Enlargement of the mammary glands may occur in both sexes. This is particularly noticeable
about the third day of life. Breast secretion may also occur. Swelling usually subsides in two to
three weeks. The breast should not be squeezed; it only increases the chances of infection and
injuries to the tender tissue.

2.1.2.4 Neuromuscular System

The newborn infant exhibits remarkable sensory development and an amazing ability for self-
organization in social interactions. The infant's muscles are firm and resilient. He has the ability
to contract when stimulated, but lacks the ability to control them. He wiggles and stretches, but
movements are uncoordinated.

a. Cephalo-Caudal (Head to Toe) in Development. Gross motor development occurs first,

followed by finer motor development. Reflex actions present at birth serve the infant until
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

neuromuscular development is improved. Absence of reflex activity often indicates some

form of brain damage.

Newborn Measurements

Source: newborns.standford.edu

a) Weight
 Place a paper or warm blanket on the scale basket and zero scale.
 Remove the infant’s clothing/blanket (no diaper).
 Place the infant on the scale, keeping one hand over the infant without touching.
 Read and note weight.

Source: www.colourbox.com

b) Length
 Lay the infant on a flat surface in a recumbent position.
 Place a hand over the knees so that the infant’s legs are extended.
 with the foot flexed, draw a line marking the bottom of the heel.
 Continue to immobilize the infant and draw a line at the infant’s head.
 Remove the infant and measure the distance between the two points.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

c) Head Circumference
 Wrap measuring tape around the largest area of the infant’s head, over the occipital,
parietal, and frontal prominences. Begin above the eyebrows and ears, and continue
around the back of the head. Take the largest of several measurements. NOTE: Cranial
molding or scalp edema may affect the measurements. Head circumference- 33-38 cm
 Measure head circumference (HC) daily or as ordered if abnormal results are obtained.

Source: www.colourbox.com

d) Chest Circumference
 Place the measuring tape under the infant’s back at a level corresponding to the xiphoid
process and brings each end toward front under the axilla at the nipple line.
 secure the zero end over the sternum and then pull the other portion of the tape so it fits
snuggly around the chest.
 Read the measurement when the infant exhales.
 Chest circumference-31-36 cm

Source: www.colourbox.com

e) Abdominal Girth
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

 Place the tape under the infant’s back at a level corresponding to the position of the
umbilicus.
 Secure the zero mark above the umbilicus.
 Pull the other portion of the tape until it fits snuggly around the abdomen.
 Read measurement at the point where the zero mark meets the other portion of the tape
when the infant exhales.
2.1.3 Activity
During your clinical posting to the Maternity unit, visit the labour/post natal ward during your

posting. Assess 10 newborn babies and record them in your Midwifery Record. Document

deviations from the normal the features of a newborn baby in any of the babies. Share your

experience with your mates on the discussion forum.

2. 1.4 Self-Assessment Questions (SAQs) for unit 1

2.1.4.1 Describe how you will conduct the length and head circumference of the newborn
2.1.4.2 .Length
o lay the infant on a flat surface in a recumbent position.
o Place a hand over the knees so that the infant’s legs are extended.
o with the foot flexed, draw a line marking the bottom of the heel.
o Continue to immobilize the infant and draw a line at the infant’s head.
o Remove the infant and measure the distance between the two points.

b. Head Circumference

 Wrap measuring tape around the largest area of the infant’s head, over the
occipital, parietal, and frontal prominences. Begin above the eyebrows and ears,
and continue around the back of the head. Take the largest of several
measurements. NOTE: Cranial molding or scalp edema may affect the
measurements. Head circumference- 33-38 cm

 Measure head circumference (HC) daily or as ordered if abnormal results are

obtained.

Unit 2. Adaptation to extra uterine life

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Content
2.2.0 Unit objectives
2.2.1 Introduction
Contents

2.2.2 Transition from intra-extra uterine life

2.2.2.1 Adaptation
2.2.2.2 Physiological adaptation
2.2.2.3 Respiratory Adaptation
2.2.2.4. Circulatory Adaptation
2.2.2.5 Thermal Adaptation
2.2.2.6 Digestion
2.2.2.7 Elimination
2.2.2.8 Urinary System
2.2.2.9 Hepatic
2.2.2.10 Skin
2.2.2.11 Reaction to Organism
2.2.2.12 Skeleto-Muscular System
2.2.2.13 Reaction and Response to Environment
2.2.2.14 Special Senses
2.2.2.15 Reproductive systems

2.2.0 Unit Objectives

At the end of this unit, you should be able to:
i. Discuss the transition of the newborn to extra uterine life
ii. Assist the newborn to establish and maintain respiration
iii. Discuss the physiological, chemical and structural changes in the newborn

2.2.1 Introduction
Healthy full‐term newborns show a predictable pattern of behavioral changes, behavioural states
and cues, sensory abilities, and physiologic adaptations during the first 6‐ 8 hours following
delivery. This transitional period is divided into an initial period of reactivity and inactivity and a
second period of reactivity.

2.2.2 Transition from intra-extra uterine life

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

This transitional period is divided into an initial period of reactivity and inactivity and a second
period of reactivity.
1. 1st period of reactivity: - it occurs in the first 30‐60 minutes of life and is described by an
alert, exploratory and active newborn. During this initial period, the newborn may be tachypneic
(up to 80 bpm) and tachycardia (up to 180 bpm). Mild to moderate chest wall retractions, nasal
flaring and expiratory grunting may be observed and crackles may be heard. Periodic breathing
(pauses in breathing of less than 15 seconds) may be noted and acrocyanosis (bluish hands and
feet) is also normal
2. Period of Inactivity -The period of relative inactivity takes place 2 ‐3 hours after birth. The
newborn becomes less interested in external stimuli and falls asleep for a few minutes to several
hours. During deep sleeps, the baby is difficult to arouse. Feeding may be difficult. Heart rate
should stabilize at 100 ‐ 140 bpm and the respiratory rate decrease to 40 to 60 breaths per
minute. The newborn should be centrally pink with clear breath sounds and show no signs of
respiratory distress.
3. 2nd period of reactivity: - The second period of reactivity occurs between 4 ‐ 6 hours after
birth. This will last from 10 minutes to several hours. Heart and respiratory rates may increase
but should remain within normal limits.

2.2.2.1 Initiation of breathing

The initiation of breathing is a complex process that involves the interaction of biochemical,
neural and mechanical factors. Pulmonary blood flow, surfactant production, and respiratory
musculature also influence respiratory adaptation to extra uterine life.
• Umbilical cord clamping decreases oxygen concentration, increases carbon dioxide
concentration, and decreases the blood pH. This stimulates the fetal aortic and carotid
chemoreceptors, activating the respiratory centre in the medulla to initiate respiration.
• Mechanical compression of the chest during the vaginal birth forces approximately 1/3 of the
fluid out of the fetal lungs. As the chest is delivered, it re‐expands, generating a negative
pressure and drawing air into the lungs. Passive inspiration of air replaces fluid. As the infant
cries, a positive intra-thoracic pressure is established which keeps the alveoli open, forcing the
remaining fetal lung fluid into the lymphatic circulation.
In order for the respiratory system to function effectively, the infant must have:
- Adequate pulmonary blood flow
- Adequate amount of surfactant
- Respiratory musculature strong enough to support respiration
Common characteristics of newborn respirations.
(a) Nose breathers. Sleeps with mouth closed, does not have to interrupt feedings to breathe.
(b) Irregular rate.
(c) Usually abdominal or diaphragmatic in character.
(d) Ranges from 40 to 60 breathers per minute.
(e) Breathing is quiet and shallow.
(f) Easily altered by external stimuli.
(g) Periods of apnea less than 15 seconds is normal.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

(h) Acrocyanosis may occur during periods of crying. Acrocyanosis refers to cyanotic look of the
baby's hands and feet when he is crying. When the baby stops crying, his hands and feet get pink
again.

2.2.2.2 Respiratory Adaptation

Breathing is the first function to be established at birth. In-utero the nervous system plays little
role in respiratory exchange of gas, as this is done mainly by the placenta; because the lungs are
solid, the presence of fluid containing surfactant (lecithin), a phospholipids substance in the
lungs reduces surface tension. It facilitates alveolar expansion, stabilizes it and prevents collapse
of the small alveoli by permitting air to remain there after expiration. During delivery some of
this fluid is expelled by the compression of the chest wall. The rest is absorbed by the pulmonary
circulation and lymphatic system.
Respiration is triggered by the sensory stimuli, tactile, thermal, pain and the centre chemosensory
mechanism which is sensitive to blood gas state. This stimulates respiratory centre and helps to
maintain respiration. Respiration is therefore a response to low Oxygen (hypoxia Acidosis) and
high carbon dioxide level in the blood stream (asphyxia) caused by uterine contractions. This is
responsible for the first gasp and aided by external sensory stimuli i.e. cool air on the face,
compression of the chest wall, gravity, noise, light, odour and suctioning of the oropharynx.
Increase pulmonary blood flow is required to facilitate gaseous exchange in the alveoli. The
normal baby cries as soon as he is born, after the first breathe and this is followed by the first
gasp. Initially respiration is rapid average of 40 beats per minute may be irregular for a few
seconds but soon regulates itself. To facilitate lung expansion, healthy baby should be made to
cry vigorously for complete aeration of the lungs. Breathing is almost entirely abdominal in the
newborn. Tongue is a good index of central oxygenation. The newborn’s respiratory,
cardiovascular and central nervous system must be structurally normal and the airways patent to
enable ventilation of the lungs.

2.2.2.3 Circulatory Adaptation

Placenta is the organ of gaseous exchange in fetal life. At birth when the baby is separated from
the placenta (life support system) he has to make a major adjustment within his circulatory
system for blood to flow to the lungs for re-oxygenation. This involves several mechanisms
which are influenced by clamping of the cord and pulmonary vascular bed resistance. In-utero
only about 10% of blood flow to the lungs, but with the clamping of the cord most of the blood
goes to the lungs. As this oxygenated blood from the lungs return to the heart, the pressure in the
left atrium increase and the pressure in the right atrium decreases because blood no longer flow
from the cord there. This results in functional closure of the foramen Ovale. The Ductus
arteriosus contracts and closes to become a cardiac ligament within five minutes of birth.
Sometimes this may not be complete immediately leading to periodic cyanotic attack e.g.
preterm and respiratory distress syndrome. But final closure takes place within first one year of
birth. All other temporary openings i.e. umbilical vein, Ductus venous are hypogastric arteries
also close down. Due to high metabolic need the heart beats rapidly (120-160/min) with the
mean of 140 and this can be influenced by baby’s activities. The heart lies transversely and the
apex beat can be detected at the 3rd or 4th intercoaster space on the left side. Peripheral
circulation is sluggish resulting in cyanosis of the limbs. Blood pressure varies according to
activities 50/25 – 70/40 mmHg.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Blood: Pulse rate 100-120b/min. The total blood volume at birth is about 80ml/kg ~ 8% of the
body weight, but this may increase if cord is not closed on time. Haemoglobin level is between
17-20gm milliliter and is 70% fetal Hb. As soon as normal saturation of oxygen is normalized
production of FHB ceases and is gradually replaced by adult type within 1-2 years of life.
Haematocrit is 55%, Red cell Count (RCC) is 5-7 x 102/l. The excess is broken down in the liver
and spleen which predisposes the infant to jaundice. Prothrombin level is low due to lack of
vitamin K until the gastrointestinal tract is colonized by bacteria which synthesize intrinsic
vitamin k when feeding is established. Hence the infant is prone to bleeding in the first week of
life especially the preterm infants. The platelet level is equal with adult’s white blood cell is high
but soon returns to normal.
2.2.2.4 Thermal Adaptation
Heat regulation in the newborn is very poor and unstable, due to undeveloped heat regulating
centre in the hypothalamus, low metabolic rate, excretion, large surface area, poor insulation and
wet skin. The new born does not shiver like the adult but uses adaptive mechanism by
metabolizing brown fat found at the base of the neck, between the scapulae, mediastenum,
around the kidneys and adrenals, which produces heat at a faster rate (Non-shivering
thermogenesis). Heat loss from the surface is by vasoconstriction of the skin due to changes in
skin blood flow, through processes of radiation, convection, conduction and evaporation. A baby
nursed in a low temperature adjusts by increasing heat production thereby increases oxygen
consumption, that is, valuable calories for maintenance of growth will now be diverted to
maintaining temperature. It is therefore very important to dry baby’s skin, wrap properly and
transfer to warm environment to prevent heat loss. The first bath should be down in a warm room
(21 – 260c) and water at 36.70c- 37.70c in cold weather.

2.2.2.5 Digestion
At birth gastrointestinal tract is structurally complete through functionally immature. In-utero,
the fetal requirement for nutrient is met by the mother through the placenta. The enzymes needed
for digestion is not fully matured to function until a few days after birth, it is important to avoid
over feeding, as the digestive capacity is low at this period (15-30 ml).It increases rapidly with
the first one week of life. Early feeding is required to maintain normal blood glucose level (2.2 –
4.4mm/l feeding stimulate liver function and colonization of the gut which aid formation of
vitamin K. Cardiac sphincter is weak and this predisposes the infant to possetting or
regurgitation.
2.2.2.6 Elimination
Elimination of waste product involves the bowel, kidneys, liver, skin and the lungs. In the
absence of hypoglycemia and hypothermia the new born is capable of evacuating its wastes (e.g.
meconium, stool, urine etc) provided there is no mechanical obstruction. Meconium is the first
stool and is present in the rectum as early as the 16th week of pregnancy. It should be passed in
the first 48 hours of birth. Composition of Meconium: Fatty Acid, bile pigments, debris from the
intestinal tract (epithelial cells), vernix caceosa, lanugo and liquor amni starts to change colour to
yellowish brown by 3rd – 5th day of birth and completely yellow when feeding is established.
2.2.2.7 Urinary System
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The kidneys are well formed in-utero but not functioning well. This account for the metabolic
acidosis in the preterm baby. Urine secretion occurs in the latter half of pregnancy. Baby
sometimes passes urine at birth or within 24 hours after birth. The frequency and volume of urine
passed depends on the amount of fluid intake. Therefore baby needs fluid by 4-6hrs after birth.
Those prone to hypoglycaemia should have glucose water about 2 hours after birth. Urine should
be clear, odourless, at least about 20-30mls per day in the first 1-2 days and 100-200mls by the
end of the first week of life.
2.2.2.8. Hepatic
The liver act as a biochemical factory for preparation of proteins and other substances necessary
for tissue growth. It plays a major role in elimination of toxic product of metabolism. It
conjugates bilirubin non-toxic by conjugating with glucoronic Acid to form bilirubin
diglucuronide which is water soluble and non harmful to the tissue. The enzyme glucuronyl
transferase is responsible for the conjugation. This enzyme is inadequate in the first few days of
life this is the cause of jaundice in the newborn. The liver is capable of synthesizing protein
(albumin) especially in time of needs e.g. Infection, tissue break down, loss of protein etc. the
liver is able to take up oxygen and glucose as adults liver. The liver plays significant roles in
Iron storage, carbohydrate metabolism, coagulation and bilirubin conjugation. Iron is stored in
last 3 months of pregnancies.
2.2.2.9 Skin
A healthy newborn’s skin is smooth, pink with good tugor. The colour depends on race, ranging
from pink and white to olive or dark brown. There is hyper pigmentation of the genitalia and
nipple in dark colour, linear nigra may be present. The skin is darker for children of dark colored
parents in the first week of life except the palm and sole of the feet which remain pink. Sweat
glands are inactive in the first few days. There are plenty of palm and sole creases. Nails are fully
formed and adherent to the tips of the fingers, many extend beyond the finger. Hair is soft and
silky, may be straight or curly. The ear cartilage is well formed. Vernix caseosa is seen on the
skin especially around the folds. It protects the skin against infection.
2.2.2.10 Reaction to Organism
Baby does not produce active immunity during the intrauterine life because the environment is
relatively sterile, some passive immunity. However cross the placenta barrier to the baby. This
protects the baby for the first 3-6 months after birth when the baby starts to produce active
immunity for himself e.g. malaria, tetanus, measles, poliomyelitis etc. Baby has low resistance to
staphylococcus aureus etc. Out of the three immunoglobulin IgG, IgA and IgM only IgG with
small molecular weight is present adequately. It provides passive immunity during the first
month of life. Increase level of IgG at birth is suggestive of intrauterine infection. IgA and IgM
do not cross the placenta barrier but can be manufactured by the fetus. This prones the baby to
infection. IgA protects against specific viral infection of the Respiratory tract G.I.T., Eyes skin
and umbilicus. So all equipment used for delivery should be properly sterilized and
immunization should start as soon as possible. Cholostrum provides immunity in form of
lactobacillus bifidus, lactofarrin, Lysosymes and IgA.
2.2.2.11 Skeleto-Muscular System
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

At birth the long bones are incompletely ossified to allow growth of epiphysis. The vaults leave
sutures between them. Muscles are complete, growth occurs by hypertrophy rather than
hyperplasia. Skeletal muscle are used for movement very early in fetal life, this promotes motor
development.
Weight: The average weight at birth is 2.5 – 3.5kg. The birth weight is generally influenced by
the period of gestation but occasionally term babies weigh quite less than average. Boys are
usually 250g heavier than girls. Weight tends to increase with subsequent deliveries. Other
factors are placenta functions, nutritional state of the mother, race, structure and size of the
parents, sex, and type of pregnancy (single or multiple) state of health of the mother. There is
physiological weight loss in the first 3 days of life of about one tenth of the birth weight. The
bigger the weight the more the baby loses weight through the skin, meconium, urine, respiration,
inadequate food and fluid intake. With good feeding the baby should regain back the birth
weights by 8-10th day after birth. Sometime baby loses much less and gains the birth weight
much earlier. Weight may double by 5 months and triple by 1year. From the 4 th day a steady
weight gain 150-200g per week may occur.

Umbilicus
The stump of the umbilical cord shrivels and dries up by a process of dry gangrene and it
separate from the normal skin by 4-7 days (average of 6 days) a thick cord may take a longer
period. It is important to keep the cord dry and clean to aid separation. Delay in separation may
be due to infection.
2.2.2.12 Reaction and Response to Environment
A normal infant sleeps for about 20-22hrs a day during the first week of life. He only wakes up
to feed; this period of wakefulness later lengthens for social interactions
Crying: First cry is called Vagitus, usually with first breath that results in lung expansion.
Crying is the baby’s only language. Baby cries to alert of the slightest discomfort e.g. pain,
hunger, cold wet cloths.. Different cries cannot be easily recognized in first two weeks of life
because baby cries vigorously most times. Reasons for crying can be recognized by the nature of
the cry. A hunger cry is soft supple and continuous. Normal cry is lusty. High pitched or shrill
cry indicate intracranial injury. If the baby is neither hungry nor wet common changing of
position many quiet him. Later the baby may scream for colic pain, caused by air swallowing.
Parent may get advice on how to deal with crying to avert battered baby syndrome as mother
with unstable personality may be provoked by his cry and handle the baby roughly. The baby
does not weep but cries.
2.2.2.13 Special Senses
Vision
The structures necessary for vision are present and functioning at birth but they are immature
giving rise to poor focusing. Baby can focus at 15-20cm at the level of mother’s face and at 30
degrees in either direction when being nursed, this aid bonding process. He can track a moving
object. Bright light seems unpleasant which makes him to blink or frown. He can recognize
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

mother’s face by 2wks. He can recognize bright, black and white colours, interest in colour
variety develops within the first two months of life.
Full term baby can shed tears though may not be obvious until a few weeks after birth.

Taste
Sense of taste is highly developed. This is shown by his preference for sweet fluids and breast
milk and rejection of sour, salty and bitter tastes.
Touch
This is the most highly developed of all the senses and this is more acute on the lips, tongue, ears
and forehead. They enjoy skin to skin contact, immersion in water, stroking cuddling and
rocking movement. Baby withdraws from painful stimulus and cries. Failure to grasp nipple is an
indication of brain damage.
Hearing
Neonate can hear though can not distinguish between sounds. He reacts to high pitched sound
while a sudden sound can cause a startle or blink reflex. He prefers the sound of human voice to
other sounds. He reacts to the mother’s voice. This promotes mother child bonding. Baby reacts
to loud noise.

Smell
Baby can distinguish the smell of mother’s milk from others. He turns away from unpleasant
smells. Strong scents give the baby cold.
2.2.2.14 Reproductive systems
The sex of the fetus is determined at the time of fertilization, but not distinguishable until the end
of second months of pregnancy. In boys the testes descend into the scrotum as early as 24-34wks
of pregnancy. The canal through which they descend is not completely closed until several
months of age. Sometimes one or both testes are undescended at birth; such require doctor’s
attention for evaluation of the course and further treatment. The urethral meatus opens at the tip
of the penis and prepuce is adherent to the glans. Spermatogenesis does not occur until puberty.
In girls, labia majora cover the labia minora, the hymen and clitoris are large. The premodial
follicle containing primitive ova are present in the ovary. In both sexes withdrawing of maternal
oestrogen results in breast engorgement sometimes accompanied by secretion of milk by 4 th – 5th
day. Baby girl may develop Pseudo menstruation for the same reason. At birth, both sexes have
nodule of breast tissue grounded in the nipple on the chest wall.

2.2.3 Activity
During your posting in the labour ward, describe the first response of the baby to life,
describe your experience on the discussion forum.
2.2.4 Self-Assessment Question(SAQ) Unit 2
Describe circulatory adaptation of the newborn
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

2 2.4.1 Self Assessment Answer(SAQ)

Circulatory Adaptation

 Placenta is the organ of gaseous exchange in fetal life. At birth when the baby is
separated from the placenta (life support system) he has to make a major adjustment
within his circulatory system for blood to flow to the lungs for re-oxygenation.

 This involves several mechanisms which are influenced by clamping of the cord and
pulmonary vascular bed resistance.

 In-utero only about 10% of blood flow to the lungs, but with the clamping of the cord
most of the blood goes to the lungs.

 As this oxygenated blood from the lungs return to the heart, the pressure in the left
atrium increase and the pressure in the right atrium decreases because blood no longer
flow from the cord there.

 This results in functional closure of the foramen Ovale. The Ductus arteriosus contracts
and closes to become a cardiac ligament within five minutes of birth.

 Sometimes this may not be complete immediately leading to periodic cyanotic attack e.g.
preterm and respiratory distress syndrome. But final closure takes place within first one
year of birth.

 All other temporary openings i.e. umbilical vein, Ductus venous are hypogastric arteries
also close down.

 Due to high metabolic need the heart beats rapidly (120-160/min) with the mean of 140
and this can be influenced by baby’s activities.

 The heart lies transversely and the apex beat can be detected at the 3rd or 4th intercoaster
space on the left side. Peripheral circulation is sluggish resulting in cyanosis of the limbs.
Blood pressure varies according to activities 50/25 – 70/40 mmHg.
Blood:

 Pulse rate 100-120b/min. The total blood volume at birth is about 80ml/kg ~ 8% of the
body weight, but this may increase if cord is not closed on time.

 Haemoglobin level is between 17-20gm milliliter and is 70% fetal Hb. As soon as normal
saturation of oxygen is normalized production of FHB ceases and is gradually replaced
by adult type within 1-2 years of life. Haematocrit is 55%, Red cell Count (RCC) is 5-7 x
102/l.

 The excess is broken down in the liver and spleen which predisposes the infant to
jaundice. Prothrombin level is low due to lack of vitamin K until the gastrointestinal tract
is colonized by bacteria which synthesize intrinsic vitamin k when feeding is established
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

 . Hence the infant is prone to bleeding in the first week of life especially the preterm
infants.

 The platelet level is equal with adult’s white blood cell is high but soon returns to
normal.
Unit 3. Care of the newborn
Content
2.3.0 Learning Objectives for unit 3
2.3.1 Introduction

2.3.2 Immediate Care

2.3.2.1 Assessment of the Baby’s Condition at Birth
2.3.2.2 Subsequent Care
Maintenance of Respiration
Maintenance of Warmth
Provision of Food
Protection from infection and injuries
Observation and Recording
Education of Mother
2.3.3 Immunization and Immunization schedule

2.3.4 Activity

2.3.5 SAQ (Tests Learning Outcome 3.3

2.3.0 Learning Outcomes for unit 3

At the end of this unit, you should be able to:
a. Perform immediate care of the newborn
b. Evaluate the newborn using Apgar scoring
c. Maintenance of Respiration , warmth, nutrition and protection the newborn from
Infection and injuries
d. Give health education to mothers on the care of newborn
2.3.1 Introduction
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

It is the duty of the Nurse to assess the neonate's physical and behavioral condition, conduct
routine procedures teach the parent important aspect of child care. During this time the nurse
looks for deviation from the normal or other concerns that may need further evaluation or
intervention.
Nursing care of the newborn therefore emphasized neonatal assessment, procedures, infection
prevention and the teaching of infant care to the mother and family.

2.3.2 Immediate Care:

This includes care given during and after delivery. Immediately the baby’s head is delivered, the
face, mouth and eyes are wiped. The airways are sucked with mucus extractor or low grade
suctioning machine. The remaining liquor from the mouth is drained by lowering the head or
turn upside down (this is not done if the baby is in shock). When the baby is completely
expelled, note the time, double clamp the cord with artery forceps, first forcep being at 8cm and
the second one at 10cm from the base of the umbilicus and cut in between them and ligate the
cord. The baby obtains about 30-60mls of blood if the cord is not clamped until pulsation ceases.
Wipe the baby’s body; show the baby to the mother to identify the sex. Assess the baby’s
condition within the first 1 minute and 5 minutes later. Label the baby before leaving the
bedside. Throughout, the baby’s need for warmth should be kept in mind.
2.3.2.1 Assessment of the Baby’s Condition at Birth
As soon as the baby is born, the general condition of the baby is assessed using the most widely
used method APGAR SCORE (invented by Dr. Virgina Apgar in 1953. The assessment is done
at 1 minute and 5 minutes later. The first 1 minute is important for further management of
resuscitation.
Apgar score can be defined as clinical assessment of the baby’s condition measured in numerical
term at 1 minute after birth and 5 minutes later. Apgar score makes for proper evaluation, closer
observation of the baby and ensures early evaluation of the baby’s condition; it prevents
unnecessary delay in resuscitation. Apgar score should be properly documented. The higher the
score the better the prognosis of the baby and lesser the score the greater risk of permanent brain
damage.
The factors to look for are:
A - Activity - Muscle tone
P - Pulse - Heart rate
G - Grimace - Response to stimulus
A - Appearance - Colour
R - Respiration - Breathing
A score of 0, 1, or 2 is awarded to each item.
Apgar Score
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Signs 0 1 2

Heart Rate Absent Less than 100 More than 100 bpm
b.p.m.

Respiratory effort Absent slow, irregular Good or crying

Muscle tone Limp some reflexion of Active

limbs.

Response to None Minimal grimace Cough or sneeze

Stimulus

Colour Blue, Pale Body pink, Completely pink.

extremities blue

A score of 8-10 is good. A score less than 7 will need medical Aids and active resuscitation.
8-10 -Good
5 -7 -Mild asphyxia
0-4 -Severe asphyxia

2.3.2.2 Subsequent Care

Principles of Care
1. Maintenance of Respiration
2. Maintenance of Warmth.
3. Protection from Infection and injuries
4. observation and Recording
5. Provision of food/fluids
6. Education of the mother.

 Maintenance of Respiration
It is important to ensure that the baby maintain patent airways. Baby should continue to breath. If
the baby is mucousing, clear the airways frequently. Stomach washout could be done if
necessary. Keep baby on his side and turn from side to side. Avoid suffocation from clothing and
pillow or mother lying over the baby.
Maintenance of Warmth
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Source: newborns.standford.edu

 Maintenance of Warmth
At birth the baby’s temperature regulatory centre is very poor, so it is important to keep baby
warm. Avoid over exposure to prevent heat loss. Put on warm clothing, cotton materials are
good, wooly material on the skin can lead to heat rashes. Additional clothing or blanket may be
required on cold days; a hat may also be required. Avoid over clothing of baby especially on hot
days. Clothing should vary with environmental temperature.

 Provision of Food
As much as possible breast feeding should be encouraged. Mother should put her baby to breast
as soon as possible. Feeding should be on demand. In the first day the infant needs about 30mls
of feed. Baby friendly should be practiced as much as possible. If need be in case of sick or dead
mother plain fluid or glucose water may be given 4-6hrs after birth. Glucose aids proper
absorption and gives calories to the baby.

 Protection from infection and injuries

Neonate should be protected from all forms of injuries. Midwife must keep her finger nails short
when holding the baby and grip the hand securely, protect baby when sleeping to avoid rolling
down from bed. Avoid the use of sharp object/instruments for the baby. Dresses must be clean,
napkins should be changed as necessary. Wash hand thoroughly before handling the baby.
Baby’s items must be separated from the family’s. Restrict handling by visitors. Maintain
hygiene of mother and the baby and feeding utensils. There should be proper cot spacing in the
nursery. Ideally baby should be with the mother – (Rooming in method). Avoid the use of pillow
to prevent suffocation prevent choking; fall, over laying, bright light and strong wind.

 Observation and Recording

After the initial assessment, a general and complete examination is performed later. Neonate
must be examined daily to ensure he is healthy and thriving well. During the first 24 hrs close
observation is necessary as the majority of complication manifest during this time. The doctor
depends on the vigilant observation of the Midwife to detect abnormalities and early signs of
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

illness, and on her careful recording of her finding. The baby is examined from head to toe, both
physically and neurologically.
Head – For size, shape, sutures and fontanelles and any abnormalities are noted.
Eyes and Ears for – discharges
Mouth - Infection, thrush
Skin – colour for cyanosis and jaundice rashes around the neck, axilla and groins buttocks
and all skin folds.
Temperature – twice daily, normal 36.50 – 37.50
Respiration – Rate and type are most important during the first 48hours of life. It should be
smooth, regular and quiet. Any periodic apnoea, grunting respiration, flaring of the nasal alae or
withdrawing of the chest wall should be reported.
Abdomen – check for distension rashes or protrusion.
Umbilicus: Note bleeding, infection etc.
Groin & Buttocks – Sore and rashes.
Stool & Urine – Meconium should start to change colour by the 2nd day. Bowel should
open 3-4 times daily in a breast feeding baby.
Urine – Passed within 24 hours, should be clear, it may be up to 6 times in 24hrs and
should not be less than 30mls.
Weighing – At birth then every alternate days, maximum drop of 50gm daily for the first 3
days. From the 4th day there should be daily increase of 30gm and should recover the lost weight
by 8-10 days.
Feeding – should suck actively on breast if given artificial milk amount is recorded.
Healthy baby feeds eagerly on demand or timed.
Cord – check for signs of infection should be dry and not-offensive. It should fall of 5-7
days after birth.
Behaviour – Activities, sleep, feeding patterns are observed

 Education of Mother
This should have started from the ante natal clinic. Midwife must ensure that the woman receives
enough instruction and supervision. She must be a good example to her patient. She should
demonstrate how to do baby bathing, changing of napkin, feeding and general care of the baby.
Instruction should be given as regard self medication to herself and baby, regular immunization
and further care at the nearest welfare clinic. She should report any problem to her doctor or
Nurse.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Mother should be taught how to deal with baby’s crying. She should have adequate education on
nutrition for herself and the baby.
2.3.3 Immunization
To improve child health in Nigeria, a new pentavalent vaccine has been introduced to the normal
routine immunization schedule. Pentavalent vaccine is a combination of five vaccines-in –one
that prevents diphtheria, tetanus, whooping cough, hepatitis B, and haemophilus influenza type
B, all through a single dose.
Children between six weeks and one should receive three doses of pentavalent vaccine with an
interval of at least four weeks between doses. They are also to receive other routine
immunizations like BCG for tuberculosis, OPV for polio, measles and yellow fever vaccines
must be completed
Immunization schedule

AGE ANTIGEN

Birth BCG, OPV0,HepB0,(OPV0 and HepB0 must be given

within 2weeks of delivery)

6 weeks OPV1 , pentavalent 1

10 weeks OPV2 , pentavalent 2

14 weeks OPV3 , pentavalent 3

9 months Measles, and Yellow Fever vaccine

2.3.4 Activity
Visit the infant welfare clinic and choose five mothers and find out the immunization schedule of
their babies, check if appropriate with the age of their babies. Investigate what the mothers know
about immunization, their concerns and plans to complete the immunization of their children.
Share your experience with your colleagues on the discussion forum.

2.3.5 SAQ (Tests Learning Outcome)

 Describe the immediate care of the newborn

SAQ 3.3 (Tests Learning Outcome 3.3)

Immediate Care:
This includes care given during and after delivery. Immediately the baby’s head is delivered, the
face, mouth and eyes are wiped. The airways are sucked with mucus extractor or low grade
suctioning machine. The remaining liquor from the mouth is drained by lowering the head or
turn upside down (this is not done if the baby is in shock). When the baby is completely
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

expelled, note the time, double clamp the cord with artery forceps, first forcep being at 8cm and
the second one at 10cm from the base of the umbilicus and cut in between them and ligate the
cord. The baby obtains about 30-60mls of blood if the cord is not clamped until pulsation ceases.
Wipe the baby’s body; show the baby to the mother to identify the sex. Assess the baby’s
condition within the first 1 minute and 5 minutes later. Label the baby before leaving the
bedside. Throughout, the baby’s need for warmth should be kept in mind.

References

Baker, P. N., & Kenny, L. C. (Eds.). (2011). Obstetrics by 10 Teachers. Hodder Arnold.
Cowen, K., J., London, M. L& Ladewig, P. A. (2010). Skills manual for maternal and child
nursing care. Prentice Hall
Fraser, D. M., & Cooper, M. A. (Eds.). (2009). Myles' textbook for midwives. Elsevier Health
Sciences.
Holmes, Debbie, Philip N. Baker (2006). Midwifery by ten teachers. Hodder Arnold,
Ladewig, P., Ball, J., & Bindler, R. (2011). Maternal & child nursing care. Pearson Education.

Module 3: Culture and care of the newborn

Introduction:
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Cultural and traditional practices, values and beliefs play an important role in the medical

attention-seeking behaviour of postpartum mothers as well as in newborn babies during the

postnatal period.

There are various traditional and cultural practices followed which affect the newborn. A family

which mirrors values, traditions, customs and beliefs, i.e. culture of a society to which it belongs,

plays an important role in physical, psychological, social development and health in children.

Module Objectives
At the end of the module the learner will be able to:
i. Articulate cultural practices and other factors that contribute to child development.
ii. Discuss the role of the paediatric nurse in cultural care of newborn

Content
Unit 1: Cultural practices in child care and factors contributing to child
development.
Content
3.1.0 Introduction
3.1.1 Learning Objective
3.1.2 Cultural practices in child care

3.1.2.1 Behavioral Expectations

3.1.2.2 Affection
3.1.2.3 Education

3.1.2.4 Physical Punishment

3.1.3 Factors That Influence Infant Development

3.1.3.1 Good Nutrition

3.1.3.2 Stimulation and Interaction
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.1.3.3 Secure Attachment

3.1.3 4 Adequate Sleep
3.1.3.5 Hereditary Factors
3.1.3.6 Physical characteristics
3.1.3.7 Socioeconomic Factors
3.1.3.8 Poverty
3.1.3.10 Homeless
3.1.3.11 Migrant Families
3.1.3 12 Communication
3.1.3.13Food Customs

3.1.3 Activity
3.1.4 Self-Assessment Questions (SAQs) for Unit 2
3.1.0 Introduction:
Cultural beliefs and practices are an important part of data gathering in the nursing assessment.
Nurses continually encounter beliefs and practices that may facilitate or impede nursing
interventions, including attitudes toward family planning, food habits, and folkways that are
firmly entrenched in the culture. The language of the client may be different from that of the
larger culture, or there may be regional or ethnic peculiarities in the use of basic English. Sub-
cultural influences, such as some religious beliefs and practices, may be in conflict with standard
health practices and therapeutic interventions
Many factors affect a child's development. Some of them we don't even see or know about
except when we look out for them and pay attention to family interactions. Some examples of
factors that affect a child's development are the child's housing, their family's financial status,
their parent's employment, their education, gender, race, class, physical and mental health, their
level of attachment, their parent's parenting styles and the social group they are exposed to.
3.1.1 Learning objectives
At the end of the unit you will be able to:
i. Explain the cultural practices in child care

ii. Discuss the factors influencing child development

3.1.2 Cultural practices in child care

Parenting is an activity rooted not only in one’s own childhood experiences, but in the culture
one grew up and lives in. Culture can have a powerful effect on parenting styles and practices,
according to the Centers for Disease Control and Prevention. For example, a culture in which the
father is expected to be a stern disciplinarian and the breadwinner will have a different effect on
child-rearing practices than one in which both parents work full time and parenting
responsibilities are shared.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.1.2.1 Behavioral Expectations

Parents have behavioral expectations about their children that are similar in many cultures,
according to the CDC. Among the areas of consensus: children should be respectful and polite,
not interrupt, be honest, share and do well in school. However, some cultures have additional
expectations. Asian and white parents expect children to exert self-control, while black, Latino
and American Indian fathers often feel their children should have a religious or spiritual
foundation, according to the CDC. Asian, Latino or black fathers often expect their children to be
assertive, independent and willingly take responsibility for their mistakes.

3.1.2.2 Affection

One area in which cultures often differ is in the ways parents display affection toward their
children. West African, Arabic and Asia-Pacific communities often stop such practices as kissing
or fondling a child once she becomes a toddler. However, some cultures consider physical
attention such as bathing, skin care or braiding a child’s hair to be appropriate physical ways to
express affection. Monetary rewards and praise are also signs of affection in these cultures,
according to a presentation at the 2012 National Foster & Kinship Care Conference.

3.1.2.3 Education

Many parents see educational attainment as desirable for their children. In some Chinese
families, however, physical punishment might be used to induce children to study hard and get
good grades, according to the NFKCC. Furthermore, Asian and Indian families might also exert
considerable pressure on their child to achieve scholastically. Parental involvement in activities
such as checking a child’s homework also varies by culture. The Center for Public Education
reports that 82 percent of white parents check homework, while 91 percent of Hispanic and 94
percent of black parents check homework.

3.1.2.4 Physical Punishment

Physical punishment is another area in which parents of different cultures act differently. Most
parents view spanking as a last-resort strategy, but felt it was acceptable, according to the CDC.
Black parents were more willing to spank a child in a public place because they felt the need to
immediately respond to misbehavior. White and American Indian parents were less comfortable
with spanking in public. Some black, Latino and white parents think it's acceptable to use a belt
or strap for spanking for serious misbehavior, while Asian-American and American Indian
parents felt that they should only use their hands.

3.1.3 Factors That Influence Infant Development

Infant growth and development is fascinating to witness, to which most parents can attest. The
rate at which a baby goes from being a helpless newborn to sitting, crawling and walking is
nothing short of astounding. In the first year of life, several key factors can influence a baby's
development positively -- and the good news is that parents can do concrete, everyday things to
ensure their infant is happy, healthy and thriving.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.13.1 Good Nutrition

First things first: To grow well, babies must be fed properly.

"Feeding of your baby appropriately during the first year of life is

extremely important, as more growth occurs during your baby's
first year than any other time in her life. Starting good eating habits
at this early stage will help set healthful eating patterns for life,"
Children's Hospital Boston.

For the first few months, all a baby needs is breast milk or formula; you should not start solid
foods before an infant is 4 months old. When a baby does start solid foods, parents should try to
offer a variety of foods early, which may lead to good eating habits down the road.

3.1.3.2 Stimulation and Interaction

Infants need lots of stimulation and interaction, which is essential for their cognitive and
emotional development. Talking, singing, playing music, carrying on "conversations" (such as
exchanging babbling-type sounds counts for conversation), and reading stories with babies builds
their vocabulary, demonstrates emotions, and teaches problem-solving skills, says the California
Childcare Health Program. The program recommends that parents provide their infants with a
variety of experiences and surroundings, and visit museums, aquariums, zoos and farmers’
markets to stimulate their senses. Babies in the first year also love it when you read to them, the
CA Childcare Health Program notes -- and, even though they cannot follow the story, the
pictures and sound of a parent's voice are fascinating to them. And perhaps most important of all,
the program says, is touch, which is critical for infants, because it is how infants know their
parents love and want them. Physical contact with parents and caregivers sends signals to infants'
brains, telling them to grow and to make important connections.

3.1.3.3 Secure Attachment

A healthy, secure attachment in infants, which is defined as "the emotional connections babies
form with their parents and caregivers," develops gradually over time, if adults provide
"consistent, sensitive" care, note Linda Gillespie and Amy Hunter of the National Association
for the Education of Young Children. This idea stems from attachment theory, which is the work
of psychologists John Bowlby and Mary Ainsworth, which holds that babies relate to their
primary caregiver, in different ways, depending on the quality and consistency of their care. A
secure attachment is crucial: As the U.S. Department of Health and Human Services writes, "The
importance of early infant attachment cannot be overstated. It is at the heart of healthy child
development and lays the foundation for relating intimately with others, including spouses and
children. It affects parents' abilities to nurture and be responsive to their children.

The effects of infant attachment are long-term, influencing generations of families." Parents can
create a healthy attachment in their infant by reading her cues (such as crying, screeching,
laughing, turning away, pointing) and responding promptly to her needs and wants -- which is
how an infant learns that the caregiver is "a source of comfort and security," say Gillespie and
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Hunter. They also note that research demonstrates that how parents interact directly with their
babies affects later development: Babies who display secure attachments become children who
learn their world is a safe place to be because the people in it are caring; that close relationships
feel good; that their attempts at communication result in responsiveness and understanding; and
they can feel confident in exploring their world, which enables them to learn.

3.1.3.4 Adequate Sleep

Once infants are past the newborn phase, which is usually between 3 and 4 months, they need
between nine and 12 hours of sleep per night for optimal health. When they get this sleep
depends, as nap times of infants vary, with most taking 30-minute to 2-hour naps one to four
times a day. As tough as it is to teach a baby to sleep well, parents should try to instill good sleep
habits in infancy, notes Michael J. Breus, Ph.D. in the article "Good, Sound Sleep for Your
Child" on WebMD. He notes that babies who do not get enough sleep are more " Freitful l and
socially demanding," and are not as comfortable playing independently. And it is not just the
baby years that are affected: Breus contends that chaotic and erratic sleep patterns in infancy
relate to problems with learning, attention and memory in childhood.

To establish positive sleep habits, HealthyChildren.org recommends that you put infants to bed
drowsy, but not asleep, allowing them to become "self-soothers" who can fall asleep
independently and who also can put themselves back to sleep in the middle of the night if they
wake in their cribs. Also important: Developing regular daytime and bedtime schedules, creating
an enjoyable and relaxing bedtime routine, and creating a sleep-friendly, optimal temperature in
a quiet and calm environment for babies.

3.1.3.5 Hereditary Factors

The genetic constitution of individuals as groups influences the degree to which they are
susceptible to a specific disorder. It may be the result of an inherent lack of resistance to a
disease organism, a trait that is an advantage in one environment but which places the possessor
at a disadvantage in another, or it may be the consequence of intermarriage within a relatively
narrow range of geographic, ethnic, or religious restrictions.
A geographic constraint is illustrated by the classic example of the common communicable
disease rubeola. The rubeola virus, or the populations that were continually exposed to it,
became altered in such a way that the disease was considered to be a universal disease of
childhood from which the majority of children suffered without ill effects. When other
populations (e.g., the inhabitants of the Hawaiian Islands) were exposed to the virus by explorers
and missionaries, they experienced a violent response that resulted in high mortality.
Another communicable disease, tuberculosis, appears to be more prevalent in certain ethnic
groups such as the Native Americans of the Southwest, Vietnamese immigrants, and Mexican-
Americans (Orque, l983b). In many populations it is difficult to determine how much the
increased incidence can be attributed to ethnic factors and how much is related to the life-styles
in the lower social strata.
A number of diseases show ethnic or racial differences. For example, Tay-Sachs disease,
characterized by early neurologic deterioration and mental retardation, affects primarily
Ashkenasi Jewish families, particularly those of Northeastern European origin, while Sephardic
Jewish families appear to be no more at risk for the disease than other populations. The incidence
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

of cystic fibrosis is highest in whites, it is almost nonexistent in Orientals, and the rare affected
blacks are usually in areas where there is apt to be mixed ancestry. Some selected genetic
disorders that are more prevalent in certain populations are listed in Table 2- 2. Racial and ethnic
differences are further considered in relation to diseases and defects as they are discussed
throughout the book.
Other groups appear to have a predisposition for certain diseases. Although sickle cell disease is
a classic disorder of blacks, especially Africans, cardiovascular disease, pneumonia, and diabetes
are also high among blacks. Hispanics are more likely to suffer from diabetes and
infectious/parasitic diseases than their Anglo counterparts, and Native Americans have
particularly high rates of tuberculosis, diarrhea, alcoholism, and suicide (Bullough and Bullough,
1982; Markides and Coreil, 1986).
Common food items and drugs may cause health problems in certain racial groups. For example,
persons with glucose-6-phosphate dehydrogenase (0-6-PD) deficiency develop acute hernolytic
anemia after they ingest fava (horse or broad) beans or certain drugs such as aspirin preparations,
sulfonamides, or primaquine. The deficiency is the most common enzyme abnormality and is
found in a large percentage of people around the world, especially those of Mediterranean,
African, Near Eastern, and Asian origin (Cohen, 984).
The sensitivity to foods containing lactose is a common hereditary characteristic of several
cultural groups, especially southern Europeans, Jews, Arabs, blacks, Asians, and Native
Americans. Lactose intolerance usually does not become a problem until the child reaches 3 to 5
years of age. However, lactose-intolerant children become uncomfortable with distention, flatus,
and diarrhea after ingesting milk or milk products. Unknowing but well-meaning health workers
may be responsible for these symptoms in their clients when they prescribe foods containing
lactose as sources of nutrients.
An example of resistance to disease, or selective advantage, of a population is found in persons
who possess the sickle cell trait. Persons with sickle cell trait are highly resistant to a form of
malaria, and in the parts of the world
Where the organisms are prevalent, there is a high frequency of the trait. However, in an
environment where malaria is not a threat, possession of the trait has no advantage and only the
negative aspects of the condition remain (risk of sickle cell anemia in offspring).
3.1.3.6 Physical characteristics.
Among racial groups there are observable differences in physical appearance. The most obvious
are skin and hair coloring and texture. Skin color is determined by the amount of melanin
pigment present in the skin. Persons from countries located near the equator have darkly
pigmented skin, which serves to protect the skin from the year-round exposure to the sun’s rays;
persons from the northern countries have very light skin, which provides for maximum exposure
to the sun’s rays (necessary for vitamin D metabolism) during the short daylight hours. There can
be wide variations in skin color between these two extremes in terms of geographic origin or
from intermixing of dark and light skin color.
As a consequence of the dark pigmentation, the detection of skin color changes can be difficult
and requires modification of assessment techniques. For example, vasomotor alterations,
cyanosis, and jaundice observable in the skin are not easily recognized in very dark or black skin.
Variations in the skin color can alter the appearance of the skin in a given circumstance (see
Table 7-8).
Variations in the newborn are often related to racial or ethnic origin. For example, newborn
infants of Asian and black parents are smaller than infants of white parentage (David, 1990).
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Bluish pigmented areas (mongolian spots) on the sacral region are a common observation on
Oriental, black, Native American, and Mexican-American infants.
Evaluation of stature and body build reveals some racial tendencies. Oriental children are usually
smaller at all ages and black children are taller and heavier between ages 5 and Id than white
children of the same age (see growth measurements, Appendix C). This difference in stature can
lead to misinterpretation of health status and capabilities. Black children who appear normal for
their age may, in fact, be underdeveloped when compared with other black children (Bloch,
1983). In communication and education a child who is smaller than the average may appear
precocious and one who is larger might appear to be slow. Expectations determined on this basis
can be detrimental to the child.

3.1.3.7 Socioeconomic Factors

The most overwhelming adverse influence on health is socioeconomic status. A higher
percentage of lower-class individuals are suffering from some health problem at any one time
than are those in any other group. The sum of all aspects of their situation contributes to and
compounds health problems; this includes crowded living conditions and poor sanitation, which
facilitate transfer of disease. There is a higher incidence of lead poisoning in children from
tower-class families, where there is more ready access to lead in the environment, such as paint
and other lead- containing compounds or utensils, pottery with lead-containing glazes, and
burning of lead-containing batteries for heat in winter.
In the lower classes, children are less likely to be immunized against preventable diseases than
are children in the upper and middle classes. Lack of funds or inaccessibility to health services
inhibits treatment for any but severe illness or injury. Sometimes health care is inadequate
because of ignorance. In some areas a disorder is so commonplace that it is looked on as
unavoidable; it is not recognized as something that requires (or is amenable to) treatment. The
parents may not have information regarding causes, treatment, outcome of the illness, or
preventive measures.
3.1.3.8 Poverty
A high correlation between poverty and the prevalence of illness has long been observed.
Impoverished families suffer from poor nutrition; they have little if any preventive health care,
inadequate health maintenance, and very limited access to health services. One of the most
significant health problems related to poverty is a high infant mortality rate (Wise and Myers,
1988). Health care often ranks low on their list of priorities. Day-to-day needs of food, clothing,
and lodging take precedence as long as the ailing person feels able to perform activities of daily
living.
Poor families are denied access to many health institutions for emergency or other hospital care.
Frequently they must travel long distances to service centers that are willing to assume their care.
In an emergency they must find money for taxi fare, borrow an automobile, or seek other means
of transportation. They must find care for dependents, such as other infants and small children, or
have them accompany them when taking the ill child for care. Families tend to delay preventive
care indefinitely unless health services are relatively accessible. They are more likely to consult
folk practitioners or other persons within their community.
Poor nutrition accounts for many health problems in the lower classes. Lack of funds and
ignorance result in a diet that may be seriously lacking in essential food substances, especially
protein, vitamins, and iron. This inadequate diet often leads to nutritional deficiency disorders
and growth retardation in children. In many the total intake is insufficient to support normal
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

growth. Unstructured eating pat- ferns and irregularly scheduled mealtimes can also contribute to
erratic food intake and a proportionately larger consumption of nonnourishing snacks, which can
result in excessive weight gain.
Because of deficient preventive care, dental problems are more prevalent. Lack of standard
immunizations together with reduced resistance from poor nutrition renders the exposed children
in poor segments of the population vulnerable to communicable diseases. Poor sanitation and
crowded living conditions also contribute to the higher incidence and perpetuation of illness. In
general poor people become ill more frequently and remain ill for longer periods of time than
persons in the general population.

3.1.3.9 Homeless
Homeless children experience all of the health problems associated with poverty, as well as
other types of disorders. Preventive health care, especially immunization and dental care, is
seriously lacking. Both delayed growth and overweight problems are common (Miller and Lin,
1988). Developmental delays, severe depression, anxiety, and learning difficulties have been
reported (Bass and others, 1990; Bassuk and Rosenberg, 1990). The erratic chaotic life-style of
these children increases their vulnerability to any number of physical and psychosocial problems,
including child abuse, illicit drug use, and prostitution (Alperstein and Arnstein, 1988).

3.1.3.10 Migrant Families

Migrants generally suffer more illness, both acute and chronic, than does the general population.
They are subject to unhealthy environments, poverty, and insufficient medical care; their health-
seeking behavior in general is an illness- or injury-oriented recourse to medical care. Affected
persons will postpone seeking care for themselves or their children until physical pain or
suffering is almost unbearable (O’Brien, 1982).
When medical care is provided to a migrant family, follow-up care is usually impossible because
of their transient life-style. Compliance to medical therapies is primarily related to accessibility
and availability. For example, medications provided by health workers are more likely to be
taken than those that must be obtained at a pharmacy. In addition, medications are often
discontinued following self-perceive recovery. Treatment regimens that do not interfere with
work or family responsibilities are most likely to be adhered to. Their entire approach to health
care is described by O’Brien (1982) as “pragmatic survivalism,” a concept “symbolizing a
pattern of health-illness attitudes and behaviors that locus on the achievement and maintenance
of low- level wellness in the most practical manner possible for the continuance of productive
life.”
The health problems of migrant children appear to be dental caries, upper respiratory tract
infections, otitis media, scabies and lice, intestinal parasites, pesticide exposure, injuries, teenage
pregnancy, and growth and development delay (American Academy of Pediatrics, 1989).
3.1.3.11 Communication
Communication is basic to all human relationships, but it may be a source of distress and
misunderstanding between persons from different ethnic groups, especially if the languages are
different. Ideally, conversations with families who are unable to speak the dominant language are
best conducted by a health care worker who speaks the language of the family. If this is not
possible, it may be necessary to engage the services of an interpreter. However, use of an
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

interpreter can be a source of misunderstanding if the interpreter is unfamiliar with the medical
terminology or if there are no corresponding words
:ne second language to express the ideas and concepts .Under discussion (see Communicating
with Families Through an Interpreter, Chapter 6).
Some persons with poor or limited language comprehension may simply smile and nod in
agreement if they do not understand the questions or directives, It is vital that the family fully
understand all implications of a child’s care and management before they sign permits for special
procedures or assume responsibility for the child’s care. It is not uncommon for an Oriental
family to indicate “yes” when in fact they mean “no” in order to avoid social disharmony.
They tend to use indirectness rather than confrontation and may become evasive when direct
questioning makes them feel uncomfortable (Chen-Louie, 1983; Orque, 1983b).
Nonverbal communication is a practiced art in many American Indian tribes, and the members
are highly sensitive to body language. They emphasize periods of silence to formulate thoughts
in preparation for speech and often remain silent after listening to statements by others in order
to properly assimilate what has been said, Interruption, interjection, or haste to arrive at abrupt
conclusions is perceived as immature behavior.
Eye contact is viewed differently in cultures, It is not uncommon for persons in some ethnic
groups to avoid eye contact and become uncomfortable when conversing with health workers. In
non-Western cultures, a patient may not look directly into the nurse’s eyes, as a sign of respect.
Some Native Americans will make eye contact during the initial greeting, but continued,
unwavering eye contact is considered insulting and disrespectful (Wilson, 1983).
There may be reluctance on the part of families to question or otherwise initiate contact with
health professionals. In the Asian cultures, for example, it is considered a sign of disrespect to
question those who are viewed as persons of authority (Orque, 1983b). A Japanese family may
wait silently rather than ask or question. They believe that the health professionals know best and
will meet their needs without being asked (Hashizume and Takano, 1983). It is also important to
avoid criticism. Criticism can cause the Japanese-American to “lose face,” to feel ashamed,
which is highly undesirable.
It is necessary to speak slowly and carefully, not loudly, when conversing with families who
have poor language comprehension. Many persons are able to read and write English better than
they can speak or understand it. Also, the dominant language usually takes over in anxiety-
provoking situations, even in persons who are able to communicate satisfactorily under ordinary
circumstances.
Terms of address and use of first and last names vary among cultures and can create confusion in
institutions. For example, in Asian cultures, the family name is given first in respect for the
family and the given names follow. Therefore all siblings in a family have the same first name
(in some families it may be the middle names that are the same). Ethiopians use no last names
but have a very complex system whereby women retain their last names after marriage and the
paternal grandfather’s name becomes a child’s last name. The Mennonites refer to children as
sons and daughters of a particular parent, such as “Josiah’s son,” rather than by the son’s name
(Elkin and Handel, 1989).
Although all people share the basic emotions, there are decided ethnic variations in the way
emotions are expressed. In some cultures (eg., persons of Latin orJewish background) emotions
are expressed openly and members are accustomed to share their sorrows and joys with family
and friends. Conversely, Nordic and Asian groups are more restrained in expressing emotion.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Nurses caring for persons of another culture will be better able to communicate if they
understand the common names used to describe symptoms and diseases: for example, miseries
(pain) and locked bowels (constipation) in black people and caida de la mollera (fallen fontanel
from dehydration), susto (fright), and la diarrhea (diarrhea) in Latinos.

3.1.3.12 Food Customs

Food customs and symbolism of various cultural, ethnic, and religious groups have become an
integral part of their lives. Although in a large country such as the United States most persons
have adopted the eclectic food habits that have evolved over countless generations, many ethnic
and Geographic food traditions and preferences are retained. Special holidays, ceremonies, and
life experiences such as births, birthdays, weddings, and death are often marked by special food
items or feasts. In many cultures specific food practices are followed during pregnancy in the
belief that certain foods damage the developing fetus.
The distinctive food customs of ethnic groups are a product of their native environment,
determined by availability. Fish is a staple food of persons living near the ocean, such as people
from Japan, Polynesia, and Scandinavia. Fruit and vegetable preferences are also directly related
to the climate in which these grow naturally or can be cultivated. The types of grin that are
ethnically associated are also those that grow best in their native lands. For example, rice is the
staple grain of the Orient and Pacific islands, wheat of the temperate climates of Europe, rye in
Scandinavia, and corn of the North American Indians, The diet of the Eskimo is predominantly
fish and meat, depending on which is the most easily procured in the area. Even in the
continental United States there are regional favorites, such as rice, horminy grits, and okra in the
southern states. In some cultures food is highly spiced; in others foods tend to be bland. Table 2-
3 lists the food items common to all cultures, and Table 2-4 outlines some of the foods associated
with some specific ethnic groups.
There are a number of restrictions related to food items. Some have a physiologic origin, such as
lack of dairy foods in the diets of some persons of African or Asian ancestry with lactose
intolerance. Others have religious restrictions, such as kosher foods and food preparation of the
Orthodox Jewish faith and the vegetarian diet of Seventh Day Adventists (see Vegetarian Diets,
Chapter 13).
Children in a strange environment, such as the hospital, feel much more comfortable when they
are served foods to which they are accustomed (Fig. 2-5). The hospital food often tastes strange
and bland, especially to children who enjoy the highly seasoned foods of their culture. The
family may be concerned that the child is receiving foods appropriate to their culture and beliefs
(see Health Beliefs, p. 46). Where possible, it is advisable to provide children’s ethnic foods or
allow families to bring favorite foods that are not available on the hospital menu. Concern for
differences in food habits and patterns projects an attitude of respect of the family’s ethnic or
religious heritage.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Now that you have completed this study session, you can assess how well you have achieved its
Learning Outcomes by answering these questions. You can check your answers with the Notes
on the Self-Assessment Questions at the end of this Unit.
3.1.4 Activity
There are several dialects in Nigeria perhaps with different cultural practices. Which ethnic
group do you belong to? Interview women from your ethnic group and 2 other ethnic groups
about cultural practices surrounding child birth and child care in the first to five years of life.
What are the similarities and differences? How do the identified cultural practices contribute to
the health or ill health of children from your understanding of factors contributing to the growth
and development of the child? Categorise the cultural practices into “useful”, “harmful”,
“undecided”. Submit your report to your facilitator.

3.1.4 Self-Assessment Questions (SAQs) for Unit 1

3.1.4.1 SAQ 1 Explain homelessness as a factor that influence infant development

Homelessness
Homeless children experience all of the health problems associated with poverty, as well as
other types of disorders. Preventive health care, especially immunization and dental care, is
seriously lacking. Both delayed growth and overweight problems are common (Miller and Lin,
1988). Developmental delays, severe depression, anxiety, and learning difficulties have been
reported (Bass and others, 1990; Bassuk and Rosenberg, 1990). The erratic chaotic life-style of
these children increases their vulnerability to any number of physical and psychosocial problems,
including child abuse, illicit drug use, and prostitution (Alperstein and Arnstein, 1988).

From Endres, J.B., and Rockwell, RE.: Food, nutrition, and the young child, St. Louis, 1980,
Mosby-Year Book, Inc., p. 180.

Unit 2: Role of the Midwife and Role of the Peaditric nurse in child care
Content
3.2.0 Introduction
3,2,.1 Learning Objectives
3.2.2 Role of the Midwife and the Peadiatric nurse
3.2.2.1 Family Advocacy
3.2.2.2 Child Advocate
3.2.2.3 Educator
3.2.2.4 Illness Prevention/Health Promotion
3.2.2.5 Health Teaching
3.2.2.6 Support/Counseling
3.2.2.7 Therapeutic Role
3.2.2.8 Coordination/Collaboration
3.2.2.9 Ethical Decision Making
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.2.2.10 Research
3.2.2.11 Health Care Planning
3.2.3 Activity
3.2 .4 Self-Assessment Questions (SAQs) for Unit
3.2.0 Introduction
Nursing of infants and children is consistent with the definition of nursing as ‘the diagnosis and
treatment of human responses to actual or potential health problems” (Nursing, 1980). Its
purpose is to promote the highest possible state of health in each child. Pediatric nursing consists
of preventing disease or injury; assisting children, including those with a permanent disability or
health problem, to achieve and maintain an optimum level of health and development; and
treating or rehabilitating children who have health deviations. At all times nursing of children
incorporates the family in the scope of care.
The emerging trend toward health care has been prevention of illness and maintenance of health,
rather than treatment of disease or disability. Nursing has kept pace with this change, especially
in the area of child care. In 1965 specialized pediatric nurse practitioner (PNP) programs began
to develop that have led to several specialized ambulatory or primary care roles for nurses. The
thrust of these programs has been to educate nurses beyond the basic preparation stage in areas
of child health maintenance so that all children can receive high-quality care. The practitioner
programs have expanded to prepare school nurse practitioners, hospital nurse practitioners, and
other specialists, such as the developmental pediatric nurse practitioner. Although the curriculum
varies from program to program, the course content generally includes history taking, physical
diagnosis, growth and development, health education, counseling, common childhood problems,
and planning care for individuals and groups.
The clinical nurse specialist (CNS) role has been developed in an attempt to provide expert
nursing care. The term nurse clinician is based on a primary philosophy of clinical competence in
direct patient care. The clinical specialist is competent in providing nursing care during all stages
of illness or wellness and functions in any of the settings where patients may be found-the
hospital, home, community, clinic, or long-term facility. The CNS role has developed within
each of the traditional specialty areas, as well as in other areas. The educational preparation
includes a graduate degree in nursing that may incorporate the practitioner skills. In some
settings the roles of the PNP and CNS are merging to create a new professional-advanced
practice nurse (Gleeson and others, 1990).

3.2.1 Learning Objectives

At the end of the unit you will be able to

i. Discuss the role of the paediatric nurse

3.2.2 ROLE OF THE PEDIATRIC NURSE

Pediatric nurses are involved in every aspect of a child’s growth and development. Nursing
functions vary according to regional job structures, individual education and experience, and
personal career goals. Just as clients (children and their families) present a vast and unique
background, so it is that each nurse will bring to the clients an individual set of variables that will
affect their relationship. No matter where pediatric nurses practice, their primary concern is the
welfare of the child and family.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.2.2.1 FAMILY ADVOCACY

Although the nurse is responsible to self, the profession, and the institution of employment,
primary responsibility is to the recipient of nursing services, the child and family. The nurse
must work with members of the family, identifying their goals and needs, and plan interventions
that best meet the defined problems. As a consumer advocate the nurse has the goal of ensuring
that families are aware of all available health services, informed adequately of treatments and
procedures, involved in the child’s care when possible, and encouraged to change or support
existing health care practices. The pediatric nurse is aware of the United Nations Declaration of
the Rights of the Child
3.2.2.2 CHILD ADVOCATE
Of special significance is the nurse’s role as child advocate. The Pediatric Bill of Rights,
composed by a 10-year-old child, clearly states the child’s views regarding the desired “rights”
(Box 1-3).

Unfortunately, most of these “rights” are not in the child’s best interest when health care is
needed. However, they emphasize the need for nurses to consider the child’s feelings and to
individualize care to allow for personal preferences, fears, and dislikes.
The concept of a traumatic care is particularly important to the pediatric nurse. A traumatic care
is the provision of therapeutic care in settings, by personnel, and through the use of interventions
that eliminates or minimizes the psychological and physical distress experienced by children and
their families in the health care system (Wong, 1989). The overriding principle in providing a
traumatic care is first do no harm. A concern for the child’s total welfare is the priority.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Throughout the text there are numerous examples relating to special needs of children in various
age-groups. As child advocate the nurse uses this knowledge to adapt care l)r the child’s
optimum physical and emotional well-being. Examples of this may be fostering the parent-child
relationship during hospitalization, preparing the child before any unfamiliar treatment or
procedure, allowing the child privacy, providing play activities for expression of fear,
aggression, or loss of control, and respecting cultural differences relating to childrearing
practices.
3.2.2.3 EDUCATOR
The nurse is aware of the needs of children and works with all caregivers to ensure that these
fundamental requirements are met. This often necessitates that the nurse expand the boundaries
of practice to less traditional settings. The nurse may be involved in education,
political/legislative change, rehabilitation, screening, administration, at in even engineering and
architecture. Regardless of how removed from direct patient care individual nurses become, they
continue to foster health care practices that promote the well-being of children by incorporating
knowledge of child growth and development into particular roles of practice. For example, as
educator the nurse has the primary responsibility of helping others learn about and care for
children.
The audience for this information may be other nurses, parents, schoolteachers, other members
of the health team, or the general public. In some states nurses are involved in mass media
programs for immunization of all children.

3.2.2.4 Illness Prevention/Health Promotion

The pediatric CNS plays an important role in the care of children, performing all the functions of
the pediatric nurse. In addition, however, the CNS should serve as a role model to the staff for
clinical practice, a researcher to validate nursing observations and interventions, a change agent
within the health care system, and a consultant/teacher to the health care team.
Every nurse involved with child care must practice preventive health. Regardless of the
identified problem, the role of the nurse is to plan care that fosters every aspect of growth and
development. Based on a thorough assessment process, problems related to nutrition,
immunizations, safety, dental care, development, socialization, discipline, or schooling
frequently become obvious. Once the problem is identified, the nurse acts to intervene directly or
to refer the family to other health persons or agencies.
The best approach to prevention is education and anticipatory guidance. In this book each
chapter on health promotion includes sections on anticipatory guidance
An appreciation of the hazards or conflicts of each developmental period enables the nurse to
guide parents regarding childrearing practices aimed at preventing potential problems. One of the
most significant examples is safety. Since each age-group is at risk for special types of injuries,
preventive teaching can help prevent most injuries, thus significantly lowering permanent
disability and mortality from injuries in children
Prevention also involves less obvious aspects of child care. Besides preventing physical disease
or injury, the nurse’s rote is also to promote mental health. For example, it ts not sufficient to
administer immunizations without regard for the psychologic trauma associated with the
procedure, Optimum health involves the practice of good medicine with a humane approach to
health care; the nurse is often the one professional capable of ensuring “humanity.” Because of
the current educational emphasis on holistic care, the extended and less formal interaction with
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

the family, and the nursing role within the health team, the nurse’s role is often one of facilitator
of care rather than direct intervention.
3.2.2.5 Health Teaching
Health teaching is inseparable from family advocacy and prevention. Health teaching is the
direct goal of the nurse, such as during parenting classes, or may be indirect, such as informing
parents and children of a diagnosis or medical treatment, encouraging children to ask questions
about their bodies, referring families to health-related professional or lay groups, and supplying
patients with appropriate literature. Anticipatory guidance is one of the most important types of
health teaching.
Health teaching is often one area in which nurses feel competent because it involves translating
information rather than receiving messages, translating them, and planning intervention. In other
words, it is a concrete, structured type of communication as opposed to other emotionally laden,
non-directed types of interaction. However, the nurse focuses on giving appropriate health
teaching with generous feedback and evaluation to promote learning.

3.2.2.6 Support/Counseling
Attention to emotional needs requires support and sometimes counseling. Frequently, the role of
paediatric is supportive by the very nature of the individualized approach. Support can be
offered in many ways, the most common of which include listening, touching, and physical
presence. The last two are most helpful with children because they facilitate nonverbal
communication.
Counseling involves a mutual exchange of ideas and opinions that provides the basis for mutual
problem solving. Although it is similar to health teaching, its focus is broader and more intense
because it frequently implies some crisis or upsetting event that needs intervention. It involves
support as well as teaching, techniques to foster expression of feelings or thoughts, and
approaches to help the family cope with stress. Optimally counseling not only results in a
resolved problem but also helps the family attain a higher level of functioning, greater self-
esteem, and closer relationships. Although counseling is often the role of nurses in more
specialized areas, counseling techniques are discussed in various sections of the text to help
students and nurses cope with immediate crises and refer families for additional professional
assistance.
3.2.2.7 Therapeutic Role
The most basic of all nursing roles is the restoration of health through care-giving activities.
Nurses are intimately involved with meeting the physical and emotional needs of children,
including feeding, bathing, toileting, dressing, security, and socialization, Although they are
responsible for instituting physicians’ orders, they are also held singularly accountable for their
own actions and judgments regardless of written orders.
A significant aspect of restoration of health is continual assessment and evaluation of physical
status. Indeed, the concentrated focus throughout the text on physical assessment,
pathophysiology, and scientific rationale for therapy is to assist the nurse in decision making
regarding health status. Only when aware of normal findings can the nurse intelligently identify
and document deviations. In addition, the pediatric nurse never loses sight of the emotional and
developmental needs of the individual child, which can significantly influence the course of the
disease process.
3.2.2.8 Coordination/Collaboration
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The paediatric nurse, as a member of the health team, collaborates and coordinates nursing
services with the activities of other professionals. Working in isolation does not serve the child’s
best interest. First, the concept of “holistic care” can only be realized through a unified
interdisciplinary approach. Second, aware of individual contributions and limitations to the
child’s care, the nurse must collaborate with other specialists to provide for high-quality health
services. Failure to recognize limitations can be non-therapeutic at best and destructive at worst.
For example, the nurse who feels competent in counseling but who is really inadequate in this
area may not only prevent the child from dealing with a crisis but may also impede future
success with a qualified professional.
Even nurses who practice in isolated geographic areas widely separated from other health
professionals cannot be considered independent. Every nurse works interdependently with the
child and family, collaborating on needs and interventions so that the final care plan is one that
truly meets the child’s needs. Unfortunately, this is one aspect of collaboration and coordination
that is lacking in health care planning. Often numerous disciplines work together to formulate a
comprehensive approach without consulting with clients regarding their ideas or preferences.
The nurse is in a vital position to include consumers in their care, either directly or indirectly, by
communicating their thoughts to the health team.
3.2.2.9 Ethical Decision Making
Ethical dilemmas arise when competing moral considerations underlie various alternatives.
Parents, nurses, physicians, and other health Care team members may reach different but morally
defensible decisions by assigning different weight to the competing moral values. Thus, nurses
are forced to determine the most beneficial or least harmful action within the framework of
societal mores, professional practice standards, the law, institutional rules, religious traditions,
the family’s value system, and the nurse’s personal values.

When ethical conflicts occur, nurses may experience conflicting loyalties to their profession,
colleagues, patients and families, institutions, and society. Moreover, the nurse’s role in ethical
decision making can be ambiguous. A nurse may be obliged to carry out procedures based on
physician orders or hospital policy that are inconsistent with the patient’s best interest. At times,
members of the health care team do not seek the nurse’s input or involvement, leaving the nurse
with incomplete information about the clinical situation or without a voice in decision making.
The role of nurses as members of the health care team justifies their participation in collaborative
ethical decision making. Nurses routinely use systematic problem-solving skills to resolve
clinical problems. Each decision requires the nurse to collect pertinent physiologic and
psychosocial data, assess relevant values held by the patient and family, and incorporate those
data into a plan of care. Each of these activities is a crucial component of ethical decision
making.

Furthermore, since nurses spend the most time directly caring for the child, they are in a unique
position to provide insight about the patient’s condition and response to therapy. In addition, they
assist families in dealing with their grief and stress and often interpret information regarding the
child’s condition, prognosis, and treatment options to help families make informed decisions.
Because of their relationship to families, nurses are often able to represent the child’s and
parents’ values, beliefs, and preferences, thus serving as an important liaison for communication
between the family and other health team members.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Participation in ethical decision making requires knowledge of ethical theory and principles, and
skills in moral reasoning, communication, and group process. Nurses have an individual
responsibility to clarify their personal values and beliefs and to be informed about contemporary
ethical thinking and legal, institutional, public policy, as well as professional guidelines such as
the Code for Nurses. Therefore, nurses must prepare themselves systematically for collaborative
ethical decision making. This can be accomplished through formal coursework, continuing
education, contemporary literature, and working to establish an environment conducive to ethical
discourse.

The nurse can also use the professional code of ethics for guidance. A code of ethics provides
one means for professional self-regulation. The Code for Nurses by the American Nurses’
Association focuses on the nurse’s accountability and responsibility to the client and emphasizes
the nursing role as an independent professional role that upholds its own opal liability (Box 1-4).
Nurses may face ethical issues regarding patient care, such as the use of lifesaving measures for
severely impaired newborns or the terminally ill child’s right to refuse treatment. Throughout the
text such dilemmas are addressed under a section titled “Questions and Controversies.” The
conflicting ethical arguments are presented to help nurses clarify their value judgments when
confronted with similar sensitive issues.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3.2.2.10 Research
Practicing nurses rarely consider themselves researchers, yet they are the individuals most likely
to observe human responses to health and illness. Unfortunately, few nurses systematically
record or analyze such observations. For example, pediatric nurses devise innovative methods to
encourage children to comply with treatments. Only if these interventions are shared with other
nurses, especially through publications, can a body of knowledge on nursing practice develop.
Research also implies a questioning of why something is effective and if there is a better
approach. Evaluation is essential to the nursing process, and research is one of the best
evaluators. Therefore nurses need to be more involved in research and in applying research
findings to their practice. Throughout the text research relevant to nursing of children and
families is incorporated as appropriate and is also highlighted in the Questions and Controversies
section. Research findings are presented to encourage nurses to base their practice on theoretical
foundations, not tradition, and additional questions may be proposed in the hope of stimulating
research in a particular area.

3.2.2.11 Health Care Planning

Up to this point the nurse’s role has been viewed through the nucleus of a family. However, the
nursing role is far more extensive and includes the community or society as a whole.
Traditionally nurses have been involved in public health care, on either a continuous or an
episodic basis. Rarely, however, have nurses been involved in health care planning, especially on
a political or legislative level.

Their role must also involve the decision-making body of government. Nursing, as the largest
health profession, needs to have a voice, especially as family/consumer advocate. This does not
mean that the nurse must hold public office. Rather it suggests knowledge and awareness of
community needs, interest government formulation of bills, support of politicians to ensure
passage (or rejection) of significant legislation, and active involvement in groups dedicated to the
welfare of children, such as professional nursing societies, Parent-Teacher Organizations, parent
support groups, religious organizations, and voluntary organizations.
Health care planning involves not only providing new services but also promoting the highest
quality of existing ones. Nursing needs to ensure the excellence of its own profession through
each individual member, who practices according to the Code of Nurses and standards of
practice.

A standard of practice is the level of performance that is expected of a professional. Pediatric

nurses are obligated to follow the Standards of Maternal-Child Health Nursing and specific
standards for their specialty, such as pediatric oncology nursing or school nursing. They should
also be involved in making certain their colleagues implement the standards, through education,
role modeling, and supervision. Throughout the text the highest standards of nursing practice are
continually reflected in the emphasis on thorough assessment, focus on scientific rationale as the
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

basis for care, summary of nursing care goals and responsibilities, and comprehensive discussion
of growth and development. Family-centered principles are continually evident in the
consideration of dynamics affecting the child, parents, siblings, and extended members. The
nurse is viewed as a vital component of the health care delivery system. Although nursing
functions are clearly outlined, nursing responsibilities must be equally emphasized. It is hoped
that the roles briefly described here will be studied, practiced, and implemented to the ultimate
benefit of all children.

3.2.3 Activity

Visit a paediatric ward during your posting and manage a baby on admission, write a report on
the care given by you. Share your report on the discussion board.

3.2.4 Self-Assessment Questions (SAQs) for Unit 2

Discuss the role of a paediatric nurse as a family advocate.
3.2.4.1 Self-Assessment Answer (SAAs) for Unit 2
Family advocacy
Although the nurse is responsible to self, the profession, and the institution of employment,
primary responsibility is to the recipient of nursing services, the child and family. The nurse
must work with members of the family, identifying their goals and needs, and plan interventions
that best meet the defined problems. As a consumer advocate the nurse has the goal of ensuring
that families are aware of all available health services, informed adequately of treatments and
procedures, involved in the child’s care when possible, and encouraged to change or support
existing health care practices. The pediatric nurse is aware of the United Nations Declaration of
the Rights of the Child

Unit 3: Parenting the healthy infant

Content
Introduction
3.3.1Learning objectives
3.3.2Concept of bonding and parent child attachment

3.3.2.1 What is the attachment bond?

3.3.2.2 The attachment bond shapes an infant’s brain

3.3.2.3 Parent-Infant Attachment

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3.3.2.4 Factors affecting Parent-Infant Attachment

Summary of Unit 3
3.3.3 Activity

3.3.4 Self-Assessment Questions (SAQs) for Unit 3

3.3.4.1 Notes on the Self-Assessment Questions (SAQs) for Unit 3

3.3.0 Introduction
The first few months of an infant’s life are critical periods for the formation of positive parent-
child relationships. There are numerous factors that influence the development of motherliness
and fatherliness and a couple’s transition to parenthood after the birth of a healthy infant.
Appropriate nursing intervention during the early neonatal period can help to establish positive
parent-child interaction patterns. It will have long lasting effects on the health of the child,
parents and family. Theories of child development have validated the significance of early
mother-child relationship to the development of trust and trust building capacity of the child in
later years of life. In this unit, you will learn more about how you should promote parent-mother-
child bonding and parent-child attachment.

3.3.1 Learning objectives

At the end of the unit you should be able to:
i. Describe an attachment bond
ii. Explain parent child attachment and the factors that affect parent child attachment
3.3.2 Concept of bonding and attachment
Mother bonding with child
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Source : Campbell and Taylor 1979

Attachment between a parent and child is defined as an enduring affectionate bond that is
reciprocal and gradual in development during the first year of life( Campbell and Taylor 1979)
Rubin (1977) used the term bonding in to describe the gradual process of development of the
mother child relationship or attachment which takes place during the first 12-15 months of a
child.s life.
Tulman (1981) emphasized the importance of the reciprocal interaction between parent and
infant in the development of their attachment to one attachment to one another. Their
interactional concept of parent-infant attachment recognizes that infants are active partners in
their interaction process from birth.
3.3.2.1 What is the attachment bond?

The mother–child bond is the primary force in infant development, according to the attachment
bond theory pioneered by English psychiatrist John Bowlby and American psychologist Mary
Ainsworth. The theory has gained strength through worldwide scientific studies and the use of
brain imaging technology.

The attachment bond theory states that the relationship between infants and primary caretakers is
responsible for:

 shaping all of our future relationships

 strengthening or damaging our abilities to focus, be conscious of our feelings, and calm
ourselves
 the ability to bounce back from misfortune
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Research reveals the infant/adult interactions that result in a successful, secure attachment, are
those where both mother and infant can sense the other’s feelings and emotions. In other words,
an infant feels safe and understood when the mother responds to their cries and accurately
interprets their changing needs. Unsuccessful or insecure attachment occurs when there is a
failure in this communication of feelings.

Researchers found that successful adult relationships depend on the ability to:

 manage stress
 stay “tuned in” with emotions
 use communicative body language
 be playful in a mutually engaging manner
 be readily forgiving, relinquishing grudges

The same research also found that an insecure attachment may be caused by abuse, but it is just
as likely to be caused by isolation or loneliness.

These discoveries offer a new glimpse into successful love relationships, providing the keys to
identifying and repairing a love relationship that is on the rocks.

3.3.2.2 The attachment bond shapes an infant’s brain

The infant brain is profoundly influenced by the attachment bond—a baby’s first love
relationship. When the primary caretaker can manage personal stress, calm the infant,
communicate through emotion, share joy, and forgive easily, the young child’s nervous system
becomes “securely attached.” The strong foundation of a secure attachment bond enables the
child to be self-confident, trusting, hopeful, and comfortable in the face of conflict. As an adult,
he or she will be flexible, creative, hopeful, and optimistic.

Our secure attachment bond shapes our abilities to:

 feel safe
 develop meaningful connections with others
 explore our world
 deal with stress
 balance emotions
 experience comfort and security
 make sense of our lives
 create positive memories and expectations of relationships

Stages of Attachment

Rudolph Schaffer and Peggy Emerson (1964) discovered that baby's attachments develop in the
following sequence:
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o Up to 3 months of age - Indiscriminate attachments. The newborn is predisposed to

attach to any human. Most babies respond equally to any caregiver.
o After 4 months - Preference for certain people. Infants they learn to distinguish primary
and secondary caregivers but accept care from anyone;
o After 7 months - Special preference for a single attachment figure. The baby looks to
particular people for security, comfort and protection. It shows fear of strangers (stranger
fear) and unhappiness when separated from a special person (separation anxiety). Some
babies show stranger fear and separation anxiety much more frequently and intensely
than others, but nevertheless they are seen as evidence that the baby has formed an
attachment. This has usually developed by one year of age.
o After 9 months - Multiple attachments. The baby becomes increasingly independent and
forms several attachments.

It was indicated that attachments were most likely to form with those who responded accurately
to the baby's signals, not the person they spent most time with. Schaffer and Emerson called this
sensitive responsiveness.

Many of the babies had several attachments by 10 months old, including attachments to mothers,
fathers, grandparents, siblings and neighbors. The mother was the main attachment figure for
about half of the children at 18 months old and the father for most of the others. The most
important fact in forming attachments is not who feeds and changes the child but who plays and
communicates with him or her.

3.3.2.3 Infant parent attachment/parent child attachments

Bowlby is one of the earliest writers in the field of infant attachment as behavioural system.
Infant attachment or signaling behaviour were identified as those which served to initiate and
maintain proximity between mother and infant e.g crying, smiling, and cooing. Secure
attachment .

Attachment parenting (AP) is actually a simple concept. By developing a loving, connected

relationship based on learning to read and respond to your baby's needs -- I call it getting behind
the eyes of your baby -- you can raise a child who is confident and caring, and who has a solid
foundation for becoming an assured, empathetic adult. To help parents learn to heed their natural
instincts and incorporate AP into their everyday lives, seven attachment tools are developed
which are:

1. The first few weeks of your baby's life help set the stage for your relationship. Parents should
spend as much time in skin-to-skin and eye-to-eye contact as possible birth bonding -- after all,
cuddling with your brand-new baby is one of the richest rewards of parenthood. If medical
complications disrupt this attachment time, don't despair. Birth bonding isn't like Super Glue; it's
the start of a lifelong process, you can still find ways to connect with your newborn through your
touch, your voice and your milk.
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2. Breastfeed as often and as long as possible. Besides providing your baby with nature's perfect
milk, it's an exercise in baby reading. The intimate contact promotes bonding by teaching you to
read your baby's facial expressions and sense her body language, while the very act of nursing
teaches baby that you are a source of care and comfort she can trust. If a medical or lifestyle
complication prevents you from breastfeeding, you can make bottle-feeding a time of high touch
and high communication too. Bottle-feeding also gives dad a chance to bond with baby in a
caring, giving way. Whatever the method, think of feeding time as an opportunity for connecting
and communicating in addition to delivering nourishment.

3. When new parents go for their newborn's first checkup, they are taught baby-wearing. It’s
advisable to demonstrate the technique with dads. It's a treat for new moms to watch drape the
baby sling over dad, position baby comfortably inside and watch the pair .

In addition to enjoying a physical connection with either parent, a baby can learn a lot in their
arms: Getting a mom's-eye view helps baby tune into his environment and the people around
him. It's also another way to involve dad in attachment parenting.

4. The American Academy of Pediatrics recommends that babies sleep in the same room as
mother, on separate sleeping surfaces, to reap the benefits of nighttime attachment. When
bedding close to baby, try a co-sleeper, a bedside bassinet that attaches safely to your bed, to
keep baby within arm's reach and in a safe sleep environment.

5. A baby's cry is her way of communicating with you. Listen to it and believe in the value of
her "language." Babies cry to communicate, not to manipulate, so learning how to decipher
your baby's cries and respond appropriately -- whether with a feeding, a diaper change or a
simple, comforting touch -- teaches her to trust you to understand her needs and take care of
them. As that bond grows and you become accomplished at anticipating her needs before she
becomes upset, you may even find that she cries less.

6. I'm sure you've heard well-meaning friends and relatives deluge you with their personal how-
to's: "Get her on a schedule." "Let him cry it out so he learns not to manipulate you." "You're
spoiling her by carrying her so much." Beware of this baby-training.

Certainly, modify attachment parenting to help your baby fit into your family and your lifestyle.
After all, being child-focused is not the same thing as being indulgent. (In fact, AP is based on
the idea that being responsive to baby ultimately helps him develop the tools and confidence to
become an independent, self-assured, caring person.) But when carried to an extreme, baby
training is a lose-lose situation. By following someone else's preconceived formula for
interacting with your baby, you lose trust in your ability to read and respond to his cues, while he
loses trust that you believe and value those cues.

7. A baby needs most is a happy, rested mother. Remember: The right dose of the right medicine
is healing, but an overdose can sometimes hurt. The same is true of attachment parenting. This is
why balance and boundaries are so important. In your zeal to give so much to your baby, it's
easy to neglect your own needs and those of your marriage. Early on in the AP process, new
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

parents should check if their method, "Is this working for you? Is your baby thriving? Are you
thriving? If not, then modify things."

Adapt these tools to enhance your family life and experience mutual giving. Though attachment
parenting may initially seem like one big give-a-thon, it's really about parents and babies giving
to each other. The more responsive you are to your baby, the more responsive baby will be to
you. Before you know it, the principles of AP will become second nature for all of you, and
you'll be well on your way to creating a happy, close-knit family.

3.3.2.4 Factors affecting Parent-Infant Attachment

Parental Variables

 Age
 Self –concept ( including concepts of masculinity and feminity)
 Relationships with significant others
 Attitudes towards parenting
 Knowledge related to parenting and infant care
 Expectations of infant
 Illness
 Perceptions of infant
 Mothers physical health during pregnancy
 Parents satisfaction with interaction with infant
 Perceptions of the birth experience

Situational variables:

 Presence of other stressors or crises

 Support system
 Whether pregnancy was planned or unplanned
 Experience surrounding pregnancy, labour , and early postpartum period.
 Quality and quantity of parent-infant contact in early newborn

Infant variables:

 Temperament and behaviors

 Physical characteristics
 Illness.

Summary of Unit 3
In Module 2, you have learned that:
Module two has four units which discussed the following :The six critical concept of newborn
care , the factors affecting the development of child care.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The module also discussed the role of the paediatric nurse and parent child attachment looking at
the concept of bonding
3.3.3 Activity
1. From the knowledge acquired in this unit, develop a personal checklist that you can use to
determine the level of bonding between a child and the family members, giving
consideration to different members of the family, the mother, the father, other siblings, the
extended member of the family.
2. Discuss with a family of a newborn child, (the mother, the father and the siblings if any) on
what they think, know, do to achieve by bonding with a child. Taking it from the
information they provide, explain bonding to them in simple ways they cn understand..
Share your experience on the discussion forum

3.3.4 Self-Assessment Questions (SAQs) for unit 3

Describe the Critical Concept 6 of the new born
Explain the term Attachment parenting

3.3.4.1 Self-Assessment Answers (SAAs) for Unit 3

Describe the Critical Concept 6 of the new born
Some newborns may be at risk of poor development. Low-birth-weight infants can suffer poor
developmental outcomes, particularly within families living in poverty. Genetic disorders and
illness may also threaten healthy development in the earliest days of life. Some problems stem
from barriers to health care for families of historically underrepresented groups.
Parents should provide special support for babies in high-risk categories and their families. Low-
birth-weight infants, for example, would benefit from greater social and intellectual stimulation
in child care. Parent education programs can be provided to help families of high-risk babies
provide positive interaction in the home. Parents should serve as advocates for families of
children in high-risk categories

Attachment parenting (AP) is actually a simple concept: By developing a loving, connected

relationship based on learning to read and respond to your baby's needs -- I call it getting behind
the eyes of your baby -- you can raise a child who is confident and caring, and who has a solid
foundation for becoming an assured, empathetic adult.

References/further readings
Bennet V.R.,Brown L.K,(1999), Myles Textbook for Midwives 14th edition,Edinburgh:Churchill
Livingstone.
Bobak I.M., Lowdermilk D.L.,Jensen M.D., Perry S.E.(1995) Maternity Nursing.4th ed.,Mosby S
Louis Missouri
Endres, J.B., and Rockwell, RE.: Food, nutrition, and the young child, St. Louis, 1980, Mosby-
Year Book, Inc., p. 180.
Nicholis F.H,Zwelling E,(1997) Maternal –Newborn Nursing; Theory and
Practice.W.B.Saunders Coy.Pennsylvania
Henderson,C., Macdonal, S., (2004) Mayes Midwifery Textbook.13th ed., London: Bailliers
Tindal.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Wong.D.L,.Hockenberry M.J (2003) Nursing Care of Infant and Children.7 th edition, Edinburgh:
Elsevier

Module 4: Nutritional needs of the newborn

Introduction
Learning Objectives for Module 4
At the end of this module, you should be able to;

 Review the anatomy of the female breast

 Discuss Physiology of lactation

 Explain breast feeding components

 Explain the Principles and steps to successful breast feeding

Content
Unit 1 The female breasts

 Structure of the breast

 Gross and Microscopic structure

 Physiology of lactation

Unit 2: Breast feeding

• Exclusive Breast Feeding
• Components of breast milk
• Nutritional Requirements for the Baby
• Principles and steps to successful breast feeding

4.0 Introduction
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4.1 learning objectives

4.1.2 The female breasts
4.1.2 .1 Structure of the breast Gross
Gross and Microscopic structure
4.1.2.2 Physiology of lactation

4.0 Introduction
Human milk is described as the gold standard for nutrition of the human infant. It contains
unique constituent valuable for brain growth and immune properties that cannot be matched with
any substitutes. Mothers must be encouraged to breast feed their neonates.
The female breast is structured to produce, store and offer the product, the milk, to suckle and
nurture the child giving the child the best foundation for life. Structural and functional changes
that starts at puberty continues through pregnancy and lactation period. Successful lactation
depends on good anatomical development of the breast by oestrogen and progesterone
stimulating the growth of the mammary ducts. Other hormones prolactin, oxytocins also have
impact on lactation especially after delivery. In this unit, you will cover brief overview of the
structure and functioning of the breast with regards to lactation.
Unit 1: Anatomy of the female breast and physiology of lactation
Unit 2 Breast feeding
4.1 Learning Outcomes for unit 1
At the end of this unit, you should be able to:
i. Review the anatomy of the female breast
ii. Describe the physiology of lactation

4.1.2 The female breasts

The female breasts, also known as the mammary glands, are accessory organs of reproduction.
Situation One breast is situated on each side of the sternum and extends between the levels of
the second and sixth rib. The breasts lie in the superficial fascia of the chest wall over the
pectoralis major muscle, and are stabilized by suspensory ligaments.
Shape Each breast is a hemispherical swelling and has a tail of tissue extending towards the
axilla (the axillary tail of spence).
Size The size varies with each individual and with the stage of development as well as with age.
It is not uncommon for one breast to be little or larger than the other.

4.1.2.1 Gross structure

The axillary tail is the breast tissue extending towards the axilla.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The areola is a circular area of loose, pigmented skin about 2.5 cm in diameter the centre of
each breast. It is a pale pink colour in a fair- skinned woman, darker in a brunett, the colour
deepening with pregnancy. Within the area of the areola lie approximately 20 sebaceous glands.
In pregnancy theseenlarge and are known as montgeomery’s tubercles.
The nipple lies in the centre of the areola at the level of the fourth rib. Aprotuberance about
6mm in length, composed of pigmented erectile tissue.The surface of the nipple is perforarted by
small orifices which are the openings of the lactiferous ducts. It is covered with epithelium.
Microscopic structure
The breast is composed largely of glandular tissue, but also of some fatty tissue, and is covered
with skin. This glandular tissue is divided into about 18 lobes which are completely separated by
bands of fibrous tissue.
The internal structure is said to be resemble as the segments of a halved grape fruit or orange.
Each lobe is a self-contained working unit and is composed of the following structures:
Alveoli: Containing the milk- secreting cells. Each alveolus is lined by milk-secreting cells, the
acini, which extract from the mammary blood supply the factors essential for milk formation.
Around each alveolus lie myoepithelial cells, sometimes called ‘basket’ or ‘spider’s cells. When
these cells are stimulated by oxytocin they contract releasing milk into the lactiferous duct.
Lactiferous tubules: small ducts which connect the alveoli.
Lactiferous duct: a central duct into which the tubules run.

Ampulla: the widened-out portion of the duct where milk is stored. The ampullae lie under the
areola.
Blood supply Blood is supplied to the breast by the internal mammary, the external mammary
and the upper intercostals arteries. Venous drainage is through corresponding vessels into the
internal mammary and axillary veins.
Lymphatic drainage This is largely into the axillary glands, with some drainage in to the portal
fissure of the liver and mediastinal glands. The lymphatic vessels of each breast communicate
with one another.
Nerve supply The function of the breast is largely controlled by hormone activity but the skin is
supplied by branches of the thoracic nerves. There is also some sympathetic nerve supply,
especially around the areola and nipple.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Figure ----- Structure of the Breast

4.2.1.2 Physiology of lactation
The mechanism of milk production and ejection after delivery is controllled by hormone
secrction. During pregnancy , estrogen and progesterone induce alveolar and ductal growth in the
breast as well as stimulate the secrection of colostrum. Prolactin and other hormones produced
during pregnancy also help to prepare the breast for lactation but milk production is withheld till
until after delivery .
After delivery, when the placenta has been delivered, the level of hormone produced by the
placenta diminish thereby activating the anterior lobe of the pituatary gland to release prolactin .
prolactin acts on the acini cells of the breast to produce milk. The process of establishment of
milk production may take 2-4 days and is usually enhanced by sucking stimulation of the baby.
Oxytocin produced by the posterior pitutary gland during labour stimulates uterine
myoepithelial as well as the myoepithelial of the breast to bring about milk ejection or let-
down. After let down, milk travels into the ductules, then to the larger – lactiferous or
mammary ducts. Once milk production and ejection has been established, its continuation and
maintanance is based on response to baby’s cry, sucking stimulation, mothers emotion, feeding
patterns. Negative emotions e.g. fear, anger, anxiety, embarasment and pain may inhibit milk
let-down reflexes.
4.2.3 Activity
Draw a well labelled diagram of the female breast. Find out about deviations that can occur in
the breast that has implications for lactation and how such should be managed.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4.2.4 Self-Assessment Questions (SAQs) for unit 1

SAQ 4.2.4 (Tests Learning outcome 4.1)
• Explain physiology of lactation

SAQ 4.2.4 1 (Tests Learning outcome 4.1)

Physiology of lactation
The mechanism of milk production and ejection after delivery is controlled by hormone
secrction. During pregnancy , estrogen and progesterone induce alveolar and ductal growth in the
breast as well as stimulate the secrection of colostrum. Prolactin and other hormones produced
during pregnancy also help to prepare the breast for lactation but milk production is withheld till
until after delivery .
After delivery , when the placenta has been delivered, the level of hormone produced by the
placenta diminish thereby activating the anterior lobe of the pituatary gland to release prolactin .
prolactin acts on the acini cells of the breast to produce milk. The process of milk production
may take 2-4 days and is usually enhanced by sucking stimulation of the baby.
Oxytocin produced by the posterior pitutary gland during labour stimulate uterine myoepithelial
as well as the myoepithelial of the breast to bring about milk ejection or let- down. After let
down, milk travels into the ductules, then to the larger – lactiferous or mammary ducts. Once
milk production and ejection has been established , its continuation and maintanance is based on
response to babys cry, sucking stimulation , mothers emotion , feeding patterns. Negative
emotions e.g . fear, anger, anxiety, embarasment and pain may inhibit milk let-down reflexes.

Unit 2 Breast Feeding

Content
Breast feeding
• Exclusive Breast Feeding
• Components of breast milk
• Nutritional Requirements for the Baby
• Principles and steps to successful breast feeding

4.2.0 Introduction
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4. 2.1 Learning objectives for Unit 2

At the end of the unit you will be able to :
i. Describe the concept exclusive breast feeding
ii. Discuss the nutritional requirement for the baby
iii. Explain the Principles and steps to successful breast feeding
4.2.2 Exclusive breast feeding
4.2.2.1 Composition of breast milk
4.2.2.2. The nutritional requirement for the baby
4.2.2.3 Advantages and disadvantages of breast feeding
To the mother and baby
Some difficulties with Breast feeding
4.2.2.4 Principles and steps to successful breast feeding
4.2.3 Activity
4.2.4 SAQ 4.2 (Tests Learning Outcome 4.2)
4.2.4.1
4.2.0 Introduction

The best food for a newborn is breast milk from the mother. It is imprortant for the midwife to
assist mothers to make an informed decision to breast feed their baby exclusively for the first six
months of life.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Assisting breast feeding

Source :

Excusive bresst feeding means that

 No drink or food other than breast milk is given to the baby in the 1 st six months of life.
 No pacifier / dummes or artfiacial teats are given to the baby
 No infant formular or animal milk
 Breast feeding the baby on demand at least 8-12 times in 24 hours including nights
 Babies should continue to breast feed up to two years even when complemwntary food
has been introduced

Exclusive Breast Feeding Hospital Policy

Principles and steps to successful breast feeding

Every facility providing maternity services and care for newborn infants should:
1. Have a written breast-feeding policy that is routinely communicated to all health care
staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breast feeding.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4. Help mothers how to breast feed, and how to maintain lactation even if they should be
separated from their infants.
5. Show mothers how to breast feed, and how to maintain lactation even if they should be
separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in-allow mothers and infants to remain together -24 hours a day.
8. Encourage breast feeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast feeding
infants.
10 Foster the establishment of breast-feeding support groups and refer mothers to them on
discharge from the hospital or clinic .

4.2.2.1 Components of breast milk

Human milk varies in its composition with the time of the day, stage of lactation, and maternal
nutrition. Fore-milk at the beginning of the feed differs from the hind-milk at the end of the feed.
Human milk is unique on its own and differs from other animal’s milk. It contains all the
nutrients that the infant needs for proper growth and development at the right proportion.
Colostrum is the first milk that is produced from early pregnancy to some days after birth. It is a
thick, yellow, creamy fluid It contains higher level of anti-bodies, protein, minerals and fat-
soluble vitamins.
After 2-4 days it is replaced by transitional milk, which is produced until 2 weeks post –partum.
Transitional milk provides more calories than colostrums. It is also higher in fat, lactose and
water – soluble vitamins.
Mature milk is produced by 2 wks post partum. It has high water content, looks thin, and bluish
in colour.
It is utilized rapidly because of the action of enzyme Lipase:
Fat – Provides more than 50% of the caloric requirements. Value varies with feed, time of the
day and its proportion increases during the course of the feed
Lactose – More in human milk than other mammals. It is converted to galactose & glucose by
the action of enzyme lactase. Lactose enhances the absorption of calcium and promotes the
growth of lactobacilli which increase intestinal acidity. It inhibits the growth of pathogenic
organism.
Protein – Human milk contains less than half the amount of that of cow’s milk but it is easily
digestible and provides baby with the ideal quantity. It is mainly lactalbumin (whey protein) and
little caseinogen, 2 amimo Acids, cystine and taurine are found in human milk which are not in
cow’s milk. Cystine is necessary for growth while taurine is necessary for brain development.
Colostrum contains 3 times the amount of protein in natural milk and contains all the ten
essential amino-acids. It contains IgA and lactoferrin.

Vitamins:
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Fat soluble
Vitamins: Fat soluble vitamins A, D.E. & K.
Vitamin A: 28011. Colostrum contains double that of cow.
Vitamin D: Both fat and water soluble are available.
Vitamin E: Rich in vitamin E. than cow’s.The function is to prevent haemolytic anaemia,
protect the lungs & retina from oxidant induced injury.
Vitamin K – Necessary for synthesis of blood clotting factors. Present in human milk and
absorbed efficiently – level is high in colostrums. Level depends on maternal dietary intake –
synthesized in infant’s gut 2 weeks after birth.
Water soluble
Present at varied levels of needs.
Vitamin C – Human milk contains 43mg/100mls, cow’s milk contains 21mg/100ml.
Amount in human milk varies with dietary intake. Increase intake is necessary during lactation.
Vitamin C is necessary for collagen synthesis.
Iron – 42% of human Iron is utilized while only 4% of cow’s is absorbed the high vitamin C &
lactose in human which facilitate absorption.
Zinc – More in cow’s than human but more available in human milk deficiency may result in
failure to thrive and typical skin lesions.
Others Human milk has low levels of (i) Calcium (ii) Phosphorus (iii) Sodium (iv) Potassium
than cows milk.
Copper, cobalt and selenium are present at higher levels
Human milk is easily digestible and absorbed with less strain on the kidneys than unmodified
cow’s milk. (A baby fed on pure cow milk is prone to dehydration due to hypernatraemia (excess
sodium)). Baby on breast milk does not need additional water under normal condition. Baby
should be breast fed for as long as he desires.

Composition Table

Colostrum Breast Milk Formula

Protein 8.5% 1.5% Depends on the type

CHO 3.5% 7%
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Fat 2.5%

Minerals 0.4% 3.5%

0.2%

Water 85.1% 87.8%

Caloric value 73/100mls 70/100mls

Per 100mls = 280 joules

Colour – of Breast milk is – Bluish white

Reaction – alkaline
4.2 2..2 Nutritional Requirements for the Baby
1st day – 30mls/kg body weight/day
2nd day – 40mls/kg body weight/day
3rd day 60mls/kg body weight/day
Subsequently it depends on the tolerance of the baby – size and eagerness to feed sulking
enhances and stimulates maternal instinct.
Breast milk contains Anti-infective factors
- leucocytes
- Secretory IgA and interferon
- Immunoglobulins IgA, IgG, IgM, and IgD are all found in human milk, the most
important is the IgA – Both synthesized and stored in the liver. It coats the intestinal
epithelium and protects the mucosal surface against entry of pathogenic bacteria and
entero-viruses.

4.2.2.3 Advantages of breast feeding

To the baby

 Right amount of protein. Provides all nutrients adapted to infant’s digestion and
nutritional requirement.
 Fresh and clean, easily digested.
 Contains valuable antibodies
 Promote mother – child bonding – love & security.
 Less incidence of cot death.
 Baby is less prone to obesity
 Gives physical psychological and emotional satisfaction.
 Reduces incidence of allergies
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

To the mother

 Aids involution of the uterus.

 Convenient and readily available, portable, cost effective, no preparation
involved.
 At correct temperature.
 Saves time
 Portable, cost effective, no preparation.
 Reduces incidence of concern of the breast.
 Physical Psychological & Emotional satisfaction
Disadvantages of breastfeeding
There are actually no absolute disadvantages with breastfeeding.
- Only the mother can nurse the newborn
- Expressed breast milk (EBM) is time consuming for working class mothers.
1. Mother must be careful with her diet and mediation
Some difficulties with Breast feeding
Maternal
1. Poor Lactation
2. Breast & Nipple problems.
3. Maternal diseases
4. Emotional crises
5. Pregnancy
6. Husband’s refusal.
7. Mother on drugs: Anticoagulant Anthithyroid, disorders TB & Ca-cytotoxic drugs.
In Baby
1. Severe asphyxia
2. Preterm baby
3. Congenital deformities
4. Severe jaundice.
5. Absent of suckling & swallowing reflexes.
6. Vomiting in the Newborn.
Complications of breast Feeding
1. Sore Nipple:
Cracked nipple
Breast Engorgement
Mastitis
Breast abscess
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4.2.2.4 Essentials for successful Lactation

1. Mentally & Physically healthy mother.
2. Adequate intake of balanced diet 3,500cal/day
3. Well developed breast and nipple prominent for the baby to grasp .Hormone balance
relating to lactation should be normal.
4. Frequent suckling on the breast. Mother must genuinely want to breastfeed.
5. Complete empting of the breast at feeding time.
6. Adequate blood supply to the breast. Child’s mouth free from deformities.
7. Patent ducts
Suppression of lactation
For some reasons lactation may need to be suppressed e.g. dead fetus, puerperal psychosis,
HIV/AIDS infection.
1. Stop breast feeding
2. Firm support to the breast.
3. Do not express.
4. Reduction of fluid intake
5. Give analgesics.
6. Use of drugs e.g. stilbestrol 5mg tds. Ablactone 1ml i.m, Bromocryptin 5mg tds.
Hexoestrol 45mgs in divided dose of 15mg daily or 45mg stat after still birth or abortion.

4.2.3 Activity
In the infant welfare clinic during your posting assist a primigravida to initiate breast feeding.
Share your experience in the discussion forum
4.2.4 SAQ 4.2 (Tests Learning Outcome 4.2)
List the principles to promote exclusive breast feeding in health facilities

Principles and steps to successful breast feeding

Every facility providing maternity services and care for newborn infants should:
1. Have a written breast-feeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breast feeding.
4. Help mothers how to breast feed, and how to maintain lactation even if they should be
separated from their infants.
5. Show mothers how to breast feed, and how to maintain lactation even if they should be
separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in-allow mothers and infants to remain together -24 hours a day.
8. Encourage breast feeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast feeding
infants.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

10 Foster the establishment of breast-feeding support groups and refer mothers to them on
discharge from the hospital or clinic .

Unit 3: Discharges and Follow up

Content

4.3.0 Introduction

4.3.1 Learning objectives

4.3.2 Discharge and follow up

4.3.2.1 Evaluation on discharge

4.3.2.2 Home visiting

4.3.2.3 Family adjustment

4.3.2.4 Child health clinic

4.3.2.5 Referral and follow up

Conclusion& Summary

4.3.3 Activity

4.3.4 Self Assessment Questions(SAQ) for Unit 3

4.3.4.1 Self Assessment Questions(SAA) for Unit 3

4.3.0 Introduction
It is generally assumed that women knows how to suckle and take care of a child but this is very
wrong. It must NEVER BE ASSUMED that the mother is capable of taking care of the baby
immediately after delivery. The baby must be followed up to see their interaction in the natural
setting. Follow-up/home visit serve as a good opportunity for the midwife/health visitor assess
the home, family members and to facilitate parent-child interaction and attachment. Father
should be encouraged to participate in the care of the baby. The baby can also be assessed and
necessary corrections about care of the baby are given. The midwife must also see how the
family adjusts to their new situation and roles. The mother must be made to see the importance
of visiting the clinic with her baby either well or sick. The importance of immunization must be
emphasized and referral must be done as desirable.This unit will discuss these highly important
aspects of child care.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

4.3.1 Objectives
At the end of the lesson you will be able:

- Evaluate if the baby is thriving.

- Assess other members of the family.
- Evaluate if the mother is coping with the new role.

4.3.2 Discharge and follow up

4.3.2.1 Evaluation on discharge

Evaluation of the child is essential to ascertain the health of the child before discharge or leaving
the Hospital. There are various approaches of such evaluation.
1. Physical examination of the baby. This is similar to that which was carried out one hour
after birth.
2. Attention is paid to feeding pattern bowel elimination and bladder.
3. Vital signs are checked – temperature, pulse and respiration (TPR) apex beats etc. Any
abnormalities are noted.
4. General state of health of the baby is assessed – activities, cry, sleep etc.
Cord should be inspected for dryness or infections. If everything is alright then the baby is fit to
leave the Hospital.

4.3.2.2 Home visiting

After the child has been discharged home, the child must be followed up for the first 10days
(Health visitors) to see the mother and baby in their natural habit.
To see the state of health of the two of them, and how the mother is coping with the care of the
baby. During the visit the child is observed for any signs of infection especially the cord if
infected. Eyes and ears are examined for discharges. The mother is questioned on the feeding,
bowel and bladder movement and sleeping pattern, activities of the child and any other problems
are noted. Mother is supervised on care of the baby.
The other siblings are also assessed. The home environment, personal and environmental
hygiene, toilet water, light systems are checked. Health education and counseling are given when
necessary.

4.3.2.3 Family adjustment

The presence of a newborn in the home necessitates great adjustment in the family. Areas of
adjustment include:
1. Home: The environment must be clean, no over crowing, good water and light supply. The
house must provide comfort and safety, adequate ventilation warmth, fresh air without draught.
2. Facilities: The infant should have a bed to him if possible or sleep with the mother in a side
enough bed to avoid lying over the baby. The mattress of the bed should be firm but not hard,
with water proof cover. Beddings should be cotton, no need for pillow as baby can get suffocated
if he rolls over it. The baby’s bed must have a drawer. The mother must take intelligent interest
and assume responsibility for monitoring, maintenance of the health of the family.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The role of the father includes, apart from providing for the maintenance of the family, he must
assist the mother in the care of the newborn and the siblings. His well being is also very
important.

Midwife’s role: Another essential part of your role is teaching the new family, assessing their
knowledge deficit and level of understanding about child care. The midwife should help them get
started in a new healthy and rewarding life together. She should help them resolve their
anxieties. She should function as calm, reassuring supportive person ready to assist the family
and promote parent-child relationship.
Each newborn is distinctive and the midwife has the gratifying task of introducing them to this.
Total care must be delegated to the parent as soon as possible.

4.3.2.4 Child Health Clinic

All newborn should register in child health clinic nearest to their home, with their environment.
Assessment and monitoring should continue on a regular basis at the child health clinic. All
infants should visit, well or ill. The well children should visit clinic for:
i. Immunizations
ii. Monitoring of growth
iii. Health education of the mother, through regular visit to the clinic.
Chronic illness and potential ones could be detected on time and treatment given e.g. under
weight, worm infestation, anaemia, malaria, vitamin deficiency and skin problems are detected.
Healthy infant should visit the clinic monthly for the first 6 months to get his vaccinations and
growth assessed by weight and general assessment.

4.3.2.5 Referral and follow up

All babies with problems should be referred to specialist in the particular problems for early and
proper management and follow up.
Such cases include:
1. Congenital abnormalities that will require surgery.
2. Congenital metabolic problems that require pediatrician’s follow up.
3. Babies with Down’s syndrome and cases of mental problems.
4. Ignorant mother should also be referred to nutrition unit where she would be taught.
5. Social problems, to the social welfare unit or Public Health unit

Summary Conclusion
It is the responsibility of the midwife to ensure that a child is discharged home physically and
psychologically fit. She must ensure that both the mother and the child are coping well at home.
In situations where she cannot make home visit the community health department is involved to
make sure that the woman, the baby and the family as whole are adjusting well. Her visit is a
holistic one, in which she sees to the welfare of the whole family. She evaluates if the mother is
doing the right thing in the care of the baby.
This unit has highlighted the importance of evaluating the child before discharged from the
health institution, the need for home visit to see the state of health of the baby and all other
family members and their environment. How the family is adjusting to the presence of the new
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

born. The parents should be encouraged to visit the clinic for growth monitoring and
immunizations. All infant with problem are to be referred appropriately.

4.3.3 Activity
Perform evaluation before discharge for 3 babies of primigravida and 3 babies of multigravida
mothers. Write report on your assessment and put on discussion forum

4.3.4 Self Assessment Question (SAQ) for Unit 3

Describe briefly
1. Importance of evaluation before the neonates is discharged from the hospital.
2. Family adjustment

4.3.4.1 Self Assessment Answer (SAA) for Unit 3

Evaluation of the child is essential to ascertain the health of the child before discharge or leaving
the Hospital. There are various approaches of such evaluation.
1. Physical examination of the baby. This is similar to that which was carried out one hour
after birth.
2. Attention is paid to feeding pattern bowel elimination and bladder.
3. Vital signs are checked – temperature, pulse and respiration (TPR) apex beats etc. Any
abnormalities are noted.
4. General state of health of the baby is assessed – activities, cry, sleep etc.
Cord should be inspected for dryness or infections. If everything is alright then the baby is fit to
leave the Hospital.

References
 Baker, P. N., & Kenny, L. C. (Eds.). (2011). Obstetrics by 10 Teachers. Hodder Arnold.

 Cowen, K., J., London, M. L& LADEWIG, P. A. (2010). Skills manual for maternal and
child nursing care. Prentice Hall

 Fraser, D. M., & Cooper, M. A. (Eds.). (2009). Myles' textbook for midwives. Elsevier
Health Sciences.

 Holmes, Debbie, Philip N. Baker (2006). Midwifery by ten teachers. Hodder Arnold,

 Ladewig, P., Ball, J., & Bindler, R. (2011). Maternal & child nursing care. Pearson
Education.

 Franser M.D, Cooper M.A and Nolte AGW. (2006) Myles Textbook for Midwives
African Edition. Elsevier Limited. London.

 London M.L., Ladewing P.W., Ball J.W and Bindler R.C. (2003), maternal and child
nursing care. 2nd ed, Pearson, London.

 Ojo A.O and Briggs E.B. (2006). A Textbook for Midwives in the Tropics. 2nd ed.
Yaypec, New Delhi.
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NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Module 5: Growth and development

Source:
Introduction
Learning Outcomes for module 5
At the end of this module you should be able to:

 Discuss the theories of development

 Explain the growth and development of the child

Content
Unit 1.Theories of development
Unit 2. Growth and development

Unit 1. Theories of development

5.1.0 Introduction
5.1.1 Learning Objectives for Unit 1
5.1.2 Developmental theories
5.1.2.1 Erikson (1902-1994)
5.1.2.2 Piaget
5.1.2.3 Review other relevant theories

5.1.3 Activity
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

5.1.4 Self -Assessment Question (SAQ) 5.1 (Tests Learning outcome 5.1
5.1.4.1 5.1.4 Self Assessment Answer (SAA)

5.1.0 Introduction
5. 1.1 Learning Outcomes for unit 1
At the end of this unit, you should be able to:
a. Discuss theories of development.
b. Apply the developmental theories in child grow monitoring.
5. 1.2 Developmental theories
5. 1.2.1 Erikson (1902-1994)
Erik Erickson’s theory of social-emotional development is based on how people learn to interact
with others based on their personal experiences. Erikson focused his attention on the young child
and the way relationships with other people influence each child’s personality and behavior.
Erikson’s theory of the young child’s social and emotional development offers early care and
care giver information on proper ways to nurture and guide young children. As children care
giver you may work with children during the first four (4) social - emotional stages as defined by
Erikson.

Erikson’s First Four Stages of Social-Emotional Development

Stage Approximate Description

Age

Basic trust vs. basic mistrust Birth to 12- Infants need loving and trusting
An infant needs consistent 18months relationships with parents and other
caregivers who provide for caregivers to develop a sense of trust.
their basic needs in a nurturing Infants who do not receive consistent and
and caring environment nurturing care nurturing care are at risk
for developing a sense of mistrust of
others
Autonomy vs. Shame/Doubt 18 months to 3 During this stage the child becomes more
Toddlers need caring adults years independent, learning to walk, run,
who provide a supervised, climb, build, draw and talk. Toilet
safe, environment that learning is a key skill for this stage.
provides the child with Children who are supported and
opportunities to learn new supervised by adults as they develop new
physical skills. skills and independence feel responsible
and capable. Children who receive
negative messages from parents and
caregivers may begin to doubt their
abilities and lose self-confidence
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Initiative vs. Guilt 3 to 6 years At this age children become more

Preschool children need a safe independent, assertive and take more
environment that encourages initiative. Teachers and other adults
making choices. need to provide an environment that
supports the child’s efforts but also
helps guide their activities to prevent
“unhappy” endings that may create
feelings of guilt.
Industry vs. Inferiority 6 to 12 years School age children are learning to
School age children need an develop more complex social and
environment with encouraging academic skills.
adults that provides Children who experience success
opportunities to develop and discover that being productive is
create their own ideas satisfying. On the other hand, children
who fail in school or other settings
may begin to feel inferior and
inadequate. Adult guidance that
deemphasizes mistakes and focuses on
problem solving

Erickson’s theory helps child care giver identify the types of teacher –child interactions required
for healthy social and emotional development. Erickson’s theory helps people who work with
young children understand the importance of providing specific types of interactions and
environments to ensure positive social- emotional development for young children

5. 1.2.2. Piaget
Jean Piaget (1896 -1980) was a theorist who studied the cognitive development of young
children. Piaget made major contributions in understanding how children learn. Piaget’s theory is
based on his belief that children do not learn and understand information that is “presented” to
them by another person. Instead Piaget believed that individuals learn by creating new
knowledge through active experiences. Piaget’s theory is the foundation for the concept of child
centered learning.
Piaget’s Theory of Cognitive Development Stages

Formal Operational (12 years – adult) Stage 4

The adolescent can reason in more abstract ways. Thoughts are more idealistic, logical and
systematic

Concrete Operational (7-12 years) Stage 3

The child can reason logically about concrete objects and events and classify objects

Preoperational (2-6 years) Stage 2

The child uses symbols (words and pictures) to represent objects but does not reason logically.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Child can pretend and is very egocentric.

.

Sensorimotor (0-2 years) Stage 1

The infant explores through direct sensory and motor contact. Putting objects into their mouth.
Separation anxiety and object permanence develop during this stage

Major Contributions of Piaget:

- Children learn through actively exploring their environment through their senses, vision,
hearing, and touch.

- Until the time between the ages of 8-12 months of age the infant does not understand that
objects exist even if they cannot be seen. You may observe this characteristic in infants
who experience separation anxiety. When they are unable to see their parent they do not
understand they will return.

- Young children from 3 to 7 years of age may be egocentric which means they only see
things from their point of view and do not understand that other people may have
different ideas.

- Teachers need to provide concrete, hands-on materials that enable young children to
learn through exploration and active learning.

- Children from 7 to 11 years of age are able to make rational judgments about concrete
and observable events. Teachers need to provide opportunities to ask questions and have
the children explain the information back.

Major Contributions of Piaget to child development:

- Children learn through actively exploring their environment through their senses, vision,
hearing, and touch.

- Until the time between the ages of 8-12 months of age the infant does not understand that
objects exist even if they cannot be seen. You may observe this characteristic in infants
who experience separation anxiety. When they are unable to see their parent they do not
understand they will return.

- Young children from 3 to 7 years of age may be egocentric which means they only see
things from their point of view and do not understand that other people may have
different ideas.

- Teachers need to provide concrete, hands-on materials that enable young children to
learn through exploration and active learning.

- Children from 7 to 11 years of age are able to make rational judgments about concrete
and observable events. Teachers need to provide opportunities to ask questions and have
the children explain the information back.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Developmental Milestone

5.1.2.3 Review other relevant theories

5.1.3 Activity

5.1.4 SAQ 5.1 (Tests Learning outcome 5.1)

Unit 2. Growth and development

Content
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

5.2.0 Introduction
5.2.1 Learning Outcomes for unit 2
5.2.2 Importance of study of growth and development of the child
5.2.2.1 General Principle of Development
5.2.2.2 Development of the Child
5.2.2.3 Genetic Influence on human Development
5.2.2.4 Understanding Language
5.2.2.5 Growth & Development of Infant From Birth – 1 year
5.2.2.6 Positive Factors in child Growth & Development
5.2.2.7 Development of teeth
5.2.2.8 Child Growth Curve

5.2.0 Introduction

The period of growth & Development extends through life cycle, but the period of principal

changes is from conception to the end of adolescence. It is important for the Nurses to

understand the total life cycle of individuals in order to understand the behaviour of children and

their mothers. This unit shall discuss the principles of growth and development

5. 2.1 Learning Objectives for unit 2

At the end of this unit, you should be able to:
c. Understand the important of growth and development monitoring of a child.
d. Explain the principles of development.
e. identify the factors that influence growth and development
f. recognise and manage a child with developmental challenges

5.2.2 Importance of study and terms of growth and development of the child
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

The Nurses must know what to expect of a particular child at any given age and at what age
certain kinds of behaviour are likely to emerge in more mature and natural forms. This
knowledge is used to observe and to judge each child in term of the norms for level of specific
development.
In order for the Nurse to formulate plan for total care for each child she must understand the
stages of growth and development. It also helps the Nurse to understand the reason for particular
condition and illnesses which occur in various age groups. She can then teach the mothers how
to observe and use the knowledge to help the child achieve optimal growth and development.
She can recognize abnormal behaviors, mental & physical handicaps and refer on time.
All children go through a normal sequence of growth, but not at the same rate but there is
coronation between physical growth, mental, emotional and sexual development.
It is dangerous to force a child into a standard pattern of growth or task. Growth is not due to one
factor but combination of many factors all interdependent – heredity, Racial, national,
characteristics sex and environmental.
1. Growth: Can be described as an increase in size (weight & height) which facilitates a
more effective functioning.
2 Development: Increase in complexity which demands improvement in skill and
functional capacity – ability to provide progressively for greater – capacity in
functioning.
Development can be achieved through three main processes Maturation, Adaptation and
learning.
Maturation: This is a qualitative change not induced by learning or experience but it comes
about as a result of mere passage of time. It is simply a process of ripening.
Adaptation: This is the result of body’s accommodation or adjustment to meet its environmental
needs.
Learning: Acquiring of knowledge through experience. A relative permanent change in
behaviour resulting from experience, experimentation and training.
This change is induced by interaction with the environment. The ability to learn is highly
dependent upon the unborn capacity for mental development.
In contrast, learning is externally oriented while maturation is internally oriented. The change in
behaviour in a child follows pattern of stages: sitting, crawling, and standing, walking and
running. Maturation and learning are interrelated. Child Development includes:
1. Physical Development: This deals with physical and physiological characteristics of an
individual.
2. Social Development: Deals with the development of the awareness of one in relation to
others and interactional style of the child at home, in the school and among his age group
i.e. peer group.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

3. Emotional Development: This deals with the development of affection and cognition of
the child.
The individual is an entity, a whole: any malfunction in one area may therefore affect the
other areas e.g. a physical defect may cause social or emotional problems.

5.2.2.1 General Principle of Development

1. Principle of the Director of Growth
a. Cephalo –Caudal: Follows the spine downwards Growth proceeds from the head to the
other part of the body. E.g. the brain attains 70% of it’s growth by the age of 2 years –
parent should provide adequate stimulation from infancy. To stimulate visual perception,
toys of bright objects should be presented to the baby from the first week of life.
b. Proximo-distal: States that growth proceeds out from the central axis of the body e.g. the
trunk develops before the buds (i.e. arms and legs). As the child matures general
movement becomes specific, for example he uses the whole hand first before picking up
small object with pincer grasp (i.e. between thumb and forefinger). Child should be given
opportunity for learning by either experience or instruction when he is ready to acquire
the skill or by direct experience through instruction from others.
2. Principle of Differentiation: This stipulates that growth proceeds from simple to complex,
from homogeneous to heterogeneous and from general to specific e.g. fertilization starts from a
single cell to trillions of cells that form human body.
3. Principle of Asynchronous Growth: This emphasis that development shift from one part to
another at different times .That means the various parts of the body do not grow simultaneously.
When focus of growth is on one particular part the other parts rest. e.g. at conception placental
develops before the fetus.
4. Principle of Discontinuity of Growth rate starts that the rate of growth changes at
different periods e.g. there is accelerated growth from birth to 2 years, then slows down
until 10 years when adolescent growth takes over.
5. Principle of complexity of Growth: Growth is a complex process and interwoven e.g.
physical impairment is likely to cause emotional and social problems.
6. Principle of uniqueness of the individual: Each individual is a unique entity with its
quality. NO two people are exactly the same even identical twins are not exactly the
same.
7. Principle of the modifiability of the Rate pattern of Growth. This states that growth
although is innate, and the urge to grow is very strong, some factors can modify growth.
a. Genetic Accident: Genetic abnormality can cause genetic impairment such as albinism
and mental retardation.
b. Interference with fetal Development: Accident or falls during pregnancy may result in
fetal abnormalities. Diseases such as German measles or high fever exposure to radiation
before 34 weeks. Poor nutrition slows down rate of growth and poor brain development.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

c. Environmental Influence: If a child develops where there is a poor or no mental

stimulation it will lead to retarded intellectual development. The first 6 years of life is
critical in the development of intellect. Parent should therefore provide necessary
stimulation for their children.
d. Emotional Growth of the child: If a child is raised in an emotionally tense environment
where there is frequent marital disorder, display of hostility and aggression, the child
could develop emotional problems. He could be aggressive or withdrawn. Separation of
child from the mother before five years could affect the child’s emotional development.

5.2.2.2 Development of the Child

Development of the child can be divided into two: Pre and Post natal periods. The first 8 weeks
is the most critical period in life because most organs, nervous system, blood and heart are
formed. At this stage any chemical changes in the mother’s blood stream caused by virus or
drugs can lead to mal-development and can affect any organ in the process of being formed.
From here the fetus starts to grow and develop in the woman at various stages until viable (24
weeks).
5.2.2.3 Genetic Influence on human Development
This affect the unique characteristics of individuals e.g. sex, Genotype (internal) and Phenotype
(external e.g. colour).
Development can be influenced by External fetal environment e.g Amniotic fluids, nutrient
(protein) hormones, oxygen, chemicals and other substance from the mother’s blood stream.
Some factors that can cause damage in the development of the fetus are poor diet, drugs,
radiation, and age of mother, infectious diseases, Rhesus blood factors, and emotional status and
birth complications.
5.2.2.4 Understanding Language
Children learn to understand language before they speak. Language development starts with the
cry at birth.
At 12 months – Baby can use 3-4 words.
At 18 months – 3-4 year his vocabulary increase rapidly.
At 2 years –Baby can use 272 – 300 words.
At 3 years – 800, 1,000 words, 80% legible.
5.2.2.5 Growth & Development of Infant From Birth – 1 year
1 month
Weight gain – steady weight gain.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Height – Increase of 2.5cm is expected in the first 6 month.

May lift head up intermittently, cannot hold head up; can turn head side to side. Posture at birth
is face down and can lie on its stomach.
Stare indefinitely at his surrounding notices face and bright objects. Smiles indefinitely and cries
when hungry or uncomfortable.
2 months
Posterior fontanelle closes, raises his chest up with arms, can hold head erect in mid-position.
Can follow a moving light or object with is eyes. Begins social behaviour – smile in response to
another’s smile. Learnt that he gets something from cry, sound of cry varies with the reason for
crying .e.g. sleep, pain, hunger etc.

3 months
Hold hands up in front of him and plays with fingers and hands. Hold head erect and steady. Lies
on his back. Shows awareness of presence of people. Laugh aloud and shows pleasure in making
sounds. Cries less, smiles in response to mother’s face.
4-5 months
Increasing aware of his surroundings, Gasps object with the whole hand and carries it to mouth
(Proximodistal principle) can hold head steadily. Can sit without support. Drools with saliva
running down his mouth. Becomes more talkative and respond to name, recognizing strange look
and places.

6 – 7 months
Teeth starts to appear (lower 2 incisor) grasp with flexion of fingers. Hold leg and put in the
mouth. Balances well by leaning forward slightly on one or both hands. Moves backwards in a
sitting position by using his hands to push. Begins to make sound like Ba, Da, Ma, Ta Bounces
actively when held in upright position.
There is emotional instability by changing from laughing to crying and visa versa. Doubles birth
weight. There is indiscriminate social attachment. Not attached to any particular person.

8-9 months
Sit alone steadily. Stand with help at 8 months holding furniture by 9 months. There is perfect
co-ordination of hand and eyes. Shows first fear reaction to strangers. Greets strangers by turning
away and crying and may not stop crying until he sees familiar face. Affection or love of family
group appears, increase interest in activities. Can put nipple in and out of the mouth at will, crawl
with the trunks above the floor stand supported. May triple the birth weight.
10-12 months
Stands by holding on to something, as support. Stand alone unsupported. Walk with help, can
hold crayon or pencil, to make strokes and marks on a piece of paper. Participates in dressing/
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can say two words – Mama, Dada, Baba, and Tata, knows his own name. Recognizes meaning
of “NO”, egocentric, concern only with himself, can climb stairs steps by 13 months.
13-15 months can walk alone.
This is however not strictly by all children Nigerian children have been found to be faster in
locomotion – sit unsupported by 5-6 months and walk by 10 months. Generally African children
are trained by siblings and parents. After 1 year of age the weight and height do not give accurate
information about growth because of several factors. Boys are heavier and taller than girls, but
girls mature at more rapid rate. Genetic factors have much to do with body build e.g. effect of
nutrition on weight and height.
5.2.2.6 Positive Factors in child Growth & Development
Definitions
Growth and development depend on combination of many factors, all interdependent.
Heredity and constitution make up.
Fetus develops from genetic inheritance from both parents.
Members of families bear physical remembrances and there is high degree of correlation of
stature with weight among siblings. Some children are small not due to endocrine or nutritional
disturbance, but due to their genetic constitution. Racial and National characteristics have a great
role to play in different growth potentials. Some races are noted to be big e.g. Scandinavian
while Asians are generally smallish.
Prenatal environment; has great influence on their growth e.g. nutrition during pregnancy,
health, number of fetus. After delivery the factors that influence development is more of
environment than genetic.
Sex: Male infant is usually longer and heavier than female infant. For positive growth and
development the infant has to be physically and neurologically normal.

Environmental Factors
Adequate Nutrition & Feeding
- Nutritional need of the child has to be met.
- Child requires greater nutrition than adult. This is related to both quantity and quality.
Supply of protein, fat, CHO, minerals, vitamins and water
Save and Desirable environment: Children develop better in good living condition and with
good food.
Socio economic status of the parents; Children of parents of lower socio economic groups will
be less favourable than those of middle or upper group. Parents in poor financial state lack
money to maintain health and diet.
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Psychologically – The child needs appropriate stimulation to grow and develop. The child needs
love and attention. Good parenting, appropriate learning experience, (toils good colour and
environment, play, schooling).
Exercise
Exercises promote physiological activities and stimulate muscular development. Fresh air,
moderate sunshine favour health and growth, prolong exposure to sunshine may cause serious
consequence on the child.
Ordinal Position in the family: This is significant as child learns from older sibling, this is an
advantage which the first child lacked. The last child may be slow in development because he is
given little encouragement to express himself. He is the baby and petted by family members. The
lone child is likely to develop more rapidly along intellectual line because he is constantly with
adult. He is mentally stimulated by their companionship. Like the last born he may be slow in
motor development because he has so much done for him.
Internal environment: A child of high intelligence is better developed than less gifted
child. Intelligence influence mental and social development.
Hormonal Balance: Normal secretion of the endocrine glands promotes normal growth of
the body.
Emotion: – Emotional disturbance influence growth – disturbed child will neither sleep
nor eat well.
Intelligence: Can be defined as the ability to adjust to new situations, to think abstractly or to
profit from experience.
Meaning of the Intelligence quotient (IQ) – Ratio between the child’s chronologic age and his
mental age as gained from an intelligence test.

Mental Age
X 100  I .Q
Choro log ic age

Mental maturity is usually reached between 16-21 years. An I.Q. between 90-109 is
considered normal or average.
I.Q may range below or above this point. Children with I.Q of 140 or over are called gifted
children while those below the average represent retardation of varying degrees.
5.2.2.7 Development of teeth
Infant is usually born without teeth. Already he has 20 deciduous (primary) teeth in his mandible
and maxilla which begins to calcify in-utero.
Eruption of primary teeth begins at about 6-7 months. For some it brings no discomfort but for
some it is a painful experience. The claim that teething causes high fever, diarrhea or other
serious upset is not justified. Baby with these symptoms should be investigated and treated.
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Development of Teeth
Eruption Shedding
Central incisor 6-7 months 6-7½ years
First permanent molar 6-7 years 10½ years
Second baby molar (Lower) 20 month 11 years.
Lateral 9-13 months
Canines 16-20 months
First Molars 13-19 months
2nd Molars 25-33 months
5.2.2.8 Child Growth Curve
The growth curve tells us if the child is growing or not. A child who is growing is usually
healthy. So in the process of monitoring health we monitor growth and vice versa. Healthy
children should always visit clinics for growth monitoring. The child should be seen every month
for the first 6 months, then six monthly. Weight and height are assessed periodically. The weight
of the child increases each month. A chart should be used, the weight, indicated by a dots and all
the dots are joined together to form a growth curve. If the growth curve is rising the child is
growing and he is healthy but if it remains flat it means the child is not gaining weight well. If
falling it means is loosing weight.
The upper line shows the weight of a child that is well fed and healthy child. The lower line
shows a malnourished child and under weight. The line between these is called the road to heath.
Children should be on the road to health. The best way to assess the child’s health is by
measuring the arm circumference. During the first year the arm circumference grows rapidly but
from 1-5 years it remains stable. But if arm circumference is less than 14cm during this time the
child is malnourished. Arm circumference is used because the age does not have to be known. A
tape measure is used to measure the child’s upper left arm. A coloured string can be used as well,
then the length is measured on a ruler.

5.2.3 Activity
Visit the infant welfare clinic and familiarize yourself with the growth curve of 4 babies,
compare and discuss with their parents.Discuss your findings on the discussion forum
5.2.4 Self-Assessment Questions (SAQs) for unit 2

Describe how to measure intelligence Qotient in a child

SAQ 5.2 4.1 5.2.4 Self-Assessment Answer (SAAs) for unit 2

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Intelligence
Intelligence can be defined as the ability to adjust to new situations, to think abstractly or to
profit from experience.
- Meaning of the Intelligence quotient (IQ) – Ratio between the child’s chronologic age
and his mental age as gained from an intelligence test.

Mental Age
- X 100  I .Q
Choro log ic age

- Mental maturity is usually reached between 16-21 years. An I.Q. between 90-109 is
considered normal or average.
- I.Q may range below or above this point. Children with I.Q of 140 or over are called
gifted children while those below the average represent retardation of varying degrees

5.2.4.1 Self Assessment Answer(SAA)

References

- Basavanthappa B.T (2007) Nursing Theories. Jaypee Brothers Medical Publisher. New
Delhi.
- Cowen, K., J., London, M. L& LADEWIG, P. A. (2010). Skills manual for maternal and
child nursing care. Prentice Hall
- Fraser, D. M., & Cooper, M. A. (Eds.). (2009). Myles' textbook for midwives. Elsevier
Health Sciences.
- Gonzales-Mena and Eyler (2009). Infant, toddler and caregivers: A curriculum of
respectful, responsive, relationships based care and education. (8th ed.). McGraw-Hill.
- Holmes, Debbie, Philip N. Baker (2006). Midwifery by ten teachers. Hodder Arnold,
- Ladewig, P., Ball, J., & Bindler, R. (2011). Maternal & child nursing care. Pearson
Education.
- Trawick-Smith, J. (2008). Early childhood development: A multicultural perspective
(Fifth ed.). New York, New York: Pearson.

Module 6 Childhood diseases

Introduction

Module Objectives:
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At the end of this module you will be able to:

 Explain the common health problems of the neonate

 Discuss the Integrated management of childhood diseases

Content
Unit 1

 Common Health Problems of Neonate

 Integrated management of Childhood diseases (IMCI)

6.1.0 Introduction
Introduction
Every day, millions of parents seek health care for their sick children, taking them to hospitals,
health centres, pharmacists, doctors and traditional healers. Surveys reveal that many sick
children are not properly assessed and treated by these health care providers, and that their
parents are poorly advised. At first-level health facilities in low-income countries, diagnostic
supports such as radiology and laboratory services are minimal or non-existent, and drugs and
equipment are often scarce. Limited supplies and equipment, combined with an irregular flow of
patients, leave health workers at this level with few opportunities to practice complicated clinical
procedures. Instead, they often rely on history and signs and symptoms to determine a course of
management that makes the best use of the available resources.
These factors make providing quality care to sick children a serious challenge. WHO and
UNICEF have addressed this challenge by developing a strategy called the Integrated
Management of Childhood Illness (IMCI)

6.1.1 Unit Objectives

At the end of the unit you will be able to:
i. Explain the common childhood illness
ii. Discuss the concept integrated Management of Childhood disease(imci)
6.1.2 Childhood diseases
6.1.2.1 Common Childhood diseases
6.1.2.2 Integrated management of Childhood diseases
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6.1.2.2.1 What is IMCI?

6.1.2.2.2 Objectives of IMCI
6.1.2.2.3 Components of IMCI
6.1.2.2.4 Features of IMCI
6.1.2.2.5 Why is IMCI better than single-condition approaches?
6.1.2.2.6 Implementation IMCI
6.1.2.2.7 Evaluation of IMCI strategy
6.1.3 Activity
6.1.4 Self Assessment Questions ( SAQ)
6.1.4.1 Self Assessment Answer (SAA)
6.1.2 Childhood diseases
6.1.2.1 Common childhood diseases

The neonate can have following problems after birth.

 Hyperbilirubinaemia: Hyperbilirubinaemia may occur due to physiological jaundice and

Rh or ABO incompatibility.

 Neonatal hypoglycaemia: This condition of low blood glucose (less than30 mg/100 ml.)

Commonly occurring during the first 48 hours of life, is a hazardous state that must be

recognised and dealt with at once. Early feeding of babies has reduced the incidence of

hypoglycaemia.

 Hypothermia: The normal baby's temperature may fall to 35.5°C or less within one hour

of birth, unless precautions are taken to avoid chilling, the new born may go into

hypothermia with the temperature falling below35.5°C.

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

 Sepsis: Within few hours of birth, staphylococci generate colonies on the baby's skin and

in the nasal passages: the umbilicus becomes infected, more readily then nostrils and skin

folds such as axilla and groin. Any person suffering from respiratory infection or

diarrhea, or one who has any septic focus should not be allowed to come in contact with

babies

 Eye infections: The baby's eyes may be infected during his passage through the birth

canal, or later by the mother's hands. A number of cases of neonatal conjunctivitis are due

to the B-Proteus and staphylococci which produces a yellow discharge. Pneumococci and

streptococci are sometimes found but gonococcal infection is the most dreaded infection.

 Oral thrush: Oral thrush is characterized by white patches in the mouth. The causal

organism is the Candida albicans which is present in the vagina of some women.

6.1.2.2 Integrated Management of Childhood Illness (IMCI)

6.1.2.2.1 What is IMCI?

IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

IMCI aims to reduce death, illness and disability, and to promote improved growth and

development among children under five years of age. IMCI includes both preventive and

curative elements that are implemented by families and communities as well as by health

facilities.

The strategy includes three main components:

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Improving case management skills of health-care staff

Improving overall health systems

Improving family and community health practices.

In health facilities, the IMCI strategy promotes the accurate identification of childhood illnesses

in outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens

the counselling of caretakers, and speeds up the referral of severely ill children. In the home

setting, it promotes appropriate care seeking behaviours, improved nutrition and preventative

care, and the correct implementation of prescribed care.

6.1.2.2.2 Objectives of IMCI

Reduce deaths and frequency and severity of illness and disability

Contribute to improved growth and development

6.1.2.2.3 Components of IMCI

Improve case management skills of health care staff

Improve overall health systems

Improve family and community health practices

The IMCI ensures the combined treatment of major childhood illnesses emphasizing prevention

of disease through immunization and improved nutrition

6.1.2.2.4 Features of IMCI

Not necessarily dependent on the use of sophisticated and expensive instruments

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

A more integrated approach to managing sick children

Move beyond addressing single diseases to addressing overall health and well being of the child

Careful and systematic assessment of common symptoms and specific clinical signs to guide

rational and effective actions

Integrates management of the most common childhood problems (pneumonia, diarrhea, measles,

malaria, dengue, malnutrition, anemia, ear problems)

Includes preventive interventions

Adjusts curative interventions to the capacity and functions of the health system

Involves family members and community in the health care process

6.1.2.2.5 Why is IMCI better than single-condition approaches?

Children brought for medical treatment in the developing world are often suffering from more

than one condition, making a single diagnosis impossible. IMCI is an integrated strategy, which

takes into account the variety of factors that put children at serious risk. It ensures the combined

treatment of the major childhood illnesses, emphasizing prevention of disease through

immunization and improved nutrition.

6.1.2.2.6 Implementation IMCI

Introducing and implementing the IMCI strategy in a country is a phased process that requires a

great deal of coordination among existing health programmes and services. It involves working

closely with local governments and ministries of health to plan and adapt the principles of the

approach to local circumstances. The main steps are:

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Adopting an integrated approach to child health and development in the national health policy.

Adapting the standard IMCI clinical guidelines to the country’s needs, available drugs,

policies, and to the local foods and language used by the population.

Upgrading care in local clinics by training health workers in new methods

To examine and treat children, and to effectively counsel parents.

Making upgraded care possible by ensuring that enough of the right low-cost medicines and

simple equipment are available.

Strengthening care in hospitals for those children too sick to be treated in an outpatient clinic.

Developing support mechanisms within communities for preventing disease, for helping

families to care for sick children, and for getting children to clinics or hospitals when needed.

IMCI has already been introduced in more than 75 countries around the world.

6.1.2.2.7 Evaluation of IMCI strategy

MCA has undertaken a Multi-Country Evaluation (MCE) to evaluate the impact, cost and

effectiveness of the IMCI strategy. The results of the MCE support planning and advocacy for

child health interventions by ministries of health in developing countries, and by national and

international partners in development. The MCE was conducted in Brazil, Bangladesh, Peru,

Uganda and the United Republic of Tanzania.

The results of the MCE indicate that:

IMCI improves health worker performance and their quality of care;

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

IMCI can reduce under-five mortality and improve nutritional status, if implemented well;

IMCI is worth the investment, as it costs up to six times less per child correctly managed than

current care;

Child survival programmes require more attention to activities that improve family and

community behaviour;

The implementation of child survival interventions needs to be complemented by activities

that strengthen system support;

A significant reduction in under-five mortality will not be attained unless large-scale

intervention coverage is achieved.

6.1.3 Activity

During you MCH posting visit the Infant Welfare Clinic and identify the most common

childhood disease in your area of posting. Compare with mates in other area on the discussion

forum

6.1.4 Self Assessment Question(SAQ) for Unit 1

Discuss how IMCI can be evaluated in a health centre in your state

6.1.4.1 Self Assessment Answer(SAA) for Unit 1

MCA has undertaken a Multi-Country Evaluation (MCE) to evaluate the impact, cost and

effectiveness of the IMCI strategy. The results of the MCE support planning and advocacy for
NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

child health interventions by ministries of health in developing countries, and by national and

international partners in development. The MCE was conducted in Brazil, Bangladesh, Peru,

Uganda and the United Republic of Tanzania.

The results of the MCE indicate that:

IMCI improves health worker performance and their quality of care;

IMCI can reduce under-five mortality and improve nutritional status, if implemented well;

IMCI is worth the investment, as it costs up to six times less per child correctly managed than

current care;

Child survival programmes require more attention to activities that improve family and

community behaviour;

The implementation of child survival interventions needs to be complemented by activities

that strengthen system support;

A significant reduction in under-five mortality will not be attained unless large-scale

intervention coverage is achieved.

References

Baker, P. N., & Kenny, L. C. (Eds.). (2011). Obstetrics by 10 Teachers. Hodder Arnold.

Cowen, K., J., London, M. L& LADEWIG, P. A. (2010). Skills manual for maternal and child

nursing care. Prentice Hall

NSC 312 MATERNAL AND CHILD HEALTH NURSING 11

Fraser, D. M., & Cooper, M. A. (Eds.). (2009). Myles' textbook for midwives. Elsevier Health

Sciences.

Holmes, Debbie, Philip N. Baker (2006). Midwifery by ten teachers. Hodder Arnold,

IMCI Handbook

Ladewig, P., Ball, J., & Bindler, R. (2011). Maternal & child nursing care. Pearson Education.

London M.L., Ladewing P.W., Ball J.W and Bindler R.C. (2003), maternal and child nursing

care. 2nd ed, Pearson, London.

Ojo A.O and Briggs E.B. (2006). A Textbook for Midwives in the Tropics. 2nd ed. Yaypec, New

Delhi.