Acute Conditions of the Neonate

RE S PI RAT O RY DI S T RES S ↓
S YNDRO ME The ability to stop alveoli from collapsing with each
o Formerly termed hyaline membrane disease expiration becomes more and more difficult
o Often seen in newborns born prematurely
o Cause: a low level or absence of surfactant, the ASS ES S ME NT
phospholipid that normally lines the alveoli and reduces Most infants who develop RDS have difficulty
surface tension to keep the alveoli from collapsing on initiating respirations at birth. After resuscitation, they appear
expiration to have a period of hours or a day when they are free of
o Other causes: newborns with meconium aspiration symptoms because of an initial release of surfactant. During
syndrome, sepsis, a newborn who is slow to transition to this time, however, subtle signs may appear, such as:
extrauterine life, and pneumonia. o Low body temperature
o Pathologic feature: a hyaline like (fibrous) membrane o Nasal flaring
formed from an exudate of an infant’s blood that begins to o Sternal and subcostal retractions
line the terminal bronchioles, alveolar ducts, and alveoli. o Tachypnea (more than 60 breaths/min)
This membrane prevents the exchange of oxygen and o Cyanotic mucous membranes
carbon dioxide at the alveolar–capillary membrane,
interfering with effective oxygenation. Within several hours, expiratory grunting occurs caused
by closure of the glottis as it tries to increase the pressure in
Surfactant does not form until the 34th week of gestation, alveoli on expiration in order to help to keep them from
hence, as many as 30% of LBW infants and as many as 50% collapsing. Even with this attempt at better oxygen exchange,
of VLBW premature infants are susceptible to this however, as the disease progresses, infants become cyanotic
complication. and their Po2 and oxygen saturation levels fall in room air. On
auscultation, there may be fine rales and diminished breath
PAT HO PH YS I OL O G Y sounds because of poor air entry. As distress increases, an
High pressure is required to fill the lungs with air for infant may exhibit:
the first time and overcome the pressure of lung fluid. For o Seesaw respirations (on inspiration, the anterior chest
example, it takes a pressure between 40 and 70 cm H2O to wall retracts and the abdomen protrudes; on
inspire a first breath but only 15 to 20 cm H2O to maintain expiration, the sternum rises)
quiet, continued breathing. If alveoli collapse with each o Heart failure, evidenced by decreased urine output
expiration, as happens when surfactant is deficient, forceful and edema of the extremities
inspirations requiring optimum pressure are still required to o Pale gray skin
inflate them o Periods of apnea
o Bradycardia
With deficient surfactant, areas of hypoinflation o Pneumothorax
begin to occur and pulmonary resistance increases. Blood then
shunts through the foramen ovale and the ductus arteriosus as Diagnosis of RDS
it did during fetal life. The lungs become poorly perfused. As Clinical signs: grunting, central cyanosis in room air,
a result, the production of surfactant decreases even further tachypnea, nasal flaring, and retractions.
Chest X-ray: a diffuse pattern of radiopaque areas that look
Poor oxygen exchange like ground glass (haziness) in the lungs.
↓ Blood gas studies: respiratory acidosis.
Tissue hypoxia
↓ T HE RAPE UT I C MANAG E ME NT
Release of lactic acid & Increased CO2 level a. Surfactant Replacement – immediately after birth,
↓ synthetic surfactant is administered into an endotracheal
Formation of the hyaline membrane on the alveolar surface tube by a syringe or catheter (lung lavage).
↓ b. Oxygen Administration – often n necessary to maintain
Severe acidosis correct Po2 and pH levels following surfactant
↓ administration, and it may be administered in a variety of
Vasoconstriction ways from a simple cannula or mask, continuous positive
↓ airway pressure (CPAP), or assisted ventilation with
Decreased pulmonary perfusion positive end-expiratory pressure (PEEP). High frequency,
↓ oscillatory, and jet ventilation are still other methods of
Further limitation of surfactant production introducing oxygen to infants with noncompliant lungs.
c. Ventilation - these are pressure cycled to control the force
with which air is delivered.
d. Nitric Oxide - a potent vascular dilator. It causes
pulmonary vasodilation without decreasing systemic
vascular tone. It combines with hemoglobin in the
intravascular space to form methemoglobin. This causes
systemic vasodilation.
e. Extracorporeal Membrane Oxygenation – used for the
management of severe hypoxemia in newborns with
illnesses such as meconium aspiration, RDS, pneumonia,
and diaphragmatic hernia. Formerly used as a mainstay of
therapy for RDS, it is now rarely needed because
surfactant lavage is so effective.
f. Supportive Care - An infant with RDS must be kept warm
because cooling increases acidosis in newborns, and for
the newborn with RDS, acidosis may increase to lethal
levels. Keeping an infant warm also reduces the infant’s
metabolic oxygen demand. Provide hydration and
nutrition with intravenous fluids and glucose or gavage
feedings because the respiratory effort makes an infant
too exhausted to suck
PRE VE NT I O N
Using a tocolytic agent such as magnesium sulfate
can help prevent preterm birth for a few days. During this
time, if a woman receives two injections of a
glucocorticosteroid, such as betamethasone, it may be possible
to prevent RDS in the newborn because steroids appear to
quicken the formation of lecithin.
ME CO NI UM AS PI RAT I O N
S YNDRO ME
Meconium is present in the fetal bowel as early as 10
weeks of gestation. If hypoxia occurs, a vagus reflex is
stimulated, resulting in relaxation of the rectal sphincter. This
releases meconium into the amniotic fluid.
An infant may aspirate meconium either in utero or
with the first breath at birth. Meconium can cause severe
respiratory distress (tachypnea, retractions, and grunting). The
infant may also require increased oxygen to maintain
saturations in the mid to upper 90s.
Babies born breech may expel meconium into the amniotic
fluid from pressure on the buttocks. In both instances, the
appearance of the fluid at birth is green to greenish black from
the staining.
ASS ES S ME NT
o Difficulty establishing respirations at birth
o Apgar score is apt to be low
o Tachypnea, retractions, and cyanosis almost immediately
The infant should be placed on the warmer, and resuscitation
should begin including the initiation of positive pressure
ventilation as necessary
After initiation of respirations:
o Infant’s respiratory rate may remain rapid (tachypnea)
and coarse bronchial sounds may be heard on auscultation
o The infant may continue to have retractions because the
inflammation of bronchi tends to trap air in the alveoli,
limiting the entrance of oxygen.
o Pulse oximetry or blood gases will reveal poor gas
exchange evidenced by a decreased PO2 and an increased
PCO2.
o A chest X-ray will show bilateral coarse infiltrates in the
lungs, with spaces of hyperaeration (a peculiar
honeycomb effect).
o The diaphragm will be pushed downward by the over-
expanded lungs.
T HE RAPE UT I C MANAG E ME NT
a. Amnioinfusion – can be used to dilute the amount of
meconium in the amniotic fluid and has shown to improve
the outcomes for the newborn with meconium in
situations where perinatal observation is limited.
b. Oxygen Administration and Assisted Ventilation
c. Antibiotic Therapy – to forestall the development of
pneumonia as a secondary problem.
d. Surfactant Administration – if lung compliance is poor.
e. Temperature-neutral Environment – to prevent the infant
from having to increase metabolic oxygen demands.
f. Chest Physiotherapy with Percussion and Vibration –
maybe helpful to encourage the removal of remnants of
meconium from the lungs
g. Some infants may need to be administered nitric oxide or
maintained on ECMO to ensure adequate oxygenation
SE PS IS
Newborns are susceptible to infections during
pregnancy and at birth because their ability to produce
antibodies is immature.
Β- H E MOL YT I C, G RO UP B
ST RE TO CO CCAL I NFE CT IO N
A serious cause of infection in newborns is the gram-
positive β-hemolytic, group B streptococcal (GBS) organism,
a natural inhabitant of the female genital tract. Between 50 and
300 infants out of every 1,000 live births display a positive
culture for the organism. It also may be spread from baby to
baby if good hand washing technique is not used in caring for
newborns.
ASS ES S ME NT
o Universal screening is recommended for pregnant women
at 35 to 37 weeks of gestation to see if they have GBS
organisms in their vaginal secretions
o Colonization by GBS can result in either an early-onset or
a late-onset illness.
o With the early-onset form, signs of pneumonia such as
tachypnea, apnea, extreme paleness, hypotension, or
 hypotonia become apparent within the first day of life.
Decreased urine output can occur from the hypotension.
o A late-onset type occurs at 2 to 4 weeks of age. With this,
instead of pneumonia being the infection focus,
meningitis tends to occur. Typical signs include lethargy,
fever, loss of appetite, and bulging fontanelles from
increased intracranial pressure.
T HE RAPE UT I C MANAG E ME NT
If a newborn displays signs of infection or a blood
screening test is positive, antibiotics such as penicillin,
cefazolin, clindamycin, or vancomycin are all effective against
the GBS organism.
Immunization of all women of childbearing age
against streptococcal B organisms could decrease the
incidence of newborns infected at birth.
O PT H AL MI A NE O NAT O RI UM
Ophthalmia neonatorum is an eye infection that
occurs at birth or during the first month of life. The most
common causative organisms are Neisseria gonorrhoeae and
Chlamydia trachomatis, which are contracted from vaginal
secretions. An N. gonorrhoeae infection is an extremely
serious form of infection because, if left untreated, the
infection progresses to corneal ulceration and destruction,
resulting in opacity of the cornea and severe vision
impairment.
ASS ES S ME NT
o The conjunctivae become fiery red and covered with thick
pus
o The eyelids appear edematous
PRE VE NT IO N
a. Prophylactic instillation of erythromycin ointment into the
eyes of newborns
T HE RAPE UT I C MANAG E ME NT
a. If gonococci are identified, intravenous ceftriaxone
(Rocephin) and penicillin are effective drugs.
b. If Chlamydia is identified, an ophthalmic solution of
erythromycin is commonly used.
c. Use standard and contact infection precautions when
caring for this newborn.
d. Sterile saline solution lavage to clear the copious
discharge from the eyes may be prescribed
e. When irrigating eyes, use a sterile medicine dropper or
bulb syringe and use barrier protection, including goggles
to avoid splashing any solution into your own eye. (The
solution should be at room temperature)
f. The mother of the infected infant needs treatment for
gonorrhea or chlamydia before fallopian tube sterility or
pelvic inflammatory disease can result.
g. Sexual contacts of the mother should be treated also so
the spread of the disease can be halted.
H E PAT IT I S B VI RUS
I NFE CT IO N
Hepatitis B virus (HBV) can be transmitted to the
newborn through contact with infected vaginal blood at birth
when the mother is positive for the virus. Hepatitis B is a
destructive illness with greater than 90% of infected infants
becoming chronic carriers of the virus as well as the risk of
developing liver cancer later in life.
PRE VE NT IO N
To reduce the possibility of HBsAg being spread to newborns
in the future, parents are asked if they would like their infant
vaccinated against hepatitis B at birth.
T HE RAPE UT I C MANAG E ME NT
o Infant should be bathed as soon as possible after birth to
remove HBV-infected blood and secretions
o Gentle suctioning is necessary to avoid trauma to the
mucous membrane, which could allow HBV invasion.
o Infant is administered serum hepatitis B immune globulin
(HBIG) in addition to the HBV vaccination.
Although the virus is transmitted in breast milk, once immune
globulin has been administered, women may breastfeed
without risk to an infant.
GE NE RAL I Z E D HE RPE S VI RUS
I NFE CT IO N
A herpes simplex virus type 2 (HSV-2) infection,
which is most prevalent among women with multiple sexual
partners, can be contracted by a fetus across the placenta if the
mother has a primary infection during pregnancy.
ASS ES S ME NT
o Infant may be born with vesicles covering the skin (if the
infection was acquired during pregnancy.
o A loss of appetite
o Low-grade fever
o Lethargy
o Stomatitis (ulcers of the mouth) or a few vesicles on the
skin appear
o Herpes vesicles always cluster, are pinpoint in size, and
are surrounded by a reddened base
o They develop dyspnea, jaundice, purpura, convulsions,
and hypotension.
o Death may occur within hours or days
o To confirm the diagnosis, cultures are obtained from
representative vesicles as well as from the nose, throat,
anus, and umbilical cord. Blood serum is analyzed for
IgM antibodies.
T HE RAPE UT I C MANAG E ME NT
a. An antiviral drug such as acyclovir (Zovirax), a drug that
inhibits viral DNA synthesis, is effective in combating
this overwhelming infection
b. Antenatal antiviral prophylaxis reduces viral shedding and
recurrences at birth and reduces the need for cesarean
birth
c. Women with active herpetic vulvar lesions are advised to
have cesarean birth rather than vaginal birth to minimize
the newborn’s exposure.
d. Infants with an infection should be separated from other
infants in a nursery
e. Women with herpes lesions on their face (herpes simplex
I, or cold sores) need to be assessed before they hold their
newborns to be sure lesions are crusted and, therefore, are
no longer contagious.
H I V I NFE CT I O N
HIV infection and AIDS can be caused by placental
transfer or direct contact with maternal blood during birth.
HEMOLYTIC DISEASE:
HYPERBILIRUBINEMIA
o The term “hemolytic” is Latin for “destruction” (lysis) of
red blood cells.
o Hemolytic disease is present when there is excessive
destruction of red blood cells, which leads to elevated
bilirubin levels (hyperbilirubinemia).
o Was most often caused by: Rh blood type incompatibility
o Now most often caused by: ABO incompatibility
The fetus has a different blood type than the mother, the
mother builds antibodies against the fetal red blood cells,
leading to hemolysis of the cells, severe anemia, and
hyperbilirubinemia.
Rh I NCO MPAT I B IL I T Y
If the mother’s blood type is Rh negative and the
fetal blood type is Rh positive, this introduction of fetal blood
causes sensitization to occur and the woman to begin to form
antibodies against the specific antigen (most commonly the D
antigen). Because of this surge in antibody formation after a
pregnancy, in a second pregnancy, there will be a high level of
antibody already circulating in the woman’s bloodstream. This
will then act to destroy the fetal red blood cells beginning
early in the next pregnancy if the new fetus is Rh positive.
Rh incompatibility is not commonly seen today
because if Rh-negative women receive Rho immune globulin
(RHIG or RhoGAM) (passive Rh antibodies) within 72 hours
after birth of an Rh-positive newborn, the process of antibody
formation will be halted and sensitization will not occur.
AB O I NCO MPAT I B I L IT Y
ABO incompatibility, the maternal blood type is O and the
fetal blood type is either A or B type blood.
Hemolysis can become a problem with a first
pregnancy in which there is an ABO incompatibility because
the antibodies to A and B cell types are naturally occurring
antibodies or are present from birth in anyone whose red cells
lack these antigens.
Hemolysis of the blood begins with birth, when blood
and antibodies are exchanged during the mixing of maternal
and fetal blood as the placenta is loosened; destruction may
continue for as long as 2 weeks. Interestingly, preterm infants
do not seem to be affected by ABO incompatibility.
ASS ES S ME NT
o Rh incompatibility of the newborn can be predicted by
finding a rising anti-Rh titer or a rising level of antibodies
(indirect Coombs test) in a woman during pregnancy.
o It can be confirmed by detecting antibodies on the fetal
erythrocytes in cord blood (positive direct Coombs test)
by percutaneous umbilical blood sampling or at birth.
o Not pale at birth
o The liver and spleen may be enlarged
o Heart failure due to severe anemia: heart has to beat at a
faster rate than normal to push the diluted blood forward.
o With birth, progressive jaundice, usually occurring within
the first 24 hours of life
o An increasing bilirubin level becomes dangerous if the
level rises above 20 mg/dl in a term infant and perhaps as
low as 12 mg/dl in a preterm infant
o An infant is forced to use glucose stores to maintain
metabolism in the presence of anemia which can cause
progressive hypoglycemia.
T HE RAPE UT I C MANAG E ME NT
Bilirubin levels in blood may be measured by either a blood
draw (TsB) or by holding a transcutaneous meter against the
infant’s skin (transcutaneous bilirubin TcB).
a. The initiation of Early Feeding – stimulation of bowel
peristalsis. Bilirubin is removed from the body by being
excreted through the feces. Therefore, the sooner bowel
elimination begins, the sooner bilirubin removal begins.
b. Phototherapy – additional light supplied by phototherapy
appears to speed the conversion of unconjugated (fat-
soluble) into conjugated (water-soluble) bilirubin.
Phototherapy exposes the infant to continuous specialized
light such as quartz halogen, cool white daylight, or special
blue fluorescent light. The lights are placed 12 to 30 in.
above the newborn’s bassinet or incubator.
c. Exchange Transfusion – The use of intensive phototherapy
in conjunction with hydration and close monitoring of
serum bilirubin levels has greatly reduced the need for
exchange transfusions. If this is done, small amounts (2 to
10 ml) of the infant’s blood are drawn from the infant’s
umbilical vein and then replaced with equal amounts of
donor blood. The therapy may be used for any condition
that leads to hyperbilirubinemia or polycythemia. When
 used as therapy for blood incompatibility, it removes
approximately 85% of sensitized red cells. It reduces the
serum concentration of indirect bilirubin and can prevent
heart failure in infants with severe anemia or
polycythemia.
The stools of an infant under bilirubin lights are often bright
green because of the excessive bilirubin being excreted as the
result of the therapy. They are also frequently loose and may
be irritating to the skin. Urine may be dark colored from
urobilinogen formation.
S UDDE N I NFANT DE AT H
S YNDRO ME
Sudden infant death syndrome (SIDS) is a sudden
unexplained death in infancy. It tends to occur at a higher than
usual rate in infants of adolescent mothers, infants of closely
spaced pregnancies, and underweight and preterm infants.
Also prone to SIDS are infants with BPD, twins, Native
American infants, Alaskan Native infants, economically
disadvantaged Black infants, and infants of narcotic-dependent
mothers.
Possible contributing Factors:
 Sleeping prone rather than supine
 Viral respiratory or botulism infection
 Exposure to secondary smoke
 Brainstem abnormalities
 Neurotransmitter deficiencies
 Heart rate abnormalities
 Distorted familial breathing patterns
 Decreased arousal responses
 Possible lack of surfactant in alveoli
 Sleeping in a room without moving air currents (the
infant rebreathes expired carbon dioxide)
Typically, affected infants are well nourished. Parents
may report an infant had a slight head cold. After being put to
bed at night or for a nap, the infant is then found dead a few
hours later.
ASS ES S ME NT
o Infants who die this way do not appear to make any sound
as they die, which indicates they die with laryngospasm
o Blood-flecked sputum or vomitus in their mouths or on
the bedclothes
o Petechiae in the lungs and mild inflammation and
congestion in the respiratory tract
R E CO MME NDE D PRE VE NT I O NS
a. Put newborns to sleep on their back
b. The use of a firm sleep surface
c. Breastfeeding
d. Room sharing without bed sharing
e. Routine immunizations
f. Consideration of using a pacifier
g. Avoidance of soft bedding
h. Overheating
i. Exposure to smoke, alcohol, and illicit drugs
HI RS CH S PRUNG ’S DI S E ASE
SPI NA BI FI DA
H YDRO CE PH AL US
ACUT E OT I T IS ME DI A
o Inflammation of the middle ear (otitis media)
o It occurs most often in children 6 to 36 months of age and
again at 4 to 6 years.
o Children most susceptible to it are males, Alaskan and
Native American children, those with cleft palate, and
infants who are formula-fed rather than breastfed
o The incidence of otitis media is highest in the winter and
spring because it frequently follows an upper respiratory
infection and is higher in homes in which a parent smokes
cigarette
o Permanent damage c
o an occur to middle ear structures, leading to permanent
hearing impairment.
Formula feeding leads to this because infants are held in a
more slanted position while feeding, allowing milk to enter the
eustachian tube.
ASS ES S ME NT
 Usually occurs following a respiratory tract infection
 Children have a “cold,” rhinitis, and perhaps a low-grade
fever for several days.
 Suddenly, their fever peaks to about 102°F (38°C), and
sharp, constant pain begins in one or both ears
 On examination, the external canal is usually free of wax
because the warmth of the inflammation and fever melts
the wax and moves it more readily out of the canal
 The tympanic membrane appears inflamed or reddened.
 It may bulge forward into the external canal because of
fluid and edema behind it
 The landmarks of the tympanic membrane, the malleus
and incus, can be visualized only poorly or not at all
 The light reflex of the otoscope will not be as definite as
usual because of the “pushed out” or convex shape of the
eardrum
 There is decreased mobility on a pneumatic examination.
Palpate the mastoid process behind the ear to be certain it
doesn’t feel tender to your touch. If it does, the infection
probably has spread out of the middle ear into the mastoid
cells, a very serious complication that may lead to meningitis.
T HE RAPE UT I C MANAG E ME NT
Most middle ear infections are caused by
Streptococcus pneumoniae, Haemophilus influenzae
(especially in children younger than 5 years of age), or
Streptococcus pyrogenes. An otitis media infection may
resolve spontaneously; however, if it does not:
a. Antibiotic therapy may be indicated
b. Analgesic and antipyretic such as acetaminophen
(Tylenol) and decongestant nose drops to open the
eustachian tubes and allow air to enter the middle ear
c. Providing a smoke-free home environment can help
prevent further episodes of otitis media
d. Caution parents about conductive hearing loss (may last
up to 6 months) so they will not think the infection is
growing worse if they first notie the impairment
e. Parents need to know about the possibility of hearing loss
so that when the child gets hearing screening in school
during the 6 months following the infection, they can
account for the hearing loss
f. If a child still has a conductive hearing loss after 6 months
(or has other symptoms), the child should be reevaluated
to see whether a new infection or serous otitis media has
developed.
Otitis media with effusion occurs when otitis media becomes
chronic.
B ACT E RI AL ME NI NG I T IS
Meningitis is, as the name implies, infection of the
cerebral meninges. It tends to occur most frequently in
children younger than 24 months of age and most often in
winter. The organisms most frequently seen are Streptococcus
pneumoniae or group B Streptococcus. In children younger
than 2 months of age, Escherichia coli is a common cause. If
children with myelomeningocele develop meningitis,
Pseudomonas infection may be the causative agent.
Brain abscess or invasion of the infection into cranial
nerves can result in blindness, hearing impairment, or facial
paralysis. If a thick exudate accumulates in the narrow
aqueduct of Sylvius, it can cause obstruction leading to
hydrocephalus. Brain tissue edema can put pressure on the
pituitary gland, causing increased production of antidiuretic
hormone, resulting in the syndrome of inappropriate
antidiuretic hormone secretion (SIADH), causing
hyponatremia.
ASS ES S ME NT
 Children usually have had 2 or 3 days of upper respiratory
tract infection prior to the development of meningitis
 They then grow increasingly irritable because of an
intense headache
 They experience sharp pain when they bend their head
forward.
 In the newborn, symptoms such as poor sucking, weak
cry, or lethargy develop
 As the disease progresses, signs of meningeal irritability
then occur, as evidenced by positive Brudzinski and
Kernig signs.
 Children may hold their back arched and their neck
hyperextended (opisthotonos)
 If third and sixth cranial nerve paralysis occurs, a child
will not be able to follow a light through full visual fields.
 If the fontanelles are open, they bulge upward and feel
tense; if they are closed, papilledema may develop
 If the meningitis is caused by H. influenzae, the child may
develop septic arthritis
 If it is caused by Neisseria meningitidis, a papular or
purple petechial skin rash may occur
 After this beginning of a myriad of general symptoms,
sudden cardiovascular shock, seizures, nuchal rigidity, or
apnea can occur
 Sudden cardiovascular shock, seizures, nuchal rigidity, or
apnea can occur
 CSF analysis obtained by lumbar puncture confirms the
diagnosis
 If the child has had close association with someone with
tuberculosis, a tuberculin skin test to rule out tuberculosis
meningitis will be done.
 A CT scan, MRI, or ultrasound study will be prescribed to
examine for brain abscess.
T HE RAPE UT I C MANAG E ME NT
a. Antibiotic therapy as indicated by sensitivity studies is the
primary therapy.
b. Intrathecal injections (directly into the CSF) may also be
necessary, especially because the blood– brain barrier
may prevent the chosen antibiotic from passing freely into
the CSF
c. A corticosteroid such as dexamethasone or the osmotic
diuretic mannitol may be administered to reduce ICP and
help prevent hearing loss.
d. In addition to standard precautions, children with
meningitis are placed on respiratory precautions for 24
hours after the start of antibiotic therapy to prevent
transmission of the infection to other family members or
healthcare providers
e. In addition, an antibiotic may be prescribed
prophylactically for the child’s immediate family
members or for playmates who have been in close contact
with the child.
If symptoms are recognized early and treatment is effective,
however, a child will recover with no sequelae. Neurologic
sequelae, such as learning problems, seizures, hearing and
cognitive challenges, and inability to concentrate urine from
lessened antidiuretic hormone secretion, must be assessed in
the weeks to come because these can be long-term
consequences.
FE B RI LE S EI Z URE S
Seizures associated with high fever (102° to 104°F or
38.9° to 40.0°C) are the most common type seen in preschool
children, although these can occur as late as 7 years of age.
They are most serious if they occur under 6 months of age.
Such seizures may occur after immunization with live
vaccines because these most commonly produce fevers. The
 seizure is usually a generalized tonic–clonic pattern, which
lasts for 15 to 20 seconds.
The seizure is due to a sudden spike of temperature, not a
gradual incline. The seizure only lasts 1 to 2 minutes or less.
PRE VE NT IO N
a. If ibuprofen or acetaminophen is given to keep a
developing fever below 101°F (38.4°C), the seizures rarely
occur (caution parents to read the bottle label carefully
before administration to be certain they are administering
the correct dosage).
b. Family history and younger age at onset of first seizure are
risk factors for reoccurrence of a febrile seizure.
c. Teach parents that every child who has a febrile seizure
must be seen by a healthcare provider to rule out
meningitis and to be aware that it will be assumed by
emergency room personnel that the child has meningitis
until it is ruled out by a complete neurologic workup.
T HE RAPE UT I C MANAG E ME NT
a. After a febrile seizure subsides, parents should sponge the
child with tepid water to reduce the fever quickly. Advise
them not to put the child in a bathtub of water to do this
because it would be easy for the child to slip under water
should a second seizure occur. Caution parents not to apply
alcohol or cold water because extreme cooling causes
shock to an immature nervous system; in addition, alcohol
can be absorbed by the skin or the fumes can be inhaled in
toxic amounts, compounding the child’s problems
b. Parents should not attempt to give oral medications such as
acetaminophen because the child will be in a drowsy, or
postictal, state after the seizure and might aspirate the
medicine.
c. Suppositories may be given at the appropriate dose.
d. If attempts to reduce the child’s temperature by sponging
are unsuccessful, advise parents to put cool washcloths on
the child’s forehead, axillary, and groin areas and transport
the child, lightly clothed, to a healthcare facility for
immediate evaluation
e. At the healthcare facility, a lumbar puncture will be
performed to rule out meningitis
f. If warranted, antipyretic drugs to reduce the fever below
seizure levels will be administered.
g. Appropriate antibiotic therapy will be prescribed if an
infection is documented.
Many parents need to be reassured that febrile seizures do not
lead to brain damage and that the child is almost always
completely well afterward.
AT T E NT I O N DE FI CI T
H YPE RACT I VI T Y DI SO RDE R
(ADH D)
Attention deficit hyperactivity disorder (ADHD) is
one of the most common neurobiologic conditions in
childhood that can also persist into adulthood. It is a persistent
pattern of inattentive or impulsive symptoms, or both, present
before the age of 12 years, that causes impairment in at least
two settings. Although the cause is unknown, environmental
(such as very low birth weight.
The disorder is characterized by three major
behaviors—inattention, impulsiveness, and hyperactivity—
and can present differently, depending on the age at
presentation. Inattention can include symptoms such as
difficulty organizing tasks and a reluctance to do tasks that
require mental effort over time. Impulsiveness includes a child
acting before thinking and therefore having difficulty with
such tasks as waiting his or her turn, blurting answers before a
question is completed, and interrupting or intruding on others’
conversations. With hyperactivity, children may shift
excessively from one activity to another and can be described
as “on the go” or “acts as if driven by a motor.”
ASS ES S ME NT
 Excessive motor activity when the child is a toddler
 Preschool-age child often presents with hyperactivity and
impulsivity
 The child ages and moves through older grades,
inattention may become the predominant manifestation
 During adolescence, symptoms of hyperactivity are
usually limited to fidgeting or an inner feeling of
restlessness or impatience
 In women, inattentive features are more common during
presentation and may escape diagnosis because of less
disruptive behavior
 The criteria for diagnosis of ADHD includes a thorough
initial history, physical examination, and completion of
evidence-based rating scales by an individual who is
familiar with the child, such as parents, teachers, primary
care providers, and other caretakers
 A family history is important to review, as ADHD is more
common in first-degree relatives
 Evaluations include height, weight, body mass index
(BMI), vision, hearing, complete blood count (CBC) with
differential (to rule out anemia), a thyroid-stimulating
hormone (TSH) and free thyroxine (T4 ) test (to rule out
thyroid disorders), a lead screen, a genetic screen, and a
toxicology screen.
 The physical exam is also important to assess for
comorbid conditions that are common with ADHD,
including specific learning disabilities (10% to 40%),
oppositional-defiant disorder (30% to 60%),
depression/anxiety disorders, bipolar disorders, fetal
alcohol affect, Tourette syndrome, and psychosocial
morbidities
 As a rule, children with ADHD do not have a deficit in
intelligence, although they may seem to because of their
impulsive behavior and an unawareness that their
behavior is upsetting to family, friends, and teachers.
 On physical assessment, they often show many “soft”
neurologic signs, such as difficulty performing tests such
as a finger-to-nose test or rapid hand movements
 (touching one finger after another with the thumb).
Children with ADHD also tend to show “mirroring” with
these movements (their second hand imitates what the
first hand is doing)
 Cerebellar difficulty may be evidenced by the inability to
perform a tandem walk or a heel-to-shin test.
 Children may not show the normal responses of
graphesthesia (ability to recognize a shape that has been
traced on the skin) or stereognosis (ability to recognize an
object by touch).
 Children may not show the normal responses of
graphesthesia (ability to recognize a shape that has been
traced on the skin) or stereognosis (ability to recognize an
object by touch).
 More definite neurologic signs, such as a unilateral
Babinski reflex, may also be present.
 Testing children through the use of games may be
necessary so that their attention is maintained long
enough to complete the assessment
 IQ testing is used to document intelligence. The Wechsler
Intelligence Scale for Children (WISC), the test most
often chosen, consists of two portions: a verbal scale and
a performance scale. A child is given three final scores:
verbal IQ, performance IQ, and a combination or full-
scale IQ.
 The child with perceptual and motor deficits tends to do
poorly on the performance scale but average or better on
the verbal scale.
 .Children with language difficulty typically do poorly on
the verbal scale but average or greater on the performance
scale.
 Children with ADHD show a “scatter” pattern on both
performance and verbal portions, doing well on some
portions and poorly on others.
 Because they have difficulty filtering out stimuli, they
tend to do poorly on groupadministered intelligence tests.
For this reason, test results are more accurate if they take
IQ tests individually
 Children’s behavioral and emotional functioning skills are
also assessed across a variety of settings with checklists
(completed by children, parents, and teachers) and/or
direct observation in classroom and home settings.
 Completion of evidence-based rating scales is important
during the diagnostic phase as well to monitor progress
with the treatment plan.
 Children with ADHD are often referred to a healthcare
facility by school personnel due to difficulty achieving in
school.
 Parents may notice their child’s difficulty settling down to
tasks and use excuses such as “he’s adventurous” or
“every child is different.” Parents may need time to accept
the child’s diagnosis as one that interferes with learning.
 Because caring for the child can be exhausting, parents
may be unaware themselves of the strain the child’s
symptoms have produced in their family system
T HE RAPE UT I C MANAG E ME NT
a. Environmental Modification - construction of a stable
learning environment is crucial for children with ADHD
so instruction can be free from the distractions of an entire
class. The main goal of behavior management is to
increase appropriate behavior and decrease negative
behavior. Children and teens with ADHD respond best in
an environment, both at home and at school, that is
structured and predictable, with clear and consistent rules
and expectations.
b. Family Support - Parents of a child with ADHD may have
more frequent healthcare encounters because of
unintentional injuries, such as lacerations or simple burns.
Ask parents at these visits if they are having difficulty
managing the challenge of raising a child who exhibits so
much activity. Help them to understand that because of a
very complex and as yet ill-understood syndrome, the
behavior is the best their child can achieve.
c. Medication - The decision to use medication is the
parent’s personal decision, and the nurse can support the
parents by providing accurate information about the
medications, expected response, and side effects. Several
medications are helpful in reducing the excessive activity
of children with ADHD as well as lengthening attention
span and decreasing distractibility so they can function in
school. Stimulant medications, methylphenidate, and
amphetamines are the most frequently prescribed for
individuals with ADHD. There are short-, intermediate-,
and long-acting formulations as well as methylphenidate
transdermal (Daytrana) in a patch form. Stimulants work
by stimulating dopamine receptors so there is more
regular nerve transmission, which results in increased
attention span. Other medications that may be used for
ADHD include nonstimulant medications, atomoxetine
(Strattera), SNRIs, and centrally acting adrenergic agents,
guanfacine (Intuniv, Tenex) and clonidine. Atomoxetine
may be a first-line medication for children with ADHD
who cannot tolerate stimulants. Centrally acting
adrenergic agents work by strengthening actions in the
prefrontal cortex, which includes regulation of attention,
planning, impulse control, and processing. Guanfacine is
available in both immediate- and extended-release
formulations.
Persons with ADHD need counseling to find a career that fits
with these behaviors and allows them to succeed as adults.
AUT I S M S PRE CT RUM
DI S O RDE R
Autism spectrum disorder (ASD) is marked by
difficulties in three main areas: social deficits,
communications issues, and restricted behaviors, with onset in
the early developmental stages, that impair everyday
functioning. Within the first 36 months of life, children with
ASD often lack responsiveness to people around them, display
gross impairment in communication skills, and produce
bizarre responses to various aspects of the environment.
 ASS ES S ME NT f. Encourage parents of children with ASD to seek support
ASDs often are typically recognizable in children through organizations in the community to help support
between 12 and 24 months but may be noticed earlier if the their own mental well-being and that of their families.
condition is more severe (APA, 2013). The first symptoms of g. A day care program can help promote social awareness.
ASD noticed by parents are delay in language development, Some children may eventually reach a point where they
odd communication, lack of social interest, or unusual can become passively involved in loosely structured play
interactions, such as avoiding eye contact, and unusual play, groups.
with repetitive play and preference becoming more apparent
as the child ages.
 Failure to develop social relations
 Stereotyped behaviors such as hand gestures
 Extreme resistance to change in routine
 Abnormal responses to sensory stimuli
 Decreased sensitivity to pain
 Inappropriate or decreased emotional expressions
 Specific, limited intellectual problem-solving abilities
 Stereotyped or repetitive use of language
 Impaired ability to initiate or sustain a conversation

Bizarre responses to the environment may include intense

reactions to minor changes in the environment (perhaps
screaming if a toy box is moved across the room), attachment
to odd objects such as always carrying a string or a shoe, and a
rigid demand for routine.
Children are said to have a labile mood (crying occurs
suddenly and is followed immediately by giggling or laughing
or vice versa). They may overrespond to sensory stimuli, such
as light or sound, but then be unaware of a major event in the
room, such as the sound of a fire alarm.
In contrast to these mannerisms, long-term memory and
“savant” skills (exceptional skills such as virtuoso piano
playing) may be excellent

T HE RAPE UT I C MANAG E ME NT
a. Primary treatment for children with ASD includes
educational, compensatory, and behavior modalities, such
as the evidence-based applied behavior analysis (ABA)
treatment based on the associations between behavior and
learning
b. Atypical antipsychotic medications, such as risperidone
(Risperdal) and aripiprazole (Abilify), are approved by
the U.S. Food and Drug Administration (FDA) for
children and teens with ASD. Advantages of these agents
include improving sociability while decreasing tantrums,
aggressive outbursts, and self-injurious behavior
c. Atypical antipsychotic medications, such as risperidone
(Risperdal) and aripiprazole (Abilify), are approved by
the U.S. Food and Drug Administration (FDA) for
children and teens with ASD. Advantages of these agents
include improving sociability while decreasing tantrums,
aggressive outbursts, and self-injurious behavior
d. Melatonin is an over-the-counter medication that may be
recommended to reduce sleep difficulties
e. It is important for nurses to ask at healthcare visits
whether parents are finding time for both care of their
child and themselves because there is a danger that
excessive parental stress can lead to child maltreatment