W5: Pain Assessment and Management in Children

Pain in Children in Healthcare Settings

- Pain is a pervasive problem among children in various healthcare settings. Needle procedures,
such as injections and blood tests, are particularly distressing for children.
- Preterm infants in neonatal intensive care units (NICUs) are highly exposed to needle
procedures, experiencing anywhere from 1 to 10 or more painful procedures each day during
their hospitalization.
- Needle pain, while a significant contributor to acute pain in hospitalized children, is not the
only source. Up to 86% of hospitalized children experience acute pain from various sources,
including their underlying disease, treatment, and invasive procedures like surgery.
- Acute pain can be a precursor to chronic pain, with uncontrolled acute pain recognized as a
significant risk factor for developing chronic pain.
- The prevalence of chronic pain in children varies widely, ranging from 4% to 88%, with the
highest rates for headaches (up to 83%) and abdominal pain (up to 53%). These rates can be
influenced by factors like gender, age, ethnicity, and geographic region.
- Role of Pediatric Nurses:
- Pediatric nurses have a pivotal role in addressing and managing children's pain in
healthcare settings.
- However, research indicates that pediatric nurses often do not effectively translate their
knowledge of pain prevention, assessment, and treatment into their daily care of
children.
- This chapter aims to provide an overview of pain theory, prevention, assessment, and
management, with a particular focus on pain experiences during childhood.
- Pain in children can manifest in various ways, including acute, recurrent, chronic, or
mixed acute and chronic pain. The chapter explores examples of these pain types and
their underlying causes.
- The chapter also covers the importance of developmentally appropriate, valid, and
reliable measurement tools and techniques for assessing pain in pediatric patients.
- Furthermore, it discusses various strategies for preventing and treating pediatric pain,
shedding light on their mechanisms.

Understanding Pain:
- Pain is described as a complex biopsychosocial phenomenon with multiple components.
- It involves processes in the peripheral and central nervous systems that are characteristic of
acute pain.
- When a tissue injury occurs, peripheral sensory neurons send signals to interneurons in the
spinal cord, which then transmit this information to the brain.
- Painful stimulation is observed to activate certain brain regions, such as somatosensory and
limbic cortices. These areas have connections to the frontal cortex, which plays a role in
complex human behaviors, including attention and emotional regulation.
- The periaqueductal gray matter (PAG) is activated by painful stimuli. Activation of the PAG
can lead to analgesia when stimulated through methods like opiate administration or electrical
stimulation.
- The PAG sends projections to the raphe nucleus magnus in the rostroventral medulla, which, in
turn, projects to the dorsal horn of the spinal cord. These descending projections inhibit further
activation in ascending pain pathways, modulating the amount of pain information transmitted
from the spinal cord to the brain.
 - The brain's neural network, or brain neuromatrix, is a complex system that combines cognitive,
sensory, and affective pathways in a feedback loop unique to each individual. It assigns
meaning to pain stimuli and modulates the pain experience.
- Connections between emotional and cognitive processing areas and descending pathways offer
additional ways by which pain is modulated, and prior painful experiences may affect these
modulatory processes.
- The neuromatrix is also involved in both acute and chronic stress responses, which contribute
to pain perception. Chronic stress can result in heightened pain sensitivity or decreased pain
threshold.

Impact of Pain:
- Pain is not only uncomfortable but also harmful to the body. Pain triggers physiological stress
responses that affect hormonal and immune system activity.
- Prolonged exposure to unrelieved pain can hinder the healing process.
- Complications of untreated pain in preterm neonates can include impaired growth and
neurodevelopment.
- Poorly controlled acute pain is a risk factor for the development of chronic pain in children.
Common Acute Pain Conditions in Children:
- Children frequently experience acute pain in various situations, including immunizations,
minor injuries (e.g., knee abrasions), illnesses, and various medical and surgical procedures
during hospitalization.
- Even procedures that may seem minor to healthcare providers, such as bandage removal,
nasogastric tube placement, or urinary catheter placement, can be extremely painful for
children.
- Premature infants, in particular, are at risk for experiencing frequent painful procedures as part
of their care, which necessitates special attention from healthcare professionals.

Needlestick pain is a common source of distress and fear in children, especially during immunizations:
- Procedure-related fear may be a consequence of inappropriate procedural pain
management, and long-term consequences of unaddressed fear may follow
- Needle fear is a common reason for noncompliance with immunizations.
Postoperative Pain:
- Postoperative pain is a common issue in pediatric patients who undergo surgery, with
millions of children undergoing surgical procedures each year.
- A significant proportion of these children report moderate to severe pain during the first
day after surgery.
- Surgery and traumatic injuries, like fractures, lacerations, and burns, lead to a catabolic
state with increased secretion of hormones, which affects various physiological
processes.
- Opioids and local anesthetic nerve blocks are commonly used to modify the
physiological responses to surgical injury.
- Pain associated with surgeries in areas like the chest or abdomen can lead to pulmonary
complications, as pain often causes splinting and guarding, decreasing lung function
and increasing the risk of complications like atelectasis and pneumonia.

Common Chronic Pain Conditions in Children:

- Chronic pain in pediatric patients is a substantial concern, and the most prevalent chronic pain
conditions in children are headaches (up to 83%), abdominal pain (up to 53%), and
musculoskeletal pain (up to 36%).
- Chronic pain may also be episodic, with recurrent bouts of pain occurring at least every 3
months.
- Specific types of chronic pain, such as primary headaches (migraines and tension-type
headaches), are not associated with an identified cause, while secondary headaches are linked
to an underlying condition.
- The diagnosis of these headaches helps guide the appropriate treatment plan for pain relief and
functional improvement.

Common Mixed-Pain Conditions in Children

 - Burn pain, stemming from burns that are the fifth most common nonfatal injury in children and
a leading cause of death among children aged 1 to 9, is challenging to control.
- It is difficult to manage because it results from multiple pain triggers, manipulations over
injured sites during care, and changing pain patterns.
- Pain perception is influenced by factors such as the degree of the burn, sensory input, and
individual child factors like underlying anxiety.
- Symptoms like anxiety, depression, and insomnia can modulate the chronicity of burn pain.
- Burn pain can manifest as background pain, breakthrough pain, procedural pain, and
postoperative pain, each associated with specific triggers and characteristics.
- Long-term posttraumatic stress symptoms may be inversely related to early opiate dosing in
children recovering from severe burns.

CANCER PAIN
- Children with cancer experience pain from various causes throughout their cancer
journey, which may include pain as a symptom of cancer itself and pain related to
cancer treatment.
- Cancer treatment may help alleviate cancer-related pain, but it can also lead to its own
pain issues. For instance, survivors of childhood cancer might experience chronic pain
from treatment-related factors like phantom limb pain, graft-versus-host disease, or
postherpetic neuralgia.
- Mucositis is a common source of treatment-related pain, resulting from inflammation of
mucosal linings in areas such as the mouth, esophagus, stomach, and more. It occurs
after chemotherapy, radiotherapy, or bone marrow transplantation and can be severe.
- Various other treatment-related pain conditions are associated with different stages of
the disease and treatment protocols, including abdominal pain after allogeneic bone
marrow transplantation, typhlitis (cecum infection), phantom limb pain, peripheral
neuropathy, medullary bone pain, and pain related to immunotherapy.
SICKLE CELL PAIN:
- Pain is a hallmark symptom of sickle cell disease (SCD), ranging from severe, acute,
and episodic pain in vaso-occlusive crises (VOC) to chronic pain due to repeated tissue
damage or avascular joint necrosis.
- Infants with SCD often experience dactylitis, which presents as painful swelling in the
fingers, hands, toes, or feet. As children grow, they may also develop headaches, low
back pain, and bone pain. VOC is a leading cause of ER visits and hospital admissions
among children with SCD.
- Sickle cell pain is often more intense than surgical, arthritis, or childbirth pain and can
be triggered by factors like weather changes or acute illnesses.

MEASURING PAIN IN CHILDREN:

- Pain assessment is crucial for effective pain management in children. The assessment
should use appropriate tools based on the child's developmental level and condition.
- Pain assessment encompasses more than just a pain rating; it should consider factors
like location, frequency, duration, and what triggers or alleviates the pain.
- Different types of pain assessment tools are available, such as observational measures
(for non-verbal children), self-report rating scales (for verbal children), and
multidimensional tools to evaluate various aspects of pain.
- The choice of assessment tools should be guided by the child's age and pain type, with
the trend being toward using a common metric to make pain scores easier to interpret
and integrate into research and practice.
 - Special populations like cognitively impaired children, children post-anesthesia, and
those in the Pediatric Intensive Care Unit may require specific pain assessment tools.
- A self-report is highly reliable for children above the age of 3-4 years, while younger
children may benefit from observational pain assessment tools that rely on the
observation of pain-related behaviors.
- Different types of pain assessment:

Special Populations:
Preterm Infants:
- Pain assessment in preterm infants is complex and depends on factors such as gestational age,
behavioral state, and validated observational tools.
- Preterm infants may not always display typical behavioral responses to pain, so it's important
to presume that pain exists in various situations.
- Special pain assessment tools validated for neonates are used.

Cognitively Impaired Children:

 - Children with cognitive impairment may have difficulty expressing pain through behaviors or
self-report.
- Parents can report pain behaviors in these children, including crying, irritability, and changes in
activity.
- Validated tools for pain assessment in this population include rFLACC, NCCPC-r, and PPP.

Children Postanesthesia:
- Assessing pain in children recovering from anesthesia can be challenging.
- Observational pain assessment tools, such as the FLACC tool, are commonly used in the
postanesthesia care unit.

Children in the Pediatric Intensive Care Unit (PICU):

- Pain assessment in the PICU can be complicated due to distress, anxiety, and sedation.
- The COMFORT behavior scale is commonly used to assess pain and distress in critically ill,
nonverbal children.

Children with Autism Spectrum Disorder (ASD):

- Children with ASD may have difficulty
communicating pain due to a wide range of
cognitive abilities.
- Self-report measures should be used when
possible. Nonverbal children with ASD may
exhibit self-stimulating activities when in pain

Chronic and Recurrent Pain Assessment:

- Chronic and recurrent pain assessment requires
specialized tools to measure changes and
resolution.
- Tools such as the Pediatric Pain Questionnaire
(PPQ), Adolescent Pediatric Pain Tool (APPT),
and the Functional Disability Inventory (FDI) are
used to assess domains of pain and functional
disability.
- Pain diaries and tools for measuring anxiety,
depression, and sleep disruption are also used.

Prevention and Treatment of Pain in Children:

- Biobehavioral interventions are essential for pain prevention and treatment, and they include
techniques like distraction, relaxation, guided imagery, and more.
- Biobehavioral interventions can help interrupt the cycle of pain, fear, anxiety, and stress.
- Biobehavioral strategies should be tailored to individual children's needs, considering their
developmental age and cognitive abilities.
- Parents can be involved in selecting and learning coping strategies, and these interventions
should be practiced before pain occurs.

Pharmacological Management of Pain: (just an overview, more on page 185 of the txb)
Chapter 6 ( communicable and infectious diseases)

HAI: hospital-acquired infection

standard Precautions synthesize the major features of universal (i.e., blood and body fluid) precautions and
body substance—> [PPE]), such as gloves, goggles, gowns, and masks, to prevent contamination from
blood; all body fluids, secretions, and excretions, except sweat.

-Transmission-Based Precautions : for infection or colonization) with highly transmissible or

epidemiologically ,neds more precaution

- Airborne Precautions reduce the risk of airborne transmission of infectious agents. The term airborne
infection isolation room (AIIR) has replaced negative pressure isolation room;
 -Droplet Precautions: involves contact of the conjunctivae or the mucous membranes of the nose or
mouth of a susceptible person with large-particle droplets (>5 mm) — short distance traveling, less than 3
feet

-Contact Precautions reduce the risk of transmission of microorganisms by direct (skin to skin) or indirect
contact (contact of susceptible host with contaminated objects)

NURSING ALERT: :The most common piece of medical equipment, the stethoscope, can be a potent
source of harmful microorganisms and nosocomial infections. Consider also the keyboard and desktop as
potential sources.

- NURSE SHOULD wear gloves and possibly gowns for changing diapers when there are loose or
explosive stools. Otherwise, the plastic lining of disposable diapers provides a sufficient barrier between
the hands and body substances and gloves are adequate.
- NuRSE should wear gown if child vomit or spit out during feeding→ wear glove and then after removing
it you must wash your hands

-In hospitals, patients are the most significant sources of methicillin-resistant Staphylococcus aureus
(MRSA), and the main mode of transmission is patient-to-patient transmission via the hands of a health care
provider. —-> frequent hand washing

- childhood immunizations for diphtheria, tetanus, and acellular pertussis (DTaP); poliovirus; measles,
mumps, and rubella (MMR); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); hepatitis A
virus (HAV); meningococcal; pneumococcal conjugate vaccine (PCV); influenza (and H1N1);
varicella-zoster virus (VZV; chickenpox); rotavirus; and human papillomaviruses.

-The recommended age for beginning primary immunizations of infants is at birth or within 2 weeks of
birth.

-Hepatitis B Virus:
It is recommended that newborns receive HepB before hospital discharge if the mother is hepatitis B
surface antigen (HBsAg) negative.
- If mothers whose HBsAg status is positive or unknown, newborn should receive HepB and hepatitis B
immune globulin (HBIG), 0.5 ml, within 12 hours of birth at two different injection sites

-HepB should be given as the birth dose, month 1,2,6 and then at 11 years old

-Hepatitis A Virus

Spread through oral-fecal route, vaccination should be done at age 1 and second dose should be given
with 6 months period
-Diphtheria
Respiratory manifestations include respiratory nasopharyngitis or obstructive laryngotracheitis with
upper airway obstruction. The cutaneous manifestations of the disease include vaginal, otic, conjunctival,
or cutaneous lesions

-(1) DTaP or DTaP and Hib vaccines for children younger than 7 years of age, / or (2) in combination with a
conjugate H. influenzae type B vaccine, (3) in a combined vaccine with tetanus (DT) for children younger
than 7 years of age ,(4) Tdap for children 11 years and older,

-boosters are given every 10 years for life

-Tetanus

-(Tdap) are now recommended for persons ages 11 to 12 years who have completed the recommended
DTaP/DTP vaccine series but have not received the tetanus (Td) booster dose. Adolescents 13 to 18 years of
age who have not received the Td/Tdap booster should receive a single Tdap booster,

-For children over 7 years who require wound prophylaxis, tetanus immunization may be accomplished by
administering Td (adult-type diphtheria and tetanus toxoids).

Pertussis
Pertussis vaccine is recommended for all children 6 weeks through 6 years of age (up to the seventh
birthday) who have no neurologic contraindications to its use.
-(Tdap) is now recommended at ages 11 to 12 years for persons who have completed the DTaP/DTP
childhood series. The Tdap is also recom- mended for adolescents 13 to 18 years old

-Polio
IPV (inactivated poliovirus vaccine). All children should receive four doses of IPV at 2 months, 4 months, 6
to 18 months, and 4 to 6 years of age

-​​oral polio vaccine (OPV)

-Pediarix is a combination vaccine containing DTaP, hepatitis B, and IPV; this may be used as the primary
immunization beginning at 2 months of age

Measles
The measles (rubeola) vaccine is given at 12 to 15 months of age.

The second measles immunization is recommended at 4 to 6 years of age

- For postexposure prophylaxis, one dose of MMR may be administered within 72 hours of exposure in
vaccine-eligible individuals ≥12 months of age and is preferable to immunoglobulin

- The measles, mumps, rubella, and varicella (MMRV) vaccine is an attenuated live virus vaccine and may
be given to children 12 months to 15 months of age or at 4 through 6 years of age concurrent with other
vaccines. Children with HIV should not receive the MMRV vaccine
-Vitamin A supplementation has been effective in decreasing the morbidity and mortality risks associated
with measles

Mumps
Mumps virus vaccine is recommended for children at 12 to 15 months of age and is typically given in
combination with measles and rubella.

Rubella
-in a pregnant woman the actual infection presents serious risks to the developing fetus. Therefore the aim of
rubella immunization is actually protection of the unborn child rather than the recipient of the immunization.
-Rubella immunization is recommended for all children at 12 to 15 months of age and at age of school
entry or 4 to 6 years of age or sooner, according to the routine recommendations for the MMRV vaccine

Haemophilus influenzae Type b

When possible, the Hib conjugate vaccine used at the first vaccina- tion should be used for all subsequent
vaccinations in the primary series. All Hib vaccines are administered by intramuscular injection using a
separate syringe and at a site separate from any concurrent vaccinations.

NURSING ALERT: The use of meningococcal and diphtheria proteins in combination vaccines does not
mean the child has received adequate immunization for meningococcal or diphtheria illnesses; the child must
be given the appropriate vaccine for that specific disease.

Varicella
The first dose of varicella vaccine is recommended for children ages 12 to 15 months, and to ensure
adequate protection, a second varicella vaccine is recommended for children at 4 to 6 years of age.

Pneumococcal Disease
Streptococcal pneumococci are responsible for a number of bacterial infections in children under 2 years,
(usually in daycare)

- standard pneumococcal vaccine for children ages 6 weeks to 24 months old.

- The PCV13 vaccine is administered at 2, 4, and 6 months of age, with a fourth dose at 12 to 15 months of
age.

Influenza: The influenza vaccine is recommended annually for children ages 6 months to 18 years
Meningococcal Disease

-Neisseria meningitidis is the leading cause of bacterial meningitis .

Children at increased risk for meningococcal infection should receive a two-dose series of either
MenACY-D (Menactra) or MenACY-CRM (Menveo), both of which are MCV4 vaccines (intramuscular
injection),

Rotavirus
Rotavirus is one of the leading causes of severe diarrhea in infants and young children and is transmitted by
the fecal-oral route
 -Rotarix (1 ml) may be administered beginning at 6 weeks of age, with a second dose at least 4 weeks after
the first dose but before 32 weeks of age

-Human Papillomavirus

Human papillomaviruses (HPVs) are a large family of viruses that consist of cutaneous (i.e., skin warts) and
genital (i.e., mucosal) types . for both girls and boys
-The vaccine is administered intramuscularly, preferably in the deltoid muscle, in three separate doses; the
first dose in the series is commonly administered at 11 to 12 years of age, and the second dose is given 1 to 2
months after the first, with the third dose given 6 months after the first dose. Women should do the regular
PAP test.

It has to be given between 9-26 years old

-Reaction:
A child may react to the preservative in the vaccine rather than the vaccine component

-Although influenza vaccines contain small amounts of egg protein, recent evidence shows no risk of an
anaphylactic reaction with the inactivated influenza vaccine among children with an egg allergy and these
children should receive the influenza vaccine .

- With inactivated antigens, such as DTaP, side effects are most likely to occur within a few hours or days
of administration and are usually limited to local tenderness, erythema, and swelling at the injection site;
low-grade fever; and behavioral changes (e.g., drowsiness, eating less, prolonged or unusual cry)

-If epinephrine is administered, observe for adverse reactions such as tachycardia, hypertension,
irritability, headaches, nausea, and tremors.
Contraindications and Precautions

-Fewer reactions to immunizations are observed when the vaccine is given deep into the muscle rather than
into subcutaneous tissue.

-To ensure appropriate needle size for vaccine administration

● Newborns (0-28 days old): recommended needle size is 5/8 inch, 22 to 25 gauge,
recommended injection site: vastus lateralis.

● Infant/Toddler (1 month to 2 years): recommended needle size/site is 1 inch, 22 to

25 gauge for vastus lateralis or 5 8 to 1 inch, 22 to 25 gauge
● Child/Adolescent (3 to 18 years): less than 60 kg: 5 8 to 1 inch, 22 to 25 gauge in
deltoid,
-Apply the topical anesthetic EMLA (lidocaine-prilocaine) to the injection site and cover with an
occlusive dressing for at least 1 hour, or apply LAMX4( 4% lidocaine) to the site and cover it for 30
minutes

- being held by a parent or caregiver for infants and young children, and sitting upright for older
children and adolescents. Encourage breastfeeding during or before the immunizations.

-For children less than 6 years old, use distraction, such as asking the child to blow bubbles or
telling the child to “take a deep breath and blow and blow and blow until I tell you to stop.

-Nurses administering the injections should remain calm and use neutral words such as “here I go”
instead of “here comes the sting.”

-A contraindication is considered as a condition in an individual that increases the risk for a serious adverse
reaction.

-The general contraindication for all immunizations is a severe febrile illness. The presence of minor
illnesses, such as the common cold, is not a contraindication

- In general, live virus vaccines should not be administered to persons who are severely
immunocompromised or among persons whose immune function is not known
- Administration of MMR, varicella and retrovirus (live virus vaccine) should be postponed for a
minimum of 3 months after passive immunization with immunoglobulins and blood transfusions
(except washed red blood cells, which do not interfere with the immune response)
- A final contraindication is a known allergic response to a previously administered vaccine or a substance in
the vaccine. An anaphylactic reaction.
- do not to use MMR vaccines if someone had a severe allergic reaction to neomycin, gelatin, or the vaccine
itself. ( with mild reaction there is no problem to give vaccine but with severe reaction, avoid giving
vaccine)

- To identify the rare child who may not be able to receive the vaccines, take a careful allergy history, skin
testing doesn’t prove immediate hypersensitivity.

-Nurses are at the forefront in providing parents with appropriate information regarding childhood
immunization benefits, contraindications, and side effects (how to minnizing adverse effect)and the effects
of non vaccination on the child’s health.Realize that the parent is expressing concern for the child’s health.
Acknowledge the parent’s concerns in a genuine, empathetic manner.
Give the parent the vaccine information statement (VIS) beforehand, and be prepared to answer any
questions that may arise.
-Be flexible and provide parents options regarding the administration of multiple vaccines, especially in
infants, who must receive multiple injections at 2, 4, and 6 months (i.e., allow parents to space the
vaccinations at different visits to decrease the total number of injections at each visit;

- Involve the parent in minimizing the potential adverse effects of the vaccine (e.g., administering an
appropriate dose of acetaminophen 45 minutes before administering the vaccine [as warranted];
applying eutectic mixture of local anesthetics [EMLA; lidocaine-prilocaine] or 4% lidocaine [LMX4] to
the injection sites before administration.

Administration
The total series requires several injections, and every attempt is made to rotate the sites and administer the
injections as painlessly as possible.
-The DTP (or DTaP) vaccines contain an adjuvant to retain the antigen and it can cause irritation,
inflammation and abscess information→ need excellent intramuscular technique

-One of the most important features of injecting vaccines is adequate penetra- tion of the muscle for
deposition of the drug intramuscularly and not subcutane- ously

-. Report any adverse reactions after the administration of a vaccine to the Vaccine Adverse Event Reporting
System
-this represents informed consent once the parent or caregiver gives permission to administer the vaccines.
Scarlet fever:

Nurse in ambulatory care setting are often the first persons to see signs of a communicable disease, such as
a rash or sore throat. Although most often a symptom of a minor viral infection, it can signal diphtheria or
a streptococcal infection, such as scarlet fever.

When the nurse suspects a communicable disease, it is important to assess the following:

-Recent exposure to a known case

-Prodromal symptoms (symptoms that occur between early manifestations of the disease and its overt
clinical syndrome) or evidence of constitutional symptoms, such as a fever or rash
 -Immunization history
- History of having the disease
- PREVENTION OF COMPLICATION
- Primary prevention rests almost exclusively on immunization.
- instruct child hand washing after toileting and before eating

NURSING ALERT: If a child is admitted to the hospital with an undiagnosed exanthema, institute strict
Transmission-Based Precautions (contact, airborne, and droplet) and Standard Precautions until a diagnosis
is confirmed. Childhood communicable diseases requiring these precautions include diphtheria,
varicella-zoster virus (VZV; chickenpox), measles, tuberculosis, adenovirus, Haemophilus influenzae type b
(Hib), influenza, mumps, Neisseria meningitidis, Mycoplasma pneumoniae infection, pertussis, plague,
rhinovirus, group A streptococcal pharyngitis, severe acute respiratory syndrome, pneumonia, or scarlet
fever

-Children with immunodeficiency—those receiving steroid or other immunosuppressive therapy, those with
a generalized malignancy such as leukemia or lymphoma, or those with an immunologic disorder—are at
risk for viremia from replication of the varicella-zoster virus (VZV)* in the blood.---------- VZV is so
named because it causes two distinct diseases: varicella (chickenpox) and zoster (herpes zoster or
shingles).
- Varicella occurs primarily in children younger than 15 years of age.

- Complications of herpes zoster virus in children include secondary bacterial infection, depigmentation, and
scarring.

-Children with hemolytic disease, such as sickle cell disease, are at risk for aplastic anemia from erythema
infectiosum

- Early clinical manifestations of pertussis in infants may include gagging and gasping, followed by
posttussive emesis, apnea, and cyanosis; the typical “whoop” associated with the disease is absent . In
older children the disease may manifest as a common cold, but a prolonged cough (at least 21 days) is
common in adolescents. Azithromycin (for infants younger than 1 month old) and erythromycin,
clarithromycin, or azithromycin are administered to infants and children with pertussis.

- Prevention of complications from diseases such as diphtheria, pertussis, and scarlet fever requires
compliance with antibiotic therapy.---> give kids vitamin A

NURSING ALERT: Although the risk of vitamin A toxicity from these doses (they are 100 to 200 times
the recommended dietary allowance) is relatively low, nurses should instruct parents on safe storage of
the drug. Ideally, vitamin A should be dispensed in the age-appropriate unit dose to prevent excessive
administration and possible toxicity.

Provide Comfort
 - The chief discomfort from most rashes is itching, and measures such as cool baths (usually without
soap) and lotions (e.g., calamine) are helpful. Cooling the lotion in the refrigerator beforehand often
makes it more soothing on the skin than at room temperature.

NURSING ALERT: When lotions with active ingredients such as diphenhydramine in Caladryl are used,
they are applied sparingly, especially over open lesions, where excessive absorption can lead to drug
toxicity. Use these lotions with caution in children who are simultaneously receiving an oral antihistamine.

- children should wear lightweight, loose, nonirritating clothing with long sleeves or legs and keep out of the
sun . keeps nails short, use mitten.
- For severe itching, antipruritic medication, such as diphenhydramine (Benadryl) or hydroxyzine
(Atarax), may be required, especially when the child has trouble sleeping because of itching. Loratadine,
cetirizine, and fexofenadine do not cause drowsiness and may be preferred for urticaria during the day.

-An elevated temperature is common, and both antipyretic medicine (acetaminophen or ibuprofen) and
environmental manipulation are implemented

-A sore throat, another frequent symptom, is managed with lozenges, saline rinses (if the child is old
enough to cooperate), and analgesics.

- bland foods and increased liquids are usually preferred. During the early stages of the disease, children
voluntarily reduce their activity, and although bed rest is beneficial, it should not be imposed unless
specifically indicated. During periods of irritability, quiet activity (e.g., reading, music, televi- sion, video
games, puzzles, coloring) helps distract children from the discomfort.

-Acute conjunctivitis (inflammation of the conjunctiva) :

In newborns conjunctivitis can occur from infection during birth, most often from Chlamydia trachomatis
(inclusion conjunctivitis) or Neisseria gonorrhoeae. Conjunctivitis in a neonate is a serious condition and
can potentially lead to blindness;
- its signs are redness, swelling, eyelid edema and discharge.
-In infants recurrent conjunctivitis may be a sign of nasolacrimal (tear) duct obstruction or dacryocystitis,
an infection of the lacrimal sac.

- Timing of infection can provide the cause: A chemical conjunctivitis may occur within 24 hours of
instillation of neonatal ophthalmic prophylaxis; N. gonorrhoeae usually occurs within 2 to 5 days after
birth, and C. trachomatis occurs 5 to 14 days after birth
Therapeutic Management
- Treatment of conjunctivitis depends on the cause. Viral conjunctivitis treatment is limited to removal of
the accumulated secretions.
- Bacterial conjunctivitis has traditionally been treated with topical antibacterial agents such as polymyxin
and bacitracin (Polysporin), sodium sulfacetamide (Sulamyd), or trimethoprim and polymyxin (Polytrim) .
Drops may be used during the day and an ointment at bedtime because the ointment preparation remains in
the eye longer but blurs the vision
-NURSING LERT: Signs of serious conjunctivitis include reduction or loss of vision, ocular pain,
photophobia, exophthalmos (bulging eyeball), decreased ocular mobility, corneal ulceration, and unusual
patterns of inflammation (e.g., the perilimbal flush associated with iritis or localized inflammation associated
with scleritis). If a patient has any of these signs, refer him or her immediately to an ophthalmologist.

STOMATITIS
-Stomatitis is inflammation of the oral mucosa, which may include the buccal (cheek) and labial (lip)
mucosa, tongue, gingiva, palate, and floor of the mouth.

- Children with immunosuppression and those receiving chemotherapy or head and neck radio therapy
are at high risk for developing mucosal ulceration and herpetic stomatitis or aphthous stomatitis (it is
benign).

- Its onset is usually associated with mild traumatic injury (e.g., biting the cheek,
hitting the mucosa with a toothbrush, or a mouth appliance rubbing on the mucosa),
allergy, or emotional stress. The lesions are painful, small, whitish ulcerations
surrounded by a red border. The ulcers persist for 4 to 12 days and heal
uneventfully.

-recurrent herpes labialis (commonly called cold sores or fever blisters). The primary infection
usually begins with a fever; the pharynx becomes edematous and erythematous; and vesicles erupt on
the mucosa, causing severe pain
. Cervical lymphadenitis often occurs, and the breath has a distinctly foul odor. In the recurrent form, the
vesicles appear on the lips, usually singly or in groups.
The factors for the cold sores include emotional stress, trauma (often related to dental procedures),
immunosuppression, or exposure to excessive sunlight. The disease can last 5 to 14 days, with varying
degrees of severity.
 - Stomatitis may occur as a manifestation of hand-foot-and-mouth disease (HFMD) and herpangina

Therapeutic Management
Acetaminophen and ibuprofen are usually sufficient for mild cases, but with more severe HGS, stronger
analgesics such as codeine may be needed. Topical anesthetics over the counter is useful

- Lidocaine (Xylocaine Viscous) can be prescribed for the child who can keep 1 tsp of the solution in the
mouth for 2 to 3 minutes

- Sucralfate can also be used as a coating agent for oral mucous membranes. Treatment for children with
severe cases of HGS includes the use of antiviral agents such as acyclovir

Nursing Care Management

The chief nursing goals for children with stomatitis are relief of pain and prevention of spread of the
herpes virus. Analgesics and topical anesthetics are used as needed to provide relief, especially before
meals to encourage food and fluid intake

- For younger infants and toddlers who cannot swish and swallow, apply the diphenhydramine and Maalox
solution
- Drinking bland fluids through a straw is helpful in avoiding the painful lesions. Encourage mouth
care; the use of a very soft bristle toothbrush or disposable foam-tipped toothbrush provides gentle cleaning
near ulcerated areas.

- Careful hand washing is essential when caring for children with HGS. keep hands out of hands.

NURSING ALERT: When examining herpetic lesions, wear gloves. The virus easily breaks in the skin and
can cause herpetic whitlow of the fingers.

ZIKA VIRUS

- the virus can also be transferred from mother to child during pregnancy (transplacental) and to others by
contact with urine, blood, semen, or vaginal fluid and mosquito.
- 18% will develop fever, arthralgia, maculopapular rash, or conjunctivitis 3 to 12 days after being infected,
with symptoms lasting up to 7 days
- Therapeutic Management
There is no current therapy available, rest, adequate hydration, analgesics, and antipyretics as needed. As
with any other viral illness, aspirin and other salicylates should not be administered to children to avoid
Reye syndrome . Avoiding mosquito bites is the best method to prevent the disease.

INTESTINAL PARASITIC DISEASE

Giardiasis has increased among young children who attend day care centers. Young children are especially
at risk because of typical hand-to-mouth activity and uncontrolled fecal activity.

Giardiasis
You see in day care and in child who drank untreated water. the children may pass cysts for months.
 Therapeutic Management
- The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and
nitazoxanide (Alinia).

- The most important nursing consideration is prevention of giardiasis and education of parents, child care
center staff, and others who assume the daily care of small children. Attention to meticulous sanitary
practices, especially during diaper changes, is essential
-discourage young children who are infected or who have diarrhea from swimming in community or private
pools until they have been infection free for 2 weeks
Enterobiasis, or pinworm
contaminating anything they contact, such as toilet seats, doorknobs, bed linen, underwear, and food. Sign is
intense rectal itching associated with pinworms, the clinical manifestations are nonspecific

- Diagnosis is most commonly made from the tape test

- Because pinworms are easily transmitted, all household members should be treated. The dose of
antiparasitic medication should be repeated in 2 weeks to completely eradicate the parasite
Nursing Care Management
Direct nursing care at identifying the parasite, eradicating the organism, and preventing
reinfection. Parents need clear, detailed instructions for the tape test. A loop of transparent
(not “frosted” or “magic”) tape, sticky side out, is placed around the end of a tongue
depressor, which is then firmly pressed against the child’s perianal area

- Pinworm specimens are collected in the morning as soon as the child awakens and before
the child has a bowel movement or bathes. The procedure may need to be performed on 3 or
more consecutive days before eggs are collected

-hand washing after toileting and before eating, keeping the child’s fingernails short to
minimize the chance of ova collecting under the nails, dressing children in one-piece sleeping
outfits, and daily showering rather than tub bathing. Inform families that recurrence is
common.

BEDBUGS

-secondary health problems that may occur as a result of their bites: infection, cellulitis,
folliculitis, intense urticaria, impetigo, anaphylactic reaction, and sleep loss

-The cutaneous manifestations of bedbug bites tend to be primarily on arms, legs, and trunk
areas.

Which childhood vaccine provides some protection against bacterial meningitis, epiglottitis,
and bacterial pneumonia?
A. Hib vaccine

Which childhood vaccine provides protection against streptococcal infections such as otitis
media, sinusitis, and pneumonia? C. Pneumococcal
 Celiac Disease
Gluten Sensitive Enteropathy

Permanent intestinal intolerance to wheat gliadin and related proteins which produce mucousal lesions
in genetically susceptible children and Characterized by failure to thrive with 4 major typical presentations
qSteatorrhea
qGeneral malnutrition
qAbdominal distention
Secondary vitamin deficiencies

Clinical manifestation:
-Symptoms appear with the introduction of pasta and beans usually around 1 year
-Symptoms that lead parents to seek medical attention include ‘ dropping off their curve’, chronic diarrhea,
abdominal distention, muscle wasting and anorexia

-IF KIDS STAND AND YOU SEE THESE CREESES IN HIS BUT , YOU DIAGNOSE HIM WITH
CELIAc( Muscle wasting)

What are the other considerations related to these symptoms?

● abdominal pain and/or cramps.

● abdominal distension (bloating)
● diarrhea (loose stools)
● constipation (hard stools)
● nausea.
● vomiting.
● decreased appetite.
● increased fatigue.
Gold Standard for Diagnosis of Celiac Disease:
-Abnormal small bowel biopsy (endoscopy)
Presence of antigliadin and antiendomysial immunoglobulin G ( IgG) and IgA antibodies

Treatment:
-Gluten free diet- complete elimination of wheat, barley, rye and oats (Hard and expensive diet)
-Substitute with corn, rice and millet
-Supplementation of iron, folic acid and fat soluble vitamins( ADEK)
-Long term issues related to malignancies in the gut- particularly lymphoma in the small bowel

Assessment

Ages 3 to 9 months

1. Acutely ill; severe diarrhea and vomiting

2. Irritability
3. Possible failure to thrive

Ages 9 to 18 months

1. Slackening of weight followed by weight loss

2. Abnormal stools
■ Pale, soft, bulky
■ Offensive odor
■ Greasy (steatorrhea)
■ May increase in number
3. Abdominal distention
4. Anorexia, discoloration of teeth
5. Muscle wasting: most obvious in buttocks and proximal parts of extremities
6. Hypotonia, seizures
7. Mood changes: ill humor, irritability, temper tantrums, shyness

8. Mild clubbing of fingers

9. Vomiting: usually occurs in the evening
10. Aphthous ulcers, dermatitis

Older Child and Adult

 1. Signs and symptoms are commonly related to nutritional or secondary
deficiencies resulting from disease.
■ Anemia, vitamin deficiency (A, D, E, K)
■ Hypoproteinemia with edema
■ Hypocalcemia, hypokalemia, hypomagnesemia
■ Hypoprothrombinemia from vitamin K deficiency
■ Disaccharide (sugar) intolerance
■ Osteoporosis due to calcium deficiency
2. Anorexia, fatigue, weight loss.
3. May have colicky abdominal pain, distention, flatulence, constipation, and
steatorrhea.

Diagnostic Evaluation

1. Small bowel biopsy, which demonstrates characteristic abnormal mucosa.

2. Hemoglobin, folic acid, and Vitamin K levels may be reduced.
3. Prothrombin time may be prolonged.
4. Elevated immunoglobulin (Ig) A endomysium antibodies and IgA anti-tissue
transglutaminase antibodies.
5. Total protein and albumin may be decreased.
6. 72 hour stool collection for fecal fat is increased.
7. D-xylose absorption test – decreased blood and urine levels.
8. Sweat test and pancreatic function studies may be done to rule out cystic fibrosis
in child.

Therapeutic Intervention

1. Dietary modifications includes a lifelong gluten-free diet, avoiding all foods

containing wheat, rye, barley, and possibly, oats.
2. In some cases, fats maybe reduced.
3. Lactose and sucrose may be eliminated from diet for 6 to 8 weeks, based on
reduced disaccharidase activity.

What are the nursing priorities in the care of children with celiac disease?
Nursing Intervention

1. Monitor dietary intake, fluid intake and output, weight, serum electrolytes, and
hydration status.
2. Make sure that the diet is free from causative agent, but inclusive of essential
nutrients, such as protein, fats, vitamins, and minerals.
3. Maintain NPO status during initial treatment of celiac crisis or during diagnostic
testing.
4. Provide parenteral nutrition as prescribed.
 5. Provide meticulous skin care after each loose stool and apply lubricant to prevent
skin breakdown.
6. Encourage small frequent meals, but do not force eating if the child has anorexia.
7. Use meticulous hand washing technique and other procedures to prevent
transmission of infection.
8. Assess for fever, cough, irritability, or other signs of infection.
9. Teach the parents to develop awareness of the child’s condition and behavior;
recognize changes and care for child accordingly.
10. Explain that the toddler may cling to infantile habits for security. Allow this
behavior, it may disappear as physical condition improves.

KIDS WITH CANCER

STANDARD I: Supporting and Partnering with the Child and their Family:Paediatric Nurses demonstrate
and mobilize their understanding of the social determinants and other systemic factors that impact child
health.
STANDARD II: Advocating for Equitable Access and the Rights of Children and their Family Paediatric
Nurses demonstrate and mobilize their understanding of the social determinants and other systemic factors
that impact child health.
STANDARD III: Delivering Developmentally Appropriate Care Paediatric Nurses perform assessment
based on growth and development and deliver paediatric-specific care.

STANDARD IV: Creating a Child & Family Friendly Environment Paediatric nurses play an essential role
in creating a child and family friendly environment that welcomes families and promotes hope and healing.
It is understood that the environment changes as the child grows and is influenced by multiple factors
including but not exclusive to psychological, spiritual, and social.
STANDARD V: Enabling Successful Transitions Paediatric Nurses support the child and family through
health care transitions to maximize their well-being. This may include, but is not limited to, hand-off
between healthcare providers, admission and discharge, and facility transfer (such as from paediatric to adult
care institutions)