Community health nursing Maternal—child health: working with Perinatal, Infant, Toddler, and Preschool clients Chapter 21

Introduction the majority of the community health nurse’s clients are pregnant teens; women who are pregnant with a third, fourth, or fifth child; and infants and young children. Working with maternal and infant populations is a primary aspect of CHN.

Introduction Why should maternal–infant populations require this amount of attention from community health nursing? Despite the existence of advanced technology and the availability of excellent prenatal services, This group remain at high risk for disease, disability, and even death.

Introduction This lecture addresses three major areas in the health of maternal–infant populations: (1) health status and needs (2) design, implementation, and evaluation of maternal–infant health programs; (3) availability of community resources.

HEALTH STATUS AND NEEDS OF PREGNANT WOMEN AND INFANTS CHN constitute a key group of health care workers involved in both the planning of programs and the actual delivery of services to mothers and babies.

HEALTH STATUS AND NEEDS OF PREGNANT WOMEN AND INFANTS A solid understanding of vital statistics and other data regarding maternal infant populations provide nurses to determine both the appropriateness and the effectiveness of programs and services.

Global Overview In 2005, an estimated that half million women died of maternal causes, 88% of them in subsaharan Africa and south Asia. In these areas, maternal mortality rate (MMR) exceeds 1,000 per100,000 live births, but it is less than 10 per 100,000 live births in Canada, Australia, new Zealand, Japan, and most European counties

Global Overview Most maternal deaths are the result of direct causes (complication of pregnancy, labor, and delivery)

Global Overview Infant mortality Globally, 3.5 to 4 million neonatal deaths and 3.3 to 4.million stillbirths occur each year; they are largely caused by the same factors that result in death and disability of the mothers, including poor maternal health, inadequate care, poor hygiene, and inefficient management of delivery, as well as lack of essential newborn care

Birth Weight and Preterm Birth Low-birth-weight (LBW) babies are those weighing less than 2500 g at birth; very-low-birth-weight (VLBW) babies weigh less than 1500 g at birth. Maternal mortality, LBW, and VLBW births are three areas requiring attention.

Risk Factors for Pregnant Women and Infants The factors associated with low birth weight and infant mortality can be grouped into three categories 1- lifestyle 2- sociodemographic 3- medical and gestation

Lifestyle smoking, inadequate nutrition, low pre pregnancy weight, high alcohol consumption, narcotic addiction environmental toxins, prolonged standing, strenuous work, stress, and lack of social support

Sociodemographic low maternal age, low educational level, poverty, and unmarried status

Medical and gestational history—primiparity multiple gestation, short inter pregnancy intervals, premature rupture of the membranes, uterine abnormality, febrile illness during pregnancy, abortion, genetic factors, gestation-induced hypertension, and diabetes

Drug Use Substance abuse during pregnancy is problem of huge scope and amazing social and medical implications VLBW infant is primarily associated with preterm birth, which may itself be associated with the use of illicit drugs during pregnancy

Drug Use According to Healthy People 2010, two thirds of LBW and 98% of VLBW births are attributable to preterm delivery. Preterm birth is associated with a number of modifiable risk factors, including the use of illicit ( illegal) drugs during pregnancy

Drug Use Associated with drug use are limited prenatal care, inadequate nutrition, low pre pregnancy weight, alcohol consumption, and smoking In addition, cocaine use during pregnancy is associated with impaired fetal growth, neonatal seizures, and congenital anomalies.

Drug abuse Neonatal withdrawal is characterized by abnormal functions of the gastrointestinal tract, the central nervous system, and the respiratory system. Poor feeding, abnormal sleep patterns, long-term learning disabilities, and delayed language development in the infant are observable results of maternal drug use.

Drug abuse In addition, the child face a high risk of infectious diseases, including hepatitis B and Infants exposed to heroin or cocaine prenatal are also more likely to sudden infant death syndrome (SIDS)

Drug abuse women who are (drug exposed )use drugs intermittently( occasionally) women who are (drug dependent) (physically and psychologically require use of drugs to function). Many pregnant addicts do not receive prenatal care, and it is not until their newborns show signs of withdrawal after birth that many of these women are identified

Alcohol Use Use and especially addiction to alcohol as the substance of choice is another problem in society. Fetal alcohol spectrum disorders (FASD) Use alcohol even when limited to early pregnancy and in the absence of addiction, and can lead to an array of neurocognitive and behavioral disorders, sometimes with structural anomalies

Alcohol Use Alcohol use can cause destructive effects in the fetus, even when limited to early pregnancy and in the absence of addiction. fetal alcohol syndrome (FAS), regular intake of alcohol during pregnancy, especially in the first trimester which is characterized by structural abnormalities of the head and face (microcephaly and flattening of the maxillary area), intrauterine growth retardation,

Alcohol Use fetal alcohol syndrome (FAS), decreased birth weight and length, developmental delays, intellectual impairment, hyperactivity, altered sleep patterns, feeding problems, perceptual difficulties, impaired concentration, mood problems, and language dysfunction.

Fetal alcohol effects (FAE) syndrome causes some but not all of the symptoms of FAS. It occurs in children whose mothers have used varying amounts of alcohol while pregnant, including those who have engaged only in irregular overuse drinking. FAE is seen three times more often than FAS. “There seems to be no safe threshold below which pregnant women can safely drink”

Alcohol use Alcohol-related birth defects (ARND) Indicating problems with hearing, bones, or heart and kidneys, Alcohol-related neurodevelopmental disorder ARND) Represented by mental or functional problems, include cognitive and/or behavioral abnormalities

Alcohol use Mothers who drank heavily and also smoked during pregnancy delivered babies that weighed 500 g less than babies of mothers who withdraw from both. The combined effects of drinking and smoking are important factors in infant mortality and impaired mental and physical development

Tobacco Use Tobacco use increased dramatically among women in the last third of the 20th century, inevitably affecting maternal and newborn health.

Tobacco Use The nicotine in tobacco is a major addictive substance, and smoking is an addiction that many people find difficult to stop

Smoking during pregnancy It has been associated with ectopic pregnancy, spontaneous abortions, intrauterine growth retardation, preterm birth, stillbirths, higher perinatal mortality, small-for-gestational-age (SGA) birth, LBW birth, neonatal anomalies, and lower Apgar scores,

Tobacco Use Infants of women who smoked during pregnancy continue to be at higher risk for Sudden infant death syndrome (SIDS, respiratory infections, asthma, ear infections, and decreased lung function As the children get older, they are at higher risk for learning disabilities and behavioral problems

Passive smoking which is exposure to tobacco smoke from other people smoking in one’s environment also puts a person at risk for smoking-related disease

Passive smoking inhaled passively by the nonsmoker, contains a higher concentration of toxins and carcinogens than the smoke inhaled directly by the smoker;

Tobacco Use The use of smokeless tobacco products, such as chewing tobacco, has led to an increase in oral cancers Any form of tobacco is extremely hazardous to health.

Tobacco Use An initial health history of a pregnant woman should include the assessment of tobacco use, smoking status, always and smoke in the personal environment. And stress

Tobacco Use Nurses can be positive role models for health and demonstrate health promotion strategies to clients by their own behavior. The nurse must not only advise clients to quit smoking but also offer supportive and empathetic approaches to smoking cessation, including methods or interventions that can help.

Tobacco Use Finally, there is a need for more research on the reasons why women smoke. Specific attention is needed to address the effects of depression and social isolation on the initiation and continuation of smoking by women

Sexually Transmitted Diseases Globally, the prevalence of syphilis in developing countries is up to 100 times that in developed countries; rates are10 to 15 times higher for gonorrhea, and 3 times higher for chlamydial infection (WHO, 1998).

Sexually Transmitted Diseases Women who discover that they have an STD ashamed, betrayed, embarrassed, and angry. Those who are often feel asymptomatic may deny the existence of the disease and not carry out the treatment plan. Although educating the pregnant client about the effects of STDs is critical, providing information alone is not enough.

The community health nurse has a essential role in enhancing the empowerment of women so they can act on the information they receive. The nurse talks with the women and helps them understand that they have control over their bodies. Usually, STDs are first discovered in pregnancy during routine prenatal screening .

HIV and AIDS An HIV-positive woman who is pregnant or has delivered a baby requires special nursing management of the pregnancy and of the family after the birth of the newborn.

Breast-Feeding HIV-infected women are advised not to breast feed their infants, because the infants will become infected with HIV from breast milk

Poor Nutrition and Weight Gain Research has demonstrated a positive correlation between weight gain during pregnancy and normal birth weight in the babies. Weight gain of 15 to 35 lb during pregnancy is recommended for women with body mass indexes (BMIs) ranging from 19.8 to 25 28 to 40 Ib for underweight women with BMI under 19.8

Obese women have a higher incidence of gestational diabetes, urinary tract infections, wound infection, thromboembolism, pregnancy induced hypertension, fetal monitoring difficulties, prolonged labor, and birth trauma

Poor Nutrition and Weight Gain maternal weight change in the first trimester of pregnancy more strongly influenced newborn size than did weight change in the second or third trimester.

Teenage Pregnancy There is a strong association between young maternal age and high IMR, and infants born to teenagers are at increased risk for preterm delivery, neonatal, and post neonatal mortality

Teenage Pregnancy The issues of adolescent parenting are complex. Including emotional, physical and social issues, and the life experiences of adolescent mothers The CHN has a unique challenge when teaching teens about pregnancy-related changes, accompanying needs, and preparation for the important role of parent to the infant.

Emotional Needs Teenagers who become pregnant deal with this change in their life in a variety of ways. Some have such a strong denial system that they deny the pregnancy even to themselves. It may take 3 or 4 months into the pregnancy before they can admit it and seek out a physician’s diagnosis

Physical Needs Pregnant teens have a range of physical needs that can be addressed by routine prenatal care and education,. Routine prenatal care is one of the most important needs, and teens may require assistance in recognizing the value of monitoring the pregnancy

The pregnant teen needs education regarding changes in her emotional state and her body, the growth and development of the fetus, dietary requirements, rest and relaxation needs, and anticipatory guidance for infant care giving and parenting

Physical needs Teaching can take place as part of each prenatal appointment, in specific classes at school for pregnant teens in the health department clinic, or during home visits

Social Needs Pregnant teens are dealing with two stages of their own growth and development at the same time, which makes their social needs complex. They are struggling with the normal adolescent challenges along with the responsibilities of pregnancy and parenting (young adulthood stage of development).

Maternal Developmental disability Over the past 20 yrs. Studies identified that a primary problem affecting the children of developmentally disabled mothers is the poor quality of maternal-infant/child interaction The establishment of a trusting relationship between the nurse and the family is of foremost importance. Teaching by demonstration with many visual aids and promotes, along with games and creative approaches to engage and sustain attention, can challenge the nurse’s activity

Complications of Child Bearing hypertensive disease in pregnancy, gestational diabetes, postpartum depression, and grief in families who have lost a child

Hypertensive Disease in Pregnancy prevention and control hypertension during pregnancy, namely, a diet high in fresh fruits and vegetables, weight gain limitations, sodium restriction, rest, and regular exercise.

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy.

Postpartum Depression Depression during a woman’s lifetime is a fairly common phenomenon; 20.6% of women and 11% of men were experience depression in their lifetimes

Fetal or Infant Death More than 2,250 infants die annually from SIDS. An role for CHN in maternal–infant care is that grief counselor. the nurse has an important and supportive role. The nurse should encourage the parents to express feeling

National perspective on Infants, Toddlers, and Preschoolers Neonate ( Birth to one month) The infant (one month to 1 year) Toddler (ages 1 and 3 years) preschooler population (ages 4 and 5 years).

GLOBAL VIEW OF INFANT, TODDLER, AND PRESCHOOL HEALTH The health of children in one country can affect that of children in other countries, including the United States. Infants and young children travel internationally with their parents. Major natural disasters whole populations at risk, especially the very young and the very old

National perspective on infants, toddlers and preschoolers The major causes of death among the 1 – to – 4years-old population are unintentional injuries ( motor vehicle crashes, falls, drowning, fires, and burns), followed by birth defects and cancer Assault (homicide) and diseases of the heart are also among the five leading the causes of death for this age group

Accidents and Injuries Toddlers and preschoolers are vulnerable to many types of accidents and unintentional injuries such as those caused by:- unsafe toys, falls, burns, drowning, automobile crashes, and poisonings. Injury from many sources may result in death.

Accidents and Injuries Unintentional injuries are the leading cause of death for people aged 1 to 3, 4 years and the fifth leading cause of death in the United States (USDHHS, 2000). Motor vehicle crashes account for approximately half the deaths from unintentional injuries.

Accidents and Injuries falling Infants are at risk of falling when they are not supervised adequately. Falls from a bed or other furniture item that occur when a baby is not properly secured or supervised can cause permanent injury or death. As the infant grows and learns to walk, frequent falls are common and continuous supervision and “

Accidents and Injuries Burn Injury from burns can happen to children of all ages. Child deaths and injuries from burns result primarily from house fires but also from electrical burns, cigarette lighters, matches.

Poisoning Poisoning. Sources of poisoning include household plants, prescription medications, over-the-counter drugs, unintentional medication overdoses, household cleaning products, other chemicals stored within a child’s reach, and lead.

Poisoning A major cause of childhood poisoning is lead. The primary sources of lead exposure in preschool-aged children continue to be lead-based paint, lead-contaminated soil and dust, and drinking water from lead-soldered pipes

Poisoning Toxic household substances, such as cleaning supplies, must be clearly labeled, and harmful drugs must be packaged with special seal and safety caps. Children have also been exposed to lead in some toys, candies, cosmetics, traditional medicines, and eating or drinking utensils imported from other countries.

Accidents and Injuries drowning Young children are at risk for drowning wherever water occurs in depths exceeding a few inches such as in toilet bowls, bathtubs, buckets or cans filled with rainwater, and swimming pools. Infants, toddlers, and preschool-aged children are especially vulnerable because they are not aware of water dangers and explore unafraid.

Child Maltreatment Child abuse Is the maltreatment of children, which may include any or all of the following: Physical abuse Emotional abuse Neglect (physical, medical, or educational) and sexual abuse

Child Maltreatment Shaken baby syndrome Suspected in infants or toddlers who exhibit traumatic brain injuries caused by violent shaking or impact, is characterized by a triad of symptoms: retinal hemorrhage, subdural hemorrhaged.

Child Maltreatment Risk factors for child maltreatment are found in four areas: Parent or care giver behaviors Family characteristics Child factors environment

Communicable Diseases Toddlers and preschool-aged children experience a high frequency of acute illnesses, more than any other age group. Morbidity from communicable diseases among young children is high. Respiratory illnesses, followed by infectious and parasitic diseases, injuries, and digestive conditions, are the most common

Chronic Diseases Many young children are distress with chronic diseases that affect quality of life. Asthma is the most common chronic illness among young people in the United States, It is a leading cause of hospitalization in children

Chronic Diseases Autism A development spectrum disorder that is often first noticed in toddlers.

Chronic Diseases Sickle cell anemia An inherited blood disorder, affects thousands of children in the US

Chronic Diseases food allergies The incidence is increasing in the population. can be identified early in an infant’s life by offering one new food at a time, with a 3-day interval between new foods. This helps to determine which foods cause an allergic reaction.

Chronic Diseases Other chronic illnesses Muscular dystrophy (MD) and cystic fibrosis CF) are two diseases that not only affect quality of life but also severely shorten the child’s life. MD (is a familial disease characterized by progressive atrophy and wasting of muscles. Onset usually occurs at an early age, and MD is more common in boys than in girls. The cause is thought to be a genetic defect in muscle metabolism.

Chronic Diseases Cystic fibrosis usually begins in infancy and is characterized by chronic respiratory infection, pancreatic insufficiency, and increased electrolytes in sweat It is the major cause of severe chronic lung disease in children.

Poor Nutrition and Dental Hygiene nutritional problems (underfeeding or overfeeding, overeating, and inappropriate food choices) and poor dental health. Nutritional and dental health needs are great during this period of rapid growth. Bonding between mother and infant and overall maternal health are predictors of infant weight gain Both nutrition and bonding can be accomplished by breast feeding.

Poor Nutrition and Dental Hygiene Benefits of breast feeding Convenience:. Cost: Complete Nutrition:; Anti-infective and anti-allergic properties: Infant growth Long-term health effects Benefit for mother

Poor Nutrition and Dental Hygiene Overfeeding of an infant can lead to childhood obesity and becomes a risk factor for heart disease, hypertension, and diabetes. Obesity is a contributing factor to the worldwide increase in diabetes type 2 and has been reported to result in lower health-related quality of life

HEALTH SERVICES FOR INFANTS, TODDLERS, AND PRESCHOOLERS 1- Preventive health programs Immunization programs Parent training programs Quality day care preschool programs

HEALTH SERVICES FOR INFANTS, TODDLERS, AND PRESCHOOLERS 2- Health Protection Programs Safety and Injury Protection Protection From Child Abuse and Neglect Use (primary, secondary, and tertiary prevention)

HEALTH SERVICES FOR INFANTS, TODDLERS, AND PRESCHOOLERS 3- Health Promotion Programs Infant Brain development Research and parent-child interaction Developmental screening Programs for children with special needs Nutritional programs

ROLE OF THE COMMUNITY HEALTH NURSE CHN face the challenge of continually assessing each population’s current health problems, Some gaps can be filled by nursing interventions. Others must be filled by referrals to various members of the community health team, the nurse may sometime collaborate with ‘ services.

ROLE OF THE COMMUNITY HEALTH NURSE focused on education, engineering, and enforcement. the nurse uses enforcement interventions force people into compliance with laws that that require certain immunizations or mandate reporting of suspected child abuse and environmental health standards