• UNIT4:PROMOTION OF HEALTH IN CHILDREN

    Key Unit competence
    Provide promotional activities for the wellbeing of a child
    Introductory activity 4
    At health center, a nurse receives a 24 months old child brought by his mother, 
    after he fell down from the bed this morning when he was crawling on the bed.
    The mother told the nurse that when the child wakes up, he doesn’t pull himself 
    to standing position and crawls. The mother said that his child is the last born 
    in the family and she has other 2 children with 9 and 5 years respectively. The 
    child was born with 1.8kgs at 35 weeks of gestational age and delayed to cry for 
    about 15 min that led him to be admitted in neonatology for 42 days. The child 
    was fed with cow’s milk from the second day of life as the mother was unable to 
    breast feed. The nurse examined the child to see if there was no broken bone. 
    While the child was on the examination table, his head was supported by his 
    mother as he was unable to sit alone without being supported. The nurse only 
    noticed ecchymosis on the right arm but there was no broken bone. 
    Based on your knowledge, discuss the growth and development in gross motor 
    of the child in the scenario above
    Health promotion in children aims to keep children healthy with a focus on early 
    interventions and implementing programs for the youngest children. The early 
    years of a child’s life lay the foundation for future physical, cognitive, emotional, 
    and social development.
    Children’s health and well-being is influenced by a variety of factors, including 
    family characteristics, community dynamics, and other social determinants of health 
    (SDOH). These include systems, policies, and environmental conditions in which 
    children are born and grow up.
    4.1 Key Concepts used in child health
    Learning activity 4.1
    Using different sources of information discuss the following concepts:
    – Pediatric
    – Child
    – Adolescen
    4.1.1 Pediatric 
    Branch of medicine that deals specifically with children, their development, childhood 
    diseases and their treatment.
    4.1.2 Pediatric nursing
     This is the art and science of giving nursing care to children from birth through 
    adolescent with emphasis on the physical growth, mental, emotional and 
    psychosocial and spiritual development of the child. It focuses on providing holistic 
    care to infants, children and adolescent.
    4.1.3 Child
    Biologically, a child is a human being between the stages of birth and puberty, 
    or between the developmental period of infancy and puberty. The United Nations 
    Convention on the Rights of the Child (UNCRC) defines a child as everyone under 
    18 years old.
    4.1.4 Childhood
    The period of life of the human being considered to extend from infancy to puberty.
    4.1.5 Infant
    Infant is defined as a child under the age of 1 year.
    4.1.6 Toddler
    A toddler is a child approximately 12 to 36 months old, though definitions vary; the 
    toddler years are a time of great cognitive, emotional and social development. The 
    word is derived from “to toddle”, which means to walk unsteadily, like a child of this 
    age. 
    4.1.7 Child health care
    Specialized branch of medicine that promotes child health, prevent child illness, 
    care of the ill, disabled and dying child from birth through adolescent to maintain 
    physical, emotional and social wellbeing of that individual or child.
    4.1.8 Adolescent
    Adolescence is a transitional stage of physical and psychological development that 
    generally occurs during the period from puberty to legal adulthood. Adolescence is 
    the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique 
    stage of human development and an important time for laying the foundations of 
    good health.
    4.1.9 Health
    Health, according to the World Health Organization, is “a state of complete physical, 
    mental and social well-being and not merely the absence of disease and infirmity.”
    4.1.10 Family centered care
    Family-centered care is a way of providing services that assures the health 
    and well-being of children and their families through respectful family/
    professional partnerships. It honors the strengths, cultures, traditions, and 
    expertise that families and professionals bring to this relationship.
    4.1.11 Atraumatic care
    Atraumatic care is the philosophy of providing therapeutic care through the 
    use of interventions that eliminate or minimize the psychological and physical 
    distress experienced by children and families.
    4.1.12 Health promotion
    Health promotion is the process of enabling people to increase control over, and 
    to improve, their health. It moves beyond a focus on individual behavior towards a 
    wide range of social and environmental interventions. 
    Self-assessment 4.1
    – Identify the differences between pediatrics and pediatric nursing.
    – Describe infant, toddler and adolescent periods.
    4.2 Monitoring of growth and development
    Growth monitoring is a process of following the growth of a child compared with 
    a standard by periodic frequent anthropometric measurements and assessments.
    Growth monitoring and promotion is a preventive and promotional activity. It 
    facilitates communication and interaction between health care providers and care 
    givers so as to encourage appropriate timely intervention to promote optimal child 
    development and growth.
    The main purpose of growth monitoring is to assess growth adequacy and identify 
    changes at early stages before the child reaches the status of under nutrition.
    Weight gain is the most important sign that a child is healthy and is growing and 
    developing well. Also, a health check-up can detect if a child is gaining weight too 
    fast or too slow in comparison to his/her age
    4.2.1 Steps involved in growth monitoring
     5 major steps in growth monitoring are:
    Step 1: Determining correct age of the child
    Step 2: Accurate weighing of the child
    Step 3: Plotting the weight accurately on a growth chart of appropriate gender
    Step 4: Interpreting the direction of the growth curve and recognizing if the child is 
    growing properly.
    Step 5: Discussing the child’s growth and follow up action needed with the mother.
    4.2.2 Growth charts:

    Figure 4.1: Height for age chart for boys




    Figure 4.5: Weight for height chart for boys

    Figure 4.6: Weight for height chart for girls
    Stages of child development (developmental milestones)

    Figure 4.7: Stages of child development
    Children undergo various changes in terms of physical, speech, intellectual and 
    cognitive development gradually until adolescence. Specific changes occur at 
    specific ages of life. Known as developmental milestones, these changes can 
    help to identify if the child is developing at the correct pace. Failure to reach these 
    milestones may indicate developmental disorders or genetic conditions. 
    Developmental milestones are behaviors or physical skills seen in infants and 
    children as they grow and develop. Rolling over, crawling, walking, and talking are 
    all considered as milestones. The milestones are different for each age range.









    4.2.3 Child development theories 
    Child development theories focus on explaining how children change and grow over 
    the course of childhood. Such theories center on various aspects of development 
    including social, emotional, and cognitive growth.

    Psychoanalytic theory originated with the work of Sigmund Freud. Through his 
    clinical work with patients suffering from mental illness, Freud came to believe that 
    childhood experiences and unconscious desires influenced behavior.
    According to Freud, conflicts that occur during each of developmental stages can 
    have a lifelong influence on personality and behavior. The child development occurs 
    in a series of stages focused on different pleasure areas of the body. During each 
    stage, the child encounters conflicts that play a significant role in the course of 
    development.
    His theory suggested that the energy of the libido was focused on different erogenous 
    zones at specific stages. Failure to progress through a stage can result in fixation at 
    that point in development, which Freud believed could have an influence on adult 
    behavior. While some other child development theories suggest that personality 
    continues to change and grow over the entire lifetime, Freud believed that it was 
    early experiences that played the greatest role in shaping development. According 
    to Freud, personality is largely set in stone by the age of five.



    Figure 4.9: Erikson’s psychosocial developmental theory
    Erikson’s eight-stage theory of psychosocial development describes growth and 
    change throughout life, focusing on social interaction and conflicts that arise during 
    different stages of development.
    His eight-stage theory of human development described this process from infancy 
    through death. There are 5 stages in childhood until adolescence as stages are 
    based on the age. During each stage, people are faced with a developmental 
    conflict that impacts later functioning and further growth. At each stage, children 
    face a developmental crisis that serves as a major turning point:
    A. Trust versus Mistrust
    Trust versus mistrust occurs between birth and 1 year. The task of this stage 
    is for the baby to recognize that there are people in his life, generally parents 
    that can be trusted to take care of basic needs. The baby’s struggle becomes 
    evidenced in the recognition that not everyone or every situation is “safe.” Through 
    trust the baby learns to have confidence in personal worth and well-being along 
    with connectedness to others. Failure to master this stage leaves a sense of 
    hopelessness and disconnectedness. 
    B. Autonomy versus Shame and Doubt
    Autonomy versus Shame and Doubt occurs between 1 and 3 years. The task of 
    this stage is for the child to balance independence and self-sufficiency against the 
    predictable sense of uncertainty and misgiving when placed in life’s situations. It 
    is the time for the child to establish willpower, determination, and a can-do attitude 
    about self. An example of this stage happens when the toddler wants to choose 
    clothing and dress independently. The struggle happens when the parents allow 
    the child to make personal choices yet expect the choices to be socially acceptable.
    C. Initiative versus Guilt
    Initiative versus guilt occurs between 3 and 6 years. The child’s task during this 
    stage is to develop the resourcefulness to achieve and learn new things without 
    receiving self-reproach. It is difficult for a young child to resolve the conflict between 
    wanting to be independent and needing to stay attached to parents. The child’s 
    writing plays or new songs, games, or jokes are good examples of initiative.
    The child feels confident to try new ideas. It is important that parents and teachers 
    encourage this initiative to help the child develop a sense of purpose. If initiative is 
    discouraged or ignored, the child may feel guilt and lack of resourcefulness.
    D. Industry versus Inferiority
    Industry versus inferiority occurs between the ages of 6 and 12. In this stage, the 
    child develops a sense of confidence through mastery of tasks. This sense of 
    accomplishment can be counterbalanced by a sense of inadequacy or inferiority
    that comes from not succeeding. The realization that the child is competent is one of 
    the important building blocks in the development of self-esteem. Industry is evident 
    when the child is able to do homework independently and regulate social behavior. 
    Performing the prescribed tasks at school or home also show industry. If the child 
    cannot accomplish realistic expected tasks, the feeling of inferiority may result.
    E. Identity versus Role Confusion
    Identity versus role confusion occurs between the ages of 12 and 18. This is 
    a time of forging ahead and acquiring a clear sense of self as an individual in 
    the face of new and at times conflicting demands or desires. During this stage 
    the adolescent wants to define “what to be when I grow up.” She begins to 
    concentrate on goals and life plans separate from those of peers and family. 
    At this point, the child has the ability to think about self as well as others and 
    proceeds accordingly.

    Figure 4.10: Attachment theories
    Attachment refers to the bond or emotional and physical connection that develops 
    between an infant and caregiver that tends to endure. Early theorists associated 
    attachment with the mother who met the infant’s innate drive to be fed and nurtured. 
    Other examples of attachment behaviors are dressing, bathing, diapering, cuddling, 
    loving, playing, and comforting.
    Both the infant and the caregiver rely on the quality of the interaction between 
    them. In other words, a healthy infant–mother relationship is contingent on the 
    characteristic value of the communication between them

    Self-assessment 4.2 
    1. Enumerate the steps involved in growth monitoring.
    2. Describe the oral stage of Freud’s psychosexual developmental theory.
    3. Discuss any 2 stages of Erikson’s psychosocial developmental theory.
    4.3 Nutrition in children
    Learning activity 4.3
    Identify the differences between the two babies on the picture below

    The questions a healthcare provider asks regarding nutrition are based on the 
    child’s age. If the infant is breastfed, information is gathered as to how often and for 
    how long the child is fed at each feeding, and how many wet diapers are changed 
    in the course of one day. With sufficient breast milk intake, the infant will have six or 
    more wet diapers and gain weight. Newborns often lose 10% of their birth weight. 
    This weight loss is usually by the 12th day of life.
    For the infant who is receiving formula, information is gathered as to the type of 
    formula, the amount taken at each feeding, and the number of feedings per day. It 
    is also important to note if and when juices or solid foods have been started, and 
    whether supplements or vitamins have been prescribed.
    When assessing children and adolescents, a 24-hour recall elicits the food items 
    eaten in a typical day and reflects sociocultural trends. The nurse can document 
    the amount and type of milk, juices, and all other liquids. In addition, the healthcare 
    provider must document food allergies for all children. Analysis of the food intake is 
    compared to the foods suggested in the Food Guide Pyramid for Young Children.
    4.3.1 Importance of nutrition in children
    Proper nutrition supports normal growth, development and aging. It also helps to 
    maintain a healthy body weight and reduces the risk of chronic diseases.
    For children, adequate nutrition is one of the most important factors influencing 
    growth and immunity. A balanced diet must contain the proper amount of 
    protein, carbohydrate, fats, calcium, iron, vitamins and fiber. The foundation for 
    lifelong health is largely set during the first 1,000 days (this is the most critical 
    developmental period of brain growth and function). It is widely recognized as a 
    time of enormous vulnerability but also a time of tremendous potential to impact the 
    long-term health of the child. Due to the specific nutritional requirements during this 
    rapid period of growth, even small nutritional deficits may negatively impact growth, 
    neurodevelopment and adult health.
    4.3.2 Nutrition screening and assessment


    Nutrition screening is a rapid and simple identification of children who may be 
    malnourished or at risk of malnutrition and need more detailed nutrition assessment. 
    Nutrition screening requires standardized training in line with national and local 
    health policy.
    Nutrition assessment includes taking anthropometric measurements and collecting 
    information about a child’s medical history, clinical and biochemical characteristics, 
    dietary practices, current treatment and food security situation.
    Importance of nutrition assessment is to:
    1. Identify children at risk of malnutrition for early intervention or referral before 
    they become malnourished.
    2. Identify malnourished children for treatment- malnourished children who are 
    not treated early have longer hospital stay, slower recovery from infection 
    and complications and higher mobility and mortality.
    3. Track child growth.
    4. Identify medical complications that affect the body’s ability to digest food 
    and utilize nutrients.
    5. Detect practices that increase the risks of malnutrition and infections.
    6. Inform nutrition education and counselling.
    7. Establish appropriate nutrition care plan.
    Nutrition assessment should be done in: 
    Infants 0 to <6 months of age: at birth and on every scheduled postnatal 
    visit
    • Infants 6 to 59 months of age: during monthly growth monitoring sections 
    for children under 2 and every 3 months for older children.
    • Children of 5 years and above: on every clinic visit.

    • Adolescents: on every clinic visit

    4.3.3 Types of nutrition assessment 

    Types of nutrition assessment are remembered with mnemonics ABCD:
    A: Anthropometric is the measurement of the size, weight and proportion of the body. 
    Common anthropometric measurement include weight, height, MUAC (Mid Upper 
    Arm Circumference), head circumference and skin folds. Body mass index (BMI) 
    and weight-for-height are anthropometric measurements presented as indexes.
    B: Biochemical means checking level of nutrients in a child’s blood, urine or stools. 
    Lab tests results can give useful information about medical problems that may 
    affect appetite or nutritional status.
    C: Clinical assessment includes checking for visible signs of nutritional deficiencies 
    such as bilateral pitting edema, emaciation (a sign of wasting, which is a loss of 
    muscle and fat tissue as a result of low energy intake and/or nutrients loss from 
    infection), hair loss, and change in hair color. It also includes taking a medical 
    history to identify co-morbidities with nutritional implications, opportunistic infections, 
    other medical complications, usage of medications with nutritional related side 
    effects, food and drug interactions and risk factors for disease, inability to suck and 

    ineffective breastfeeding. 

    Figure 4.11: Pitting edema on feet

    Bilateral pitting edema also called nutritional edema is a swelling in both feet 
    or legs (bilateral) caused by accumulation of excess fluid under the skin in the 
    spaces within tissues. It is a sign of severe malnutrition on its own regardless of 
    the results of anthropometric assessment. Any child with severe bilateral pitting 
    edema (grade+++), even with appetite and no medical complications should be 
    admitted for inpatient management. A child with bilateral pitting edema Grade+ or 
    ++ with appetite and no medical complications should be treated for severe acute 
    malnutrition.
    D: Dietary: assessing food and fluid intake is an essential part of nutrition 
    assessment. It provides information on dietary quantity and quality, changes in 
    appetite, food allergies and intolerance, and reasons for inadequate food intake 
    during and after illness. To counsel the parents how to improve their diet to prevent 
    malnutrition or treat conditions affected by food intake and nutritional status example 

    cardiovascular disease, cancer, obesity, diabetes and hyperlipidemia

    4.3.4 Various forms of malnutrition


    Figure 4.12: Various forms of malnutrition

    a. Undernutrition

    There are 4 broad sub-forms of undernutrition: Wasting, stunting, underweight and 
    deficiencies in vitamins and minerals. Undernutrition makes children in particular 
    much more vulnerable to disease and death.
    Low weight-for-height is known as wasting. It indicates recent and severe weight 
    loss because the child has not had enough food to eat and/or they have had an 
    infectious disease such as diarrhea which has caused them to lose weight and this 

    may lead this to increase risk of death but treatment is possible.

    Low height-for-age is known as stunting. It is the result of chronic reoccurrence 
    undernutrition usually associated with poor socioeconomic conditions, poor 
    maternal health and nutrition, frequent illness and/or inappropriate infant and young 
    child feeding and care in early life. Stunting holds children back from reaching their 

    physical and cognitive potential. 

    Children with low weight-for-age are known as underweight. A child who is 

    underweight may be stunted, wasted or both.

    b. Micronutrient related malnutrition
    Micronutrients enable the body to produce enzymes, hormones and other 
    substances that are essential for proper growth and development. Iodine, vitamin 
    A and iron are the most important and their deficiency represents a major threat to 

    the health and development of the children.

    Overweight and obesity result from an imbalance between energy consumed (too 
    much) and energy expended (too little). Body mass index is an index of weight-forheight
     commonly used to classify overweight and obesity. It is defined as a person’s 
    weight in kilograms divided by the square of his/her height in meters (kg/m2).

    Body Mass Index in children (BMI)

    • A BMI-for-age plotted below the 5th percentile indicates a child who is 
    underweight; 
    • A BMI-for-age between the 5th and 85th percentile is considered a healthy 
    weight; 
    • Children with a BMI-for-age between the 85th and 95th percentile are 
    considered at risk for obesity; 

    • Children with a BMI-for age _95% are considered obese.

    Self-assessment 4.3 

    1. Discuss various forms of malnutrition.

    2. What are the elements of nutritional clinical assessment?

    4.4 Assessment of a child: History taking

    Learning activity 4.4

    Children are not small adults. Taking a history with children differs from adults and 
    comes with a set of unique challenges. Symptoms are typically reported by a parent 
    or guardian, who may not be able to accurately transmit the information from the 
    child to the examiner and characterize the child’s concerns. To fill in the gaps, a 
    health care provider must have good communication skills and the ability to develop 
    a rapport with children as well as their families.
    Taking a history from a patient is a skill necessary for examinations. It tests both 
    your communication skills as well as your knowledge about what to ask. Specific 

    questions vary depending on what type of history you are taking.

    The basics components of a pediatric history 
    • Introduce yourself, identify your patient and gain consent from the parents 
    to speak with them. Should you wish to take notes as you proceed, ask the 
    patients permission to do so.
    • Chief Complaint: brief statement of primary problem (including duration) that 
    caused family to seek medical attention.
    • History of present illness: similar to history taking in adult population, 
    the history of present illness in pediatric history is to explore the patient’s 
    primary concerns, and must be tailored to the individual presenting complaint. 
    Generally, you will want to try to characterize the symptoms of concern and get 
    a sense of the onset, timing, aggravating and alleviating factors, associated 
    symptoms, and if anything, similar has happened to the patient before.
    • Past History: The past history establishes a complete picture of the child’s 
    health to date, and should cover events from the prenatal period until the 
    child’s current presentation. The prenatal history includes inquiring about 
    maternal age, and number of previous pregnancies and the outcomes of 
    those pregnancies. It may be relevant to ask if the child is a product of natural 
    conception or if assistive reproductive technology was required. Ask about 
    whether prenatal care was accessed, medications used, substances and 
    toxins and if there were any abnormal results or concerns identified on routine 
    screening for infections and chronic diseases or ultrasounds. Additional 
    exposures that may be relevant include the mother’s occupation. 
    • Pregnancy and birth history:
    • Maternal health during pregnancy: ask about bleeding, trauma, 
    hypertension, fevers, infectious illnesses, medications, drugs, alcohol, 
    smoking, rupture of membranes 
    • Gestational age at delivery
    • Labor and delivery: length of labor, fetal distress, type of delivery (vaginal, 
    cesarean section), use of forceps, anesthesia, breech delivery
    • Neonatal period: APGAR scores, breathing problems, use of oxygen, need 
    for intensive care, hyperbilirubinemia, birth injuries, feeding problems, 
    length of stay, birth weight.
    • Growth History: Growth history is an important part of the pediatric history 
    as prolonged illness or chronic conditions may impact the child’s growth and 
    result in deviations from an established growth. When asking about growth 
    history, the pattern of growth, not just the child’s measurement at the present 
    is key as alterations in pattern of growth are often early signs of pathology. 
    Plot the child’s growth on a growth chart, and look at both numbers (z-scores) 
    and percentiles. It may be helpful to ask regarding growth and size of family 
    members, as marked deviations in a child’s growth from what is expected from 
    family trends could help in distinguishing constitutional or familial variants 
    from a pathologic growth pattern. Healthy children should achieve a minimum 
    growth velocity of 5 cm per year. 
    • Developmental History: Developmental history consists of the 5 domains 
    of child development: gross motor, fine motor, speech & language, 
    cognitive, and social/emotional development
    • Ages at which milestones were achieved and current developmental 
    abilities - smiling, rolling, sitting alone, crawling, walking, running, 1st 
    word, toilet training, riding tricycle, etc 
    • School: present grade, specific problems, interaction with peers 
    • Behavior: enuresis, temper tantrums, thumb sucking, pica, nightmares 
    etc.
    • Medical History:
    • Previous hospital admissions with dates and diagnoses 
    • Major medical illnesses: cardiac disease, hypertension, stroke, diabetes, 
    cancer, abnormal bleeding, allergy and asthma, epilepsy.
    • Major surgical illnesses, Trauma-fractures, lacerations, list operations 
    and dates
    • Medication History: Medication history includes both prescription and 
    non-prescription medications such as over the counter medications, 
    vitamins and supplements. One commonly overlooked group of 
    medications is inhalers, so it might be helpful to ask specifically if the child 
    uses any inhalers. It is also important to ask specifically about herbal 
    or homeopathic remedies, as parents may not report this unless directly 
    asked. Additionally, do not forget to ask about allergies to any drugs, foods 
    or environmental triggers.
    • Immunization History: Immunization history is an essential part of the pediatric 
    history. Ask if the child has received all of his/her routine immunizations, as 
    well as if the child has received any additional vaccines such as the seasonal 

    influenza vaccine or travel immunizations. It may be relevant to ask when the 

    child last received a vaccination for various presentations including febrile 
    seizures or fever.
    • Feeding History: 
    • Breast or bottle fed, types of formula, frequency and amount, reasons for any 
    changes in formula
    • Solids: when introduced, problems created by specific types
    • Family History: Family history may begin with clarifying ethnicity when 
    relevant, and then establishing if any medical conditions have occurred in the 
    family that may relate to the child’s current presentation. It may be helpful to 
    draw out a pedigree to better understand the health and relationships between 
    individuals in the family. Again, many items in this component of the pediatric 
    history may be sensitive, and it is important to approach these topics in an 
    open and non-judgmental manner. Mental retardation, congenital anomalies, 
    chromosomal problems, growth problems, etc.
    • Social History: The social history includes parental employment status, any 
    financial issues, health coverage and drug plans, and family composition. 
    This part of the history may lead to discussion about the impact of the child’s 
    illness on both the child and the family, and can allow the care team to better 

    support the family

    Self-assessment 4.4

    – Identify elements to include in pediatric history taking 

    – Why do we need to know prenatal history of pediatric patients?

    4.5 Assessment of a child: Review of systems

    Learning activity 4.5.1

    A review of systems Much like the physical examination, the review of systems 
    is best conducted with a “head-to-toe” approach, starting with a general question 
    regarding each body system. It can also be conducted by asking questions during 
    the physical examination. 
    It is a technique used by healthcare providers for eliciting a medical history from 
    a patient and often structured as a component of an admission note covering 
    the organ systems, with a focus upon the subjective symptoms perceived by the 
    patient (as opposed to the objective signs perceived by the clinician). Along with 
    the physical examination, it can be particularly useful in identifying conditions that 
    do not have precise diagnostic tests. The review of systems serves as a guide to 
    help identify potential or underlying illnesses or disease states subjectively, thus 
    allowing the health care provider to prioritize system for follow up and objective 
    examination. This will also help to obtain information about the chief concern as 
    well as the history of present illness.
    Whatever system a specific condition may seem restricted to, it may be reasonable 
    to review all the other systems in a comprehensive history.
    Review of systems includes the following areas:
    a. General: usual weight, change in weight, weakness, fatigue, fever or 
    allergies. 
    b. Head, Eyes, Ears, Nose, Throat (HEENT): injury to head, headaches, 
    dizziness; eye infections, itching or watering eyes, behaviors indicating 
    change in visual acuity, use of glasses, date of last eye exam; ear 
    infections, behaviors indicating change in hearing; nose bleeds, colds, 
    hay fever, sinus infections; sore throats, tonsils, dentition, caries.
    c. Neck: neck pain, enlarged lymph glands, neck range of motion 
    d. Skin and Lymph: rashes, adenopathy, lumps, bruising and bleeding, 
    pigmentation changes 
    e. Cardiac: cyanosis and dyspnea, heart murmurs, exercise tolerance, 
    squatting, chest pain, palpitations 
    f. Respiratory: pneumonia, bronchiolitis, wheezing, chronic cough, sputum, 
    hemoptysis, Tuberculosis 
    g. Gastro-Intestinal: stool color and character, diarrhea, constipation, 
    vomiting, hematemesis, jaundice, abdominal pain, colic, appetite 
    h. Genito-Urinary: frequency, dysuria, hematuria, discharge, abdominal 
    pains, quality of urinary stream, polyuria, previous infections, facial edema 
    i. Musculoskeletal: joint pains or swelling, fevers, scoliosis, myalgia or 

    weakness, injuries, gait changes

    j. Pubertal: secondary sexual characteristics, menses and menstrual 
    problems, pregnancies, sexual activity 
    k. Allergy: urticaria, hay fever, allergic rhinitis, asthma, eczema, drug 
    reactions
    l. Neurological: seizures, tics, psychiatric diseases, anxiety, depression
    m.Endocrine: history or symptoms of thyroid disease or diabetes or diseases 

    that affect normal growth

    Self-assessment 4.5

    1. Describe the constitutional symptoms in the review of systems.

    2. Explain any 4 systems that can be reviewed during history taking.

    4.6 Assessment of a child: Physical examination

    Learning activity 4.6

    1. What should be done during pediatric physical examination?

    2. Why is it relevant to perform pediatric physical examination?

    In physical examination, medical examination or clinical examination, a medical 
    practitioner examines a patient for any possible medical signs or symptoms of a 
    medical condition. It generally consists of a series of questions about the patient’s 
    medical history followed by an examination based on the reported symptoms. 
    Together, the medical history and the physical examination help to determine a 
    diagnosis and devise the treatment plan. These data then become part of the 
    medical record.
    Differences in Performing a Pediatric Physical Examination Compared to an 
    Adult: 

    I. General Approach 
    a. Gather as much data as possible by observation first 
    b. Position of child: parent’s lap vs. exam table 
    c. Stay at the child’s level as much as possible. Do not tower!! 
    d. Order of exam: least distressing to most distressing 
    e. Rapport with child:
    – Include child - explain to the child’s level 

    – Distraction is a valuable tool 

    f. Examine painful area last-get general impression of overall attitude 
    g. Be honest. If something is going to hurt, tell them that in a calm fashion. 
    Don’t lie or you lose credibility! 
    h. Understand developmental stages’ impact on child’s response. For 
    example, stranger anxiety is a normal stage of development, which tends 
    to make examining a previously cooperative child more difficult. 
    II. Vital signs 
    a. Normal differ from adults, and vary according to age 
    b. Temperature: Tympanic, oral, axillary and rectal
    c. Heart rate: In infants, auscultate or palpate apical pulse or palpate femoral 
    pulse. In older children, palpate antecubital or radial pulse
    d. Respiratory rate: Observe for a minute. Infants normally have periodic 
    breathing so that observing for only 15 seconds will result in a skewed 
    number. 
    e. Blood pressure: Appropriate size cuff - 2/3 width of upper arm 
    f. Growth parameters: must plot on appropriate growth curve (Weight, 
    Height/length, Occipital Frontal Circumference: Across frontal-occipital 
    prominence so greatest diameter).

    III. Unique findings in pediatric patients (See outline below) 
    Outline of a Pediatric Physical Examination 
    I. Vitals - see above 

    II. General

    a. Statement about striking and/or important features. Nutritional status, level 
    of consciousness, toxic or distressed, cyanosis, cooperation, hydration, 
    dysmorphology, mental state 
    b. Obtain accurate weight, height and OFC 
    III. Skin and Lymphatics
    a. Birthmarks - nevi, hemangiomas, mongolian spots etc 
    b. Rashes, petechiae, desquamation, pigmentation, jaundice, texture, turgor 
    c. Lymph node enlargement, location, mobility, consistency 
    d. Scars or injuries, especially in patterns suggestive of abuse 
    IV. Head 
    a. Size and shape 
    b. Fontanelle(s): determine its Size in a calm environment and in the sitting 
    up position
    c. Sutures - overriding 
    d. Scalp and hair 
    e. Eyes 
    General: Strabismus, Slant of palpebral fissures, Hypertelorism or 
    telecanthus 
    • EOM 
    • Pupils 
    • Conjunctiva, sclera, cornea 
    • Plugging of nasolacrimal ducts 
    • Red reflex 
    • Visual fields - gross exam 
    f. Ears 
    • Position of ears: Observe from front and draw line from inner canthi to 
    occiput 
    • Tympanic membranes 
    • Hearing - Gross assessment only usually 
    g. Nose 
    • Nasal septum 
    • Mucosa (color, polyps) 
    • Sinus tenderness 
    • Discharge 
    h. Mouth and Throat 
    • Lips (colors, fissures) 
    • Buccal mucosa (color, vesicles, moist or dry) 
    • Tongue (color, papillae, position, tremors) 
    • Teeth and gums (number, condition) 
    • Palate (intact, arch) 
    • Tonsils (size, color, exudates) 
    • Posterior pharyngeal wall (color, lymph hyperplasia, bulging) 
    • Gag reflex 
    i. Neck
    • Thyroid 
    • Trachea position 
    • Masses (cysts, nodes) 
    • Presence or absence of nuchal rigidity 
    j. Lungs/Thorax 
    • Inspection 
    • Pattern of breathing 
    Abdominal breathing is normal in infants 
    Period breathing is normal in infants (pause < 15 seconds) 
    • Respiratory rate 
    • Use of accessory muscles: retraction location, degree/flaring 
    • Chest wall configuration 
    Auscultation
    • Equality of breath sounds 
    • Rales, wheezes, rhonchi 
    • Upper airway noise 
    • Percussion and palpation often not possible and rarely helpfu
    k. Cardiovascular
    • Auscultation
    • Rhythm 
    • Murmurs 
    • Quality of heart sounds 
    • Pulses 
    • Quality in upper and lower extremities 
    L. Abdomen 
    • Inspection 
    • Shape 
    Infants usually have protuberant abdomens 
    Becomes more scaphoid as child matures 
    • Umbilicus (infection, hernias) 
    • Muscular integrity (diasthasis recti) 
    • Auscultation 
    • Palpation
     
    • Tenderness - avoid tender area until end of exam 
    • Liver, spleen, kidneys: May be palpable in normal newborn 
    • Rebound, guarding: Have child blow up belly to touch your hand 
    M. Musculoskeletal 
    • Back 
    • Sacral dimple 
    • Kyphosis, lordosis or scoliosis 
    Joints (motion, stability, swelling, tenderness) 
    Muscles 
    • Extremities: Deformity, Symmetry, Edema and Clubbing 
    • Gait
    • In-toeing, out-toeing 
    • Bow legs, knock knee: “Physiologic” bowing is frequently seen under 2 
    years of age and will spontaneously resolve 
    • Limp 
    • Hips: Ortolani’s and Barlow’s signs 
    N. Neurologic - most accomplished through observation alone 
    Cranial nerves 

    • Sensation 

    • Cerebellum 
    • Muscle tone and strength 
    • Reflexes:
    Deep Tendon Reflex, Superficial (abdominal and cremasteric), 
    Neonatal primitive
    O. GU 
    • External genitalia 
    • Hernias and Hydrocoeles

    • Almost all hernias are indirect 
    • Can gently palpate; do not poke finger into the inguinal canal 
    • Cryptorchidism 
    • Distinguish from hyper-retractile testis 
    • Most will spontaneously descend by several months of life 
    • Tanner staging in adolescents 

    • Rectal and pelvic exam not done routinely 

    Self-assessment 4.5

    • Enumerate sites for measuring body temperature. 

    • Describe any 3 differences in physical examination of a child and adult.

    4.7 Beliefs that affect Child health

    Learning activity 4.7

    Discuss different beliefs in your community that may affect the child health
    It is observed that traditional healthcare practices and cultural beliefs have a 
    significant place and are widely used in all societies. Traditional cultural practices 
    reflect values and beliefs held by members of a community for periods often 
    spanning generations. Every social grouping in the world has specific traditional 
    cultural practices and beliefs, some of which are beneficial to all members, while 
    others are harmful to a specific group, such as children and pregnant women. 
    Health beliefs are what people believe about their health, what they think constitute 
    their health, what they consider the cause of their illness, and ways to overcome 
    their illness. These beliefs are culturally determined and all come together to form 
    larger health belief systems.
    A. Cultural practices affect children’s and families’ conceptions of health, as well 
    as children social development, attitudes towards health problems they experience

    conception of illness, reactions to illness and therapy.

    Children learn their beliefs, values, capabilities, knowledge and skills from 
    their families and their culture. Furthermore, culture plays an important role in 
    socialization and development of children. Cultural background holds a significant 
    place in children’s social and emotional development, as well as improvement of 
    their motor and cognitive skills.
    B. Religion 
    Along with cultural values, concepts of religion and spirituality hold a significant 
    place in lives of the individual and society. Although the terms ‘spirituality’ and 
    ‘’religion’ are often used alternately, spirituality is inclusive of the concept of religion. 
    Religion is a factor that affects life style of the society and conception of health and 
    illness.
    Religion is a concept that may affect individuals’ and society’s philosophy of life, 
    conceptions of health and illness, types of food consumed, rituals of birth and death, 
    and healthcare practices. Societies are found to use various religious practices 
    in care and treatment. Religious practices may have various effects on children’s 
    social and moral development. Healthcare practices based on religious and spiritual 
    values may play a significant role in shaping children’s and family’s lifestyle and 
    may have a great impact on children’s health. Various religions and sects are able 
    to affect children’s health and care practices, nutrition, and medical practices.

    Concepts affected by culture

    

    C. Geographical region
    Child’s and family’s cultural values, as well as their environment of habitation result 
    in various differences in their conception and expression of health, illness, pain, 
    and their reflection to healthcare practices.
    For example, it was observed in some rural areas in Africa that food items such 
    as eggs and meat were limited due to the fear that children may turn to thieves, 
    witches or sorcerers. It was detected that, in certain societies, there are differences 
    in individuals’ conception and attribution of meaning to verbal and non-verbal 
    communication.
    Self-assessment 4.7 
    Discuss 2 concepts of culture and the way they can affect child’s health.

    4.8 Practices that affect Child health

    Learning activity 4.8


    1. Describe what you are seeing on the above picture and discuss different 
    traditional practices that affect child health in your community
    2. What is the impact of those practices to the child health?

    Traditional practices
    It is observed that individuals resort to traditional healthcare practices before 
    professional practices of care. It is noted that, in certain cultures the patients are 
    treated by individuals who are named traditional physicians or medicine man and 

    who are believed to possess divine Powers to cure illnesses.

    It is observed that traditional healthcare practices and cultural beliefs have a 
    significant place and are widely used in all societies. According to current medical 
    knowledge, traditional methods applied to the child may be classified as practices 
    that adversely affect the child’s health and practices that have no adverse effect 
    on the child’s health. Among practices that may adversely affect the child’s health 
    are attitudes such as delaying breastfeeding for a certain time after childbirth, not 
    feeding the newborn with colostrum, coating the newborn with salt, placing soil 
    under the baby, and wrapping the baby tightly to make its legs grow straight. On 
    the other hand, practices such as placing a yellow kerchief on the baby’s face to 
    prevent newborn jaundice, to dress the baby with red-colored clothing, praying, 
    placing an evil eye talisman in the baby’s room are characterized as having no 
    adverse effect on the child’s health but may nevertheless be efficient in comforting 
    the family.
    Health is influenced by culture which is a dynamic factor as well as biological 
    and environmental factors. Health practices are the outcome of health beliefs 
    generally originated from the culture of individual. Cultural practices of families 
    are directly related with the child health. Cultural practices affect children’s and 
    families’ conceptions of health, as well as children’s social development, attitudes 
    towards health problems they experience, conception of illness, reaction to illness 
    and therapy. There exist different practices that affect the child health. These are 
    named differently in Rwanda depending on the region. These includes Milk teeth 
    extraction (gukura ibyinyo), Uvulectomy (guca ikirimi), Tonsilectomy (guca 
    ibirato), Extracting millet (gukura uburo).

    Milk teeth extraction (Gukura ibyinyo)

    Normally the development of deciduous teeth begins while the baby is in utero and 
    about sixth weeks gestation, the first buds of primary teeth appear in the baby’s 
    jaw. The lower teeth are formed first followed by the upper anterior teeth. At birth 
    the baby has a full set of 20 primary teeth (10 in upper jaw, 10 in lower jaw) hidden 
    within the gums. Crown formation of the milk canine tooth in the upper jaw (maxilla) 
    is complete 9 months and the crown formation of a deciduous canine tooth in the 
    lower jaw (mandible)is complete between 8 and 9 months after birth.
    Milk teeth extraction is a process of gouging out an infant’s healthy baby canine buds 
    imbedded underneath the gums, using unsterile tools such as a hot or sharpened 
    nail, a bicycle spoke or knitting needle, with no anesthesia. It is a dangerous and 
    sometimes fatal traditional practice. Milk teeth extraction believed to cure a tooth 
    disease known as Ibyinyo. In reality, this so-called disease is the natural teething 
    stage that all babies go through, beginning at around 6 months of age. Teething 
    in babies causes mouth pain, fever and sometimes even vomiting or diarrhea, 
    prematurely extracting the teeth is not a cure, and causes serious permanent 

    damage of the child.

    Uvulectomy (Guca ikirimi)
    Uvulectomy consists of cutting the uvula which has a function of blocking the passage 
    into the nasal cavity when swallowing so that the foods or fluids do not enter the 
    nasal passages. The uvula also involves in articulation of voice to form sounds of 
    speech. When uvulectomy is performed, there is likelihood of an infant developing 
    the conditions of hypernasal speech known as velopharyngeal insufficiency (VPI) 
    and/or nasal regurgitation (entering of food into the nasal cavity).
    Tonsilectomy (gukata ibirato) 
    It consists of cutting the baby’s tonsils.
    Extracting millet (gukura uburo)
    It consists of skin cuts that are performed on chest wall of some children claimed to 
    be the remedy for chest infections in infants. 
    A. Complications of traditional practices
    All of those mentioned above traditional practices have different complications such 
    as loss of blood that may lead to shock later on Anaemia, blood infections, tetanus, 
    HIV/AIDS (because the materials used are not sterilized), facial disfigurement and 
    can be fatal. The underlying permanent tooth buds can be damaged or eradicated, 
    causing malformations and long-term crowding in the anterior region of the maxilla 
    and mandible. 
    B. Prevention
    The prevention of traditional practices involves a multidisciplinary team. This 
    goes beyond changing particular beliefs and behaviors within communities and 
    societies: it is about fundamental social change. There is need of increased, access 
    especially for poor and vulnerable people, to all essential services, including health 
    and education, social welfare and legal services. The community needs a sound 
    understanding of the importance of religion, faith and other belief systems: how 
    they can support work to end traditional practices that are harmful to children. 
    Conclusion
    Nurses should be cautious about the children’s and families’ cultural beliefs’ and 
    practices’ reflections on the child’s health. In this context, the individual should be 
    conceived in spiritual and psychosocial aspects from birth to death and holistic care 

    should be provided

    Self-assessment 4.8

    1. Discuss the complications of traditional practices that affect child health.
    2. What is your role in the prevention of traditional practices that affect the 

    child health?

    End unit assessment 4

    1. What is health Promotion?
    2. Which children should you monitor growth?
    3. What does the psychosexual development theory of Sigmund Freud say 
    about the development of personality which is different from what was 
    said by other theorists?
    4. Describe different types of nutritional assessment
    5. Describe the elements assessed during the pediatric physical 

    assessment.


     

    UNIT3:BARRIER AND PERMANENT FAMILY PLANNINGUNIT 5:PREVENTION OF DISEASES IN CHILDREN