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Infant and Toddler Growth and Development

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1 Infant and Toddler Growth and Development
Elisa A. Mancuso RNC, MS, FNS Professor of Nursing

2 Growth of Infant Cephalocaudal (head → toe)
Proximodistal (trunk → periphery) General → Specific (Large → fine muscles) 1” a month during 1st 6 months Average Ht 6 months 25 ½ inches 12 months 29 inches Use recumbent length until 3 years than standing (vertical height) Length mainly in trunk which gives infant the characteristic look

3 Weight 2.2 lbs = 1 kg 5-7oz/wk until 5-6 months
Birth weight doubles at 6 month Birth weight triples at one year Always refer to kilograms 2.2 lbs = 1 kg All medications based on weight in kg!

4 Head Circumference = HC
Reflects brain growth Posterior fontanele 2 mos. Anterior fontanel mos. Measure (Forehead → Occiput) For 1st 3 years @ birth 70 % of adult size

5 Chest (CC) and Abdomen Chest = Head circumference @ 1 year
nipple line. Barrel chested as infant Chest > Head after 3 years After 1 year of age, A/P transverse diameter = 1:2 Abdominal Girth Measure above umbilicus √ Abdominal distention R/O liver or intestinal diseases

6 Growth Charts Serial exams to assess growth progress
Plotted as percentiles: 25th %, 50th %, 75th %, 95th %. @ 95th % = Pt > 95% of kids. Used to notice any ↓ or ↑ in weight, height, or HC. Specific charts for premature infants

7 Denver Developmental Screening Test (DDST) Denver II
Assesses from birth → 6 years Age divided monthly → 24 months, then q 3 mos. → 6 years Not an intelligence test Four categories Personal/Social Fine motor/Adaptive Language Gross motor

8 Infant Reflexes Moro - Startle
Loud sound = extension & abduction of extremities Tonic neck – Fencing Turn head to one side ® arm & leg extend on ® side Babinski Dorsiflexion of big toe and toes fan out All of above disappear in about 3-4 months

9 Developmental Skills Trust vs Mistrust (Birth to one year)
Social responsiveness to others Trust develops with regular consistent, loving care Self reliance and develops confidence Early infancy months Smiles at significant other Holds head & chest up when prone Reaches for objects-grasp Laughs (social smile by 3-5 weeks

10 Developmental Skills Early Infancy 4-6 months
Pulls self to sitting position Sits with support Rolls over = “Safety issue” Tummy → back first at 2-3 months Back → tummy by 6 months stronger head and arm control Transfers objects from hand to hand Makes vowel sounds oh-oh

11 Developmental Skills Late Infancy 6-9 months Hold own bottle
Develops preference for dominant hand Probes with index finger Feeds self finger foods Pincer 9 months thumb and index finger used Sits erect-unsupported Crawls Separation Anxiety ↑cries with strangers Object Permanance Searches for items outside field of vision

12 Developmental Skills 9-12 months
Triple birth weight and ↑ height by 50% Releases objects Pulls self to feet Sits from standing position Walks with help independent walking can be as late as 18 months! Responds to name Recognizes no Says 4 -5 words: mama, dada, no, bye Teething (age – 6 = # of teeth) 12 mos – 6 = 6 teeth Cool cold items to chew on Tylenol mg/kg q 4-6 hours

13 Developmental Tasks Achieve physiological equilibrium
Rest, eat, play patterns Develop basic social interaction Desire for affection Manage a changing body ↑motor skills & eye-hand coordination Learn to understand and control world Develop a beginning symbol system Communication

14 Immunizations
Regulated by CDC and American Academy of Pediatrics (AAP) ↓ Infectious diseases = ↓morbidity & mortality ↑ incidence of recent outbreaks: immigration from poorly compliant countries religious beliefs or cultural influences ↓ trust of medical care or poor education 2003 Nigeria stopped IPV Rumors that IPV could transmit AIDS % of kids<5 no IPV and ↑ polio outbreak 2005 Amish Polio outbreak Advisory Committee on Immunizations (ACIP) of CDC and Committee on Infectious Disease of

15 2009 Immunizations Hep B Hepatitis B Vaccine (IM)
Birth, one month and six months Mom (+) HBsAg give baby HBIG (0.5mL) & Hep B within 12H @ 2 separate sites 90% infected infants → chronic Hep B carriers 25%-50% infected before age 5 RT HBV Carriers ↑ Transmission risk in adolescents All kids entering 7th grade must have Hep B 3 dose series

16 Immunizations IPV - Inactivated Polio Vaccine (SC)
2, 4, (6-18) months and (4-6) years Formerly used OPV –Virus shed Contraindication; Allergy to neomycin HIB - Hemophilus Influenza Type B (IM) 2, 4, 6 and (12-15) months Not associated with Flu Protects against many serious infections: Epiglottitis and Bacterial Meningitis

17 Immunizations PCV7 - Polysaccaride Conjugate Vaccine- (Prevnar) (IM)
2,4,6 and (12-15) months PPV – Pneumococcal Polysaccharide (IM) One dose > 2 years Protects against Strep pneumonia 6-12 months of age at high risk for S. pneumoniae ↑ Risk patients Sickle cell disease, HIV/immune deficiency chronic cardiac or pulmonary etc Must receive PPV vaccine in addition to PCV

18 Immunizations DTaP - Diptheria, Tetanus and acellular Pertussis (IM)
Rare throat infection Gray/yellow film difficult to remove Air flow obstruction Sepsis Tetanus Clostridium produced in infected wounds Severe muscle extension

19 Immunizations Pertussis Gram negative bordetella pertussis
“whooping cough” Post-tussive vomiting Cyanosis Subconjuctival hemorrhage Three stages: catarrhal, paroxysmal (2 weeks) and decline ↑ outbreaks in Adolescents and Adults RT ↓ titers

20 Immunizations DTaP Schedule 2,4,6,15 months and 4-6 years for DTaP
√ Side Effect: Redness & site New booster recommendations 2005: “Tdap” Adacel: one dose years or Boostrix: single dose years of age Adolescents years of age should receive single dose of Tdap instead of Td (if up to date and have not yet received Td booster) Need 5 year interval from Td to Tdap to ↓SE Contraindication: Encephalopathy in 7 days of DTaP

21 Immunizations MMR - Measles, Mumps and Rubella (IM) Measles
Viral illness - macular/papular rash Kopliks spots oral mucosa Encephalitis/pneumonia Mumps Inflammation salivary glands/parotid Boys develop orichitis/sterility Rubella Viral illness- rash (face → body → extremities) Pregnancy exposure: Fetal deafness, cataracts, cardiac defects, encephalitis

22 Immunizations MMR is live attenuated (weakened) vaccine
12-15 months and 4 - 6years Contraindication: Pregnancy Immunocompromised Allergy to neomycin

23 Immunizations Varicella (SC) Varicella “chickenpox”
Live attenuated virus healthy children only 12-18 months 2nd 4-6 years All kids entering 6th grade ↑Risk > 13 years Give with MMR MMRV new vaccine Contraindication Pregnancy Immunocompromised or Allergy to neomycin Effective if used within 3 days of varicella exposure ↓incidence 85%

24 Immunizations Protects against N.meningitids (not all strains!)
MCV4 - Meningococcal Conjugate Vaccine 4 (IM) MPSV4 - Meningococcal Polysacharide (SC) Protects against N.meningitids (not all strains!) MCV4/ Menactra: One dose years high school entry or college freshman in dormitories (↑risk smoking and crowds) MPSV4/Menomune: Children> years ↑risk factors Sickle cell disease.

25 Immunizations Influenza virus → pneumonia and death
TIV -Trivalent Inactivated Vaccine – Influenza (IM) Influenza virus → pneumonia and death pediatric deaths ↑↑ # of cases in February 6 mos - 5 years of age annually > 5 years only high risk population. 0.25ml<3 years or 0.5ml>3 years Contraindication – Egg Allergy √ Eat baked goods can have vaccine LAIV - Live Attentuated Influenza Vaccine > 5 years (2 doses 1st time)

26 New Vaccines Added Rotavirus vaccine Rototeq
Rotavirus is primary cause of acute gastroenteritis in US Three oral doses given at 2, 4 and 6 months Dosing must be complete by 8 months of age No catch-up for older infants Do not re-administer if infant spits up

27 New Vaccines Added Human Papillomavirus (HPV)
Non-enveloped dbl stranded DNA virus >100 types with oncogenic types 75% of sexually experienced men and women age years have had some type of HPV Quadrivalent HPV vaccine (Gardasil) Protects against HPV 6,11, 16 & 18 Type 16 and 18 account for approx 70% of cervical cancers ACIP recommended 6/29/06 Routine vaccination of girls years but may 9 Catch-up vaccination for adolescents and young women who have not been previously vaccinated Not indicated in pregnancy or hypersensitivity to substances

28 New Vaccines Added HPV administration (3 separate doses 0.5ml IM )
1st dose on elective date 2nd 2 months from first 3rd 6 months after first dose SE: Very painful Syncope & tonic –clonic movements √ Pt remains seated or lies down x 15 minutes Compliancy Issues: Moral issues can intervene Study with boys shows = a good immune response ↑ Vaccinate girls RT ↑↑ risk of Cervical CA

29 Only true contraindications to vaccine administration
Fever >102 Immunocompromised: (No MMR & Varicella) HIV, Leukemia, Lymphoma Alkylating agents or Antimetabolites Daily Corticosteroids Dose: > 2 mg/kg or 20 mg/day Allergy to vaccine component Vaccine Adverse Event Reporting System (VAERS) Allergies/anaphylaxis to: Eggs=Influenza, Baker’s yeast= Hep B, Neomycin = MMR, IPV, Varicella

30 Congenital defects Cleft palate 1/750 births cleft lip
1/2500 births cleft palate Incomplete closure of the roof of the mouth 6th -10th week of gestation Opening from uvula→ soft palate → hard palate → lip Cleft palate 1st sign Formula coming out of nose Gloved finger to assess soft and hard palate in newborn

31 Etiology Multifactorial Genetic-familial tendency
↑ in Asians and lowest in African Americans ↑ Caffeine ↑ ETOH Dilantin or Valium ↓Folic Acid ↓ Vit A Sequella Feeding difficulties Speech difficulties High risk for Otitis Media Serous and Bacterial

32 Interventions Review defect 3P Feeding technique Impact on infant
Before and after photos Support Groups 3P Feeding technique Position - upright Pore - soft, premie nipples enlarged opening Patience - burp frequently

33 Surgery Lip repair usually 1-3 months Palate repair @ 18 months
Protect incision line after operation Palate 18 months Supine with ↑ HOB Elbow restraints √ I & O

34 Tracheoesophageal (TEF) Fistula
Opening between trachea and esophagus Fluids enter lungs ↑ Aspiration PN Large amounts of air into stomach Esophageal Atresia EA Esophagus ends in a blind pouch ↑ in Pre-term and/or Polyhydramnois 30-50% multiple anomalies

35 TEF/ EA Clinical Signs Increased salivation Drooling “3 C’s”
Choking Coughing Cyanotic episodes Laryngospasms Abdominal distension Unable to pass NGT with atresia

36 Interventions NPO ↑ HOB>30º Maintain patent airway
NGT to low intermittent suction Prophylactic antibiotics Aspiration PN Surgery correction of fistula ASAP

37 Safety in Infants Accidents leading cause of death btwn 6-12 mos
Suffocation/Aspiration # 1 cause of fatal injuries <1 year √ toys, mobiles No H2O mattress or pillows Falls Walkers 45% Burns H2O 160 scalds skin in 10 seconds ↓ Temp to 120 Poisonings Plants, Cleaners, Grandma’s purse √ meds Cars Car seat < 1 year back seat, facing rear

38 Nutrition Vitamins for Infants Fluoride
0.25mg/day > 6 months - 3 years Poly-vi-flor 1cc QD >3 years ↑ 0.50mg/day FeSO4 0.5mg/kg/day > 6 months if BF mother not taking supplements after 6 months fetal stores are depleted) Vit D 400 IU/day

39 Breast Milk Contains all nutrients and Lacks Vit C, D and Fe
A,B, E Immunoglobulin IgA, T and B cells Lacks Vit C, D and Fe Twice sugar (lactose)= laxative effect ↑ # of stools ↑↑ lactalbumun more complete protein ↓↓ caesin easier to digest

40 Formula No more than 32 oz/day No whole milk in infants!
No iron in milk Infants unable to properly digest ↑ ↑ irritation of intestinal mucosa, bleeding and anemia

41 Solids Begin at 4-6 months Too early introduction of solids
↑ incidence of allergies and celiac disease. No cereal in formula bottle! Assess physiological readiness ↓ Tongue extrusion reflex ↑ Coordinated suck & swallow Tooth eruption – ↑ biting & chewing ↑ Pancreatic enzymes for complex nutrients Introduce foods one at time New food after 3 days: Cereal → vegetables → fruits →meats → egg yolks No egg whites <1 year No honey/corn syrup <2 years ↑ Risk of botulism No Nuts, Seeds or Popcorn

42 Kwashikor Severe protein deficiency
Adequate caloric intake and ↑ ↑ carb diet Mycotoxin mold found in intestines Signs and Symptoms Scaly, dry skin and ↓ pigmentation Hair thin/dry and coarse Ascites Edema RT ↓ protein Muscle atrophy Irritable, lethargic, withdrawn Permanent Blindness Diarrhea→Infection →Death

43 Nursing Interventions
Assess degree of malnutrition Neurological/muscular impairments √ Developmental milestones Hyperalimentation ↑ Protein diet Antibiotics Skin Care Collaborate with OT and PT

44 Skin Disorders Eczema (5-7% Infants)
RT allergies (egg, soy and cow’s milk) ↑ Ig E levels RT ↑ Histamine, Prostaglandins, Cytokines ↑ with stress 90% develop asthma Signs and Symptoms ↑ in winter Skin Rash Erythematous, edematous, Pruritic, dry and cracked ↑ Lesions in skin creases, Cheeks, forehead & scalp ↑ Risk of secondary infections

45 Treatment Hydrate Topical steroids Antibiotics if secondary infections
Brief bath with Dove soap Lubricants –Eucerin cream Topical steroids Antibiotics if secondary infections Elidel and Protopic 0.03% non-steroidal Pimercrolimus and Tacrolimus Only for children > 2 years Black box warning ?↑ risk of cancer

46 Impetigo Toddlers and Preschoolers ↑ incidence in Summer (hot/humid)
1st Skin is broken via bug bite infected - staph A or B strep Very contagious 1st Macular & Pruritic 2nd Honey crusted, thick & bleed Therapy Wash lesion c warm soapy H2O Soak and remove crusts Bactraban BID 7 days PO Antibiotics PCN, EES, Lorabid, Zithromax

47 Sebborrheic Dermatitis
Cradle Cap Chronic inflammatory condition Dysfunction of sebaceous glands Infants produce a lot of sebum Yellow scales from eyelids → Scalp Therapy Apply lotion, massage scalp Fine comb remove scales

48 Toddler 12-36 months Growth slows – Physiological anorexia
Average weight gain 4-6 lbs/year BW quadrupled by 2 ½ years Height 3 inches/year HC growth slows A/P diameter 1:2 Visual acuity 20/40 Eyes can accommodate distance ↑ Neuromuscular control Manipulates objects & people

49 Psychosocial Development
Autonomy vs. Shame and Doubt “Me do” stage Intense exploration of environment Fighting for autonomy Negativism “No” Ritualistic behavior to control their environment Body Image develops

50 Psychosocial 2nd Separation Anxiety Body image develops
Cling and cry when left by parent Be honest regarding separation do not disappear!! Body image develops knows certain body parts: eye, “pee pee” Begins to acquire socially accepted behaviors

51 Toilet training Holding on and letting go is very important!
Need to recognize the urge to “let go” 1st Bowel control after 18 months 2nd Bladder 2½ - 3½ years Daytime bladder control before nighttime Regular BM and patterns or child will alert you Needs ↑ awareness and self discipline Harder to train children with history of constipation

52 Temper tantrums Common response to helplessness or frustration
Inadequate verbal skills Can’t communicate needs! Strike out physically Monitor for speech delay children!

53 Interventions Set appropriate, clear and consistent limits
Safely isolate and ignore behavior Remove from situation Redirect or introduce another activity to restore self-esteem Time out = minute per age Do not let toddler get too tired, hungry or stimulated After tantrum subsides provide love and attention

54 Developmental skills 300 words by 2 years.
Understand more than they say 2 yr old 65% of speech should be comprehendible Knows first and last name Dressing - takes off own clothes Walk, run, and jump with both feet Ride tricycle, build tower of blocks Parallel play Possession = ownership Ritualism Comforting & ↓ Anxiety

55 Intellectual development
5th Stage of months Object permanence Exists when not visible “Where’d it go?” “Peek a Boo” Active experimentation Time perception Holidays, morning, noon, night 1 minute = 1 hour Space perception Nesting Stands on stool to get object Magical thinking

56 Pre-operational Stage
Transitional Stage mos ↓ Trial and error Memory and imitates actions. sweeping floor with broom is mom cleaning ↑ Problem solving Egocentric- “I” “me” “mine” Concrete thinking Literal translation “A little stick” for IV = tree branch Sense of Time Orientation RT activities Mom will be back after nap instead of at 2 o’clock.

57 Toddler Developmental Tasks
Differentiate self from others Toleration of separation of parents Slight delayed gratification Basic toilet training Socially acceptable behavior Biting and spitting bad! Communicates effectively Transitional objects Favorite toy, blanket ↓ stress

58 Nutrition ↓ Growth period = ↓ protein and fluids
Physiological 18 mos ↓ nutritional need = ↓ ↓appetite Daily diet Milk 2-3 cups/day ↑ FE, CA, PO4 Very fussy and food jags (1-2 items only!) Only peanut butter and bananas! Want to feed themselves = MESSY! May eat a lot one day and not much following day

59 Nutrition Offer small, frequent nutritious snacks
Toddlers love to graze Not too much milk or juice (↑ sugar) Fills them up = won’t eat Do not force child to eat. Will eat when hungry. If child is not losing weight it is ok.

60 Dentition Twenty primary teeth by 30 months Brush teeth 2 x/day!
No bottles of juice or milk at bedtime. Dental carries can occur.

61 Safety Toddlers have no sense of danger ↑↑ Locomotion = DANGER!!
Injuries cause > death in ages 1-4 Motor Vehicle Crash (MVC) = #1! ↑ Caused by lack or improper restraint SUV toddlers wander behind truck and get hit. DWI 2500 kids/year 7/10 in car with impaired parent

62 Car Seat Safety Rules Universal Child Safety System (UCSS)
2 point attachment with tether system by 2002 all new cars must have entire UCSS <12 years of age = sit in back of car Infant = rear facing (1 yr and 20 lbs) Forward facing convertible seat till 40 lbs >40 lbs belt positioning booster seat New York State Seatbelt Laws March 2005 any child <7 years of age appropriate restraint system or booster seat 80 lbs or 4 ft 9 inches may use seatbelt Seat belt must fit properly: on hips not stomach on shoulder not neck

63 Drowning # 2 cause of death for toddlers Only need 1” of H2O to drown
Totally Preventable! Only need 1” of H2O to drown Bucket to clean car Ponds Pools Beach Always supervise near water!

64 Burns 3rd cause of death (boys) 20,000 injuries/year and 1,000 deaths
2nd among girls 20,000 injuries/year and 1,000 deaths 16% RT child abuse Types Thermal- flames, scalds (85%),hot objects Electrical- socket, chewing wires Chemical- Ingesting cleaning products Radiation- sunburn

65 First Degree/Superficial (epidermis)
Minor sunburn Red, dry and painful Heals spontaneously 3-7 days No therapy needed

66 Second Degree Partial Thickness
Involves epidermis and upper layer of dermis Moist, bulla Skin bright red Painful Heals in days with scarring

67 Third Degree/ Full Thickness
Includes subcutaneous tissue Dry, pale or brown/black PAINLESS Eschar- thick leather like dead skin Healing requires skin grafting ↑ painful

68 Fourth Degree/ Full thickness
Extends all the way to bone Dry, whitish leathery appearance ↓Sensation to pain Scarring and contractures

69 Total Body Surface Area (TBSA)
Varies with age ↓ age = ↑ TBSA ↑ surface area = ↑ Injury “Rule of Nines” Determines % of burns Transfer to burn unit BSA>10% Open palm of hand = 1 % of BSA Thorax 18% Head 19% Arm 8% Leg 13%

70 Management Respiratory Acidosis: Moist Breath sounds = Pulmonary edema
Maintain patent airway R/O Inhalation injury Smoke, steam, toxic fumes Charred lips, singed nasal hairs, soot covered nares Humidified 100% O2 Assess for: Respiratory Acidosis: ↑ RR, retractions, nasal flaring, ↑↑effort, ↓O2 Moist Breath sounds = Pulmonary edema √ Carboxyhemoglobin (CoHb) levels > 10% need hyperbaric chamber

71 Fluid Resuscitation Hypovolemic “Burn” Shock ↑↑ capillary permeability
Leakage of intravascular fluids ↓↓ Perfusion, ↓↓ BP, ↑↑ HR, ↓ Output Parkland Formula = 4mL LR x kg x %TBSA 1st hours until capillary integrity is restored IV Maintenace Fluids: 4:2:1 Rule 4mL/kg for 1st 10 kg 45 kg child: 4 x 10 = 40 mL 2mL/kg for kg x 10 = 20 mL 1mL/kg >20 kg x 25 = 25 mL 85 mL/H Maintain urine output 1-2ml/kg/hour-(foley) Strict I & O! √ SG √ Wt. √ VS and LOC

72 Monitor Lab values Hyperglycemia Hyponatremia Hyperkalemia Hypokalemia
↑ NE/E, ↑stress, insulin resistance, glycogen released Hyponatremia 3rd spacing 1st 24 hours = ↑NA excretion Hyperkalemia 1st 24 hours = ↑ cell release of K+ Hypokalemia 2nd fluid shifts back to cell ↓ K+ Hypoalbuminia (<2) ↓ serum proteins 3rd spacing Albumin 1 gm/kg/day Metabolic acidosis Renal failure, tissue damage RT sepsis ↑BUN ↑Creatine = ↑ SG Dehydration & renal failure

73 Pain Management Acute Procedures: PAIN
Burned skin and exposed nerves Moaning, grimacing, restlessness, guarding, dilated pupils, clenched fists,↓↓ movement Procedures: PAIN Dressing changes ↑↑ anxiety & ↑↑ fear Medicate prior to all procedures. MSO4, Propofol, Fentanyl, Hydromorphone Imagery, relaxation, distraction Therapeutic Touch

74 Wound Care Aseptic/sterile technique ↓↓risk of infection
Invasive lines, compromised immune Protective Isolation Debridement Remove dead tissue Hydrotherapy Soaking wounds - remove old dsg 10 mins to prevent electrolyte and fluid loss Washing area Clean area & assess wound √ color, drainage, odor, sloughing, granulation tissue

75 Antimicrobial creams Painful but penetrates eschar
Mafenide Acetate (Sulfamylon cream) Painful but penetrates eschar Gram (+)/(-) coverage Apply & leave OTA or light dsg √ Sulfa allergies Hypersensitivity reaction SE: Metabolic acidosis

76 Antimicrobial creams Silver Sufadiazine (Silvadene) Painless
Gram (-)/(+) coverage Not to use on face or electrical burns 1st Clean wound Apply & leave OTA or light dsg √ Sulfa allergy SE: Transient leukopenia

77 Antimicrobial creams Silver nitrate 0.5% Most gram (+) & some gram (-)
Painless soak Dampen dsg q 2H or TID Need large bulky dsgs Stains clothing and linens -black SE: ↓ K+ ↓ Na+ ↓Cl+ √ lytes

78 Skin Grafts Autograft Transcyte Patient’s own skin
↓ risk for Host Versus Graft (HVG) response Transcyte Newborn foreskin Bioactive skin substitute ↑ Re-epithelialization ↓ dsg changes ↓ hospitalization ↓scarring

79 Nutritional Support NPO x 24 hours √ Bowel sounds √ Abd girth √ N & V
Curling’s Ulcer ↓ GI perfusion ↑ occult blood via NGT & stool 2-3 times daily calories for wound healing ↑ BMR RT ↓ Protein & N loss Protein 25% of calories- eggs, peanut butter and milk ↑↑ Vit A and C important for skin oranges, grapefruit strawberries, broccoli

80 Psychological Needs ↑ Contractures & ↓ROM RT scars
Pressure Ace wrap cover to ↓↓ scars Increase involvement in care Play therapy & counseling Ease transition → community Prepare friends and school Wounds/scarring & emotional needs Support groups

81 Poisoning
150,000 kids < 5 years old = 120 deaths/year ↑ 2 years (improper storage) Poison Control # = Aspirin Intoxication- # 1 most ingested drug ASA acetylsalicylic Acid ↑ Availability in home Combination OTC meds: Peptol bismal, cough and cold, wart preparations Therapeutic Dose mg/kg Toxic dose 200mg/kg Severe toxicity mg/kg

82 Signs and symptoms 6 H delay before toxicity signs noted
Hyperventilation ↑↑ RR ↓↓CO2 ↑ Metabolism ↑↑BMR ↑↑ O2 use ↓↓ Glucose Metabolic acidosis ↑ ketones and organic acids Bleeding ↓↓ platelets

83 Interventions √ Serum salicylate levels Therapeutic 5-20mg/dl
Toxic >25mg/dl Gastric lavage up to 4 hours post ingestion Activated Charcoal (1g/kg) ↓ absorption & ↑ elimination via GI tract Vit K for bleeding Correct lyte imbalances- ↑↑ Ca+ ↑↑ K+ ↑↑ Hydration Flush kidneys ↑↑Calories May need hemodialysis

84 Acetaminophen Overdose
Most common acute drug poisoning ↑↑ Risk c combination drugs ↑↑ Risk for liver damage RT metabolites binding to hepatocytes ½ life = 3 hours Liver necrosis within 2-5 days if not treated Therapeutic dose = 90 mg/kg Toxic dose = 150mg/kg

85 Clinical signs Phase one (1st 24 hours) Phase two (24-36 hours)
N/V, anorexia and malaise Phase two (24-36 hours) Hepatomegaly, RUQ pain, ↑↑LFT’s ↑INR, PT, hyperbillirubin and oliguria Phase three (2-5 days) Encephalopathy, cardiomyopathy, anorexia, emesis, liver failure, hypoglycemia, coagulopathy, renal failure and death Phase four (7-8 days) Recovery or fatal hepatic failure

86 Interventions √ Serum acetaminophen levels √ INR (1.0 WNL)
↑ validity 4 hours post ingestion. Therapeutic level = mg Toxic level > 50 mg If extended release √ level 8 hours after ingestion. Must know actual ingestion time. √ INR (1.0 WNL) Earliest and most sensitive for hepatotoxicity √ LFTs (AST Aspartate Transaminase) Bilirubin, PT Released with hepatic injury √ BMP/ Panel 7 √ Renal- BUN

87 Interventions cont Gastric lavage most effective with extended release
Activated charcoal most effective 1-2 hours after injestion. N-acetylcystein-”Mucomyst”- PO Loading dose = 140 mg/kg x 1 PO then 70 mg/kg x 17 doses PO q 4H. Most effective with-in 8 hours of ingestion Must be initiated with-in 16 hours. Mix with coke smells like rotten eggs Charcoal may bind with mucomyst give 1 hour apart May use IV mucomyst if pt not tolerating PO

88 Lead poisoning Plumbism
Home built before 1960’s ↑ Risk for lead based paint (banned in 1978) Recent ongoing renovations Nearby industry Battery plants, gas stations Leaded gasoline in soil children place hands in mouth Old furniture, ceramic pottery and lead toys Folk Remedies Azarcon, Greta, Ligra & Surma (200x Pb!) ↑Risk < 6 years Urban areas Medicaid recipients 3 x’s lead levels Lead Screening Screen at 9 months to 1 year and then 2 years Earlier/ASAP with risk factors

89 Clinical signs Most kids are asymptomatic! √ Level
Pb serum level > 10 is toxic Pb > 45 = RX Pb > 70 = Medical Emergency (RX & ICU) 90% Pb attaches to RBC Interferes binding of iron to heme molecules √ H and H , Fe ↓ HgB = Anemia Absorption of Pb > Excretion 24 H Urine (lead) >3 mg Damages cells of proximal tubules Lead deposits in tissues, bones, gums and abdomen Lead lines (bones, nails) X-rays; Femur and Tib/Fib for deposits Abdominal pain (paint chips on X-Ray) Vomiting & Constipation

90 CNS Symptoms Hyperactivity Aggression-irritability Impulsiveness
Learning disabilities Developmental delays Lead Encephalopathy = Irreversible! ↑ ICP Seizures Cortical atrophy- Permanent brain damage→ Mental retardation Coma and death

91 Treatment Chelation Therapy for level >45mg/dl
Binds Pb to H20 water soluble form → excretion via urine Must use two meds if levels >70mg/dl 1. CaNa EDTA (calcium disodium edetate) IM/IV (20 doses) √ adequate kidney function Painful injections Apply EMLA 2 H before and inject with procaine. 2. BAL (dimercaprol) IM (24 doses) √ renal function Contraindicated with peanut allergy or G6PD Usually not single therapy use in conjunction with EDTA 3.Succimer (Chemet or DMSA) PO (43 doses) Alternate treatment for EDTA 19 day therapy

92 Hydrocarbons Gasoline and kerosene Turpentine = systemic toxicity
↑Risk for aspiration/pulmonary toxicity Turpentine = systemic toxicity Antifreeze Carbon Tetrachloride Baby Oil Camphor (Moth Balls) Inhaled or ingested

93 Signs and symptoms Gagging, Choking, Cyanosis N & V
↑↑ RR Retractions Dyspnea Grunting Aspiration PN in RUL Seizures Renal failure Coma

94 Therapy No emesis RT ↑Risk of aspiration Gastric lavage
Humidified ↑ O2 + PEEP Hydration Antibiotics Prophylactic for PN

95 Lye, Corrosives Strong alkali with ↑↑ PH
Dishwasher detergent (Electrosol tablets) Batteries Denture cleaners Oven/ Drain cleaners Erodes esophagus can cause perforation

96 Signs and symptoms Severe Burning Pain White swollen mucous membranes:
Mouth, throat and stomach White swollen mucous membranes: lips, tongue, pharynx Inspiratory stridor & Dyspnea RT Esophageal and tracheal edema Drooling Violent vomiting - blood & tissue ↑↑ Anxiety

97 Treatment Don’t induce Vomiting! Maintain patent airway
Administer analgesics NPO or Dilute corrosive with 120 ml H2O only! Steroids Methylprednisolone 2mg/kg/day Humidified O2 Surgery Batteries can cause esophageal and gastric burns Esophageal strictures

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