Chapter 25

Nursing Care of the Child With

an Alteration in Immunity or an
Immunologic Disorder

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 Learning Objectives
Upon completion of the chapter, student will be able to:

1. Explain anatomic and physiologic differences of the immune system in infants and children versus adults.
2. Describe nursing care related to common laboratory and diagnostic testing used in the
medical diagnosis of pediatric immune and autoimmune disorders.
3. Distinguish immune, autoimmune, and allergic disorders common in infants, children,
and adolescents.
4. Identify appropriate nursing assessments and interventions related to medications and
treatments for pediatric immune, autoimmune, and allergic disorders.
5. Develop an individualized nursing care plan or concept map for the child with an
immune or autoimmune disorder.
6. Develop child and family teaching plans for the child with an immune or autoimmune
disorder.

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Types of Immunity

Passive
o Antibodies received from an external source (mother to baby,
Intravenous immune globulin IVIG)
Cellular
o Antibodies produced by native T-cell lymphocytes
Humoral
o Antibodies produced by native B-cell lymphocytes

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Variations in Pediatric Anatomy and Physiology
The newborn receives passive immunity from maternal antibodies via
the placenta and breastfeeding
The newborn exhibits
o Decreased inflammatory and phagocytic responses to invading
organisms
o Increased susceptibility to infection
o A functional spleen
o Cellular immunity is generally functional at birth
Humoral immunity develops over time
Young children have larger lymph nodes, tonsils, and thymus compared
to adults
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Question #1

The nurse is providing education in response to questions from new

parents concerned about keeping their child safe from infections.
Which phrase would be most appropriate for the nurse to include in the
teaching plan?
a. The baby’s immune system is fully developed at birth.
b. The child must be kept away from everyone but parents until the child
has a fully functional immune system.
c. Breastfeeding provides passive immunity to the infant that formulas
cannot provide.
d. The baby has specialized cells called phagocytes that can protect the
newborn from any infections.

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Answer to Question #1

c. Breastfeeding provides passive immunity to the infant that formulas

cannot provide.
Rationale: A child’s immune system is not fully functional until later in
childhood. The baby receives passive immunity via maternal antibodies
that can help protect the baby until the baby begins to manufacture
her/his own immunoglobulins; however, adequate hand washing and
keeping ill contacts away from the baby will help keep her/him safe.
Phagocytic cells (neutrophils and monocytes) are not fully functional
reaching adult levels until age 7.

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Primary Immunodeficiencies

Such as: Hypogammaglobulinemia, Wiskott-Aldrich Syndrome, and

Severe Combined Immune Deficiency
Mostly hereditary or congenital
Types
o Humoral deficiencies
o Cellular immunity deficiencies
o Combination of humoral and cellular immunity deficiencies
o Phagocytic system defects
o Complement deficiencies

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Ten Warning Signs of Primary Immunodeficiency

Four or more new episodes of acute otitis media in 1 year

Two or more episodes of severe sinusitis
Treatment with antibiotics for 2 months or longer with little effect
Two or more episodes of pneumonia in 1 year
Failure to thrive in the infant
Recurrent deep skin or organ abscesses
Persistent oral thrush or skin candidiasis after 1 year of age
History of infections requiring IV antibiotics to clear
Two or more serious infections such as sepsis
Family history of primary immunodeficiency

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Assessments for Wiskott–Aldrich Syndrome

Wiskott-Aldrich Syndrome is an X-linked genetic disorder resulting in

immunodeficiency, eczema, and thrombocytopenia. It affects males
only…
History of petechiae
Bloody diarrhea or bleeding episode in the first 6 months of life
History of hematemesis or intracranial or conjunctival hemorrhages
Eczema
Laboratory findings of low IgM concentration, elevated IgA and IgE
concentrations, and normal IgG concentrations

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Nursing Assessment of Severe Combined Immune
Deficiency (SCID)

Chronic diarrhea
Failure to thrive
History of severe infections early in infancy
Persistent thrush
Adventitious sounds related to pneumonia
Lab findings of very low levels of immunoglobulins

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Causes of Secondary Immunodeficiency

Such as: HIV Infection

Chronic illness
Malignancy and chemotherapy
Use of immunosuppressive medication (lowers the immune response)
Malnutrition or protein-losing state
Prematurity
HIV infection

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Signs and Symptoms of HIV Infection in Children

Failure to thrive
Recurrent bacterial infections
Opportunistic infections
Chronic or recurrent diarrhea
Recurrent or persistent fever
Developmental delay
Prolonged candidiasis

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Laboratory and Diagnostic Testing for HIV Infection
 Polymerase chain reaction (PCR) test
o Test for HIV genetic material (DNA, RNA)
o Positive in infected infants older than 1 month of age
 Enzyme-linked immunosorbent assay (ELISA) test
o Tests for antibodies to HIV
o Less accurate at detecting HIV infection in infants and toddlers than the
PCR
 Platelet count
o <30,000 requires treatment
 CD4 and ANC counts
o Low in HIV infection

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Question #2

Is the following statement true or false?

The nurse caring for children with HIV infection knows that the ELISA
test is the preferred test to determine HIV infection in infants and
exclude HIV infections as early as possible.

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Answer to Question #2

False. The polymerase chain reaction (PCR) test is the preferred test to
determine HIV infection in infants and exclude HIV infections as early
as possible.
Rationale: The enzyme-linked immunosorbent assay (ELISA) test is
positive in infants of HIV-infected mothers because of transplacentally
received antibodies. These antibodies may persist and remain
detectable up to 24 months of age, making the ELISA test less accurate
at detecting HIV infection in infants and toddlers than the PCR.

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Stressors Involved With Diagnosis of HIV Infection in
Children

Diagnosis of an incurable disease

Financial difficulties
Multiple family members with HIV
HIV-associated stigmas
Desire to keep HIV infection confidential
Multiple medical appointments and hospitalizations

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Family Education for the Child With HIV Infection

Medication regimen
Ongoing follow-up
When to call infectious disease provider
Stress reduction
HIV education

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Influencing Factors for Autoimmune Disease

Autoimmune disorders as: Systemic Lupus Erythromatosus (SLE),

Juvenile Idiopathic Arthritis, Gullain-Barre’ Syndrome, and Myasthenia
Gravis, and Dermatomyositis…
Heredity
Hormones
Self-marker molecules
Environmental influences
o Viruses
o Certain drugs

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Common Laboratory and Diagnostic Tests for Systemic
Lupus Erythematosus (SLE)

SLE definition: chronic multisystem autoimmune disorder with periods

of exacerbation and remissions.
Laboratory testing includes:
o CBC (decreased Hgb, Hct)
o Platelet count (decreased)
o WBC (decreased)
o Complement levels (C3 and C4 decreased)
o ANA titer (nonspecific, but usually positive)

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Most Common Clinical Manifestations of Systemic Lupus
Erythematosus

Alopecia, hair loss Pleurisy; inflamed pleura

Anemia Raynaud phenomena; spasms in small
Arthralgia; joint pain blood vessels in fingers and toes.
Seizures
Arthritis
Stomatitis (Cold sore); inflamed mouth
Fatigue
Thrombocytopenia; low level of
Lupus nephritis
platelets
Photosensitivity Skin rashes particularly characteristic
malar skin rash

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Systemic Lupus Erythematosus

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Types of Juvenile Idiopathic Arthritis

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Question #3

The nurse is reviewing the chart of a child with juvenile idiopathic

arthritis. The nurse notes that there is involvement of five joints
symmetrically. What is the technical name for this type of arthritis?
a. Pauciarticular
b. Polyarticular
c. Systemic
d. Primary

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Answer to Question #3

b. Polyarticular. Polyarticular juvenile idiopathic arthritis involves five

or more joints and often affects the body symmetrically.
Rationale: Pauciarticular involves four or fewer joints, quite often the
knee. Systemic involves fever and rash in addition to joint involvement.
Primary is not a type of juvenile idiopathic arthritis.

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Common Medications and Medical Treatments in
Immune Disorders

Immunosuppressants
Cytotoxic medications
Plasmapheresis
IV immunoglobulins
Antibiotics
Disease-modifying antirheumatic drugs (DMARDs)
Antiviral medications, NNRTIs, protease inhibitors
Immunizations
Bone marrow or stem cell transplantation

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Question #4

Is the following statement true or false?

The nurse is caring for a child who underwent a stem cell transplant.
This procedure involves the transfer of healthy bone marrow into the
bones of a person with immune malfunction.

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Answer to Question #4

False. With stem cell transplant peripheral stem cells are removed
from the donor via apheresis or stem cells are retrieved from the
umbilical cord and placenta. The stem cells are then transplanted as an
infusion into the recipient.
Rationale: Bone marrow transplant involves the transfer of healthy
donor bone marrow cells into the veins of the recipient. The cells will
ultimately migrate to and grow in the bone marrow of the recipient to
restore immune function.

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Health History for Immunologic Disorders

Maternal HIV infection

Frequent, recurrent infections
Chronic cough
Recurrent low-grade fever
Two or more serious infections in early childhood
Recurrent deep skin or organ abscesses
Persistent thrush in the mouth
Extensive eczema
Growth failure

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Common Food Allergens to Avoid in Children Younger
Than 1 Year

Cow’s milk
Eggs
Peanuts
Tree nuts
Fish and shellfish
Wheat
Soy

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Goals of Nursing Care of the Child With HIV Infection or
Other Chronic Immune Disorder

Avoiding infection
Promoting compliance with the medication regimen
Promoting nutrition
Providing pain management and comfort measures
Educating the child and caregivers
Providing ongoing psychosocial support

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References

Kyle, T., & Carman, S. (2019). Essentials of Pediatric Nursing (4th ed.). Wolters Kluwer
Health

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