Pediatric Nursing

Growth & Developmental Milestones

Infant (0–12 Months)

Physical Growth

• Weight: doubles by 4–6 months; triples by 12 months (~10 kg / 22 lb)
• Length: increases ~2.5 cm/month in first 6 months; ~50% increase by 12 months
• Head circumference: increases ~2 cm/month in first 3 months; posterior fontanel closes by 2–3 months; anterior fontanel closes by 12–18 months
• Teething: first teeth erupt ~6 months (lower central incisors first)

Motor Milestones (Gross & Fine)

Cognitive (Piaget — Sensorimotor Stage)

• Object permanence develops around 8–9 months (child searches for hidden object)
• Birth–1 month: Reflexes; 1–4 mo: Primary circular reactions (repeats body actions); 4–8 mo: Secondary circular reactions (repeats actions on environment); 8–12 mo: Coordination of secondary schemas (goal-directed behavior, imitation)

Psychosocial (Erikson — Trust vs. Mistrust)

• Infants develop trust when needs are consistently met (feeding, comfort, warmth)
• Separation anxiety peaks at 6–8 months (stranger anxiety begins around 6 months)
• Provide consistent caregivers; encourage parent presence during hospitalization

Toddler (1–3 Years)

• Physical: Weight gain ~2–3 kg/year; growth slows; anterior fontanel closed by 18 mo; 20 deciduous teeth by 2.5 years; bladder/bowel control achieved (~2–3 yr)
• Motor: Walks alone → runs → climbs stairs → jumps → kicks ball → rides tricycle (3 yr)
• Piaget — Preoperational (2–7 yr): Egocentrism, animism, magical thinking; language explosion (50 words at 18 mo, 300+ by 2 yr, 2–3 word sentences by 3 yr)
• Erikson — Autonomy vs. Shame/Doubt: Independence, "NO" is favorite word, parallel play, ritualism (same routines), negativism. Allow choices within limits

Preschool (3–6 Years)

• Physical: Grows 6–8 cm/year; loses baby teeth (6 yr); improved coordination — hops, skips, jumps, catches ball, dresses independently, draws circle/square/triangle, copies letters
• Piaget — Preoperational: Magical thinking, centration (focuses on one aspect), transductive reasoning (specific to specific; e.g., "I was bad, so I got sick"), fear of body mutilation and pain
• Erikson — Initiative vs. Guilt: Burgeoning imagination; guilt if scolded excessively; enjoys role-playing and helping; cooperative play

School-Age (6–12 Years)

• Physical: Slow, steady growth; 2–3 kg/year; 5–6 cm/year; permanent teeth; prepubescent changes (girls ~10–12, boys ~11–13)
• Piaget — Concrete Operational: Logical reasoning about concrete objects; understands conservation, classification, cause-effect; time concepts; seriation
• Erikson — Industry vs. Inferiority: Eager to learn skills; needs praise; competitive; peer groups become important. Illness → fear of disability, death, loss of control

Adolescent (12–18 Years)

• Physical: Rapid growth spurt; secondary sexual characteristics (Tanner staging); menarche (~12–13 yr); spermarche (~13–14 yr); peak height velocity
• Piaget — Formal Operational: Abstract thinking, hypothetical reasoning, deductive logic, metacognition
• Erikson — Identity vs. Role Confusion: "Who am I?"; peer approval critical; body image concerns; may rebel against authority; risk-taking behaviors
• Nursing: Provide privacy; confidentiality (with limits); nonjudgmental attitude; screen for depression, substance use, sexual activity, safety

Immunization Schedule (CDC — Birth to 18 Years)

Common Pediatric Illnesses

Otitis Media (OM)

• Most common in 6–18 months; Eustachian tubes are shorter, more horizontal
• S/S: ear pain (tugging), fever, irritability, crying, anorexia, purulent drainage if TM perforates
• Diagnosis: otoscopic visualization of bulging, erythematous, immobile TM; pneumatic otoscopy shows decreased mobility
• Treatment: watchful waiting (if age > 6 mo, mild symptoms), high-dose amoxicillin (80–90 mg/kg/day × 10 days), analgesics (acetaminophen, ibuprofen)
• Tympanostomy tubes if recurrent (≥ 3 in 6 months or ≥ 4 in 12 months)

RSV / Bronchiolitis

• RSV is the leading cause of bronchiolitis in infants < 2 years
• S/S: coryza, cough, wheezing, tachypnea, retractions, nasal flaring, apnea (especially in infants < 6 wks), hypoxemia
• Diagnosis: nasopharyngeal swab for RSV antigen or PCR
• Treatment: supportive — O₂, humidified air, suctioning, IV fluids if needed. Bronchodilators are not routinely recommended. Palivizumab (Synagis) prophylaxis for high-risk infants (premature, CLD, CHD)
• Isolation: Contact + Standard precautions

Croup (Laryngotracheobronchitis)

• Viral (parainfluenza most common); age 3 months–3 years; occurs in fall/winter
• S/S: barky "seal-like" cough, inspiratory stridor, hoarseness, low-grade fever, worse at night, steeple sign on X-ray (subglottic narrowing)
• Severity: Assess using Westley Croup Score; stridor at rest, retractions, oxygen saturation
• Treatment: mist therapy (cool humidified O₂), racemic epinephrine (nebulized) for moderate-severe, dexamethasone 0.6 mg/kg PO/IM/IV (single dose)

Asthma

• Chronic inflammatory airway disease; reversible airflow obstruction; hyperresponsiveness to triggers
• S/S: wheezing, cough (especially at night or with exercise), dyspnea, chest tightness, prolonged expiration
• Management (stepwise):
  • Quick-relief (rescue): SABA (albuterol) — β₂-agonist
  • Controller (daily): inhaled corticosteroids (fluticasone) — first-line for persistent asthma
  • Leukotriene modifiers: montelukast
  • Severe: LABA, theophylline, biologics (omalizumab — anti-IgE)
• Peak flow monitoring: Green zone (80–100%), Yellow (50–80%), Red (< 50% personal best)
• Status asthmaticus: severe episode not responsive to standard therapy; requires ICU, continuous albuterol, IV steroids, magnesium sulfate

Urinary Tract Infection (UTI)

• More common in girls (shorter urethra); uncircumcised boys at higher risk in first year
• S/S: Infant: fever, poor feeding, vomiting, irritability, strong-smelling urine. Older child: dysuria, frequency, urgency, suprapubic pain, enuresis
• Diagnosis: clean-catch or catheterized urinalysis & culture (+ nitrites, leukocyte esterase, WBCs)
• Treatment: antibiotics (TMP/SMX, amoxicillin, cephalosporins based on sensitivity); encourage hydration, complete voiding
• VUR (vesicoureteral reflux): common underlying cause of recurrent UTI; VCUG for children < 5 years after first febrile UTI

Gastroenteritis & Dehydration

• Leading cause of morbidity in children worldwide; rotavirus most common (now reduced by vaccine)
• S/S: vomiting, diarrhea, fever, anorexia
• Dehydration assessment:

  Parameter	Mild (3–5%)	Moderate (6–9%)	Severe (≥ 10%)
  Mucous membranes	Slightly dry	Dry, sticky	Parched, cracked
  Skin turgor	Normal	Tented/↓	Very slow > 2 sec
  Urine output	Slightly ↓	Oliguria	Anuria
  Heart rate	Normal	↑	↑↑, weak/thready
  Capillary refill	< 2 sec	2–3 sec	> 3 sec, mottled
  Eyes	Normal	Sunken	Deeply sunken
  Mental status	Alert	Irritable/lethargic	Lethargic/unconscious

• Treatment: Oral Rehydration Solution (ORS) — commercial pedialyte, not water or juice. IV fluids (NS or LR bolus 20 mL/kg) for moderate-severe dehydration. Encourage early refeeding (BRAT diet not necessary — resume age-appropriate diet)

Febrile Seizures

• Age 6 months–5 years; seizure with fever ≥ 100.4°F (38°C) without CNS infection, electrolyte imbalance, or afebrile seizure history
• Simple febrile: generalized tonic-clonic, < 15 min, single in 24 h; no neurological sequelae
• Complex febrile: focal, > 15 min, multiple in 24 h; increased risk of epilepsy
• Management: no routine antiepileptics; antipyretics (acetaminophen/ibuprofen) for comfort but do NOT prevent recurrences; treat underlying cause; reassure parents — typically benign

Cerebral Palsy (CP)

• Non-progressive disorder of movement, posture, and muscle tone due to brain injury before age 2–3 years
• Types: Spastic (most common — 70–80%), Dyskinetic/Athetoid, Ataxic, Mixed
• Risk factors: prematurity, birth asphyxia, kernicterus, intraventricular hemorrhage, congenital infections (TORCH)
• Management: multidisciplinary — PT/OT/speech therapy, orthotics, baclofen (oral or intrathecal), Botox injections for spasticity, orthopedic surgery for contractures
• Nursing: safe feeding (dysphagia risk), positioning, skin care, bowel/bladder management, maximise mobility and function

Hydrocephalus

• Excessive CSF accumulation → enlarged ventricles → ↑ ICP
• S/S in infants: rapid ↑ head circumference, bulging fontanel, scalp vein distention, "sunset" eyes (setting-sun sign), splayed sutures, high-pitched cry
• S/S in older children: headache, vomiting, papilledema, downward gaze, ataxia, behavioral changes, declining school performance
• Treatment: VP shunt (ventriculoperitoneal). Shunt infection: fever, vomiting, redness along tract. Shunt malfunction: return of hydrocephalus symptoms
• NCLEX tip: Never pump a VP shunt unless specifically ordered. Post-op: position flat on non-shunt side (prevents rapid CSF draining). Monitor for infection and increasing ICP

Spina Bifida (Myelomeningocele)

• Neural tube defect; incomplete closure of vertebral column; most severe form = myelomeningocele (sac/CSF + neural tissue)
• Prevention: folic acid 400 mcg daily before conception and during early pregnancy
• S/S: sac on back (may be leaking CSF); flaccid paralysis below level of lesion; bowel/bladder incontinence; hydrocephalus (90% of myelomeningocele); Chiari II malformation; orthopaedic deformities
• Pre-op care: cover sac with sterile moist NS dressing; prone position; assess for CSF leak; prevent infection; latex allergy precautions (allergy common!)
• Post-op: monitor for increased ICP; VP shunt often placed simultaneously; ongoing multidisciplinary care

Congenital Heart Disease (CHD)

Cystic Fibrosis (CF)

• Autosomal recessive; defective CFTR gene → abnormal Cl⁻ transport → thick, viscous secretions
• Pulmonary: chronic cough, recurrent pneumonia, wheezing, bronchiectasis, Pseudomonas/MRSA colonization. Management: chest PT & postural drainage, dornase alfa (Pulmozyme), albuterol, hypertonic saline, CFTR modulators (ivacaftor, lumacaftor), inhaled tobramycin
• GI: pancreatic insufficiency → steatorrhea, FTT, fat-soluble vitamin deficiencies (ADEK). Management: pancreatic enzyme replacement (with meals/snacks), high-calorie high-fat diet, ADEK supplementation
• Diagnosis: newborn screening (immunoreactive trypsinogen — IRT), sweat chloride test (≥ 60 mEq/L = positive)

Developmental Dysplasia of the Hip (DDH)

• Abnormal development of hip joint; femoral head not properly seated in acetabulum
• Risk factors: female, breech presentation, positive family history, first-born, oligohydramnios
• Assessment: Ortolani maneuver (reduction) and Barlow maneuver (dislocation) — < 3 months. Asymmetric thigh/gluteal folds, Galeazzi sign (apparent leg length discrepancy), limited abduction
• Treatment: Pavlik harness (< 6 months) — wear 23 h/day; do NOT remove for diaper changes unless specified; skin checks. Older: closed reduction + spica cast or open reduction + osteotomy

Pyloric Stenosis

• Thickening of pyloric sphincter → gastric outlet obstruction; age 2–8 weeks, more common in first-born males
• S/S: progressive projectile (non-bilious) vomiting after feeding, visible gastric peristaltic waves (L→R), olive-shaped mass in RUQ, metabolic alkalosis (↓ Cl⁻, ↓ K⁺), failure to thrive
• Diagnosis: ultrasound shows thickened pyloric muscle (≥ 4 mm, length ≥ 16 mm)
• Treatment: pre-op: NPO, NG tube, correct dehydration & electrolyte imbalance (IV D₅ ½NS + KCl). Surgical: pyloromyotomy (laparoscopic or open). Post-op: small clear feeds starting 4–6 h after surgery; expect occasional vomiting (resolves in 1–2 days)

Intussusception

• Telescoping of one bowel segment into another (most common at ileocecal valve); age 3 months–3 years
• Classic triad: sudden colicky abdominal pain (baby draws knees to chest), currant-jelly stools (late sign), palpable sausage-shaped mass in RUQ
• Diagnosis: ultrasound shows "target sign" or "doughnut sign"
• Treatment: non-surgical reduction with air enema or contrast enema (diagnostic & therapeutic). If failed or peritonitis → surgical reduction with possible bowel resection
• Post-reduction: observe for recurrence (~10% within 24–48 h). Signs of successful reduction: passage of stool, flatus, cessation of pain

Pediatric Assessment & Medication Administration

Vital Signs by Age

Medication Administration Differences

• Weight-based dosing: all pediatric meds calculated by mg/kg; double-check calculations with another nurse
• IM injection sites:
  • Neonates/< 12 mo: vastus lateralis (1″ needle, 22–25G)
  • Toddlers and older: vastus lateralis (preferred) or deltoid (> 12 mo, small muscle — max 0.5–1 mL)
  • Gluteal muscle (dorsogluteal/ventrogluteal): NOT used until child has been walking for > 1 year
• IV sites: scalp veins (neonates), hand/foot, antecubital; use smallest gauge (24G) for neonates
• Oral meds: use oral syringe; position upright; squirt toward buccal mucosa; never call medicine "candy"
• Ear drops: children < 3 yr — pull pinna down and back; ≥ 3 yr — pull up and back
• Distraction techniques: blowing bubbles, counting, toys, parent involvement

Child Safety & Abuse Identification

Injury Prevention by Age

Child Abuse Identification